Pharmacy Practice + Business - January/February 2024

JANUARY/FEBRUARY 2024

PUBLIC PROTECTOR WHEN WILDFIRES EVACUATED MOST OF YELLOWKNIFE, AARON LABORDE RISKED HIS OWN SAFETY TO SERVE THOSE WHO REMAINED. HIS EFFORTS EARNED HIM A 2023 PHARMACY PRACTICE + BUSINESS AWARD.

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Contents

JANUARY/FEBRUARY 2024 [VOL.11 NO.1] PRACTICE

BUSINESS

AWARDS

8

2023

6 34

5 / Editor’s Message

24 / Practice Experts

Fighting fire with passion / By Vicki Wood

NEW Mental Health / By Sunny Wang P. 24 Therapeutic Issues / By Katelyn Halpape P. 26 Cardiovascular Issues / By Arden Barry P. 28

6 / How I did it NEW How I implemented the pharmacist-first workflow system in my pharmacy

30 / 5 Tips Assessing the potential for QT-prolongation drug interactions / By Mishka Danchuk-Lauzon

/ By Carlene OIeksyn

8 / Cover Story Introducing the Pharmacy Practice + Business Award winners / By Rosalind Stefanac

34 / Clinical Feature

/ Cover Photography by Angela Gzowski

Not child’s play: A practical guide to the management of pediatric pain / By Rana Khafagy

21 / Drug News

38 / The Closer

A review of new launches, new indications, new dosage forms, discontinued drugs and Health Canada Advisories / By Lu-Ann Murdoch

A dose of prosperity: A plan to help your business—and you—succeed / By Amy Oliver

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[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS

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EDITORIAL ADVISORY BOARD

Sandra Aylward, Halifax, NS; Naushin Hooda, Vancouver, BC; Ian Lloyd, Victoria, BC; Kara O’Keefe, Newfoundland & Labrador; Barret Procyshyn, Dauphin, MB; Tim Smith, Winnipeg, MB; Andrew Tu, Toronto, ON; Kristen Watt, Southampton, ON; Bruce Winston, Calgary, AB

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Fighting fire with passion It seems that every new year blows in some new firestorm for pharmacists to fight. Payers have been chipping away at fees and markups for years. Then, as the COVID-19 pandemic wound down, some provinces rushed in scope of practice expansions, in some cases giving pharmacists only a few days’ notice before unleashing public demand for common ailment assessment or prescribing for flu. And already this year we have Express Scripts Canada’s demand for new “service” fees—a move that portends alarming changes ahead.

It’s hard to imagine any other sector repeatedly bouncing back from such a constant barrage of cutbacks and fees accompanied by demands to provide more services. (On second thought, “bouncing back” is me being too chirpy; what we’re seeing and hearing from our readers sounds more like “trying extremely hard to stay upright.”)

Mindful of this, when we launched the call for entries for this year’s Pharmacy Practice + Business Awards, I worried that we’d see a drop in the number of entries.

After all, when just surviving has become so difficult, how does one find the wherewithal to be excellent?

What a lovely surprise, then, when we actually saw a record number of entrants in all categories. Apparently when times are tough, pursuing excellence is not an option you can be too busy for—it’s the best way to ensure your business thrives.

I did not envy our judges having to select one winner in each category. They especially noted the incredible range of niche practices represented by entrants who have taken their passions and their specialized skills and carved out unique practices that are needed, appreciated and of service to their chosen patient communities. You’ll see what I mean as you read about this year’s winners in this issue.

There were also a number of truly creative and unusual practices among the entries that didn’t win this year; in fact some are so remarkable that we’ll be sharing their stories in the months ahead (watch your newsletters!).

Here’s what I find most telling: despite the formidable challenges facing the profession right now, the pharmacy that wowed our judges with the most innovative professional practice also happened to earn the award for most innovative business.

It’s fitting though, isn’t it? We are Pharmacy Practice + Business, after all.

VICKI WOOD EDITOR vwood@ensembleiq.com

[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS

5

HOW I DID IT

Carlene Oleksyn is managing partner and pharmacist at Mint Health + Drugs in Stony Plain, Alberta where the P1st workflow has been in place since 2012.

NEW FEATURE FOR 2024

Carlene Oleksyn explains how she implemented the “Pharmacist-First” workflow In the Pharmacist-First workflow, also called “P-First” (P1st) workflow, pharmacists are seated at semi-private intake desks, facing a patient chair so they can assess patients as they present to the pharmacy.

All tasks that don’t require a pharmacist’s licence are assigned to other staff. P1st workflow is not the same as a pharmacist-led clinic or appointment-based models with pharmacists providing care in an office setting (though these services are also provided by my team). P1st is the pathway the patient and their prescription(s) take through our pharmacy.

WHY DID I DO IT? P1st is best practice.

It is nearly impossible to find and resolve drug-related problems (DRPs) with only a patient profile and a prescription hard copy in front of you. Assessing the patient (not just the patient’s file) and shared decision-making with them are essential. Best pharmacist care requires that we work with the patient, engaging them in their own care and decision-making, taking responsibility for drug therapy decisions and collaborating with other care providers. To do this we need to be talking with patients when they present, assessing their medications, chief complaints and chronic disease therapy. The P1st model has been studied and has demonstrated positive patient outcomes.1

P1st is the most efficient workflow.

If a pharmacist is on the back end or “final check” position in workflow and they do discover a DRP, the prescription has already been entered, prepared and checked, and the patient has waited. Then the team must go through the entire process again to fix the problem and the patient waits yet again.

This model is a highly inefficient use of everyone’s time.

6

P1st is best for business.

Being up front with the patient allows pharmacists to identify gaps in care which are opportunities to provide needed services. When a pharmacist is up front with patients, medication reviews are natural, follow-ups happen automatically and gaps are addressed for minor illness prescribing. Patient adherence also increases, leading to prescriptions being filled more regularly. Patients are so appreciative of this kind of pharmacist care that wordof-mouth referrals and transfers automatically increase.

HOW DID I DO IT? First, I designed a pharmacy space that is open, making it easy to greet patients as they enter. I started with only one intake station, but prioritized having chairs for both the pharmacist and the patient.

This conveys to patients that we are focused on them.

They are not "interrupting our work" but rather they are our work. As my business and my team grew, I expanded to three seated intake stations.

Secondly, I focused on leadership. Changing existing practice is hard. Even though you are transitioning to a more efficient and effective model, one that provides greater professional satisfaction and

PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

allows all team members to work at the top of their license, change is uncomfortable and causes upheaval. The leader must clearly define why change is happening, work to have all team members on board and support them during the transition and afterwards.

Times of stress and added workload can cause a team to revert back to what is familiar and comfortable, but the leader can continually bring the team back to the “why” and redirect the workflow when needed. I always include my team when evaluating how things are going and ask for suggestions on improving efficiency. We also revisit all the moving parts anytime we add a new team member or have staff missing.

HOW YOU CAN START Evaluate your current workflow and staff tasks. In traditional workflow, pharmacists are on the back end completing the final check. P1st flips this around and has the pharmacists complete the clinical check first then hand the approved prescription to a pharmacy assistant for data entry and dispensing. This requires a separation of the clinical check and the technical check, leaving the technical check to registered pharmacy

technicians (RPhTs) on the back end. Pharmacists also provide counselling at the intake station leaving technical teaching of devices to the RPTs. Data entry, insurance adjudication, dispensing, compounding, final package checks and inventory management are not part of a pharmacist’s role in this workflow, freeing up enormous amounts of pharmacist time.

I started P1st without a RPhT as I was building a practice from scratch. I still engaged patients at intake and managed the final check, but as soon as I could afford a RPhT I brought one onto my staff and it was a game changer. Over a decade we have grown to a much larger team with several pharmacists and RPhTs, but regardless of size, this can be done.

As Chris Juozaitis (another P1st leader) is fond of saying, “there are no unicorns and rainbows here.” Everyone works hard, surprises happen, but the P1st workflow gives staff greater fulfillment and professional satisfaction by providing them the structure and time needed to proactively engage—and improve the quality of life of—patients walking through their door.

1. So R, Al Hamarneh YN, Oleksyn C, Purschke M, Tsuyuki RT. Impact of a “Pharmacist First” innovative workflow plan in patients with hypertension and/or diabetes. Can Pharm J (Ott).

2021 May 27;154(6):376-380.

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COVER FEATURE

PRESENTING The 2023 Pharmacy Practice + Business Award Winners The Pharmacy Practice + Business Awards recognize Canadian pharmacy professionals who deliver exceptional patient care via innovative and successful pharmacy practice models. Read on to meet this year’s winners.

ABOUT THE AWARDS PROCESS A panel of six judges reviewed all entries to this year’s awards program and were asked to rate each entry by three judging criteria (Innovation, Contribution to the Community and Impact). The entries with the highest total overall scores in each category were declared the winners.

THANK YOU TO THIS YEAR’S JUDGES Jim Danahy, Dean Elbe, Jonathan Lu, Graham McKenzie, Carlene Oleksyn and Andrew Schonbe*

*Note: Andrew Schonbe was excused from judging the category in which he had submitted an entry.

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PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

P R A C T I C E I N N O VAT I O N & B U S I N E S S I N N O VAT I O N

Filling a reproductive care gap helps people access safe choices Why they won both awards: Recognizing prevalent gaps in care for people seeking medical abortions, this pharmacy team is ensuring that patients have access to safe reproductive choices. And by committing to fill an emerging care gap, the team has in turn extended their care and customer community to some of the far reaches of the province.

When the owners of this new downtown Toronto pharmacy were approached by a virtual abortion provider having difficulty finding pharmacies in Ontario willing to dispense medication and support patients, they took it as a clear sign to take action. Not only did they take on those patients, but within the first six months of opening, the team expanded their network of

Wholehealth Pharmacy Fashion District, Toronto, ON medical abortion providers and clinics and developed an innovative practice in providing access to medical abortion care. Wholehealth Pharmacy Fashion District is the only pharmacy offering free province-wide delivery of Mifegymso (the medication needed for medical abortions in Canada). To date they’ve provided support to more than 1,700 people across the province seeking care—including many in remote areas—and support 10 clinics and providers on a regular basis.

Beyond dispensing medication and working with abortion providers, the Wholehealth team has created a compassionate and supportive environment for people seeking abortion care. Working with an inter-collaborative network of physicians, nurse practitioners and midwives, they have successfully streamlined the process for people seeking medical abortions so they can have a seamless experience throughout.

The pharmacy team provides

What one judge said:

“An innovative, novel and comprehensive approach that’s really filling a gap in health care—and on such a large regional landscape.”

Photo above by Jaime Hogge

[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS

9

“ We have not just stretched the limits of what a pharmacist's care can do but have removed barriers to care and made medical abortions as seamless and comfortable as possible for patients.”

comprehensive guidance and personalize care to each patient, offering discretion and ongoing support/information so patients can make informed decisions about their reproductive health.

Staff pharmacists are also trained to provide pain management options in the context of medical abortions to alleviate any discomfort associated with the process, in addition to being well versed on all forms of contraceptive care so they can counsel patients on next steps in their reproductive health.

Most recently, Wholehealth Pharmacy Fashion District partnered with Planned Parenthood Ottawa to extend their services to patients and providers in the Ottawa region, and help to address the challenges in accessing Mifegymiso.

In coordination with Wholehealth Pharmacy head office, the team developed informative infographic resources tailored to pharmacies in the area offering detailed instructions on billing procedures and the dispensing of the medication to encourage other pharmacies to support patients and providers—and reduce stigma and misinformation around medical abortion. Information resources were also developed for patients.

These initiatives are having a significant impact beyond Ontario, too. With the pharmacy’s innovative efforts so far, pharmacy co-owner James Morrison was invited to contribute to national resources to support interprofessional abortion care for prescribers and pharmacy professionals with a focus on supporting marginalized patients. “We have not just

stretched the limits of what a pharmacist’s care can do but have removed barriers to care and made medical abortions as seamless and comfortable as possible for patients,” he said.

By enabling access to harder-toobtain care and prescription medication to marginalized patients and their providers, the pharmacy team is also growing a successful business. “Because we are a niche that is underserviced, we’ve been able to grow rapidly…and our prescription counts are steadily increasing,” said pharmacy manager and co-owner Ajay Chahal. “We even get patients calling in to us, and we direct them to providers and other resources, so it works both ways.”

Morrison says offering medical abortion province-wide has allowed the team to collaborate with clinicians from Sarnia to Ottawa, to Wawa and Timmins. Cultivating these relationships has attracted prescriptions from outside of the pharmacy’s local market. “We have also worked with clinicians to enhance their prescribing and take advantage of patient drug coverage to address pain management during abortion and to start patients on contraception,” says Morrison.

“Not only did we reach new patients though our outreach, but our efforts yield more prescriptions per patient.”

In being able to implement several innovative practices in addition to medical abortions (including cannabis consultations, HIV self-testing, minor ailments and on-demand deliveries) he says his pharmacy team was able to create significant networks in the community within the first year.

“Through these efforts, the pharmacy reached its break-even point within only eight months, which is uncommon given that most pharmacies take upwards of three to five years.”

“Feedback from patients about the service from Wholehealth Fashion District has been really positive,” adds staff pharmacist and co-owner Anushya Vijayaraghevan.

“I’m super proud and excited about what we’ve accomplished so far.”

Q&A:

What makes for an effective team environment? It starts with recruitment.

We are careful to invite team members that are collaborative and have an

10 PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

innovative mindset. This proactive approach ensures that our foundation is built on individuals who bring a spirit of cooperation and creativity.

Once assembled, the team benefits from clear roles and responsibilities, continuous training, and ongoing professional development to stay abreast of advancements in the pharmacy space. Effective communication channels, supported by technology integration, contribute to streamlined operations and workflow efficiency.

In our supportive and collaborative atmosphere, our pharmacists are encouraged to leverage their whole scope of practice, contributing to a wellrounded and dynamic pharmacy team.

What’s your advice for improving interprofessional practice relationships?

Understand each other’s needs and challenges. By recognizing and acknowledging the pain points experienced by different healthcare professionals, we can collectively work towards resolving these issues. Open and honest communication is paramount in this process, creating a collaborative environment where each team member’s perspective is valued. We’ve discovered that building trust is essential, especially when it comes to showcasing the full scope of pharmacy care capabilities.

Educating other healthcare providers about the range of services and expertise we offer can dispel misconceptions and foster a greater appreciation for our contributions to patient care.

Networking plays a pivotal role too, facilitating connections with other healthcare professionals whose areas of practice align with our interests, services, and patient population. Establishing such connections not only promotes a more cohesive approach to patient care but also opens avenues for shared learning and continuous improvement in inter-professional collaboration.

How do you combat stress and prevent burnout? It starts with an understanding of the unique challenges faced by pharmacy professionals. We have found that fostering a supportive work environment, where colleagues understand and empathize with each other’s workload, contributes significantly to stress reduction. Implementing a regular line of communication with our

INTERPROFESSIONAL I N I T I AT I V E

pharmacy team members provides a way to discuss any workflow issues, identify potential bottlenecks, and collaboratively find solutions. Additionally, prioritizing self-care is crucial, such as encouraging team members to utilize vacation time and maintain a healthy work-life balance.

Moreover, continuous professional development opportunities and training sessions can empower team members, boosting their confidence in handling challenging situations. In essence, a comprehensive approach that addresses both the environmental factors and individual well-being is essential.

What is most rewarding about working with your patient population? Providing access to medical abortion, we witness the profound impact on reproductive healthcare equity. Ensuring that patients, particularly in remote areas, have access to safe and dignified reproductive choices brings immense satisfaction. The direct positive impact on patients’ lives and the contribution to increased healthcare accessibility is gratifying, underscoring the significant influence on women’s health within marginalized communities.

The PrEP Clinic/Ontario Prevention Clinic and Pharmacy

Photo by Jaime Hogge

The PrEP Clinic: A team effort makes a major impact in HIV care Why they won: With cases of HIV increasing year over year across Canada—and preventative medication being underutilized—this group of healthcare professionals took initiative to break down barriers to HIV prevention and help thousands of patients in Ontario to access treatment.

Originally launched in 2019 as the country’s first online-only PrEP service, the clinic has since expanded to include in-person practice sites in Toronto, Brampton and Ottawa. Patients have access to comprehensive HIV preexposure prophylaxis treatment, along with ongoing monitoring and support provided in a wide variety of languages (between them, team members speak more than 12 languages). The team has also implemented a transitional care support program to give HIV treatment care opportunities to those lacking care providers or provincial health coverage.

All patients have access to free HPV vaccinations, in addition to sexual health information resources, and all team

members are aligned to fight stigma while providing a supportive environment for people of all backgrounds.

This is all made possible due to an inter-professional work environment where team members effectively communicate.

What one The pharmacy team judge said: members act as the “Phenomenal collaboration central navigation across a large point between patients team to achieve life-saving and the team’s allied results for a very healthcare professionals diverse, at-risk population and which include ‘meeting people registered nurses, nurse where they’re practitioners, registered at’ in a humane, accessible practical nurses, social community workers and patient setting.” support specialists.

Pharmacists have augmented roles as clinical HIV pharmacists involved in case management, and pharmacy technicians as patient care specialists.

The pharmacy team is also focussed on sexual health education, drug-related problem-solving, affordability support navigation, and medication adherence.

Patients can text, phone or Whatsapp the pharmacy team six days a week with extended hours for their queries.

Best of all, these collaborative efforts are already paying off in helping to reduce the number of new HIV infections and sexually transmitted diseases across Ontario.

Q&A:

What makes for an effective team environment? Everyone needs to be there for the same reason and believe in your mission. All should have a voice and it should be a level playing field. Too often there is a hierarchy of prescriber, then pharmacist, then support staff. We don't operate this way and everyone on the team has equal value and opinions.

It supports a friendlier workspace and minimizes the risk for egos and conflict.

For our team to remain cohesive, we balance work and social events. When there are community events or dinners, everyone is provided a ticket so we can all

[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS 11

What’s your advice for improving interprofessional practice relationships? Include everyone in the conversation and shared communication channels. One healthcare profession should not dominate the conversation, nor should there be any left out. Everyone needs to know everyone else's strengths and have clearly defined roles to support appropriate referral and maximize care planning for patients.

Positions of leadership and project

management are allocated to those with the best experience in their specific space. If there is fairness and true collaboration, you get maximum buy-in and the relationship drives synergistic outcomes. A lot of our success also comes from having actual healthcare providers making key decisions vs bureaucrats who often can be out of touch and disconnected.

How do you combat stress and prevent burnout? Team members need to know that your pharmacy puts team members first and is conscious of stress and burnout. This is shown by providing appropriate staffing levels, a reasonable schedule in the day, sufficient breaks, and rewards. In our space we are a heavily appointment-based service with ample time provided for appointments.

Work-life balance is officially assessed during annual reviews and more frequently through pathways provided to team members to share. It is also important to be aware of surroundings

Naushin Hooda: Rising to the occasion to find healthcare solutions Why she won: Naushin Hooda may have started her pharmacy career as the world shut down in a global pandemic, but that hasn’t prevented her from making an indelible mark in the profession already. She started in community pharmacy working with underprivileged and underserved populations in Manitoulin Island.

Noticing gaps in health care right off the bat, What one judge said: she initiated community “This pharmacist events to educate the has a tremendous public on safe medication impact in many areas; where she storage and disposal and sees a gap in the worked with Ontario system she seeks Cancer Care and her to find a creative solution.” interprofessional team to develop a colorectal cancer screening education program for healthcare professionals and the public.

Among her many accomplishments

and sometimes you can just sense times when the team is a bit more stressed and take action. We swiftly hire on more team members when needed and have prioritized staff burnout and patient care this way. Understaffing while increasing demands is detrimental to morale, stress and service levels.

What is most rewarding about working with your patient population? It's really about helping people and ensuring we are doing everything possible within our space to provide support. Our services reach a lot of people who are either missed by the healthcare system or face systemic barriers to access and marginalization. We get to be involved in the complete care of our patients, building great relationships and supporting the community.

The community engagement and connections made outside the clinicpharmacy space is really amazing. At the same time, we get to maximize our own scope in all of our roles and take on new responsibilities and challenges.

R I S I N G S TA R

Naushin Hooda, Vancouver, B.C.

since graduating with her Pharm. D. from the University of Waterloo in 2019, Naushin was appointed the lead critical care pharmacist at Ontario’s first designated COVID-19 hospital, Cortellucci Vaughan Hospital, with only a few months of community pharmacy experience under her belt. In seeing how overtaxed the healthcare system was, she was also inspired to develop a research program investigating pharmacists’ roles in cancer screening, with a goal to influence policy that would expand practice scope as it relates to preventative care and screening.

Beyond critical care, Hooda has

12 PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

gleaned valuable experience as a pharmacist specialist in supply chain, managing the more than 300 active medication backorders affecting acute care hospitals in B.C. Today she continues to be an advisor on drug shortage issues in BC and recently took on the role of Provincial Pharmacy Education and Residency Coordinator at BC Cancer.

Hooda is also a Clinical Instructor at the University of British Columbia and earned her Master’s in Public Health from John Hopkins University in 2023. She hopes her career trajectory so far inspires other new practitioners to challenge the status quo and expand their roles to affect positive change in health care.

Q&A:

What's your favourite part of your job? My favorite part of my job is undoubtedly the incredible people I work with. I am

Photos supplied

show up together. We have provided team sweatshirts, along with monthly team lunches and the opportunity to take part in fun content creation. For example, our annual Halloween costume photo series is displayed in our clinic all year-round.

Once a year pizza parties can't bypass team members not receiving a living wage. Recognize people for their day-today and longer-term accomplishments, both verbally and financially. Stand up for team members too as it is one of the greatest feelings to know others have your back and support you.

surrounded by a team of passionate, smart and driven individuals who consistently inspire and motivate me.

What advice would you give a young pharmacist? Embrace the uniqueness of your strengths, skills, interests and values—and consider how these factors align with the various niches within pharmacy.

Take the time to explore different facets of the profession through internships, rotations and networking opportunities Engage with mentors who can share their experiences and insights, helping you gain a deeper understanding of the diverse career paths available. Don’t be afraid to be curious and walk a different path.

What's your most effective way to combat stress? Cultivating a positive mindset and incorporating mindfulness into my daily routine. Focusing only on what I can control and practising gratitude contribute to a more resilient attitude toward stress.

Is there a mentor or role model who has inspired you in your career? While it’s challenging to pinpoint one single mentor, I am grateful for the collective impact of all those who have generously shared their knowledge and wisdom, contributing to my growth and success in the profession.

Is there something youʼd like to try next in your career? I am excited about the prospect of transitioning into the role of a pharmacist-scientist in my next career phase. I have a keen interest in bridging the gap between pharmacy practice and scientific research, particularly epidemiology and real-world evidence. By combining my clinical expertise with a more extensive involvement in research, I hope to contribute to advancements in pharmaceutical knowledge and patient care. Outside of pharmacy, I hope to open my own coffee shop someday—a green oasis with plants, natural light and inspiring artwork from local artists that could serve as a community hub to bring people together.

Describe your perfect day off. It would kick off with a cup of coffee in hand, enjoying the morning air while planning a hike in the beautiful landscapes of B.C. with my partner and our dog, Comet.

We’d hit the trails, exploring the scenic outdoors and soaking in the natural beauty. In the evening, I would wind down by the fireplace with a good book.

R A I S E YO U R V O I C E

Kelly Grindrod, Waterloo, ON

Kelly Grindrod: Putting pharmacy in the spotlight across Canada Why she won: When it comes to raising pharmacy’s profile across healthcare professions, governments and the public, pharmacist Kelly Grindrod is a formidable force. Her continuous passion for promoting pharmacies as integral to the healthcare system—and pharmacists as essential healthcare providers—has earned this Ontario-based pharmacist national recognition.

Since joining the University of Waterloo as an Associate Professor in 2011, Grindrod has What one judge said: conducted dozens of “A very media interviews on a accomplished variety of public interest pharmacist with a lot of outreach topics, such as antibiotto both the public ic stewardship and the and pharmacy opioid crisis. She has profession.” written thought-provoking opinion pieces for Canadian media outlets such as the Toronto Star, Ottawa Citizen and Yahoo News.

She is the creator of Pharmacy5in5, an innovative game-based web platform that uses various multimedia approaches— including YouTube videos, quizzes and infographics—to educate pharmacists and support their evolving practices. Her Pharmacy5in5 social media campaign earned her a gold award for “Best Use of Social Media” from the Canadian Council

for the Advancement of Education.

Over the pandemic, Grindrod’s skill at communicating complicated health-related topics to the public made her a sought-after expert. During that time, she did more than 100 radio, print and television interviews at both a local and national level. In 2020 she was also honoured as Canadian Pharmacist of the Year by the Canadian Pharmacists Association, in part for her public-facing communication work, which emphasized the critical role pharmacists play in keeping Canadians safe.

Q&A:

What's your favourite part of your job?

Working at a university means I’m surrounded by creative people who challenge my ways of thinking—including many of my students. I was recently assigned to teach a cultural humility course. It gave me a chance to bring the humanities into the classroom, which many students really enjoyed. We had really interesting speakers talk about things like how our Internet algorithms can shape our views, Indigenous history, and racism in healthcare. We also read great books like Moon on the Crusted Snow and 21 Things You May Not Know About the Indian Act. I led the course, but I felt more like a student most of the time. I’m very grateful that I

[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS 13

get to work in a job that gives me space to explore new ideas and to constantly learn.

What advice would you give a young pharmacist? Be curious about the people around you, including your patients and coworkers. There are so many ways of seeing the world. Some of the most enjoyable encounters you’ll have are with people who are wildly different from you.

What's your most effective way to combat stress? Learning how to lift weights is the best thing I’ve done for myself in a long time. I notice that many people around me are doing the same thing and I love seeing people prioritize their own bodies and health. Health care is a hard job physically and it requires a lot of stamina. I’d love to see more pharmacists and technicians make time for their own health outside of work.

Is there a mentor or role model who has inspired you in your career? Charlie Bayliff was my residency coordinator at the London Health Sciences centre 20 years ago, and he had such an impact on me. He was a highly skilled pharmacist who seemed to know everything, but who seemed to be always learning. He would push me to really challenge and deepen my thinking—the messier and more complicated the problem, the better the discussion. He really helped shape the type of work I do today.

Is there something you'd like to try next in your career? I’ve been doing some leadership training with a group of pharmacy faculty members in the US. I have really enjoyed learning about the differences between management and leadership—the latter being focused on motivating others to work towards a shared vision. It was a distinction I don’t think I appreciated before. I’m really interested in spending more time trying out different leadership roles both inside and outside pharmacy.

Describe your perfect day off. When my kids were younger, I’d crave a quiet day with a book. Now, as a mom to tweens, I love nothing more than watching my two daughters race in a swim meet.

I even have a t-shirt that says “Swim Mom”—and I absolutely wear it. The days are long but the years are short, as they say. I get a lot of joy out of watching my girls be fierce for the fun of it.

Aaron LaBorde: Risking his own safety to deliver essential pharmacy care Why he won: As multiple bush fires threatened Yellowknife this past summer and most residents evacuated to safer terrain, Sutherland’s Drugs pharmacist/ owner Aaron LaBorde was determined to provide medication services to those who remained, even if that meant being the only pharmacy left open.

“If 90% of the city leaves, there are still 2,000 people left who might need medication at some time,” he reflected.

Quickly developing an emergency plan, LaBorde acquired a satellite internet connection, generators, fuel, and an extra cellular phone to function as an emergency line. For safety’s sake, staff evacuated south to Alberta with some of the pharmacy’s computer equipment and file backups, while LaBorde stayed behind to work solo in the pharmacy assisting his own remaining patients, as well as those from other pharmacies and outlying areas. He quickly discovered that there were many people who needed help to access critical medications.

LaBorde remembers feeling overwhelmed at times, especially with logistical challenges in getting medication orders shipped into an evacuaWhat one tion zone—and the lack judge said: of access to prescription “Authentic, files, insurance details humble and and medical history focused on public health even in for patients from other the most extreme pharmacies. He had circumstances.

Who wouldn’t to drive to the airport want Aaron as himself to pick up drug their community pharmacist.” orders and relied on essential staff who came into the region for other purposes to transport medications to other fly-in communities. But his determination to keep his pharmacy open paid off. “Basically, you just do whatever you can to help [people]; and if that means working at 100% capacity for 12 hours a day for almost three weeks in a row, that is just what you have to do to try to ensure people get what they need,” he said.

14 PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

P U B L I C P R OT E C T O R Aaron LaBorde, Sutherland’s Drugs, Yellowknife, NT

Photo by Angela Gzowski

Q&A:

What's your favourite part of your job?

When you realize that you made a difference or had a positive impact on an individual’s health and/or life—the days I go home and can feel like I genuinely made a difference. It could be improving therapy, helping in the OTC section or just lining up medication so picking it up is more convenient. Helping people is what I enjoy.

What advice would you give a young pharmacist? Do not undervalue yourself and the role you play in patients’ lives and in the healthcare system overall. Pharmacy is a front-line health profession and the role we play in the healthcare system is so critical in holding things together.

What's your most effective way to combat stress? Exercise and getting outside. I have a Husky dog and we often walk him off-leash in the parks or trails around Yellowknife. I find when I have time to play with my kids it makes me forget about any of the other stresses or issues I worry about.

Is there a mentor or role model who has inspired you in your career? Ian Wasserman. He is probably not widely known in other places but is basically a legend around here.

My mother is a pharmacist and she is always willing to listen and lend advice, too. It is great having someone

who has the experience she does to bounce things off of and maybe get different perspectives on things.

Describe your perfect day off. It would be 150 km outside of Yellowknife trolling for and catching a pile of lake trout on a calm sunny day with my two boys.

Photo supplied

Melodie Spielman: Using scope to spur innovative practice Why she won: In the short time that Apothecare Pharmacy has been in operation (it opened in April 2023), lead pharmacy technician Melodie Spielman has already demonstrated an uncanny ability to find and fill care gaps to enhance patient care, while easing pharmacist workload.

The Calgary-based pharmacy has a unique practice model, with several pharmacist-led medical clinics to help patients manage conditions like diabetes, heart disease and obesity. Taking advantage of her full scope of practice, Spielman asked her pharmacist colleagues to teach her how to take accurate automated blood pressure readings and heights and weights of patients, as well as how to use blood glucose monitors and complete a diabetic foot exam.

Once Spielman felt comfortable enough, she became the initial point of contact for those coming into the pharmacy for appointments and now streamlines the first 15 minutes by gathering all the data for a pharmacist assessment. Depending on the appointment outcome, she is the one who teaches patients how to use their blood pressure monitors and What one blood glucose machines. judge said: She is also certified in “This tech is embracing an compression stocking expanded scope fittings, which has of practice and innovative become a critical service patient care.” for numerous patients who struggle with peripheral edema due to heart failure.

Spielman is doing all of this on top of streamlining the pharmacy’s processes.

Her nominator noted that these practice changes have proved incredibly beneficial to the entire pharmacy

team. “They have freed up the time of our pharmacists and ensured that fewer data points are missed or forgotten— and improved the overall care of our patients with more thorough pharmacists’ assessments able to take place.”

Q&A:

What's your favourite part of your job? I have worked in retail pharmacy for more than 30 years and patient interactions would be my favourite part. I have seen the pharmacy profession change and grow. It is an amazing journey. Pharmacy technicians aren’t just counting pills

T E C H N I C I A N I N I T I AT I V E (TIE) Melodie Spielman, Apothecare Pharmacy, Calgary, AB

or running the cash register. It’s about engaging with patients, listening, talking, documenting, being aware of the needs of our patients, advocating for them with insurance or finding other resources and information to support them or their families. We need to have time for our patients. Health care shouldn’t be a rushed service where people feel like a number.

What advice would you give a young pharmacy tech? Use your scope of practice to the fullest. If you ever find your profession feels stale it may be because you need a new challenge in your scope. Remember what pharmacy is truly about and find that passion.

What's your most effective way to combat stress? It’s an ongoing process. The easiest thing to do is walk away and take deep breaths. Sometimes I will just stand where I am, raise my arms and do deep breathing and stretching. I have learned not to take work home with me.

Communicating with the people who support me is important too, whether that’s my pharmacy family, friends or my own family. Eating healthy and exercise is part of my routine as well.

Is there a mentor or role model who has inspired you in your career? From the beginning of my career, I have had many mentors. It continues in my current work environment with pharmacists Stephanie Gysel, Daniel Burton and Christine Hong. However, in 1991 if it wasn’t for Bill Ford and Mayuri Modgill who provided the opportunity and training required, I would not be in this wonderful profession.

In 2013, the scope of assistants and technicians started changing across Canada. I felt I was too old to go to school to become registered. Again, pharmacists Erica Skopac and Selam Woldemichael believed in me. In 2015, I completed all my exams as a registered pharmacy technician.

Is there something you'd like to try next in your career? Preparing and administering injections to patients.

Training patients how to self-administer injections at home. I would like this to be in the scope of practice for Alberta pharmacy technicians. I feel there is a great need in our practice for technicians to have this knowledge and skill-set.

[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS 15

Alberta pharmacists’ scope of practice has changed to a much-needed more patient care/clinical role. However, the demand has increased their workload significantly. Pharmacy technicians should be able to relieve more of the technical stresses for the pharmacist.

Describe your perfect day off. It includes a warm, sunny day at our trailer, then taking a long walk in the wilderness, returning to relax by the pool or having a nap, and then enjoying an evening of good food, drinks and games with family and friends.

Aimee Kohler: Leading the way to better safety standards in compounding problem-solving framework certification for improving work processes­—and aims to complete her black belt.

Q&A:

Whatʼs your favourite part of your job?

Learning new things, working to create a safer environment for staff and ensuring consistent and quality medications for our patients. I am passionate about change management and process improvement.

Being able to deep dive into pharmacy standards and work towards compliance has been very satisfying.

What advice would you give a young pharmacy tech? Take all the opportunities that come your way. Offer to help out with projects, precept students and learn as much as you can! Data show that engaged employees are happier and more successful in their careers. Recent advancements in the profession mean there will be endless opportunities to do meaningful work that you enjoy.

Whatʼs your most effective way to combat stress? Different kinds of exercise, depending on how my body and mind are feeling. I may grab a yoga mat, some weights or put on my sneakers and go for a walk or run. I keep stress as low as possible by eating healthy foods and practising mindfulness.

Is there a mentor or role model who has inspired you in your career? I went into a coordinator role with more than 10 years of experience as a pharmacy assistant and had recently become a Registered Pharmacy Technician. Holly Glennie, my manager, soon had me presenting to nursing staff on pharmacy processes, working reports in our pharmacy

16 PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

T E C H N I C I A N I N I T I AT I V E (TIE) Aimee Kohler, Horizon Health Network, St. George, NB

information system, building drug files in the automated packager software, leading a team of technicians and assistants and much more. I was excited to take on these new opportunities and always knew she was there to support me. This role is where my confidence in the work I was doing began.

I worked closely with Chrystal Allen, a Lean Six Sigma Blackbelt, as she guided the department through process mapping and then through several small changes to improve efficiencies. This is where my passion for process improvement and change management came from.

And Julie Levesque has mentored me over the last couple of years in my role as acting compounding supervisor.

Is there something youʼd like to try next in your career? While I am open to exploring new opportunities, I’m quite content with the work I’m doing. At this point, I feel I am making a difference and enjoy what I do. I can’t ask for much more than that.

Describe your perfect day off. I’d wake up early to do some sort of exercise and have a bit of quiet time with coffee. The rest of my perfect day would be spent in the woods, canoeing, paddleboarding, camping or hiking with my family.

Photo supplied

Why she won: When her employer offered pharmacy technician Aimee Kohler an opportunity to lead a massive change management initiative across its compounding facilities, she jumped at the chance. Under her guidance, all of Horizon Health’s eight compounding facilities in New Brunswick are implementing NAPRA’s latest guidelines around non-sterile compounding and standardizing their practices across the board.

Kohler created a regional database of risk assessment and master formulas for non-sterile compounding, as well as a regional chart for sterile compounding.

She is also working with a team to help design compounding facilities that meet NAPRA standards, creating policies and procedures to support the implementation of safer compounding practices.

In taking on such What one judge said: a huge endeavor, her “Significant nominator said Kohler impact on demonstrated “expractice and ceptional leadership patient care.” skills by empowering her team to find solutions and work collaboratively to create a safer working environment.” She also worked with several community pharmacies to implement NAPRA’s non-sterile compounding standards, outside of Horizon.

Kohler has been recognized by groups such as the Canadian Pharmacy Technician Association where she spoke at their annual conference on the topic of pharmacy technician leadership in the workplace. She continues to hone her leadership skills via various training and certification initiatives.

Kohler received her Lean Six Sigma Green Belt in Healthcare in 2022—a

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[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS 17

INSOMNIA A sleep specialist discusses his experience managing this prevalent sleep disorder in primary care.

Dr. Atul Khullar MD, MSc, FRCPC, DABPN (Cert. Sleep Medicine) Fellow, American Academy of Sleep Medicine Diplomate, American Board of Obesity Medicine Medical Director, Northern Alberta Sleep Clinic Associate Clinical Professor, University of Alberta

Dr. Atul Khullar is a psychiatrist and sleep specialist who specializes in the integrative management of obesity, sleep, mood/anxiety and attention deficit disorders in adolescents and adults. He has a sleep and mood/anxiety disorders fellowship from the University of Toronto and is board certified in Psychiatry and Sleep Medicine.

He is the director of the Northern Alberta Sleep Clinic in Edmonton and an Associate Clinical Professor at the University of Alberta.

This educational supplement aims to provide Canadian clinicians with the latest in clinical thinking and therapeutic practice. Before recommending any mentioned medication, please refer to the appropriate product monograph. The information and opinions contained herein do not necessarily reflect those of the sponsor.

Every day in practice, many primary care clinicians have patients presenting with complaints of insomnia. One Canadian study reported that 4 in 10 adults had at least 1 symptom of insomnia for a minimum of 3 nights per week in the previous month.1 Within this study some patients (9.5%) with these symptoms met the DSM-V criteria for chronic insomnia disorder.1 This occurred when the patient had insomnia symptoms which caused clinically significant functional distress or impairment; and were present for at least 3 nights per week for at least 3 months; and not be linked to other sleep, medical, or mental disorders.2 With insomnia being the most prevalent sleep disorder1, we asked Dr. Atul Khullar, Medical Director of the Northern Alberta Sleep Clinic and Associate Clinical Professor at the University of Alberta, to provide some insights on the importance of screening and how to manage this common condition.

WHY DO YOU REGULARLY SCREEN FOR INSOMNIA? A Canadian health measures survey found that the prevalence of insomnia increased by 42% from 2007 to 2015 and in 2015 an estimated 1 in 4 Canadian adults (23.8%) reported nighttime insomnia symptoms.3 Another survey of 2000 Canadians found that 13.4% of adults met all criteria for insomnia.1 The study found that only 13% of all participants consulted a healthcare

DI D YOU K NOW ? provider (HCP) regarding their sleep difficulties.1 This matches what I have seen in my practice, where my patients treat insomnia like what I would describe as a ‘backburner’ issue and try to self-manage and delay asking me for help.

One study of 2000 Canadians found that the odds of having insomnia symptoms was 1.4 times higher in women than men (15.6% vs. 11% respectively, p = 0.02)?1

WHO DO YOU SCREEN FOR INSOMNIA? In a survey of 2000 Canadians, the relative risk for insomnia was higher in participants who had any of the following: female gender, older age and poorer selfrated physical and mental health.1 What is concerning is that insomnia is associated with significant health risks such as an increased risk of depression, anxiety, cardiovascular disease, type 2 diabetes, cognitive impairment, heart failure, work absenteeism and reduced quality of life.4 I always ask my patients if they have any problem with insomnia.

WHAT DO YOU ASK YOUR PATIENTS WHEN YOU APPROACH THEM ABOUT INSOMNIA? As a first step in assessing if a patient may be experiencing difficulties with sleep, I engage in an initial dialogue to gather

relevant information. During this conversation, my aim is to gain insight into their sleep-related experiences.

I typically start by asking one or two questions, such as: • How rested and restored do you feel your sleep is most days?

• Sleep problems are common in people with your health condition.

Can I ask you to describe your normal sleeping patterns?

• Does your sleep problem vary with any of your other health issues or is it always there to some degree?

WHAT NON-PHARMACOLOGICAL OPTIONS DO YOU TALK TO YOUR PATIENTS ABOUT FOR MANAGING INSOMNIA? Cognitive behavioural therapy for insomnia (CBT-I) is an option for the management of insomnia. CBT-I is multimodal and involves changing thoughts about sleep, behavioural interventions, such as sleep restriction, stimulus control and relaxation strategies, and educational interventions, such as sleep hygiene.5

▷

INDICATIONS

MECHANISMS OF ACTION†

BENZODIAZEPINES

WHAT MEDICATIONS ARE AVAILABLE FOR THE MANAGEMENT OF INSOMNIA? There are several different categories of medications available in Canada for the management of insomnia.6 A selection of these medications is listed the next table with their indications and mechanisms of action.

WHAT IS THE IMPACT OF INSOMNIA ON THE PATIENTS THAT YOU SEE IN YOUR PRACTICE? I have seen the impact that insomnia has on the health of my affected patients. The issue is that many people affected by insomnia will not actively discuss this with their HCPs.1 I screen my patients for insomnia as part of routine care if they present with tiredness or fatigue, or comorbidities such as depression, anxiety or hypertension. I also ensure that the comorbid issues are being treated aggressively.

REFERENCES 1. Morin CM, LeBlanc M, Bélanger L, Ivers H, Mérette C, Savard J. Prevalence of Insomnia and its Treatment in Canada. Can J Psychiatry 2011;56(9):540–8.

2. Substance Abuse and Mental Health Services Administration (US). Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD); 2016 Jun. Table 3.36, DSM-IV to DSM-5 Insomnia Disorder Comparison. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ ch3.t36/ 3. Chaput JP. Prevalence of insomnia for Canadians aged 6 to 79. Health Rep 2018;29(12):7.

4. Karna B, Gupta V. Sleep Disorder [Internet]. In: StatPearls Publishing. Treasure Island (FL); 2020 [cited 2023 Jun 23]. Available from: http://www.ncbi.nlm.nih.gov/ books/NBK560720/ 5. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med 2016;165(2):125–33.

6. Health Canada Government of Canada. Authorized Sleep-Aid Medications in Canada [Internet]. Oct. 7, 2009 [cited 2023 Jan 30]. Available from: https://recallsrappels.canada.ca/en/alert-recall/authorized-sleep-aid-medications-canada 7. Apotex Inc. Temazepam Product Monograph [Internet]. Toronto, ON.; 2022 [cited 2023 Feb 24]. Available from: https://pdf.hres.ca/dpd_pm/00063293.PDF 8. Sunovion Pharmaceuticals Canada Inc. Lunesta Product Monograph.

Mississauga, Ont.; 2022.

9. Paladin Labs Inc. Silenor Product Monograph. Montreal, QC.; 2012.

10. Eisai Limited. Dayvigo Product Monograph. Mississauga, Ontario.; June 22, 2023.

Senior Vice President, Canada: DONNA KERRY Senior Account Manager: NORM C. COOK Editor: LINDA TRACEY Project Manager: KALLI SAGOS Art Direction: DINO PERESSINI

This supplement is published by EnsembleIQ, 20 Eglinton Ave., W., Suite 1800, Toronto, ON M4R 1K8. Telephone: (416) 256-9908. No part of this publication may be reproduced, in whole or in part, without the written permission of the publisher. Copyright © 2023.

Temazepam is a benzodiazepine with hypnotic properties.

Benzodiazepines act as depressants of the central nervous system (CNS). It is believed that benzodiazepines enhance or facilitate the effects of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA).

Benzodiazepines act as agonists at the benzodiazepine receptors sites. The benzodiazepine-GABA receptor-chloride ionophore complex functions mainly in the gating of the chloride channel.

Benzodiazepines are thought to produce their pharmacological effects by facilitating GABA-mediated transmission in the CNS, which reportedly increase the frequency of the chloride channel opening.7

NON-BENZODIAZEPINE ‘Z-DRUGS’ Eszopiclone: For shortterm (usually not exceeding 7-10 days) use for: - treatment and symptomatic relief of insomnia characterized by difficulty falling asleep - frequent nocturnal awakenings and/or early morning awakening where disturbed sleep results in impaired daytime functioning.8

Eszopiclone is a non-benzodiazepine hypnotic agent, which is a pyrrolopyrazine derivative of the cyclopyrrolone class with a chemical structure unrelated to pyrazolopyrimidins, imidazopyridines, benzodiazepines or barbiturates. The effects of eszopiclone are due to modulation of gamma-aminobutyric acid (GABA)-Areceptor macromolecular complexes, containing alpha-1, alpha-2, alpha-3 and alpha-5 sub-units. GABA-evoked chloride conductance is increased resulting in neuronal hyperpolarization and thereby inhibiting neuronal transmission and causing sleep. As compared to racemic zopiclone whose effects are mediated predominantly through α1, the effects of eszopiclone are mediated predominantly through the alpha-2 and alpha-3 GABAA.8

NON-SELECTIVE MONOAMINE REUPTAKE INHIBITORS Doxepin: For the treatment and symptomatic relief of insomnia characterized by frequent nocturnal awakening, and/or early morning awakenings.9

Doxepin binds with high affinity to the histamine H1 receptor (Ki < 1 nM) where it functions as an antagonist. The exact mechanism by which doxepin exerts its sleep maintenance effect is unknown but is believed due to its antagonism of the H1 receptor.9

OREXIN RECEPTOR ANTAGONISTS Lemborexant: For the treatment of insomnia, characterized by difficulties with sleep onset and/or sleep maintenance.10

Lemborexant is a competitive antagonist of both orexin receptors, OX1R and OX2R, with a higher affinity for OX2R. It belongs to the pharmacologic class of orexin receptor antagonists. The orexin neuropeptide signaling system is a central promoter of wakefulness. Blocking the binding of wakepromoting neuropeptides orexin A and orexin B to receptors OX1R and OX2R is thought to suppress wake drive.10

† Data from separate product monographs; comparative clinical significance has not been proven.

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INSOMNIA

Temazepam: For the symptomatic relief of transient and shortterm insomnia characterized by difficulty in falling asleep, frequent nocturnal awakenings and/or early morning awakenings.7

Drug News NEW PRODUCTS Bylvay for pruritus in intrahepatic cholestasis

odevixibat 200 µg, 400 µg, 600 µg and 1200 µg capsules, Medison Pharma Canada. Canadian supplier: BioScript Solutions.

INDICATIONS Treatment of pruritus in patients aged six months or older with progressive familial intrahepatic cholestasis.

ACTION A reversible selective inhibitor of the ileal bile acid transporter. Acts locally in the distal ileum to decrease the reuptake of bile acids from the terminal ileum and increase the clearance of bile acids through the colon. This reduces the concentration of bile acids in the serum, which is believed to improve pruritus in patients with progressive familial intrahepatic cholestasis.

DOSAGE 40 µg/kg administered orally once daily in the morning with a meal. If an adequate clinical response has not been achieved after three months of continuous therapy, the dose may be increased to 120 µg/kg/day. Maximum daily dose is 7200 µg per day.

ADMINISTRATION Capsules may be swallowed whole or opened and sprinkled on soft food or in a liquid. Consult product monograph for instructions on opening and sprinkling capsule contents. Note that the capsule pellets will not dissolve in liquids; an oral syringe (size ≥ 5 mL) is required to administer the drug in a liquid.

ADVERSE EFFECTS MOST COMMON: Diarrhea (31%), vomiting (17%), abdominal pain (14.3%). Increase in alanine aminotransferase, bilirubin and aspartate aminotransferase.

MOST SERIOUS: Treatment interruption or drug discontinuation may be required to manage diarrhea.

DRUG INTERACTIONS Patients who are also taking bile acid binding resins (e.g., cholestyramine, colesevelam, colestipol) should take odevixibat at least four hours before or four hours after taking the bile acid binding resin.

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

CLINICAL EDITOR LU-ANN MURDOCH, RPh, BScPhm, ACPR

Quviviq for insomnia

daridorexant 25 mg and 50 mg tablets (as daridorexant hydrochloride), Idorsia Pharmaceuticals (Switzerland). Available through usual pharmacy wholesalers.

INDICATIONS Management of insomnia in adults. Intended for patients with difficulties with sleep onset and/or sleep maintenance.

ACTION An antagonist of orexin 1 and orexin 2 receptors. The orexin neuropeptides (orexin A and orexin B) act on orexin receptors to promote wakefulness. By antagonizing the activation of orexin receptors, daridorexant decreases the wake drive, to promote sleep.

DOSAGE 50 mg taken within 30 minutes before going to bed (with at least 7 hours remaining prior to planned awakening).

Some patients may be treated with 25 mg at bedtime (e.g., patients taking moderate CYP3A4 inhibitors; patients with moderate hepatic impairment).

ADMINISTRATION Can be taken with or without food. Sleep onset may be delayed if taken with or soon after a high-fat and high-calorie meal.

ADVERSE EFFECTS MOST COMMON: Headache. May impair daytime wakefulness even when used as prescribed. Caution patients about engaging in potentially hazardous activities (e.g., driving) unless they are fully alert. Also caution about possible next-day somnolence. MOST SERIOUS: Sleep paralysis (an inability to move or speak for up to several minutes during sleep-wake transitions), hallucinations and cataplexy-like symptoms have been reported. Possible worsening of depression and suicidal ideation.

DRUG INTERACTIONS Contraindicated

with strong CYP3A4 inhibitors (e.g., itraconazole, clarithromycin, ritonavir).

Reduce dose to 25 mg in patients taking moderate CYP3A4 inhibitors (e.g., diltiazem). Concomitant use with moderate (e.g., efavirenz) or strong (e.g., rifampin) CYP3A4 inducers substantially decreases exposure to daridorexant, which may reduce efficacy; use with rifampin is not recommended. Possible additive effects with central nervous system (CNS) depressants; dose adjustments may be required. Advise patients not to consume alcohol due to additive effects on psychomotor performance.

Patients should not consume grapefruit or grapefruit juice in the evening.

COMMENTS Second orexin receptor antagonist to be marketed for insomnia in Canada, following lemborexant (Dayvigo). The manufacturer will initially market Quviviq 50 mg tablets, with the 25 mg tablets following later in 2024.

OTHER NEW PRODUCTS Akeega

niraparib (as niraparib tosylate) and abiraterone acetate tablets; 100 mg/500 mg and 50 mg/500 mg, Janssen.

INDICATIONS A fixed-dose combination of a PARP enzyme inhibitor and an androgen biosynthesis inhibitor for treatment of adults with deleterious or suspected deleterious BRCA mutated (germline and/ or somatic) metastatic castration resistant prostate cancer. Intended for patients who are asymptomatic/mildly symptomatic and in whom chemotherapy is not clinically indicated. Patients must have confirmation of BRCA mutation before treatment is started. Issued market authorization with conditions, pending the results of clinical trials to verify clinical benefit.

DOSAGE 200 mg niraparib and 1000 mg abiraterone acetate (two 100 mg/500 mg tablets), as a single daily dose. Must be taken on an empty stomach at approximately the same time every day. Is used with 10 mg prednisone or prednisolone daily. Dose adjustments may be required to manage adverse effects.

COMMENTS Janssen also markets niraparib (Zejula) and abiraterone acetate (Zytiga) as single-entity products. Abiraterone acetate is also marketed by generic manufacturers.

[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS 21

Nuvaxovid XBB.1.5

COVID-19 vaccine (recombinant protein, adjuvanted) suspension for intramuscular injection; 5 µg/0.5 mL in a 2.5 mL multidose vial, Novavax (US).

INDICATIONS Active immunization to prevent COVID-19 in individuals 12 years of age or older. Issued marketing authorization with terms and conditions that need to be met by the manufacturer to ensure the continued quality, safety and effectiveness of the vaccine.

DOSAGE Individuals previously vaccinated with a COVID-19 vaccine series: Single (0.5 mL) dose administered intramuscularly at least six months after the most recent dose of an authorized COVID-19 vaccine. Individuals not previously vaccinated with a COVID-19 vaccine series: A two-dose series (0.5 mL per dose), with the second dose administered three weeks after the first dose.

ADMINISTRATION Vaccine is ready to administer; must not be reconstituted or diluted. Give by intramuscular injection, preferably in the deltoid muscle of the upper arm.

COMMENTS Vaccine does not contain a preservative. Store opened vial at 2°C–8°C for up to 12 hours or at room temperature (up to 25°C) for up to six hours after first needle puncture.

Tecvayli

teclistamab solution for subcutaneous (SC) injection; 153 mg/1.7 mL and 30 mg/3 mL glass vials, Janssen.

INDICATIONS An antineoplastic monoclonal antibody for treatment of adults with relapsed or refractory multiple myeloma.

Intended for patients who have received at least three prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent and an anti-CD38 monoclonal antibody, and who have demonstrated disease progression on the last therapy.

Issued market authorization with conditions, pending the results of clinical trials to verify the drug’s clinical benefit.

DOSAGE Day 1–Administer a step-up dose of 0.06 mg/kg. Day 3–Administer a step-up

dose of 0.3 mg/kg. Day 5–start first treatment dose of 1.5 mg/kg. Subsequent treatment doses of 1.5 mg/kg actual body weight should be administered SC once weekly starting one week after the first treatment dose. Pretreatment medications (corticosteroid, antihistamine, antipyretic) are required one to three hours before each dose of teclistamab (consult product monograph for details). Dose delays may be required to manage toxicities.

ADMINISTRATION Should be administered SC by health professionals at treatment centres with adequate medical equipment and personnel to manage severe reactions, including cytokine release syndrome and neurologic toxicities.

COMMENTS Available only through the BioAdvance patient support program (tecvayli@bioadvancemail.ca).

Uceris

budesonide rectal aerosol foam, 2 mg/actuation (14 actuations per can), Bausch Health.

INDICATIONS For the induction of remission in adults with active mild to moderate distal ulcerative colitis (extending up to 40 cm from the anal verge).

DOSAGE One metered dose administered rectally twice daily (morning and evening) for two weeks. This is followed by one metered dose administered rectally once daily (in the evening just before bedtime) for four weeks.

ADMINISTRATION Advise patient to empty their bowels before instilling rectal foam. Warm canister in the hands while shaking it vigorously for 10–15 seconds prior to use. Can be administered in a standing, lying or sitting position (e.g., while using the toilet). Counsel patients to try to not empty their bowels after the evening dose, until the next morning.

Discard applicator after a single use.

SUPPLIED Available as a kit containing two aerosol canisters with 28 applicators coated with paraffin lubricant for administration of the foam.

NEW DOSAGE FORMS

• Hadlima/Hadlima PushTouch

(adalimumab for SC injection), Organon Canada. A new strength (40 mg/0.4 mL) is now available for Hadlima (prefilled syringe) and Hadlima PushTouch (autoinjector) for SC injection. The new higher-concentration formulation is citrate-free. The original 40 mg/0.8 mL

22 PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

strength of Hadlima and Hadlima PushTouch continue to be available.

Hadlima is a biosimilar to Humira.

• Trikafta (elexacaftor/tezacaftor/ ivacaftor and ivacaftor), Vertex Pharmaceuticals Canada. New oral granule formulation is available in two strengths in single-use foil packets: elexacaftor/tezacaftor/ivacaftor 100 mg/ 50 mg/75 mg (morning dose) and ivacaftor 75 mg (evening dose); and 80 mg/40 mg/60 mg (morning dose) and 59.5 mg (evening dose). The new granule formulation is intended for use in children two years up to less than six years of age. The existing tablets are intended for patients six years of age or older. The tablets are supplied in two strengths: 50 mg/25 mg/37.5 mg tablets and 75 mg tablets, and 100 mg/ 50 mg/75 mg tablets and 150 mg tablets. (See also New indications.)

• Zejula (niraparib, as niraparib tosylate), GlaxoSmithKline. New 100 mg tablet is replacing the original 100 mg capsule.

Tablets should be swallowed whole, and may be taken with or without food. Instruct patients to take their dose at approximately the same time each day. Bedtime administration may help to manage nausea.

NEW INDICATIONS Jemperli

dostarlimab solution for intravenous (IV) infusion, GlaxoSmithKline.

NEW INDICATION Treatment of primary advanced or recurrent mismatch repair deficient (dMMR)/microsatellite instabilityhigh (MSI-H) endometrial cancer in adults who are candidates for systemic therapy.

Used in combination with carboplatin and paclitaxel. (Originally granted a Notice of Compliance with conditions as monotherapy for the treatment of dMMR or MSI-H recurrent or advanced endometrial cancer in adults that has progressed on or following prior treatment with a platinum-containing regimen.)

DOSAGE When used in combination with carboplatin and paclitaxel, the recommended dose of dostarlimab is 500 mg administered by IV infusion over 30 minutes every three weeks for six doses, followed by 1000 mg every six weeks for all cycles thereafter.

Trikafta

elexacaftor/tezacaftor/ivacaftor tablets/ granules and ivacaftor tablets/granules, Vertex Pharmaceuticals Canada.

EXPANDED INDICATION Treatment of cystic fibrosis in patients aged two years or older who have at least one F508del mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. (Trikafta was formerly indicated only for persons six years of age or older.)

DOSAGE Children 2 years to < 6 years of age: body weight < 14 kg: One packet of elexacaftor 80 mg/tezacaftor 40 mg/ ivacaftor 60 mg granules in the morning and one packet of ivacaftor 59.5 mg granules in the evening. Body weight ≥ 14 kg: One packet of elexacaftor 100 mg/ tezacaftor 50 mg/ivacaftor 75 mg granules in the morning and one packet of ivacaftor 75 mg granules in the evening. The dosage of the tablet formulation for persons ≥ 6 years of age remains unchanged; consult product monograph for details. The morning and evening doses should be taken with fatcontaining food, approximately 12 hours apart. Dose adjustments may be required for patients with hepatic impairment, or when co-administered with moderate or strong CYP3A inhibitors; consult product monograph for details.

ADMINISTRATION Granules: The entire contents of each packet of granules should be mixed with 5 mL of ageappropriate soft food or liquid (at room temperature or below) and the mixture completely consumed.

Examples of soft food or liquids include puréed fruits or vegetables, yogurt, applesauce, water, milk or juice (but not grapefruit juice). Once mixed, the product is stable for one hour. A fatcontaining meal or snack should be consumed just before or after each dose. (See also: New dosage forms.)

Ultomiris

ravulizumab for injection, Alexion Pharma.

NEW INDICATION Treatment of adults with anti-aquaporin 4 (AQP4) antibodypositive neuromyelitis optica spectrum disorder. (Also approved earlier for use in the treatment of paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome and generalized myasthenia gravis.)

DOSAGE Neuromyelitis optica spectrum disorder: Dose is based on body weight.

The loading dose ranges from 2400– 3000 mg. The maintenance dose ranges from 3000–3600 mg every eight weeks.

Consult product monograph for details.

After dilution, the solution is administered

by IV infusion through a 0.2 micron filter.

NEW GENERICS • pms-Pazopanib (pazopanib

200 mg tablets), Pharmascience.

Generic alternative to Votrient.

• pms-Rivaroxaban (rivaroxaban 2.5 mg, 10 mg, 15 mg and 20 mg tablets), Pharmascience. Generic alternative to Xarelto.

• Taro-Perampanel (perampanel 2 mg, 4 mg, 6 mg, 8 mg, 10 mg and 12 mg tablets), Taro. Generic alternative to Fycompa.

• Taro-Rivaroxaban (rivaroxaban 2.5 mg, 10 mg, 15 mg and 20 mg tablets), Taro. Generic alternative to Xarelto.

Miscellaneous • Medication/substance safety in

pregnancy and lactation: new online resource. First Exposure (www. firstexposure.ca) is a new, bilingual (FR/ EN) digital information hub and research network that provides evidence-based information to healthcare providers and the public on the safety of medications, plant and environmental substances and other exposures during pregnancy and lactation. Content on the website will be expanded gradually.

HEALTH CANADA ADVISORIES Dimethyl fumarate: no link to Fanconi syndrome

Dimethyl fumarate is indicated for the treatment of adults with relapsing remitting multiple sclerosis. Health Canada recently reviewed the potential risk of Fanconi syndrome with the use of dimethyl fumarate, following a labelling update for dimethyl fumarate-containing products in Europe. Health Canada’s review did not find sufficient evidence to support a link between the risk of Fanconi syndrome and the use of dimethyl fumarate for the treatment of multiple sclerosis.

Health Canada will continue to monitor the safety of dimethyl fumarate.

Lu-Ann Murdoch is a consulting clinical editor for Pharmacy Practice + Business and drug information consultant for Pharmacist’s Letter.

Further details about these advisories and safety reviews can be obtained from the MedEffect Canada website: https://www.canada.ca/en/health-canada/ services/drugs-health-products/medeffect-canada. html and https://dhpp.hpfb-dgpsa.ca/review-docum ents?search=&f%5B0%5D=content_type%3Assr.

[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS 23

Practice Experts

Our pharmacist experts share information and ideas to support your daily practice

MENTAL HEALTH By Sunny Wang / P. 24 THERAPEUTIC ISSUES By Katelyn Halpape / P. 26 CARDIOVASCULAR ISSUES By Arden Barry / P. 28

MENTAL HEALTH

Tapering benzodiazepines SUNNY WANG, RPh, PharmD

B

enzodiazepines are commonly prescribed to treat a variety of conditions ranging from insomnia and anxiety, to seizure disorders and skeletal muscle spasticity.1 In 2017, there were 533 benzodiazepine prescriptions per 1,000 population across Canada, representing an average of one in two people receiving a prescription for a benzodiazepine.2 While effective in the short-term, a myriad of concerning long-term adverse effects have led to many guidelines recommending against the use of benzodiazepines long-term.3-6 This is especially true in the elderly population, where adverse effects such as increased falls risk, cognitive impairment,

paradoxical agitation and oversedation have led Choosing Wisely Canada to generally recommend against their use in older adults.7,8 The development of tolerance over time also often leads to escalating doses of benzodiazepines, further increasing the risks of side effects and the development of dependence.9 In practice, many patients receive benzodiazepines for long periods of time, despite only a very limited number of valid long-term indications.8 Given the prevalence of long-term use, pharmacists are often faced with the difficult challenge of helping patients navigate benzodiazepine tapering.

Start conversations and educate patients Tapering benzodiazepines can be a difficult conversation with patients, and this may be one of the reasons for the prevalence of continuing benzodiazepines long-term. However, given the many

24 PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

significant adverse effects of benzodiazepines, pharmacists should avoid the path of least resistance, and initiate discussions and help guide patients through this often-difficult process.

After a thorough clinical assessment in collaboration with the patient’s care team and prescribing physician, provide education to the patient in a nonjudgmental manner. Many patients are simply unaware of the many long-term risks of benzodiazepines, and have never considered tapering because they did not know long-term use could be a potential problem.

Evidence shows that patient education leads to a significantly greater portion of elderly patients discontinuing benzodiazepines or reducing their total daily dose.10 Framing the many potential risks and their consequences in relation to the patient’s goals and lifestyle may be of benefit. For example, reviewing the increased risk of falls and fractures may be beneficial to a 67-year-old grandfather of two, who wishes to teach his grandchildren how to play soccer.

Further, given many benzodiazepine drug interactions with commonly prescribed medications (e.g., first-generation

Shutterstock / Jeff Baumgart

NEW COLUMN

antihistamines, antihypertensives, other sleep aids), informing patients of these interactions and the potential benefits of a taper may also be helpful. Patients are often unaware that benzodiazepines are the reason for their daytime drowsiness or lack of energy when combined with some of their other medications, and that a taper can lead to increased alertness, focus and energy throughout the day.

Offer solutions A wise colleague once said “Never just present problems, offer solutions.” While you may have patients’ best interests in mind, what they may hear when you propose a benzodiazepine taper is that you want to take away their sleep aid, or their ‘emergency pill’ for when they get anxious. Always find out and understand why patients are taking benzodiazepines, and present alternatives, whether it’s a safer pharmacologic option, or nonpharmacologic strategies to help manage their condition. You could even suggest a sleep study; the patient may discover that they actually have obstructive sleep apnea and that their insomnia would be better managed with a CPAP machine than a benzodiazepine.

Be aware of the logistics of tapering Evidence for benzodiazepine tapering is scarce and there are many different approaches. A good starting point is to follow the general rule of thumb of reducing the total dose by 10%–25% every one to two weeks.8,11 No strong evidence supports the use of one particular benzodiazepine for tapering, but the use of long-acting agents (e.g., diazepam or clonazepam) may be beneficial to minimize withdrawal symptoms throughout the day.8,11 Shortacting agents (e.g., alprazolam) should be avoided where possible because they generally require frequent dosing, and their fast onset and offset may cause additional instability and withdrawal symptoms.1 While diazepam’s ultra-long half life, and many dose availabilities offer many benefits, its use in the elderly and hepatically impaired individuals should be approached cautiously.1,8 Multiple benzodiazepines should ideally be consolidated into one longacting benzodiazepine to simplify the process. Although common in practice, there really is no rationale for a patient to be taking standing clonazepam

Patients are often unaware that benzodiazepines are the reason for their daytime drowsiness or lack of energy when combined with some of their other medications, and that a taper can lead to increased alertness, focus and energy throughout the day.

twice daily, plus lorazepam “as needed.”

Tapering should also generally be done using scheduled doses, with as needed (prn) doses avoided.8 Towards the end of the taper, it is reasonable to slow the taper pace both in dose and frequency (e.g., reduce by 5% every 2–4 weeks).8 However, it is important to avoid extremely long tapers (> 6 months) to minimize patients from potentially developing further psychological dependence.11,12 A firm but reassuring approach is often helpful.

Remind patients of the significant progress they’ve made, along with the many benefits of tapering. Provide alternate nonpharmacologic strategies (e.g., sleep hygiene, cognitive behavioural therapy for insomnia [CBT-I]) to help manage the patient’s concerns.12,13 Where possible, adhere to predetermined and agreed-upon tapering schedules in a firm but supportive way. If the patient experiences significant adverse effects or extremely distressing withdrawal symptoms, it is prudent to pause the taper, re-titrate the dose back to the previous step, and reassess in one to two weeks for resumption of tapering at a slower pace.

Summary Benzodiazepines are associated with significant long-term risks. Pharmacists play an important role in identifying opportunities for benzodiazepine tapers, and helping patients navigate this difficult process.

Sunny Wang is a clinical pharmacist and Pharmacy Education Coordinator at the Centre for Addiction and Mental Health (CAMH) in Toronto. His clinical work is currently with the inpatient Crisis and Critical Care

Unit, serving a diverse population of patients with acute psychiatric and substance use disorders. In addition to his role as Education Coordinator at CAMH, Sunny is involved as a Clinical Instructor at the Leslie Dan Faculty of Pharmacy and serves as an Expert Hub Member for the Addiction Medicine and Psychosocial Interventions Program with Project ECHO. REFERENCES 1. Canadian Pharmacists Association. Benzodiazepines CPhA monograph. Last revised May 1, 2015.

2. Canadian Institute for Health Information.

Pan-Canadian trends in the prescribing of opioids and benzodiazepines, 2012 to 2017. Ottawa, ON: CIHI; 2018.

3. Canadian Pharmacists Association. Six things pharmacists and patients should question: Choosing Wisely Canada; 2020.

4. College of Physicians & Surgeons of Manitoba. Standard of practice: prescribing benzodiazepines & Z-drugs (including zopiclone & other drugs). Winnipeg, MB: The College of Physicians & Surgeons of Manitoba; 2020.

5. College of Physicians & Surgeons of Nova Scotia. Benzodiazepines and Z-drugs professional standards regarding benzodiazepines and Z-drugs. Bedford, NS: College of Physicians & Surgeons of Nova Scotia; 2022.

6. The Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice, Part B – Benzodiazepines, summary of recommendations. East Melbourne, Australia: RACGP; 2019.

7. Canadian Pharmacists Association. Geriatrics: eight things physicians and patients should question: Choosing Wisely Canada; 2022.

8. College of Physicians & Surgeons of Alberta. Clinical toolkit benzodiazepines: use and taper. Edmonton, AB: CPSA; 2016.

9. Longo LP, Johnson B. Addiction: Part I. Benzodiazepines – side effects, abuse risk and alternatives. Am Fam Physician 2000;61:2121-8.

10. Tannenbaum C, Martin P, Tamblyn R, et al.

Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med 2014;174:8908. doi:10.1001/jamainternmed.2014.949.

11. Soyka M. Treatment of benzodiazepine dependence. N Engl J Med 2017;376:1147-57.

12. National Center for PTSD. Effective treatments for PTSD: helping patients taper from benzodiazepines: Veteran’s Affairs; 2015.

13. Deprescribing.org. Benzodiazepine & Z-drug deprescribing algorithm: Deprescribing.org; 2019. https://deprescribing.org/wp-content/ uploads/2019/03/deprescribing_algorithms2019_ BZRA_vf-locked.pdf (accessed October 24, 2023).

[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS 25

PRACTICE EXPERTS

When high-risk drinking is identified, one of the first steps is to provide a brief intervention to support positive behaviour change related to alcohol use.5

Unveiling the hidden struggle– Pharmacists are key allies in identifying and treating alcohol use disorder KATELYN HALPAPE, BSP, ACPR, PharmD, BCPP

A

lcohol is a leading preventable cause of morbidity and mortality worldwide.1,2 It can have profound negative health impacts.1,2 In Canada, approximately 75% of people consume alcohol and, in 2017, alcohol led to 18,000 deaths and was associated with $5.4 billion in healthcare costs.2 Alcohol use can be challenging to discuss with patients given the societal and cultural perceptions of alcohol use.

As accessible healthcare professionals, pharmacists have an essential role in providing holistic patient care, including screening for and treatment of alcohol use disorder (AUD).3,4

Imagine you are conducting a medication review with 52-year-old female patient, AB. She has a history of chronic low back pain and migraines for which she takes hydromorphone controlled-release 3 mg po twice daily, pregabalin 150 mg twice daily, and acetaminophen 500 mg po four times daily. AB discloses that she has been consuming a bottle of wine most nights for the past three years. She recognizes that this is an issue, but has been unsuccessful in past attempts to cut down. AB has been working with a counsellor to address contributing psychosocial factors, but has not disclosed her alcohol use to her family physician. She is interested in a medication to assist with reducing her alcohol use.

Building a foundation of trust and nonjudgmental communication Begin by acknowledging AB’s courage in discussing her struggles with alcohol.

26 PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

Screening The 2023 Canadian Clinical Guideline for High-Risk Drinking and Alcohol Use Disorder suggests open-ended questions to aid with screening for AUD, including the integration of AUD screening into routine clinician–patient interactions (such as during a medication review with AB).5 Initial screening can be as simple as a single question: “How many times in the past year have you consumed (4 for women/5 for men) or more drinks on any one occasion?”6 For patients that are challenging to engage, tools such as the AUDIT-C (https://www.mdcalc.com/ calc/2021/audit-c-alcohol-use) can be helpful.5 It is important to be aware that screening alone does not improve patient outcomes and early intervention is key.5 Brief intervention When high-risk drinking is identified, one of the first steps is to provide a brief intervention to support positive behaviour change related to alcohol use.5 Motivational interviewing can be a useful technique to promote change in AUD behaviour and aims to understand and

Shutterstock / everthing bagel

THERAPEUTIC ISSUES

Express empathy, validate her feelings and highlight that seeking help is a commendable step towards better health.

When addressing sensitive topics such as alcohol use, it is crucial to adopt a nonjudgmental stance. Avoid imposing personal opinions and remain open to understanding the patient’s perspective.5

enhance patients’ intrinsic motivation for change.7 For example, motivational interviewing may help AB to articulate the concerns she has related to the relationship between her alcohol use and chronic pain. Additionally, providing evidence-based resources for patients such as helpwithdrinking. ca can be a useful first step to motivate patients to make a positive change related to their alcohol use.

Referral for diagnosis Patients with identified high-risk drinking should be referred to a physician for an assessment for AUD.5 In AB’s case, a referral to her family physician for a comprehensive assessment would be crucial to screen for and provide management of alcohol-related complications, including alcohol withdrawal syndrome, as well as to identify the required information for selecting appropriate pharmacotherapy for long-term AUD management.5 Pharmacotherapies for AUD Naltrexone and acamprosate are firstline pharmacotherapies with proven effectiveness in reducing alcohol use and facilitating abstinence.5,8 The number needed to treat to prevent return to any drinking is 20 for naltrexone and 12 for acamprosate.8 Despite their established effectiveness and acceptable tolerability, a 2017 study in Ontario identified substantial underutilization of these agents, with less than 1% of public drug plan beneficiaries diagnosed with AUD being dispensed naltrexone or acamprosate a year after their diagnosis.9 As medication experts, pharmacists are well-positioned to address this healthcare gap by identifying patients who would benefit from pharmacotherapy for AUD.10 Key considerations for selecting naltrexone versus acamprosate are summarized in Table 1.5,8 For AB, it would be important to recognize that she would not be a good candidate for naltrexone, given her concurrent hydromorphone use; however, acamprosate would be a reasonable option for her to try.

Ongoing support, monitoring, and celebrating progress Patients such as AB who embark on changing their alcohol use should be offered continuous support through

TABLE 1

First-Line Pharmacotherapies for Alcohol Use Disorder5,8 Naltrexone

Acamprosate

Benefit

• Alcohol abstinence (NNT 20), • Prevents return to heavy drinking (NNT 12), • Reduces cravings (small effect size)

Alcohol abstinence (NNT 12)

Contraindications

Current opioid use, acute opioid withdrawal, acute hepatitis or hepatic failure

Severe renal impairment (creatinine clearance < 30 mL/ min), breastfeeding

Liver function tests: at baseline, 1, 3 and 6 months

Renal function (when clinically indicated)

Adverse effects Monitoring Dosing

Dose-related: nausea, headache, dizziness

25 mg daily x 1–2 weeks, then 50 mg once daily

Diarrhea, vomiting, abdominal pain (transient)

666 mg tid

NNT–number needed to treat

regular follow-up to monitor and celebrate progress, address challenges, and adjust the treatment plan as needed.5 Summary Pharmacists can play a pivotal role in addressing AUD by providing a safe space for patients to discuss their substance use, integrating AUD screening into routine patient care, offering brief interventions, and providing referrals to appropriate supports. By establishing trust, practising nonjudgmental communication, integrating pharmacotherapy, and collaborating on patient goals, pharmacists can empower patients to overcome challenges and achieve alcohol abstinence for improved health and well-being.

Katelyn Halpape is a clinical pharmacist at the Dube Centre for Mental Health in Saskatoon, SK, and an Assistant Professor in the College of Pharmacy and Nutrition at the University of Saskatchewan.

REFERENCES 1. Rehm J, Mathers C, Popova S, et al. Global burden of disease and injury and economic cost attributable to alcohol use and alcoholuse disorders. Lancet 2009;373:2223-33.

2. Street A. Canada’s guidance on alcohol and health: final report. Canadian Centre on Substance use and Addiction. January 2023. https://www. ccsa.ca/sites/default/files/2023-01/CCSA_ Canadas_Guidance_on_Alcohol_and_Health_Final_ Report_en.pdf (accessed November 6, 2023).

3. Valliant SN, Burbage SC, Pathak S, et al.

Pharmacists as accessible health care providers: quantifying the opportunity. J Manag Care Spec Pharm 2022;28(1):10.18553/jmcp.2022.28.1.85.

4. York MG, Caliendo T. Assessing substance use disorder in pharmacy practice. https:// www.uspharmacist.com/article/assessingsubstance-use-disorder-in-pharmacypractice (accessed August 29, 2023).

5. Canadian Research Initiative in Substance Misuse. Canadian clinical guideline. High-risk drinking and alcohol use disorder. October 2023. https://helpwithdrinking.ca/wp-content/ uploads/2023/10/FINAL-Canadian-AUDguidelines_ENG.pdf (accessed November 6, 2023).

6. Mitchell AJ, Bird V, Rizzo M, et al. Accuracy of one or two simple questions to identify alcoholuse disorder in primary care: a meta-analysis.

Br J Gen Pract 2014;64(624):e408-18.

7. Substance Abuse and Mental Health Services Adminstration. Using motivational interviewing in substance use disorder treatment. https://store.samhsa.gov/sites/default/files/ SAMHSA_Digital_Download/PEP20-02-02014.pdf (accessed November 6, 2023).

8. Wood E, Bright J, Hsu K, et al. Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder. CMAJ 2023;195:E1364-79.

9. Spithoff S, Turner S, Gomes T, et al. First-line medications for alcohol use disorders among public drug plan beneficiaries in Ontario.

Can Fam Physician 2017;63(5):e277-83.

10. Antrim A. Pharmacists play key role in management of alcohol use disorder, withdrawal syndrome. Pharmacy Times; December 5, 2022. https://www.pharmacytimes.com/view/ pharmacists-play-key-role-in-managementof-alcohol-use-disorder-withdrawalsyndrome (accessed November 2, 2023).

More Therapeutic Issues

Read all of Katelyn Halpape’s columns in our Blogs section under Opinions at CanadianHealthcareNetwork.ca

[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS 27

CARDIOVASCUL AR ISSUES

Dyslipidemia and statin therapy in patients with HIV

uman immunodeficiency virus (HIV) infection is now essentially a chronic medical condition owing to the effectiveness of contemporary antiretroviral (ARV) therapy. Patients are now rarely dying of Kaposi sarcoma and opportunistic infections, but rather atherosclerotic cardiovascular disease (ASCVD) and other non-HIV-related causes.

infarction (MI) in patients with HIV may be up to two-fold higher compared to those without HIV.3 The exact mechanism of this increased risk is unknown, but is thought to be a combination of chronic inflammation and immune activation (though independent of viral load, as it is still observed in patients who have achieved viral suppression), as well as traditional cardiovascular risk factors.1 Most ASCVD risk algorithms do not include HIV infection as a variable, although it is considered to be a “riskenhancing factor,” which may be used to guide decisions around the use or intensification of statin therapy.4

HIV and atherosclerotic cardiovascular disease The risk of ASCVD among HIV-positive persons is higher than in the general population.1,2 The risk of myocardial

HIV and dyslipidemia Most patients with HIV have concurrent dyslipidemia.5 Despite that, ARVinduced hyperlipidemia is much less of an issue nowadays due to advances in

ARDEN R. BARRY BSc, BSc(Pharm), PharmD, ACPR

H

28 PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

therapy. Commonly used nucleoside reverse transcriptase inhibitors, such as emtricitabine and tenofovir, have been associated with hypertriglyceridemia and hypercholesterolemia. However, many of the ARV agents known to cause hyperlipidemia are rarely used in practice anymore, such as efavirenz and early-phase protease inhibitors (e.g., lopinavir, ritonavir). Second-generation protease inhibitors (e.g., atazanavir, darunavir) and integrase inhibitors (e.g., bictegravir, dolutegravir) have more favourable effects on lipid parameters.

The often-used combination tablet of bictegravir/emtricitabine/tenofovir has a relatively minor impact on lipid values other than a possible increase in lowdensity lipoprotein cholesterol (LDL-C).

Currently, the most controversial issue regarding ARV-induced dyslipidemia involves the salt form of tenofovir.

Tenofovir disoproxil fumarate has now been replaced by tenofovir alafenamide in newer formulations; it has more advantageous pharmacokinetic properties but has been associated with increased levels of total cholesterol, LDL-C and triglycerides.6 The 2021 Canadian Cardiovascular Society dyslipidemia

Shutterstock / Lightspring

PRACTICE EXPERTS

guidelines recommend screening patients with HIV for dyslipidemia regardless of age, but do not make any specific treatment recommendations.7 HIV and statin therapy Due to the increased risk of ASCVD in patients with HIV, aggressive treatment with lifestyle modifications and lipid-lowering therapy are generally recommended. Historically, many patients may have been not treated or were undertreated due to drug– drug interactions between ARV and statin therapy. However, newer ARV agents have fewer interactions with statins. For example, the interaction between CYP3A4 statins (e.g., atorvastatin) and protease inhibitors is now basically irrelevant with the introduction of integrase inhibitors.8 Randomized trial to prevent vascular events in HIV The international, multicentre REPRIVE trial, published in August 2023, was designed to ascertain whether statin therapy reduces cardiovascular events in HIV-positive patients without a history of ASCVD.9 It is the first, and only, outcomedriven trial of lipid-lowering therapy in patients with HIV. Included were persons aged 40–75 years with HIV on stable ARV therapy who had no established ASCVD (i.e., primary prevention).

Participants needed to be low-tointermediate risk (10-year risk of ASCVD up to 15% based on the American Pooled Cohort Equations). Patients were randomized to pitavastatin 4 mg daily (moderate-intensity) or identical placebo.

Pitavastatin (not available in Canada, but available in other countries) was chosen because of its lack of drug interactions with ARV therapy.8 The primary outcome was an extensive composite endpoint that included cardiovascular death, MI, unstable angina, stroke/ transient ischemic attack, peripheral arterial ischemia, revascularization, and death from an undetermined cause.

The study was primarily funded by the US National Institutes of Health.

A total of 7,769 patients were enrolled.

Median age was 50 years, median CD4 count was 621 cells/mm3, 31% were women and 65% were non-white.

Only 2% had substance use disorder or chronic active hepatitis C. At baseline, median 10-year cardiovascular risk was

4.5% (low-risk) and median LDL-C was 2.8 mmol/L, which decreased to 1.9 mmol/L in the pitavastatin group. Over 5.1 years, the primary outcome was significantly lower with pitavastatin (4.8 vs 7.3 events per 1,000 patient-years, hazard ratio 0.65, 95% confidence interval 0.48–0.90, estimated 5-year number needed to treat of 106).

Pitavastatin also significantly reduced MI/cardiac ischemia, but there was no significant difference in cardiovascular or all-cause death. Significantly higher

Due to the increased risk of ASCVD in patients with HIV, aggressive treatment with lifestyle modifications and lipid-lowering therapy are generally recommended. rates of incident diabetes (5.3% vs 4.0%) and myalgias/myopathy (2.3% vs 1.4%) were seen with pitavastatin, but only 2% of patients discontinued pitavastatin due to adverse events.

Pharmacist’s role A first step in addressing ASCVD risk in HIV-positive persons is educating other clinicians about the REPRIVE trial and recommending statin therapy to appropriate patients with HIV (aged 40–75 years without ASCVD at lowto-intermediate cardiovascular risk).

Some patients, particularly younger patients with no other cardiovascular risk factors, may be reluctant to start a statin. Pill burden, which used to contribute to ARV therapy nonadherence, is presently less of an issue. For instance, the combination tablet of bictegravir/ emtricitabine/tenofovir is just one tablet daily. It is vital, however, to check for drug–drug interactions between statins and a patient’s ARV regimen, as older ARV agents are still used occasionally.

Of note, statin therapy should be recommended for all patients with HIV who have experienced a cardiovascular event (i.e., secondary prevention). Finally, it is essential to educate all HIV-positive patients about modifiable cardiovascular risk factors, such as smoking, sedentary lifestyle and poor dietary habits.

Summary The REPRIEVE trial demonstrated that moderate-intensity statin therapy reduced cardiovascular events, mostly coronary and cerebrovascular events, in patients with HIV at low-risk of ASCVD. As pitavastatin is unavailable in Canada, a reasonable alternative would be fixed-dose rosuvastatin 5–10 mg daily or atorvastatin 10–20 mg daily.

Arden Barry is a clinical pharmacy and research specialist in ambulatory cardiology at the Jim Pattison Outpatient Care and Surgery Centre in Surrey, BC, and associate professor (partner) at the Faculty of Pharmaceutical Sciences, University of British Columbia in Vancouver, BC. REFERENCES 1. So-Armah K, Benjamin LA, Bloomfield GS, et al. HIV and cardiovascular disease.

Lancet HIV 2020;7:e279-e293.

2. Bernelli C, Danzi GB, Cerrato E, et al.

Cardiovascular events recurrence and coronary artery disease in HIV patients: the price we have to pay for the chronicization of the disease. Can J Cardiol 2020;36:127-34.

3. Shah ASV, Stelzle D, Lee KK, et al. Global burden of atherosclerotic cardiovascular disease in people living with HIV: systematic review and meta-analysis. Circulation 2018;138:1100-12.

4. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;74:e177-e232.

5. Waters DD, Hsue PY. Lipid abnormalities in persons living with HIV infection.

Can J Cardiol 2019;35:249-59.

6. Surial B, Mugglin C, Calmy A, et al. Weight and metabolic changes after switching from tenofovir disoproxil fumarate to tenofovir alafenamide in people living with HIV: a cohort study. Ann Intern Med 2021;174:758-67.

7. Pearson GJ, Thanassoulis G, Anderson TJ, et al. 2021 Canadian Cardiovascular Society guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in adults. Can J Cardiol 2021;37:1129-50.

8. Giguère P, Nhean S, Tseng AL, et al. Getting to the heart of the matter: a review of drug interactions between HIV antiretrovirals and cardiology medications. Can J Cardiol 2019;35:326-40.

9. Grinspoon SK, Fitch KV, Zanni MV, et al.

Pitavastatin to prevent cardiovascular disease in HIV infection. N Engl J Med 2023;389:687-99.

More Cardiovascular Issues

Read all of Arden Barry’s columns in our Blogs section under Opinions at CanadianHealthcareNetwork.ca

[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS 29

5 Tips

PEARLS YOU CAN USE IN YOUR PRACTICE NOW

Assessing the potential for QT-prolongation drug interactions

By Mishka Danchuk-Lauzon, PharmD, ACPR, RPh, MScCH

Picture this: you’re filling/verifying prescriptions and you get that all too familiar pop-up that notifies you of a QT-prolongation interaction…how should you approach this?

1

Recognize that QTprolongation interactions can occur through three main mechanisms First, it is important to understand the mechanism of the drug interaction you are faced with. You can categorize it as one of the following: a pharmacodynamic interaction, a pharmacokinetic interaction or a drug-induced electrolyte imbalance.

In this context, a pharmacodynamic interaction occurs when you have two or more drugs co-prescribed that can prolong the QT-interval through additive or potentiating effect.1 For example, methadone and azithromycin.

A pharmacokinetic interaction occurs when you have a drug that does

2

Assess the torsades de pointes (TdP) risk of the drug(s) being prescribed The main concern with QT-prolongation is that it can degenerate into TdP and further into ventricular

30 PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

fibrillation, which can cause sudden cardiac death.2,3 Drugs vary in their risk of causing QT-prolongation and TdP. It is possible for a drug with a high risk of QT-prolongation to have a low risk of causing TdP and vice versa. It is therefore important to understand the risk of the drug(s) involved in the interaction.

Multiple references are available to assess for QT prolongation and TdP risk (see Box 1). One of my favourites is Credible Meds (https://www. crediblemeds.org/). It includes a QTdrugs list that categorizes drugs according to their risk of TdP (known risk; possible risk; or conditional risk, i.e., drugs that can cause TdP under certain conditions). It also summarizes clinical factors that have been associated with QT prolongation and/or TdP. A brief literature search can also be performed to determine whether any additional research is available.

Gather an accurate drug history with a focus on QTprolonging drugs.5 Consider the drugs the patient is currently taking and the drug that is newly prescribed.

Some questions to think about regarding the patient’s current drug regimen are: ● Does the current regimen include any QT-prolonging drugs? ● For any drugs the patient is taking that do cause QT prolongation: ○ What is the risk of TdP? (see Tip 2) ○ What is the dose? The risk of TdP tends to increase as higher doses are used. ○ How long have they been taking the drug? Is the drug at steady state?

Are they stable on this therapy? (i.e., did the patient have any issues with QT-prolongation or TdP on the current drug regimen in the past?).

Some questions to think about for the newly prescribed drug are: ● What is the dose? The risk of TdP tends to increase as higher doses are used. ● What is the duration of therapy? (e.g., acute vs chronic therapy – is this a short-term or long-term risk; will the drug have a chance to reach steady-state?) ● How is it metabolized and cleared? (e.g., hepatic, renal

Shutterstock / Titima Ongkantong

This is a common occurrence for any pharmacist working in a clinical setting, but it tends to cause discomfort. As pharmacy students, many of us were taught to be aware of this type of drug interaction, but were not given much information on how it should be approached.

As a pharmacy resident at Sunnybrook, I took a deep dive into the literature surrounding this topic and put together a framework to help approach these situations. The five tips provided in this article are designed to help increase pharmacists’ comfort with assessing the risk of these interactions and in making recommendations, especially in the absence of detailed data like an electrocardiogram (ECG). not prolong the QT interval, but reduces clearance or is metabolized by the same enzyme as a drug that does prolong the QT interval.1 For example, methadone and verapamil.

Finally, a drug-induced electrolyte imbalance occurs when a drug (e.g., thiazide diuretic) causes a disturbance in electrolytes (hypokalemia; hypomagnesemia), which can increase the risk of QT prolongation.1

3

Gather an accurate drug history

– does the patient have any impairment that could cause accumulation?) ● What is the half-life? Will it reach steady-state?

(If a drug reaches high concentrations with a long half-life and this is long-term therapy, this is a consideration versus a drug that will be used short term with a short half-life) ● What drugs will it overlap with? (Can any of these other drugs interact to worsen QT-prolongation/TdP risk?) ● Have they taken this drug before? Any prior issues?

(If prior issues with the drug, may want to avoid).

4

Gather a patient history Gather information about the patient to guide your decisionmaking.5 Some questions to consider asking yourself are: ● Does the patient have any risk factors for TdP? With drug-induced QT-prolongation, some nonmodifiable risk factors are female sex, age > 65, impaired renal or hepatic function, congenital long QT syndrome, structural heart diseases, untreated thyroid disease.1 ● A risk score such as the Tisdale risk score may help guide you (https://www. mdcalc.com/calc/10293/ tisdale-risk-score-qtprolongation), but be aware of its limitations.

It has been validated to predict the risk of QT prolongation > 500 msec in hospitalized patients; predictions for risk of QT prolongation in outpatients may not be as accurate. ● Does the patient have any cardiac issues (e.g., arrhythmias) that might make them at higher risk for developing TdP? ● Does the patient have a history of signs and symptoms of QT prolongation/TdP (when taking a drug that may cause this)? Signs and symptoms

of QT prolongation include: palpitations, dizziness, light-headedness, syncope.4 ● Does the patient have any modifiable risk factors that can be corrected, such as electrolyte (potassium, magnesium or calcium) imbalances?

5

Make a recommendation and gain comfort Comfort with assessing QT-prolongation interactions increases with experience, familiarity with references and knowledge of the literature.

Often, physicians are looking to pharmacists to help assess these types of interactions. It is important to make a clear recommendation when assessing a QT-prolongation interaction.

Typically, one of three options will be chosen: ● No change to the new prescription. Counsel the patient on potential risk (if relevant) and advise them to report any symptoms (e.g., palpitations, syncope, light headedness, dizziness). Ensure QTprolonging medications are dosed appropriately (e.g., lowest effective dose, dose adjusted for kidney and liver function). ● Recommend a change to the new prescription after assessing the information you have gathered in Tips 2–4 and the QT prolongation/TdP potential of alternate medication(s).

The recommendation should be clear and appropriate. You may wish to first have a discussion with the prescriber concerning risk/benefit of the original prescribed drug and the potential alternative(s). It is important to avoid delaying therapy. ● Recommend a change to the patient’s current drug regimen. For example, this could include holding a certain medication in the short term (if the new prescription is for a short-term medication).

BOX 1

Key resources for assessing the QT-prolongation/TdP potential of a drug Credible Meds

(https://crediblemeds.org/)

Lexicomp Drug Interaction Checker (https://online.lexi.com/lco/ action/login)

Literature Search through PubMed

The credible meds QTdrugs list links to a PubMed search for each drug on the list. (https://pubmed.ncbi.nlm. nih.gov/)

More detailed information about assessing the potential for QT-prolongation drug interactions is available in references #2, 6–9.

Summary

The five tips presented in this article provide a streamlined approach to conducting your assessment, with the aim of minimizing treatment delays, optimizing medication selection and making best use of time and resources. Pharmacists can also refer to the infographic (online only) that summarizes these five tips.

Mishka Danchuk-Lauzon (mishka. danchuk.lauzon@mail.utoronto.ca) is currently the pharmacy manager of the Collingwood General and Marine Hospital. She became passionate about the above topic during her residency at Sunnybrook Health Sciences Centre in Toronto.

Throughout her residency she taught multiple workshops to pharmacists, pharmacy residents, and pharmacy students on the topic.

REFERENCES 1. Khatib R, Sabir FRN, Omari C, et al. Managing drug-induced QT prolongation in clinical practice.

Postgrad Med J 2021;97:452-8.

2. Communities Oncology Network Pharmacy Educators. Pharmacy FAQ: QT prolongation in oncology.

March 2, 2023. http://www.bccancer. bc.ca/pharmacy-site/Documents/ Pharmacy%20FAQs/Pharmacy-FAQQT-Prolongation.pdf

● Porta‐Sánchez A, Gilbert C, Spears D, et al. Incidence, diagnosis, and management of QT prolongation induced by cancer therapies: a systematic review. J Am Heart Assoc 2017;6(12). (https://www.ahajournals. org/doi/epub/10.1161/ JAHA.117.007724) ● Davies RA, Ladouceur VB, Green MS, et al. The 2023 Canadian Cardiovascular Society clinical practice update on management of the patient with a prolonged QT interval. Can J Cardiol 2023;39(10):1285-301. (Also lists interclass differences) (https://onlinecjc.ca/action/ showPdf?pii=S0828282X%2823%2900520-2)

(accessed November 22, 2023) 3. Mayo Clinic. Ventricular fibrillation.

October 28, 2022. https:// www.mayoclinic.org/diseasesconditions/ventricularfibrillation/ symptoms-causes/syc-20364523 (accessed November 22, 2023).

4. de Lemos ML, Kung C, Kletas V, et al. Approach to initiating QT-prolonging oncology drugs in the ambulatory setting. J Oncol Pharm Pract 2019;25(1):198-204.

5. Grindrod KA, Nagge J. Simplifying QT prolongation for busy clinicians. Can Fam Physician 2019;65(4):268-70.

6. ISMP Canada. A multi-incident analysis on QT-prolongation in the community. Pharm Connect 2016. https://www.ismp-canada.org/ download/PharmacyConnection/ PC2016-QT-Prolongation.pdf (accessed November 22, 2023).

7. Kim PY, Irizarry-Caro JA, Ramesh T, et al. How to diagnose and manage QT prolongation in cancer patients.

JACC CardioOncol 2021;3(1):145-9. doi:10.1016/j.jaccao.2021.01.002.

8. Porta‐Sánchez A, Gilbert C, Spears D, et al. Incidence, diagnosis, and management of QT prolongation induced by cancer therapies: a systematic review.

J Am Heart Assoc 2017;6(12). https://www.ahajournals.org/doi/ epub/10.1161/JAHA.117.007724 (accessed November 22, 2023).

9. Davies RA, Ladouceur VB, Green MS, et al. The 2023 Canadian Cardiovascular Society clinical practice update on management of the patient with a prolonged QT interval. Can J Cardiol 2023;39:1285-301. https://onlinecjc. ca/action/showPdf?pii=S0828282X%2823%2900520-2 (accessed November 22, 2023).

[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS 31

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CLINICAL FEATURE

Not childʼs play

By Rana Khafagy, PharmD, ACPR, RPh, MPH Epidemiology

A

lthough pain is common in children, it is often inappropriately assessed or treated due to the unique challenges presented by this population.

Despite an incidence of 33%–82% in children, pain continues to be poorly evaluated, leading to over- and undertreatment.1 One of the main reasons for this is the difficulty in assessing pain in children, especially in the youngest children or those who are cognitively impaired.2 Without proper management, pain can lead to chronic distress and pain, anxiety around healthcare interactions, increased pain during future medical procedures and increased risk of adverse events from drug therapies.3 Pharmacists are well situated to help assess pain in children and liaise with the rest of their healthcare team to implement appropriate pain management strategies.

DIAGNOSIS AND ASSESSMENT As pain is a subjective symptom, it is hard to quantify, making management tricky. This is further complicated in pediatrics, where patients may not be able to verbalize how they are feeling or articulate changes from their baseline.4 Proper assessment by the pharmacist should

34 PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

Shutterstock / altanaka

A practical guide to the management of pediatric pain

aim to distinguish the pain’s location, quality, duration and intensity, as well as impact on daily activities.3,5 Several self-reported pain scales have been developed specifically for use in children and may help the pharmacist assess ongoing therapy. When possible, children’s pain should be assessed directly using these scales, rather than relying on information provided by a parent or guardian. It is important to note that several of these available scales have not been validated for chronic pain or in children younger than five to six years of age. Of the available scales, the Numeric Rating Scale-11 (NRS-11) is the most commonly used and preferred, owing to its ease of use and validation in multiple clinical settings.3 Thus, the NRS-11 is recommended to start for community pharmacists managing pediatric patients. Table 1 lists some of the common pain assessment scales used in pediatric practice.6-9 For children who are unable to communicate their pain verbally, several observational tools can be used.3,10 These scales focus on behavioural changes in a child and assign them a score, which can then be used to infer the likelihood of the child experiencing pain.10 The EVENDOL and FLACC scales are typically recommended as a starting point for community practitioners given the wide age range they are appropriate for, their ease of use and their validation in procedural, acute and chronic pain.3 Table 2 lists recommended behavioural pain scales.11-17 MANAGEMENT Early treatment of pain is recommended and does not interfere with diagnostic accuracy.18 While it’s important to incorporate nonpharmacologic interventions, this article focuses on drug therapies used in pediatric pain.

Nonopioid analgesics As per the World Health Organization’s pain ladder, nonopioid analgesics should be tried first-line for mild to moderate pain.19 Acetaminophen and ibuprofen are the most commonly used drugs due to their safety profiles and variety of well-tolerated formulations. Studies report better pain management with ibuprofen compared to acetaminophen, specifically in headaches, musculoskeletal pain and dental extractions.20,21 In practice, it can be advantageous to alternate between acetaminophen and ibuprofen. From studies looking at fever management, acetaminophen and ibuprofen may be alternated every three hours.22 Recently, intravenous acetaminophen has become available in Canada. Lack of studies demonstrating better efficacy, and its high-cost compared to oral acetaminophen, limit its use to post-operative patients who are not taking anything by mouth.23 Opioids are indicated when pain is not resolved with ibuprofen or acetaminophen, and in moderate to severe cases.19 Morphine, hydromorphone and fentanyl, in all available routes of administration, can be used in children in the community when appropriately monitored. Due to risk of misuse and their side effect profile, opioids are recommended to be used for the shortest time and lowest dose needed by the patient.24,25 However, this often leads to children having mismanaged pain. To ensure appropriate use, pharmacists should consistently assess patients and their pain and assist in developing wean and titration plans. Nonopioid analgesics should be used concurrently to provide opioid-sparing effects.24 If a patient’s pain doesn’t appear to be responding

well to one opioid, an opioid rotation can be considered rather than continuing to increase the dose.25,26 Rotations do not always need to be from a less potent opioid to a more potent one (e.g., a strategy may be to rotate a patient from fentanyl back to morphine or hydromorphone).25 Codeine and tramadol use in children less than 12 years of age is contraindicated due to reports of respiratory depression, potentially from sporadic CYP2D6 metabolism in this population.27,28 Meperidine, hydrocodone and oxycodone have fallen out of favour due to their poor safety and tolerability profiles and extensive drug interactions.24,25 Methadone has been used in children, mainly in palliative care and to assist in weaning opioids.29 Studies have found that pharmacist-led opioid weans using methadone achieved better patient outcomes than prescriber-facilitated plans.30,31 Several methadone tapers exist in the literature, with Steineck et al providing an easyto-implement protocol that may be used in children.31 An important component of opioid management is the development of effective wean plans for patients who have been on around-the-clock opioids for more than five to seven days.

Most guidelines recommend weaning by 10% every 24 hours if the child has been on opioids for more than 10 days or if they are less than six months of age and have been on opioids for five or more days.25 If the child has been on opioids for five to 10 days and is six months old or less, a 20% wean every 24 hours may be considered. The Withdrawal Assessment Tool—Version 1 (WAT-1) should be used daily to monitor for withdrawal and to determine whether the wean should be adjusted.32 Adjunctive therapy Third-line options in children may be used as adjuncts and include certain antidepressants and antiepileptics.

Amitriptyline, duloxetine, gabapentin and pregabalin have been used in children, although data are lacking for use beyond cancer and fibromyalgia pain.33 Intranasal ketamine can also be used, with good evidence for its use in acute pain in limb injuries and fractures.3,34 Despite falling out of favour years ago, continuous ketamine infusions appear to be gaining popularity in Canada. Ketamine’s advantages include minimal effects on blood pressure and respiration.35 Due to its action on N-methyl-D-aspartate (NMDA) receptors, ketamine can also be useful in cancer, burns, sickle cell disease and if there is a component of neuropathic pain.35 Use is contraindicated in those less than three months’ old, and use in those younger than one year is controversial due to reports of laryngospasm.36 Table 3 summarizes medications that pharmacists may commonly see in community practice to manage pain in children.3,4 PHARMACIST’S ROLE Due to our extensive knowledge of medications and their properties, pharmacists play an important role in creating pain plans. This involves ensuring appropriate agents are chosen depending on the child’s pain, consistently assessing the child’s pain using appropriate tools and monitoring regularly for side effects and adherence. Most practice guidelines recommend assessing pain every five to seven days in the beginning and during acute episodes to ensure optimal management.3,25 Given the global opioid crisis we are facing, pharmacists are also uniquely situated to counsel families on the risks of developing addiction and tolerance in a manner that [Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS 35

TABLE 1

Common self-reported pain measurement scales used in children6-9 Scale

Brief Description

Recommended Age

Strengths

Limitations to Consider

The Oucher

Similar to the FPS-R, except different ethnic posters available (African-American, Asian, Caucasian, First Nations, Hispanic)

≥ 3 years old

Validated in acute and cancer pain

Not recommended in chronic pain

Faces Pain Scale Revised (FPS-R)

Child ranks their pain using 6 facial images

≥ 4 years old (although some studies suggest ≥ 7 years old)

Not recommended in chronic pain

Numeric Rating Scale-11 (NRS-11)

Child ranks their pain from 0 (no pain) to 10 (worst possible pain)

≥ 6 years old

• Preferred by children • Revised version allows scoring from 0–10 by the healthcare provider • High correlation with visual analogue pain scales

Colour Analogue Scale (CAS)

Child ranks their pain using a colour scale which correlates to a score of 0–10 on the back

≥ 8 years old

Validated in traumatic and nontraumatic pain in the emergency department

• Not recommended in chronic pain • Less evidence for use in post-operative pain

• Simple, most commonly used • Only self-reported scale recommended in chronic pain • Can be done verbally • Validated in many clinical areas and highly correlated with other pain tools

TABLE 2

Common behavioural pain assessment scales used in children11-17 Scale

Brief Description

Recommended Age

Strengths

Limitations to Consider

Neonatal Infant Pain Scale (NIPS)

Practitioner scores a neonate on a 7-point scale based on facial expression, cry, breathing pattern, arms, legs and state of arousal

0–1 month old

• Validated in procedural pain • High correlation with visual analogue scales

• Not recommended in postoperative or chronic pain • Least evidence for use in acute pain

Practitioner uses facial actions to assess neonate’s pain

0–4 months old

Harder tool to administer than other scales

Evaluation Enfant Douleur (EVENDOL)

Practitioner assigns a score out of 15 based on vocal or verbal expression, facial expression, movements, postures and interaction with environment

0–7 years old

• Recommended in acute, chronic and procedural pain • Some evidence that it may be valid in post-operative pain

Face, Legs, Activity, Cry, Consolability (FLACC)

Practitioner assigns a score out of 10 based on 5 domains

Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS)

Practitioner assigns a score out of 14 based on a child’s cry, facial, verbal, torso, touch and legs

2 months–7 years Note: revised FLACC scale is more appropriate in cognitively-impaired or nonverbal children aged 4–19 years

Neonatal Facial Coding System (NFCS)

COMFORT-B

Practitioner assesses child’s pain based on alertness, calmness/agitation, respiration (if mechanically ventilated), crying, physical movement, muscle tone and facial tension

• Recommended in acute, chronic and procedural pain • Validated in the emergency department • Able to distinguish between tiredness, anxiety and hunger

Requires assessing the child first at rest, then during examination or after analgesia

• Easy to administer • Preferred in hospital settings, particularly critical care

Conflicting evidence in procedural pain

1–7 years

New evidence validating its use in immunizations in children aged 2–22 months

• Conflicting evidence in procedural pain • Not recommended in acute or chronic pain

All ages

• Validated in children mechanically ventilated and/or in postoperative pain • Recommended in intensive care, particularly in children < 3 years

Time-consuming

doesn’t scare the family from administering opioids, but also doesn’t diminish this very real risk.3 “As needed” opioids, when appropriate, should be prescribed for two to three days, with a plan for children to see their healthcare team if they have inadequate relief, and to return any unused drug to a pharmacy for disposal.3 SUMMARY Pain in children can be difficult to manage. Using ageappropriate pain assessment scales can help pharmacists 36 PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

properly assess a child’s pain and track it during therapy.

Although acetaminophen and ibuprofen are effective in most cases, several children will require opioids for pain relief. In more severe and refractory cases, some antidepressants and antiepileptics may also be safely used as adjuncts in children.

Rana Khafagy (rana.khafagy@sickkids.ca) is a clinical pharmacist working in the intensive care unit at the Hospital for Sick Children in Toronto, ON. She also has experience working in pediatric oncology and cystic fibrosis.

She recently completed a Master’s in Public Health epidemiology, with research interests in genetics and pediatric oncology surveillance.

TABLE 3

Pharmacologic options for pain management in children3,4 Drug Class First Line

Nonopioid analgesic

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Drug

Dosagea,b

Acetaminophen

10–15 mg/kg/dose po/IV q4–6h

Ibuprofen

Naproxen Ketorolac

Acetylsalicylic acid (ASA)d

Second Line Opioide

Morphine

Hydromorphone

Fentanyl Oxycodone

Third Line

Anesthetic

Ketamine

15–30 mg/kg/dose PR q4–12h

(max 650–1000 mg/dose depending on formulation; 4000 mg/day OR 75 mg/kg/dayc) 5–10 mg/kg/dose po q6–8h

(max 600 mg/dose; 2400 mg/day OR 40 mg/kg/day) 5–7 mg/kg/dose po q8–12h (max 1000 mg/day)

0.5 mg/kg/dose IV/IM q6–8h

(max 15 mg/dose if < 16 years of age OR 30 mg/dose if ≥ 16 years of age) 10–15 mg/kg/dose po q4–6h

(max 650 mg/dose; 4000 mg/day OR 90 mg/kg/day) 0.2–0.5 mg/kg/dose po q4–6h

0.05–0.1 mg/kg/dose IV q2–4h

(usual max 15 mg/dose po; 5 mg/ dose IV) 0.03–0.08 mg/kg/dose po q4–6h

0.01–0.015 mg/kg/dose IV q2–4h in children < 50 kg; 0.2–0.6 mg/kg/dose IV q2–4h in children ≥ 50 kg (usual max 4–8 mg/dose po)

1–3 µg/kg/dose IV/intranasal q2–4h (usual max 100 µg/dose)

0.025–0.2 mg/kg/dose po q4–6h (usual max 20 mg/dose) 1–2 mg/kg IV/intranasal preprocedures (max 100 mg/dose)

1–4 µg/kg/min IV (0.06–0.24 mg/kg/ hr) as a continuous infusion

Tricyclic antidepressant

Amitriptyline Duloxetine

Children ≥ 13 years of age: 30–60 mg po daily

Antiepileptic

Gabapentin

Start at 5 mg/kg/dose po daily, then titrate to up to 12 mg/kg/dose po tid (max 3600 mg/day)

Serotoninnorepinephrine reuptake inhibitor (SNRI)

Pregabalin

0.1–2 mg/kg/dose po qhs

Children ≥ 12 years of age: start at 37.5 mg po bid, then titrate up to 225 mg po bid

IM–intramuscular; IV–intravenous; PR–per rectum; aAll doses expressed as scheduled, but may also be used “as needed”; bWhen deciding what mg/dose to cap at, consider what a usual mg/dose an adult would be prescribed; c 60 mg/kg/day maximum acetaminophen dose in neonates > 32 weeks post-conceptual age; dAvoid in acute febrile and viral illness due to risk of Reye’s syndrome; eMay consider higher doses for children who are not opioid-naive

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3. Trottier ED, Ali S, Doré-Bergeron MJ, et al. Best practices in pain assessment and management for children. Paediatr Child Health 2022;27(7):429-48.

4. O’Donnell FT, Rosen KR. Pediatric pain management: a review. Mo Med 2014;111(3):231-7.

5. Manworren RC, Stinson J. Pediatric pain measurement, assessment, and evaluation. Semin Pediatr Neurol 2016;23(3):189-200.

6. Beyer J, Denyes M, Villarruel A. The creation, validation and continuing development of the oucher: a measure of pain intensity in children. J Pediatr Nurs 1992;7:335-46.

7. Hicks CL, von Baeyer CL, Spafford PA, et al. The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain 2001;93(2):173-83.

8. Hartrick CT, Kovan JP, Shapiro S. The numeric rating scale for clinical pain measurement: a ratio measure? Pain Pract 2003;3(4):310-6.

9. McGrath PA, Seifert CE, Speechley KN, et al. A new analogue scale for assessing children’s pain: an initial validation study. Pain 1996;64(3):435-43.

10. Bailey B, Trottier ED. Managing pediatric pain in the emergency department. Paediatr Drugs 2016;18(4):287-301.

11. Lawrence J, Alcock D, McGrath P, et al. The development of a tool to assess neonatal pain. Neonatal Netw 1993;12(6):59-66.

12. Duhn LJ, Medves JM. A systematic integrative review of infant pain assessment tools. Adv Neonatal Care 2004;4(3):126-40.

13. Grunau RE, Oberlander T, Holsti L, et al. Bedside application of the Neonatal Facial Coding System in pain assessment of premature neonates. Pain 1998;76(3):277-86.

14. Fournier-Charrière E, Tourniaire B, Carbajal R, et al. EVENDOL, a new behavioral pain scale for children ages 0 to 7 years in the emergency department: design and validation. Pain 2012;153(8):1573-82.

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18. Poonai N, Paskar D, Konrad SL, et al. Opioid analgesia for acute abdominal pain in children: a systematic review and metaanalysis. Acad Emerg Med 2014;21(11):1183-92.

19. Ventafridda V, Saita L, Ripamonti C, et al. WHO guidelines for the use of analgesics in cancer pain. Int J Tissue React 1985;7(1):93-6.

20. Pierce CA, Voss B. Efficacy and safety of ibuprofen and acetaminophen in children and adults: a meta-analysis and qualitative review. Ann Pharmacother 2010;44(3):489-506.

21. Tan F, Braithwaite I, McKinlay C, et al. Comparison of acetaminophen (paracetamol) with ibuprofen for treatment of fever or pain in children younger than 2 years: a systematic review and meta-analysis. JAMA Netw Open 2020;3(10):e2022398.

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[Vol.11 No.1] January/February 2024 PHARMACY PRACTICE + BUSINESS 37

The Closer CREATIVE THOUGHTS AND SMART IDEAS FOR PHARMACY OWNERS AND MANAGERS

A DOSE OF PROSPERITY

Prelude to a series on success and prosperity

Together, we can create a profession that not only attracts top talent but also retains and nurtures them.

38 PHARMACY PRACTICE + BUSINESS January/February 2024 [Vol.11 No.1]

aspect of our work environment is crucial.

However, what we can control is our response to challenges and our commitment to creating a professional culture grounded in best practices, knowledge-sharing and collaboration.

Strength lies in recognizing when we need support or when our methods could benefit from fresh insights. With this column, I aim to contribute to a collective pool of wisdom that elevates our entire profession. It goes beyond personal success—it’s about advancing the field, creating an industry that future professionals find appealing and, most importantly, enhancing our ability to provide excellent patient care.

Let’s choose to be architects of a culture where success is celebrated, challenges are met with collective problem-solving, and the spirit of collaboration is the driving force. Together, we can create a profession that not only attracts top talent but also retains and nurtures them, ultimately fostering an industry that consistently delivers outstanding care to our communities. It’s a responsibility we all share, and by embracing it, we pave the way for a brighter future for our profession and the patients we serve. Welcome to a year of prosperity and success!

Amy Oliver is an experienced pharmacy executive and the founder of Amy Oliver + Co (www.amyoliver.ca) and host of The Healthy Business Series and The Pocket Society. She offers advisory services, certified professional coaching, and business training to practice owners looking to master their strategy, management, and leadership on their journey to excellence.

Shutterstock / TA design

AMY OLIVER MBA, BScPh, RPh, PMP, CLC

As the New Year unfolds, I am excited to embark on a new journey with you through a column focused on the prosperity success factors crucial for your pharmacy practice in 2024. Having worked with practices across the country for many years, I’ve witnessed the elements that elevate a pharmacy from merely existing to truly thriving—both in business and within its team. This journey extends beyond financial success, touching upon various facets that not only foster the overall growth of the business but also nurture its health.

Throughout the coming year, this column will delve into holistic topics, exploring the elements required for not only financial success, but also patient satisfaction and loyalty, employee engagement and well-being, innovation, community involvement, effective management, and more. In a world saturated with negative news and the numerous challenges facing pharmacy practices, this column will serve as a positive force, focusing on small, actionable steps and wins that are within your control—steps every practice can take to achieve greater success.

Maintaining a balance in discussions by spotlighting prosperity tips contributes to a more uplifting and constructive narrative, benefiting both individuals and the broader community. I aim to share practical tips and best practices to attract positive and achievable opportunities for your practice to thrive. From entrepreneurial insights to innovation, from sustainability to loss prevention, community impact, creativity and beyond, this column will feed you ideas to fuel your journey to success.

In the ever-evolving landscape of health care, each professional shoulders the responsibility not only to manage what is within their control but also to recognize when challenges might become overwhelming. This journey involves both self-awareness and collective growth to propel pharmacy forward.

Acknowledging that we can’t control every

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