PPB-Jan/Feb 2023

FROM LEFT TO RIGHT: Amy Randhawa (consultant pharmacist), Jocelyn McKnight (operations supervisor), Pranjal Bhatt (consultant pharmacist), Sharda Hariprashad (pharmacy assistant supervisor), Adrienne Pham (operations pharmacist), Gennadiy Rakov (pharmacy manager), Jonathan

CONSIDER TRINTELLIX FOR YOUR PATIENTS WITH MAJOR DEPRESSIVE DISORDER (MDD)1

Vortioxetine is recommended as a first-line treatment for major depressive disorder in the 2016 CANMAT guidelines.2*

DEMONSTRATED TO TREAT MULTIPLE SYMPTOMS OF MDD1,5

Depressive symptoms (MADRS total score)

Demonstrated 60% improvement from baseline at 8 weeks with Trintellix 20 mg vs 37% with placebo (-18.8 vs -11.7, p<0.0001) ‡§

Overall function (SDS)

Demonstrated improvement from baseline at 8 weeks with Trintellix 20 mg vs placebo:

Up to 87% improvement in overall function (-8.4 vs -4.5; p=0.0005) ‡§

Up to 86% improvement in function at work (-2.6 vs -1.4; p=0.0059) ‡§

Up to 82% improvement in function at home (-3.1 vs -1.7; p<0.0001) ‡§

Up to 82% improvement in function in a social setting (-3.1 vs -1.7; p<0.0001) ‡§

§ The starting and recommended dose of Trintellix is 10 mg once daily for adults <65 years of age. See Product Monograph for complete dosing and administration information.

CANMAT=Canadian Network for Mood and Anxiety Treatments; MADRS=Montgomery-Åsberg Depression Rating Scale; SDS=Sheehan Disability Scale

* See guidelines for complete recommendations.

† Trintellix is eligible for reimbursement by Non-Insured Health Benefits, Veteran Affairs Canada and Correctional Service Canada, and for formulary coverage in the following provinces and territories: Quebec, Ontario, Alberta, Manitoba, Saskatchewan, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Northwest Territories, Yukon and British Columbia (special authorization). Refer to provincial formularies for more information.

COVERED by most private insurance plans and public formularies across Canada (restrictions may apply)3† 47.9

Visit Trintellix.ca for more information

million patients treated worldwide for up to 3 months4

Pr Trintellix® (vortioxetine) is indicated for the treatment of MDD in adults.

Clinical use:

Efficacy in providing symptomatic relief of MDD demonstrated in trials of up to 8 weeks’ duration; efficacy in maintaining an antidepressant response demonstrated for up to 24 weeks. Physicians who elect to use Trintellix for extended periods should periodically re-evaluate the usefulness of the drug for individual patients.

The lowest effective dose of 5 mg/day should always be used as the starting dose in elderly patients (≥65 years of age). Not indicated in patients <18 years of age.

Contraindication:

• Combined use with monoamine oxidase inhibitors (MAOIs)

Most serious warnings and precautions:

• Potential association with behavioural and emotional changes, including self-harm: Severe agitation-type events reported; rigorous clinical monitoring for suicidal ideation or other indicators of potential for suicidal behaviour is advised in patients of all ages; this includes monitoring for agitation-type emotional and behavioural changes.

• Discontinuation symptoms: Gradual reduction in dose, rather than abrupt cessation, is recommended.

Other relevant warnings and precautions:

• Dependence/tolerance

• Caution when driving or operating machinery

• Abnormal bleeding

• Potential for increased risk of postpartum hemorrhage

• Caution in moderate or severe hepatic impairment

• Bone fracture risk

• Caution in patients who have a history of seizures or in patients with unstable epilepsy

• Serotonin syndrome/ neuroleptic malignant syndrome

• Cognitive and motor disturbances

• Angle-closure glaucoma

• Caution in patients with a history of mania/hypomania and discontinue use in any patient entering a manic phase

• Aggression/agitation

• Caution with concurrent use of electroconvulsive therapy (ECT)

• Hyponatremia

• Caution in patients with severe renal insufficiency

• Not recommended during breastfeeding

• Dosage adjustment in elderly patients

For more information: Consult the Trintellix Product Monograph for important information relating to adverse reactions, drug interactions and dosing information not discussed in this piece. The Product Monograph is also available by calling 1-800-586-2325.

DSM= Diagnostic and Statistical Manual of Mental Disorders ; MADRS=Montgomery-Åsberg Depression Rating Scale; MDE=major depressive episode; SDS=Sheehan Disability Scale

‡ Double-blind, fixed-dose, placebo-controlled study of 608 patients aged 18-75 years with a primary diagnosis of recurrent MDD according to DSM-IV-TR criteria, a current MDE >3 months’ duration and a MADRS total score ≥26. Patients were randomized to Trintellix 15 mg, 20 mg (10 mg/day during Week 1 and 15 or 20 mg/day from Weeks 2 to 8) or placebo for 8 weeks. Mean baseline MADRS total scores were 31.5 for placebo, 31.8 for Trintellix 15 mg and 31.2 for Trintellix 20 mg. Mean baseline SDS total scores were 19.8 for placebo, 20.6 for Trintellix 15 mg and 20.7 for Trintellix 20 mg. Mean baseline SDS work scores were 6.3 for placebo, 6.8 for Trintellix 15 mg and 6.9 for Trintellix 20 mg. Mean baseline SDS social scores were 6.8 for placebo, 6.9 for Trintellix 15 mg and 6.8 for Trintellix 20 mg. Mean baseline SDS family scores were 6.9 for placebo, 6.7 for Trintellix 15 mg and 7.0 for Trintellix 20 mg.1,5

References:1. Trintellix Product Monograph. Lundbeck Canada Inc., August 4, 2021. 2. Kennedy SH, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 3. Pharmacological treatments. Can J Psychiatry 2016;61(9):540-60. 3. Data on file. Trintellix Coverage Canada. Lundbeck. December 2021. 4. Data on file. Lundbeck Canada Inc., January 2023.

5. Boulenger JP, et al . Efficacy and safety of vortioxetine (Lu AA21004), 15 and 20 mg/day: a randomized, double-blind, placebo-controlled, duloxetine-referenced study in the acute treatment of adult patients with major depressive disorder. Int Clin Psychopharmacol 2014;29(3):138-49.

Trintellix ® is a registered trademark of H. Lundbeck A/S, used under license by Lundbeck Canada Inc.

Contents

JANUARY/FEBRUARY 2023 [VOL.10 NO.1]

5 / Editor’s Message

Is this the year you find your ‘Ikigai?’

8 / Meet...

This issue: Margaret Wing, CEO of the Alberta Pharmacists’ Association / Photography by Curtis Trent

12 / Cover Story

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

/ Photography by Mike Ford

21 / Drug News

A review of new launches, new indications, new dosage forms, discontinued drugs and Health Canada Advisories

/ By Lu-Ann Murdoch

25 / Practice Experts

Minor Ailment Therapeutics / By Nardine Nakhla / P. 25

Practical Diabetes / By Shelley Diamond / P. 28

Therapeutic Issues / By Jillian Reardon / P. 30

34 / Clinical Feature

Environmental stewardship and medication management / By Suzanne Singh

38 / The Closer

A dose of strategy: Five common mistakes that hold us back / By Amy Oliver

CONTINUING EDUCATION LESSON INSIDE

PAGES 17-20

The pharmacist’s role in hypoglycemia in patients with diabetes treated with basal insulin (0.75 CEUs) Made possible by Novo Nordisk Canada

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Contents copyright © 2023 by EnsembleIQ; may not be reprinted without permission. EnsembleIQ does not assume liability for content. Pharmacy Practice + Business receives unsolicited materials (including letters to the editor, press releases, promotional items and images) from time to time. Pharmacy Practice + Business, its affiliates and assignees may use, reproduce, publish, re-publish, distribute, store and archive such unsolicited submissions in whole or in part in any form or medium whatsoever, without compensation of any sort. Pharmacy Practice + Business, established in 1985, is published 7 times a year. Pharmacy Practice + Business is abstracted in International Pharmaceutical Abstracts (IPA). ISSN 08-29-2809. Publications mail agreement no. 42940023.

Editor’s Message

Is this the year you find your ‘Ikigai?’

In our first issue of 2023, we are very pleased to introduce the winners of our inaugural Pharmacy Practice + Business Awards

What was immediately obvious about our winners (and the majority of the entrants, for that matter) is that each one has found their unique place in the world of pharmacy by following a passion of their own which also meets a specific patient need. Lindsay Dixon, creator of the popular and often-shared Friendly Pharmacy 5 YouTube channel, has the storytelling bug and is compelled to combat misinformation. Fairuz Siraj has a coaching heart and gets excited about helping patients take better control of their health. Dean Elbe is passionate about helping new health practitioners serve adolescents struggling with their mental health to gain the optimal benefits from their medications. Andrew Schonbe believes sexual health information and services should be easily available without judgment to everyone without discrimination. Technician Kayla Ross finds joy in relieving cancer patients and their families of the burden of sorting out drug access and coverage issues. And Jonathan Lu and his Silver Fox Pharmacy team found their purpose during the COVID-19 pandemic by coming alongside overextended long-term care workers to support them, in any and all ways they could, ensuring continuity of care to vulnerable elderly patients.

When someone hits the sweet spot of turning their passion and skills towards a known service gap, that’s when magic happens. Lu refers to this in his profile when he says he strives to meet the Japanese philosophy of Ikigai: doing what you love, are good at, can be paid for and the world needs.

Our Strategy columnist Amy Oliver stressed this very message in her keynote at Pharmacy U Vancouver last November. Oliver spoke in depth about the ideal of pharmacists who combine their passion and their skills in a way that meets a demonstrated societal need.

Readers of this column know that encouraging pharmacists to find their perfect niche in the profession is one of my personal passions. Meeting our award winners has only confirmed my belief that everyone should have the chance to find satisfying, rewarding work that they love—that also benefits their world.

Need inspiration? Come hear Oliver speak at Pharmacy U Toronto, April 1. Or click on the Finding Your Niche or Innovators tabs on our website (CanadianHealthcareNetwork.ca) for reams of ideas. And keep reading in 2023.

VICKI WOOD

vwood@ensembleiq.com

FIND US ONLINE

The online home for Pharmacy Practice + Business is CanadianHealthcareNetwork.ca

Registration is easy and free to qualified pharmacy professionals. @Ppr_plus @PharmacyPracticePlusBusiness

FOR WHEN A STRIKES MIGRAINE

Pr CAMBIA® (diclofenac potassium) is indicated for the acute treatment of migraine attacks with or without aura in adults 18 years and older.

Completely dissolve one sachet of CAMBIA® in 30–60 mL of water only and drink immediately1* 30 mL = 2 Tbsp

Significantly measurable plasma levels were observed within 5 minutes of CAMBIA dosing, in fasted healthy individuals1†

Tmax was achieved1,2†:

• After ~15 minutes under fasting conditions‡

• After ~10 minutes under fed conditions§

Tmax: Time to reach maximum plasma levels.

*No other liquids should be used with CAMBIA.

† Clinical significance is unknown.

‡Range: 10–40 minutes.

§Range: 5 minutes–4 hours.

Please refer to the Product Monograph for complete administration information.

Indication and clinical use:

PrCAMBIA® (diclofenac potassium) is indicated for the acute treatment of migraine attacks with or without aura in adults 18 years and older. Efficacy and safety of CAMBIA beyond a single dose have not been studied.

CAMBIA is not intended for the prophylactic therapy of migraine or for use in the management of hemiplegic, basilar or ophthalmoplegic migraine. Safety and efficacy have not been established for cluster headache which is present in an older, predominantly male population.

Geriatrics (> 65 years of age): Safety and efficacy of CAMBIA have not been studied in individuals over 65 years of age, and its use in this population is not recommended.

Pediatrics (< 18 years of age): Safety and efficacy of CAMBIA have not been in patients below the age of 18 years, and its use in this population is contraindicated.

Contraindications:

• Perioperative pain setting of coronary artery bypass graft surgery;

• Third trimester of pregnancy;

• Nursing women;

• Severe uncontrolled heart failure;

• History of asthma, urticarial, or allergic-type reactions after taking ASA or other NSAIDs;

• Active gastric/duodenal/peptic ulcer, active GI bleeding;

• Cerebrovascular, or other bleeding disorders;

• Inflammatory bowel disease;

• Severe liver impairment or active liver disease;

• Severe renal impairment or deteriorating renal disease;

• Known hyperkalemia;

• Children and adolescents less than 18 years of age

Most serious warnings and precautions:

Risk of CV adverse events: Diclofenac is associated with an increased risk of cardiovascular adverse events (such as myocardial infarction, stroke or thrombotic events) that is comparable to COX-2 inhibitors and which can be fatal. The risk may increase with duration of use. Metaanalysis of randomized clinical trials comparing several difference NSAIDs suggest that diclofenac, particularly at higher doses, is associated with an increased risk of cardiovascular adverse events that is comparable to COX-2 inhibitors. Large population-based observational studies conducted in the general population also support these findings. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk. To minimize the potential risk for adverse CV event, CAMBIA should be used for the shortest possible duration.

Treatment with CAMBIA is not recommended in patients with preexisting cardiovascular disease (congestive heart failure NYHA II--IV, ischemic heart disease, peripheral arterial disease), cerebrovascular disease, uncontrolled hypertension, and caution should be exercised in patients with risk factors for cardiovascular disease (e.g. hypertension, hyperlipidemia, diabetes mellitus and smoking). These patients should be treated with CAMBIA only after careful consideration. Use of NSAIDs, such as CAMBIA can promote sodium retention in a dose dependent manner, which can result in increased blood pressure and/or exacerbation of congestive heart failure.

Risk of GI adverse events: Use of NSAIDs such as CAMBIA is associated with an increased incidence of gastrointestinal adverse events (such as peptic/duodenal ulceration, perforation, obstruction and GI bleeding) which can be fatal. Elderly patients are at a greater risk.

Risk in pregnancy: Caution should be exercised in prescribing CAMBIA during the first and second trimesters of pregnancy. Use of NSAIDs at approximately 20 weeks of gestation or later may cause fetal renal dysfunction leading to oligohydramnios and neonatal renal impairment or failure. CAMBIA is contraindicated for use during the third trimester because of risk of premature closure of the ductus arteriosus and uterine inertia.

Other relevant warnings and precautions

• CAMBIA cannot be replaced by any other diclofenac formulations, nor is it possible to convert dosing from any other formulation of diclofenac to CAMBIA;

• Not recommended in individuals over 65; increased risk of adverse events; safety and efficacy have not been studied;

• Special care in frail or debilitated patients;

• Caution in the treatment of elderly patients who are more likely to be suffering from impaired renal, hepatic or cardiac function;

• Hepatic, renal and genitourinary impairment;

• Patients with a history of peptic/duodenal ulcer disease or gastrointestinal bleeding;

• Use in phenylketonurics patients;

• Use in women attempting to conceive, first and second trimesters of pregnancy;

• Caution in patients with Helicobacterpylori infection, prolonged use of NSAID therapy, excess alcohol intake, smoking, poor general health status;

• Observation for patients with hemophilia or platelet disorders;

• Monitor patients taking warfarin;

• Blood dyscrasias and antiplatelet effects;

• Use in patients with asthma, seasonal allergic rhinitis, swelling of the nasal mucosa, chronic obstructive pulmonary diseases or chronic infections of the respiratory tract, Quicke’s edema or urticarial, and patients who are allergic to other substances;

• Serious skin reactions;

• May mask signs and symptoms of infectious disease;

• May cause photosensitivity and vision changes upon exposure to sunlight or UV light;

• Neurological adverse events including blurred or diminished vision, decreased alertness or depression;

• Concomitant use with: other NSAIDs, with the exception of low-dose ASA for cardiovascular prophylaxis; diclofenac sodium containing products; anti-coagulants; anti-platelet agents; oral corticosteroids; Selective Serotonin Reuptake Inhibitors; drugs that are known to be potentially hepatotoxic (e.g. acetaminophen, certain antibiotics, antiepileptics)

For more information:

Please consult the Product Monograph at: https://www.miravohealthcare. com/wp-content/uploads/2021/12/Cambia-PM-ENG-Dec2021.pdf for adverse reactions, interactions, dosing and conditions of clinical use. The Product Monograph is also available by calling Miravo Medical Information at 1-866-391-4503.

REFERENCES: 1. CAMBIA ® Product Monograph, Aralez Pharmaceuticals Canada Inc. December, 2021. 2. Diener HC, Montagna P, Gacs G, et al. Efficacy and tolerability of diclofenac potassium sachets in migraine: a randomized, double-blind, cross-over study in comparison with diclofenac potassium tablets and placebo. Cephalagia 2006:26:537–547.

Describe your place in the world of pharmacy.

Throughout my career as a pharmacist, I have followed a path that has naturally led me to become an advocate for the profession. I am so lucky to have found my perfect fit as RxA’s CEO. I’m a cheerleader, a strategist, a defender, a dreamer and a risktaker. I am the eternal advocate for the profession.

What’s your personal “mission statement”?

To be genuine and true to myself. Practise what I believe in, keep an open-mind, not automatically accept the status quo, stay progressive and keep moving forward.

What motivates you?

Talking to other pharmacists about pharmacy. There is no shortage of challenges or pressing issues to deal with. It’s motivating to find solutions to problems and to have a great team of colleagues to work with, from board members to staff. Their passion and commitment are contagious.

How do you define success for yourself?

Success for me is loving the work I do and knowing that it makes a difference. Working with policy makers, regulators, researchers, academics, administrators and pharmacists, then being able to see the profession make a difference in people’s lives is very rewarding.

What’s the best part of what you do in your career?

The people and the friendships that I’ve developed are the best.

The world of pharmacy continues to have emerging complex challenges and solutions won’t come easy. They will require commitment from many stakeholders, and I believe all these relationships matter. I have come to truly appreciate the professional relationships that I have developed throughout my career.

What’s your favourite thing to do when you’re not working?

In the summer, I love outdoor activities like walking the dogs and riding my KTM 790 Adventure motorcycle. During the winter, my two favourite pastimes are sewing and baking.

Favourite food?

I am very lucky to have a son who is a chef. He cooks many outstanding dishes. Though if I had to pick only one, I would go with his braised short ribs. Yum!

Any pets?

My husband and I have grown a fantastic pet family since COVID-19 began. First was Elsa, who we got as a kitten in July 2020. In July 2021 came Zoey, an Italian Mastiff. Then Buddy, a stray tomcat, in January 2022. And finally Tikka, a Black Russian Terrier, in April 2022. They bring us so much joy and often laughter every single day. What is really amazing is that they all get along so well. But now I am a little worried because my husband mentioned that he saw another stray cat hanging around the backyard…

What’s your secret to good mental and physical health?

My pets play a major role in helping me maintain both positive mental health and good physical health. I walk Zoey and Tikka daily. Both Zoey and Buddy practice yoga with me, but if I am honest, Zoey is mostly in the ‘couch potato’ position for the entire session.

What’s next for Margaret Wing?

One of the lessons I learned from COVID-19 is that you can’t see what is around the corner. In recent months, my husband and I have found ourselves in the role of caregivers to our parents. My Dad would have said, “Life is a beautiful ride. Keep your foot on the gas and don’t be scared to live it,” which I fully intend to do.

/ Photography by Curtis Trent

CEO of the Alberta Pharmacists’ Association (RxA)

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What is BLEXTEN indicated for?

PrBLEXTEN® (bilastine) is indicated for the symptomatic relief of nasal and non-nasal symptoms of seasonal allergic rhinitis (SAR) and for the relief of the symptoms associated with chronic spontaneous urticaria (CSU) (e.g. pruritus and hives), in patients 4 years of age and older with a body weight of at least 16 kg.1

What are the pediatric formats?

BLEXTEN offers the flexibility of two pediatric dosage formats. The pediatric formats are suitable for children 4-11 years old with a body weight of at least 16 kg.1

BLEXTEN Orodispersible Tablets (ODT)

• Grape flavour, 10 mg tablet once daily

• To be placed in the mouth where it disperses rapidly in saliva, so it can be easily swallowed

• Convenient tablet formulation that can be taken without water

BLEXTEN Oral Solution

Raspberry flavour in a clear, colourless liquid

• 2.5 mg/mL oral solution; 4 ml equivalent to 10 mg bilastine per dose

• A convenient dosing cup is provided with a mark of 4 mL

Ages 12+ 20 mg tablet once daily

• No dose adjustments needed for elderly patients, kidney disease or liver disease.

Administraton1

• BLEXTEN should be taken without food or grapefruit juice or other fruit juices, as these dietary compounds may decrease the effect of bilastine.

• The BLEXTEN ODT is to be placed in the mouth where it disperses rapidly in saliva, so it can be easily swallowed. Alternatively, the ODT may be dispersed in water before administration. Grapefruit juice or any other fruit juice should not be used for dispersion.

Counselling tips for parents

• Patients should be instructed to take BLEXTEN and wait for one hour before taking food or fruit juice; or if food or fruit juice has been taken to wait for two hours before taking the medication.

• The maximum daily dose for pediatrics (ages 4-11) is 10 mg (1 orodispersible tablet or 4 mL oral solution); for ages ≥12, the maximum daily dose is 20 mg (1 tablet). See the Product Monograph for complete dosing and administration information

Demonstrated efficacy data in adults and adolescents - Seasonal allergic rhinitis

Blexten 20 mg significantly reduced Total Symptom Score area under the curve (TSS AUC) from baseline to day 14 vs. placebo (98.4 vs. 118.4, p<0.001), but did not differ from the active comparator.1‡

BLEXTEN Tolerability ProfileAdults and Adolescents

BLEXTEN was generally well tolerated with treatment emergent adverse events equal to placebo.1à

Treatment-emergent adverse reactions reported in ≥1% of subjects treated with BLEXTEN 20 mg in Phase 2 and 3 trials

BLEXTEN is covered under most private insurance plans.

Clinical use:

BLEXTEN should not be administered to children below 4 years of age and under 16 kg due to limited data in this population.

Contraindication:

• History of QT prolongation and/or torsade de pointes, including congenital long QT syndromes.

Relevant warnings and precautions:

• QTc interval prolongation, which may increase the risk of torsade de pointes.

• Use with caution in patients with a history of cardiac arrhythmias; hypokalemia, hypomagnesaemia; significant bradycardia; family history of sudden cardiac death; concomitant use of other QT/ QTc- prolonging drugs.

P-glycoprotein inhibitors may increase plasma levels of BLEXTEN in patients with moderate or severe renal impairment; co-administration should be avoided.

BLEXTEN should be avoided during pregnancy unless advised otherwise by a physician.

• A study was performed to assess the effects of BLEXTEN and bilastine 40 mg on real time driving performance compared to placebo. Bilastine did not affect driving performance differently than placebo following day one or after one week of treatment. However, patients should be informed that very rarely some people experience drowsiness, which may affect their ability to drive or use machines.

For more information:

Please consult the product monograph at www.miravohealthcare.com/wp-content/uploads/ 2021/08/ Blexten-PM-ENG-Aug2021.pdf for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-866-391-4503.

References

1. Blexten Product Monograph. Aralez Pharmaceuticals Canada Inc. 2021.

What is the worldwide patient exposure for BLEXTEN?*

BLEXTEN 10 mg

• More than 2.2 million patients treated

• Available in 58 countries

• Pediatric formats available in Canada since February 2022

BLEXTEN 20 mg

• More than 213 million patients treated

• Available in 121 countries

• Available in Canada since December 2016

‡ Double-blind, placebo-controlled, randomized, activecontrolled parallel-group trial of 720 patients with SAR, 12-70 years old. Patients were randomized to BLEXTEN 20 mg, desloratadine 5 mg or placebo once daily for 14 days. Primary endpoint was change in AUC of the TSS from baseline to day 14. TSS was comprised of the reflective total nasal symptom score (rTNSS) and the reflective total non- nasal symptom score (rTNNSS).

* As of August 31, 2021, the estimate from internal data of patient exposure is based on units sold of the defined daily dose of 10 mg (pediatric) and 20 mg (adult) bilastine and the mean treatment duration of 3 weeks.

• If it is difficult to ensure that your child does not eat anything for one hour after taking BLEXTEN, try administering it before bedtime.

Aralez Pharmaceuticals Canada Inc.* 6733 Mississauga Road, Suite 800, Mississauga, Ontario L5N 6J5

BLEXTEN is a registered trademark of FAES used under license by Aralez Pharmaceuticals Canada Inc.

*A wholly owned subsidiary of Searchlight Pharma Inc.

Continuing Education

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

Where GLP1-RAs fit in the journey to improve outcomes for patients with type 2 diabetes

Author(s): Melinda Franklin, B.sc. (Pharm), CDE

Sponsored by Novo Nordisk Canada Inc. 1.0

Maximizing influenza vaccination in older adults

Author(s): Victor Wong, PharmD; and Tara Zheng, PharmD

Sponsored by Seqirus, A CSL Company

FOR

A Guide to Caring For Seniors

Author(s): Sarah-Lynn Dunlop, BA, MEd, RPhT

Sponsored by Teva

1.25 CEUs

Hidradenitis

Suppurativa: Breaking the Prejudices to Help Improve the Patient Journey

Author(s): Michael Boivin, Bsc Pharm; Dr. Parbeer Grewal; Ravina Sanghera-Grewal, BSc PHarm, PharmD

Sponsored by AbbVie

Cell-Based Influenza Vaccines: What Pharmacists Need to Know

Author(s): Dr. Sherilyn Houle, BSP, PhD, CTH, AFTM RCPS(Glasg)

Sponsored by Seqirus, a CSL Company

1.0 CEU

Improving workflow efficiency in the pharmacy

Author(s): Barbara Violo, B.Sc.H.Msc.Phm.R.Ph, and Deven Saxena

Sponsored by Teva

1.25 CEUs

2022

AND THE WINNERS ARE…

The Pharmacy Practice + Business Awards recognize Canadian pharmacy professionals providing exceptional patient care and demonstrating creativity and innovation in pharmacy practice. We are pleased to introduce this year’s winners.

ABOUT THE PROCESS

In 2022, we opened the awards for entries in six categories and asked a panel of six judges to review and score each entry. The entries with the highest total scores in each category were declared the winners.

THANK YOU TO OUR JUDGES

BUSINESS INNOVATION

Andrew Schonbe

Breaking down barriers to sexual health services

Why he won: In 2019, pharmacist Andrew Schonbe launched the country’s first-ever online PrEP service to address significant gaps in access to HIV prevention medication and sexual health services. Today, his collaborative PrEP Clinic/Ontario Prevention Clinic + pharmacy have helped more than 5,000 Ontarians and counting. Plus, in addition to providing in-person services in Toronto, he and his team offer satellite physical locations in Ottawa and Brampton to underserviced community members in collaboration with local AIDS service organizations. To ensure easy access to services, there is a late-night phone line, text and email services, walk-in, evening and online options—and a multilingual pharmacy team. The pharmacy also ships free harm reduction tools and offers naloxone counselling services.

What one judge said: “The Prep Clinic is reaching a muchunderserved community and breaking down barriers to access.”

Schonbe says pharmacists are “the literal glue that hold the team together” and are fully embedded in patient care. They work in an augmented clinical role and are the key point of contact for patients, while leading interprofessional practice with pharmacy technicians, nurse practitioners, nurses and social workers on the team. With a more appointment-based model, pharmacists can also have private, thorough one-onone consultations. This has maximized patient care levels while elevating respect for the profession and role of the pharmacist.

Ashwin Juneja, Samier Kamar, Graham MacKenzie, Carlene Oleksyn, Amy Oliver and Bing Wang

Q&A with Andrew Schonbe

What do you most enjoy about what you do?

I love the spontaneity and freedom to be creative in this space. I really feel like it is limitless. Almost daily, I think of new ideas or ways to engage with the community and can very quickly bring these to fruition. It’s very rewarding to be able to quickly improve the lives of patients with new programs and services—to just go out and make it happen.

What is your biggest challenge?

Spreading myself a bit too thin at times and having focus in too many directions. It can be difficult to balance the limitless nature of innovation that I love with the realities of how many things you can do at once. It’s really a balancing act but organization, delegation and teamwork are essential to navigate this.

Is there someone who mentored you, or served as a role model?

While I have not had a mentor or role model personally, I have taken my learnings and experiences to be a mentor to my current pharmacy team. It has been rewarding to inspire and uplift those newer practitioners.

What’s one piece of advice you’d give a young pharmacist who wants to make a difference in their career?

Keep an open mind and look beyond your horizons. Sometimes we get comfortable within four walls of a “safe” role or employer, which prevents us from conceiving something outside the box. This stunts innovation potential that could be hiding deep inside you. Attend events and conferences, read what others are doing, and reach out to pharmacists in spaces that are interesting to you to share their experiences and open a dialogue.

What’s next for you—any goals or dreams you hope to achieve in the future?

I hope to continue to grow the pharmacy-clinic and reduce barriers to access for even more Ontarians. This includes an increased focus on rapid PrEP starts, preparing for the launch of injectable PrEP, and integrating doxy PrEP/PEP into practice.

What’s your favourite way to spend time outside of work?

I’m pretty much always on the go with work these days but I would say taking care of my pup (and our pharmacy mascot) Achilles. He forces me to take those pauses and go for a breath of fresh air—literally.

PRACTICE INNOVATION Dean Elbe

Why he won: Dean Elbe has developed formalized psychiatry resident/fellow rotations, which he precepts as a clinical pharmacy specialist in child and adolescent mental health. Being on rotation with Elbe for four to six weeks, with a sole focus on managing pharmacotherapy for multiple patients, has given psychiatry residents some much-needed repetition to make the transition to prescribing much easier for attending physicians, and shown them how to effectively collaborate with pharmacists after they enter practice.

Since starting these rotations in 2016, 15 child and adolescent psychiatry (CAP) fellows have completed

the rotation—usually alongside a pharmacy student or resident—and the rotation is in high demand.

What one judge said:

“Very unique and creative idea. To have a subspeciality of medical residents undergo a pharmacyspecific rotation prior to graduation is unparalleled. Well done!”

CAP fellows are expected to provide pharmaceutical care services, patient monitoring, respond to clinical inquiries and drug information requests, participate in journal clubs performing critical evaluation of pharmacotherapy trials, and deliver a case presentation to the pharmacy department during their rotation.

For both the psychiatry fellow and the pharmacy learner there are many opportunities for co‐teaching and the chance to learn and understand the perspective and skills of the other profession. This has encouraged a more collegial working relationship overall.

Q&A with Dean Elbe

What do you most enjoy about what you do?

In terms of clinical care, I enjoy seeing a patient be discharged with improved functioning compared to how they were at the time of admission, and knowing that the medication management services performed by me or my residents in training made a difference. Occasionally, former patients will come by the hospital to let the care team know they graduated from university or are working in their chosen industry, and that always puts a smile on my face. In terms of teaching, I most enjoy witnessing that “a-ha!” moment for pharmacy residents and psychiatry fellows when I’m able to help them gain clarity on a medicationrelated concept they were struggling with, that they turn around and put into action to improve patient care.

Is there someone in particular who mentored you, or served as a role model?

So many pharmacists have mentored me during my career and served as role models over the past 30-plus years. To name just a few: Doug Danforth (Westminster West End Pharmacy), Dr. Peter Jewesson and Dr. Nilu Partovi (both at Vancouver General Hospital), Helen Lee (Lower Mainland Pharmacy Services Informatics) and Dr. Ric Procyshyn (BC Children’s Hospital Research Institute).

What’s your favourite way to spend time outside of work?

It’s a three-way tie between playing late-night hockey with the Pharmacy Line (my linemates Malcolm, Benny, Iqbal and Chi are all pharmacists), playing bass in our 90s alternative rock band, Bitter Pills (https://www.youtube.com/@ bitterpills4108) and exploring new restaurants around Vancouver with my wife Lisa.

What’s next for you—any goals or dreams you hope to achieve in the future?

I am so excited to launch www.drugnutritioninteractions.com in 2023. Having worked and presented with a prominent U.S. dietitian in this area for a number of years, I really feel like launching this site is a kind of culmination of my clinical work and my interest and passion for information systems and website design.

Photos: Andrew Schonbe by Jennifer Roberts, Dean Elbe supplied

PUBLIC PROTECTOR

Jonathan Lu, Silver Fox Pharmacy

Why they won: When Ontario’s long-term care pharmacy sector was impacted by a transition from a fee-forservice to capitation model in 2020, the result was significant cuts to pharmacy operations. But rather than lay off staff and reduce operations for seniors, Silver Fox Pharmacy adapted its service to address those early needs during the pandemic. As a family-owned senior care pharmacy, Jonathan Lu and his team were quick to act to provide the best care possible.

Q&A with Jonathan Lu

What do you most enjoy about what you do?

I’ve been able to make my work part of my life, or to borrow a ikigai. My day-to-day tasks are varied and engaging, whether it’s direct patient care or IT development. While working in pharmacy has been hard these past years with strains on funding and staffing, there is still work to be done and I’ve been lucky enough to have some amazing colleagues and a stellar team that make it happen.

Is there someone who mentored you, or served as a role model?

foster excellence in a pharmacy practice, whether it be through procedures, culture or technology.

Name something you’re really good at, that has nothing to do with pharmacy. I’ve always had a soft spot for the arts. I used to teach violin and I’m a competent enough multiinstrumentalist.

What’s one piece of advice you’d give a young pharmacist who wants to make a difference in their career? Sometimes there is a difference between hard work and smart work.

What’s your favourite way to spend time outside of work? Every day after work I do a workout to be in my body and take a break from my head, which I think has helped me become more resilient, healthy and balanced.

What one judge said:

“In spite of facing huge cutbacks from government, this pharmacy stepped up for one of the most vulnerable sectors to address COVID-specific problems in longterm care—even putting their own health at risk.”

Among numerous initiatives championed by the team was one of the first LTC-specific e-prescribing platforms that let prescribers order and review medications securely and remotely, with nurse access to complete order processing and immediate transmission to pharmacy. As evidence emerged around best practices in COVID-19 care, Silver Fox Pharmacy worked with medical directors and leaders in the space to develop COVID order sets to guide clinical decisions, which were upated as new information came to light. This has included a dedicated Paxlovid order set to guide prescribing, clinical decisions and document eligibility.

The pharmacy also implemented an outbreak on-call pharmacist to support clinical needs after hours, and partnered with Silver Lining Health Care to ensure all their homes received required medical supplies, including surgical masks, N95 masks, gloves, gowns, sanitizer and face shields.

Even when the majority of nursing staff were off due to illness, pharmacy staff went on-site and supported them daily for weeks until staffing stabilized. Having staff on the front lines further highlighted pharmacy’s role in long-term care and its potential to help alleviate and pilot important care decisions.

It’s hard to pick a single role model because I’ve been shaped by a diverse community of people. The ethics of daily life provided by my family inform my work and continuous learning. Colleagues and preceptors have shaped my professional practice. My friends ground me in life, and some motivate me to be a better person.

What is your biggest challenge?

Lately, it’s determining the boundaries of a sustainable and scalable pharmacy practice. The past three years have highlighted the importance of work-life balance and the limits of individual excellence, so it has been a question of how to sustain and

Otherwise, I really enjoy communal activities—I grew up with Italian neighbours and my family have carried the tradition of tomato passata since I was eight years old. One of my favourite annual events is hosting a dumpling- and lantern-making party for my friends.

What’s next for you—any goals or dreams you hope to achieve in the future?

I’m trying to improve my Mandarin and keep my indoor plants alive.

RAISE YOUR VOICE

Lindsay Dixon

A credible voice dispelling misinformation

Why she won: It all started in 2020 with a series of videos to combat misinformation circulating around COVID-19. Since then, Lindsay Dixon has posted some 120 videos to her popular Friendly Pharmacy 5 YouTube channel (https:// www.youtube.com/channel/UCFhP_ Yn_5xF0_bRDmaG_5qg), which reached more than one million views in August 2022 and currently has more than 15,500 subscribers. Dixon is using her video platform to empower community members to better understand health issues and advocate for their own health through easy

Rising up for the most vulnerable of populations

to understand, science-based education that their doctors or other healthcare professionals may not have the time or thought to share.

Dixon’s videos have included more than 30 interviews with healthcare experts from around the world, covering topics such as diabetes remission, childhood vaccination, vitamins and supplements, polypharmacy, seasonal affective disorder and more. She also educates people about the pharmacy profession and the value of the pharmacist through appearances on local news and radio.

Q&A with Lindsay Dixon

What do you most enjoy about what you do?

Every video is an opportunity to create change in the mind of the viewer, to help them understand their health better, and to help them value their pharmacist or healthcare provider that much more. Using storytelling to elevate the role of pharmacists and other healthcare professionals, by providing evidence-based education on a platform where the public is actively searching for solutions to their health problems, is truly the most rewarding part of this work.

What is your biggest challenge?

There are endless possibilities for this type of platform. I have so many ideas every day about what we could do to reach more people and increase our impact, but at the moment there is a very real limit of both time and resources.

Is there someone who mentored you or served as a role model?

I have been privileged to have had many influential leaders in my life. Most recently, I started working with Heart Pharmacy Group in Victoria, B.C. I cannot say enough good things about them and how they treat their people. In particular, President Rasool Rayani has been an incredible mentor and encourager. We meet for 30 minutes every other week and he always seems to be at least 10 steps ahead of me. When you are trying to do something new,

there are times when you really need someone with a big vision to remind you of what’s possible.

What advice would you give a young pharmacist who wants to make a difference in their career?

Ask yourself who you want to reach and how you can best serve those people. Stay focused, be generous and always give more than you take. Go after that thing that interests you, even if it seems unconventional. Choosing something now does not mean that you cannot do other things in the future. Find a mentor who believes in you and commit to getting 1% better every day.

What’s your favourite way to spend time outside of work?

I read books about marketing and the creator economy, or listen to podcasts about innovators in healthcare or digital health while I’m exercising. I read the latest news on Canadian Healthcare Network and plan out videos and infographics. The only way I truly turn this off is when I’m busy with my kids. Aside from learning more about all things content creation, and the future of healthcare, my favorite moments are when I’m surrounded by nature while on some type of adventure with my family.

What’s next for you—any goals or dreams you hope to achieve in the future?

Partnering with other innovators in the healthcare industry, launching an audio podcast of the interviews from the channel and creating online courses with subject matter experts are short-term goals. Eventually, I would love to write a book and create a framework to help pharmacy owners and innovators create their own content and get their message out into the world.

What one judge said:

“Phenomenal work!

Her YouTube channel has garnered more than half a million views on one video alone.”

RISING STAR

Fairuz Siraj

Empowering patients through education

Why he won: As a recent pharmacy graduate, Fairuz Siraj is already making an indelible impact on both patients and the profession. His unique and comprehensive consultation service for patients with diabetes or those suffering with migraine empowers them with knowledge to optimize their therapy and improve their quality of life.

During migraine consultations, for example, Siraj educates patients on migraine pathophysiology and non-pharmacological measures, then reviews their past and current medication use to assess migraine frequency, severity and risk of medication overuse headache. Based on his assessment, he provides recommendations to the patient’s doctor and/or neurologist to optimize therapy—and follows up to reassess as needed.

What one judge said: “So many accomplishments in so little time; and the impact of his outreach is Canadawide.”

Passionate about inspiring others to move the profession of pharmacy forward, Siraj is now working with Migraine Canada to develop a Migraine Educator Certification for pharmacists. He has been featured in media outlets on how pharmacists can address the primary care access challenges patients are currently facing in B.C., and is a local speaker/educator on chronic disease topics such as diabetes and migraine management.

Q&A with Fairuz Siraj

What do you most enjoy about what you do? I absolutely love patient consultations. This allows me to connect with them, empower them with appropriate knowledge and provide them with multiple medication options. It also gives patients an active role in decisionmaking about managing their conditions. Patients taking ownership in managing their condition is music to my ears.

What is your biggest challenge?

The biggest challenge for most community pharmacists, including myself, is the lack of individual billing codes. The current model for pharmacy cognitive services reimbursement is limited, and unique consultation services such as the ones I provide for migraine management, are not recognized by government and third-party insurance. Furthermore, the

Photos: Jonathan Lu by Mike Ford, Fairuz Siraj by Jon-Mark Photography, Lindsay Dixon supplied

lack of individual billing codes means that pharmacists must be attached to a pharmacy to claim reimbursement for cognitive services, which limits our abilities to be entrepreneurs and start our own businesses. I believe that if pharmacists were given individual billing codes, many more would start their own ventures and not be tied down to their dispensing roles.

Is there someone who mentored you, or served as a role model?

There are so many, but here is a short list. Andre Gauthier (Walmart Pharmacy in Hawkesbury, ON.). His ability to connect with patients and his knowledge about therapeutics really inspired me to pursue a career as a pharmacist. Terralyn Scharnatta, (Save-On-Foods in Kelowna, B.C.) was very supportive while I was a student and allowed me to learn, grow and develop skills that I use today. Darin Shaw (Kelowna General Hospital). He shared practical, real-life knowledge that helped me be ready to practise as a pharmacist.

We still keep in touch and talk about patient-centred care.

Name something you’re really good at, that has nothing to do with pharmacy.

I think I’m pretty average at everything. But I do like to think that I’m kind of a comedian and I like making people laugh with a good story. However, if you asked my wife, she would advise me to not quit my day job anytime soon.

What advice would you give a young pharmacist who wants to make a difference ?

However impossible it may seem and whatever the obstacles are, if you believe in yourself, are willing to put in the hard work and are not afraid to fail, you will succeed.

What’s next for you ?

I have a few collaborative projects in mind for chronic disease management that I’m hoping to work on for 2023. The aim is to optimize patients’ chronic disease management and show the value that pharmacists can play in a collaborative setting.

TECHNICIAN INITIATIVE

Kayla Ross

Spearheading new roles for pharmacy techs in cancer care

Why she won: With her unique team of Drug Access Navigators in Atlantic Canada, pharmacy technician Kayla Ross helps to eliminate financial barriers around medication access so cancer patients can focus on their health and treatment. As hospital employees, navigators work on a referral from the oncology team to investigate and coordinate funding for a patient’s prescribed therapy, staying up to date on drug plan submission processes, temporary drug release programs, and financial assistance options. The ultimate goal is to keep the patient and the oncology team informed, while also keeping the treatment plan moving smoothly.

With no formal training for this role, most navigators learn on the job. In 2020, Ross became the co-founder and vice president for Atlantic Canada Oncology Drug Access Navigators Association (https://acodana.ca), a not-for-profit organization with a goal to improve the quality and availability of

What one judge said:

“This is a great ‘best practice’ that is shareable and shows real innovation and leadership.”

oncology drug access navigator services throughout the region. Since its inception, the group has been instrumental in standardizing the role of oncology navigators in the region. Its website features education opportunities and information-sharing, as well as resources for cancer patients/their families, healthcare professionals and plan and program representatives. Since Ross become the first Drug Access Navigator in Nova Scotia in 2015, there are now a total of 22 navigators across the province (18 of whom have a pharmacy technician background) and counting!

Q&A with Kayla Ross

What do you most enjoy about what you do?

Helping others, specifically cancer patients! The role of the Drug Access Navigator has endless opportunities. Finding innovative ways to help patients gain access and funding for their treatment lifts one of the many burdens these patients and family bear—and I am happy to be a part of this.

What is your biggest challenge?

Being in a unique role means that there is no specific education to prepare for it. However, this is also one of the many reasons I love this role. You must be self-motivated, passionate and driven as you learn on the job.

Is there someone who served as a role model?

As I was the first Drug Access Navigator here in Nova Scotia, I owe many thanks to the large body of drug navigators in Ontario who helped me navigate this new role, specifically Alan Birch and Amy Pilon. These individuals helped me bring more accessible access to Cancer patients here in NS.

What’s your favourite way to spend time outside of work?

I am a single mom to a beautiful little girl. Most of my time is spent running around to different activities such as dance! I also enjoy volunteering to support other navigators and cancer patients through the Atlantic association, where I am the co-founder and hold the role of Director of Education.

Name something you’re really good at that has nothing to do with pharmacy.

Event planning and do-it-yourself craft projects!

What’s one piece of advice you’d give a young pharmacy technician who wants to make a difference in their career?

The opportunities are endless! Don’t stop looking for your dream job until you find it!

What’s next for you?

I hope to see a course developed for pharmacy technicians and others who want to further their education and become a Drug Access Navigator. Furthermore, I hope to be involved in creating this course. I think if more pharmacy technicians knew about this, it would help expand this role within many parts of the healthcare system, which in turn helps patients and families with the burden of a cancer diagnosis.

Photo: Kayla Ross supplied

Learning objectives

After completion of this continuing education lesson participants should:

1. Know the prevalence of hypoglycemia in Canadians with type 1 and type 2 diabetes treated with insulin

2. Know the difference between mild, moderate, and severe hypoglycemia

3. Be comfortable with asking patients with diabetes if they are experiencing hypoglycemia

4. Know how much carbohydrate is used to treat hypoglycemia and know the two options for glucagon

5. Be able to offer options to prevent future episodes of hypoglycemia

Instructions

1. After carefully reading this lesson, review the test questions. Answer online at eCortex.ca.

2. To pass the test and earn your continuing education credit(s), a grade of at least 70% (5 out of 6) is required.

3. Complete the required course feedback at eCortex.ca.

DISCLOSURES

The author and expert reviewers have each declared that there is no real or potential conflict of interest with the sponsor of this CE lesson.

TAKE THIS COURSE AT:

The pharmacist’s role in hypoglycemia in patients with diabetes treated with basal insulin

By Esmond Wong, RPh, CDE, APA

is a drug-induced side effect that is also affected by other factors such as food intake and physical activity.

Drug-induced hypoglycemia is both a barrier to achieving glycemic control in people with diabetes as well as an opportunity for pharmacists to help patients and reduce healthcare costs. Hypoglycemia as defined by the Diabetes Canada clinical practice guidelines is 1) the development of autonomic or neuroglycopenic symptoms; 2) a low plasma glucose level (<4.0 mmol/L for people with diabetes treated with insulin or an insulin secretagogue); and 3) symptoms responding to the administration of carbohydrate.(1) With people who have diabetes, hypoglycemia

The global Hypoglycemia Assessment Tool (HAT) study enrolled 27,000 people with diabetes treated on insulin around the world to study real-world rates of hypoglycemia.(2) The Canadian cohort enrolled 498 Canadians and found that over a four-week prospective period, 95.2% of people with type 1 diabetes and 64.2% of people type 2 diabetes (treated with insulin) experienced an episode of hypoglycemia. The Canadian cohort of the HAT study found hypoglycemia to be associated with higher work absenteeism, higher healthcare utilization and higher self-reported fear of hypoglycemia.

The pathophysiology of hypoglycemia

The brain’s preferred source of energy is glucose. Only four grams of glucose (less than a teaspoon) is dissolved in the blood of an average 70 kg human. Functional β cells are able to respond to fluctuating glucose by secreting or supressing insulin in seconds. This

CCCEP #1329-2022-3544-I-P

FEBRUARY 2023 ¥ Take this course ateCortex.ca

keeps blood glucose in a very tight range which is delicately balanced by functional β cells.(3)

Blood glucose levels dropping below 4.7 mmol/L will result in the suppression of insulin secretion. Below 3.8 mmol/L the body will start secreting counter regulatory hormones such as glucagon and epinephrine that oppose insulin action to raise sugars.(4) Glucagon can cause nausea and vomiting. Epinephrine can cause anxiety, sweating, trembling and palpitations (think fight or flight response). These are classified as autonomic symptoms. Below 2.8 mmol/L the brain starts running low on glucose and neuroglycopenic symptoms occur such as confusion, difficulty concentrating and difficult speaking.(1)

Pseudo-hypoglycemia is when a person experiences symptoms of hypoglycemia, but their blood glucose is above 4 mmol/L. This occurs in people who have had long-standing poor glycemic control so that their body is acclimatized to high blood glucose levels. Once their blood glucose trends to a normal range, their body sometimes interprets the normal blood glucose as hypoglycemia.(5) Hypoglycemia unawareness occurs after frequent episodes of hypoglycemia and the body loses the autonomic symptoms. This results in the first symptoms of hypoglycemia being confusion or unconsciousness.

(1) This is a dangerous situation as the person may not respond (or be unable to respond) appropriately to the hypoglycemia.

Some people are more prone to hypoglycemia than others. Elderly people are at higher risk especially if they have severe cognitive impairment. Hypoglycemia unawareness, long duration of insulin therapy, renal impairment, poor health literacy and food insecurity are also risk factors for hypoglycemia.(1) For adults experiencing hypoglycemia unawareness it is suggested that they are educated to how to avoid further episodes of hypoglycemia, have less stringent glycemic targets for three months if needed, increase the frequency of monitoring, or use a continuous blood glucose monitoring device.(1)

TABLE 1 Types of Hypoglycemia

The Diabetes Canada clinical practice guidelines classifies hypoglycemia into separate categories based on severity of symptoms:(1)

Mild hypoglycemia

Moderate hypoglycemia

When autonomic symptoms are present, and the person can still selftreat

When autonomic and neuroglycopenic symptoms are present, but the person can still self-treat

When the person requires assistance of another person. The person may be unconscious and blood glucose is typically below 2.8 mmol/L. Nocturnal hypoglycemia

Severe hypoglycemia

Hypoglycemia that occurs when the person is sleeping, with symptoms including nightmares, weird dreams and waking up in the middle of the night.

Adapted from the Diabetes Canada 2018 Guidelines(1)

Next (second)-generation basal insulins and their role in hypoglycemia prevention

Insulin is a protein that is active in its monomer form. An insulin monomer can quickly interact with an insulin receptor to facilitate glucose uptake from the blood into the cell. Monomers are quicky degraded in minutes by enzymes in the blood into amino acids which do not interact with the insulin receptor. However, an insulin monomer can combine with five other insulin monomers to form a hexamer. Hexamers are resistant to degradation by enzymes and are not as easily absorbed by cells. An ideal basal insulin will form stable hexamers which dissociate back into monomers at a regular rate with little variation and without a peak in activity over at least a 24-hour period.(6,7)

Second-generation basal insulins which include insulin degludec and insulin glargine U300 use novel mechanisms to create a longer duration of action that results in lower incidence of hypoglycemia than first generation basal insulin analogues such as insulin glargine U100 and insulin detemir. Insulin degludec uses a novel mechanism of protraction with phenol, zinc and an insulin analogue structure that forms hexamer chains. These hexamer chains are stable and disassociate back into monomers at a regular rate leading to less day-to-day variation and flatter action profile. Degludec has a duration of action of 42 hours.(5,6) Insulin glargine U300 utilizes a different mechanism of action than insulin degludec. By concentrating glargine, compact conglomerates of insulin are formed. Absorption

is slowed because the surface area of the conglomerates on which absorption can occur is reduced and there is a greater distance from the conglomerate surface to capillaries.(8)

Studies have demonstrated the value of second-generation versus the first-generation basal insulins. A study compared glargine U300 vs glargine U100 in people with type 2 diabetes using oral antihyperglycemic drugs over a 12-month period. The researchers found that the people treated with glargine U300 had a 37% relative risk reduction in experiencing nocturnal hypoglycemia or severe hypoglycemia compared to glargine U100.(9)

The DEVOTE trial compared insulin degludec to insulin glargine U100 with a primary outcome of major cardiovascular event (death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke) and a secondary outcome of severe hypoglycemia. The study found insulin degludec and insulin glargine U100 had similar rates of major cardiovascular events. However, the rate of severe hypoglycemia was significantly lower in the insulin degludec group. The rate of severe hypoglycemia was 3.70 events per patient-years in the insulin degludec group and 6.2 events per 100 patient-years in the insulin glargine U100 group. This is despite the reduction in A1c being similar in both groups.(10)

The BRIGHT study was a head-tohead trial comparing insulin degludec with insulin glargine U300 in 929 patients with type 2 diabetes who were insulin naïve. The primary end point was A1c change with rates of

hypoglycemia as a safety endpoint. Participants were randomized 1 to 1 to receive either degludec or insulin glargine U300 which was self-administered by the patient. The primary end point showed comparable reductions in A1c. The mean A1c of the group assigned to insulin degludec was 8.7% which came down to 7% by the end of the study. The mean A1c of the group assigned to insulin glargine U300 was 8.6% which came down to 7% by the end of the study. The researchers concluded that the A1c reduction was comparable for both of the insulins. The incidence of confirmed hypoglycemia (at any time of day [24 h]) was comparable for both insulins, 66.5% for insulin glargine U300 and 69% for insulin degludec. The incidence of nocturnal hypoglycemia was also comparable for both insulins, 28.6% for insulin glargine U300 and 28.8 for insulin degludec.(11)

The pharmacist’s role in screening hypoglycemia

There are several interventions that pharmacists can perform to reduce the burden of hypoglycemia for patients. Most important is to ask patients with diabetes if they have experienced symptoms of hypoglycemia, especially if they are using sulfonylureas (SU) and/ or insulin. The question can be as simple as: “Hello Mr. Smith, I notice you are on the insulin A and/or pill B (sulfonylurea), these medications can cause low blood sugars which can present as dizziness, weakness, trembling or sweating. Have you experienced any of those symptoms?” An alternative could be: “Hello Mr. Smith, I notice you are on the insulin X and/or pill Z (sulfonylurea), these medications can cause low blood sugars. Have you noticed any of your blood glucose readings dipping below 4 mmol/L lately?”

There is no official way to screen for hypoglycemia mentioned in the Diabetes Canada clinical practice guidelines, so pharmacists are encouraged to personalize their approach and be consistent about asking patients using insulin and/or SU. The Canadian cohort of the HAT study found that the majority of patients using insulin did

experience hypoglycemia in a four-week period so the majority of your patient’s using insulin and/or SU are also likely experiencing hypoglycemia.(2)

Newer Technologies

New technology in blood glucose monitoring can help patients and pharmacists detect hypoglycemia. In 2021 there was an update to the blood glucose monitoring section of the Diabetes Canada clinical practice guidelines with new definitions. See Table 2.

There are now ways for pharmacists to remotely track their patients’ blood glucose levels to provide timely feedback on blood glucose excursions. Pharmacists can create a healthcare professional account on websites like LibreView (https://www.libreview.com/), Dexcom Clarity (https://clarity.dexcom.com/ professional/) or Guardian CareLink (https://carelink.medtronic.com/login). Once this account is set up, patients who use an app on a smartphone can upload their data to the healthcare professional in real time. The pharmacist can then review the patient’s data online. They can look for days where the patient had glucose excursions and review what happened that day with the patient to determine the reasons for the excursions.

Pharmacists can encourage patients to record physical activity, food, illness, missed insulin/medications or unexpected events in the app so that they can see how these events influence their sugars. It’s important for patients to understand 1) why these events increase or decrease their sugars and 2) that sugars will normally fluctuate by themselves at times. By getting patients to understand what causes their fluctuations, pharmacists can empower them to take control of their sugars instead of being a helpless bystander. The professional website will also allow the sorting

of patients to determine which patients are experiencing hypoglycemia.

One study randomized adults with poorly controlled type 2 diabetes treated with basal insulin, to either real time continuous glucose monitoring or capillary blood glucose monitoring. They found the real time continuous glucose monitoring arm had significantly lower A1c levels at eight months. Also, there was less time spent in blood glucose levels below 3.9 mmol/L.(13)

The pharmacist’s role in treating hypoglycemia

Once you have identified that the patient is experiencing hypoglycemia, it’s important to discuss why it is happening and how to treat hypoglycemia. Keep the language simple. For example, you could start by explaining that the brain needs glucose like a computer needs electricity. Just as a computer operates sub-optimally when it doesn’t get enough electricity, your brain may experience confusion, difficulty with speaking or concentrating when it doesn’t receive enough glucose from the blood. To treat hypoglycemia the Diabetes Canada clinical practice guidelines, suggests that 15 g glucose (or a similar fast-acting carbohydrate) is required. This produces an increase in blood glucose of approximately 2.1 mmol/L within 20 minutes, providing adequate symptom relief for most people. Some examples of fast acting carbohydrate include a tablespoon (15g) of sugar, a tablespoon of honey, 4 Dex-4 glucose tablets, 6 Lifesaver candies or 150 ml of juice or pop.(1)

Remember that the carbohydrate must be easily digested to be “fast-acting.” Things like chocolate cake, ice cream and fruit may taste sweet but contain significant amounts of fat or fibre which slow down the digestion of the

carbohydrate.(14) During a hypoglycemic event quick treatment is a priority. For patients experiencing severe hypoglycemia who are unconscious, glucagon is the preferred treatment.(1) There are now two different methods of administering glucagon available in Canada. Injectable glucagon requires reconstitution by mixing the powdered glucagon with a diluent before subcutaneous injection.(15) Nasal glucagon can be administered intranasally with no mixing required.(16) One study showed that participants using subcutaneous vs nasal glucagon found that nasal glucagon was easier to use, easier to prepare, had more confidence in using glucagon and overall was more satisfied than subcutaneous glucagon.(17) Some practical tips include counselling patients on the expiry date of glucagon, ensuring that they have refills left on file and that they are storing the glucagon properly.

The pharmacist’s role in preventing hypoglycemia

To manage and prevent hypoglycemia it is useful to see if there is a pattern. If the hypoglycemic event was a one-time event that occurred after a patient skipped a meal or after some unexpected exercise, reinforce the importance of regular meals and suggest carrying glucose tablets (a common mistake patients make is taking only a single Dex-4 tablet for treatment which is about 4 grams of carbohydrate; remind them it’s Dex 4 because 4 tablets is a dose of 15 grams of fast-acting carbohydrate). They can also carry glucagon with them or a diabetes-specific meal replacement, such

The pharmacist’s role in hypoglycemia in patients with diabetes treated with basal insulin

as Glucerna or Boost Diabetic. For more information with great visuals, you could refer them to the Diabetes Canada patient handout which can be found at: https://guidelines.diabetes.ca/docs/ patient-resources/hypoglycemia-lowblood-sugar-in-adults.pdf

If there is a pattern of lows, appendix 5 of the 2018 Diabetes Canada clinical practice guidelines has an excellent overview of which insulins to adjust depending on the pattern of lows. Certain sulfonylureas and insulins have a lower incidence of hypoglycemia than others. Glyburide has a moderate risk of hypoglycemia, while gliclazide has a minimal/moderate risk of hypoglycemia. As per the guidelines, gliclazide is preferred over glyburide due to lower risk of hypoglycemia, cardiovascular events, and mortality. If you have prescribing privileges in your province this is a change that is justifiable and easy to explain to patients. If you need to fax a prescriber to make the change, then including the suggestion from the guidelines is worthwhile to show your rationale. As discussed before, newer generation basal insulin analogues (insulin degludec and insulin glargine U300) have a lower incidence of hypoglycemia than first-generation insulin analogues.(18)

In the past, detecting nocturnal hypoglycemia was more cumbersome. Asking patients to set up an alarm to wake themselves over several nights to poke their fingers was sometimes a difficult conversation. Patients would be unwilling or forget to test in the middle of the night to detect nocturnal hypoglycemia. Intermittently scanned and real-time

continuous blood glucose monitoring offer an excellent alternative to capillary blood glucose monitoring at night. While these sensors can be expensive, you could contact a company representative to provide a sample or suggest contacting their insurance plan to check for coverage. The sensors will detect and record any instances of nocturnal hypoglycemia that happens overnight. Some of the sensors allow the patient to set alarms if their blood glucose fall below a certain level. If your patient is experiencing nocturnal hypoglycemia, you could reduce their basal insulin, switch to a newer generation basal insulin analogue which is associated with lower frequency of overnight hypoglycemia or switch their sulfonylurea.

Pharmacists have a major role in screening, education, prevention and treatment of hypoglycemia in patients with diabetes. In doing so, they can make a positive impact in the lives of these patients. One study done at the University of Alberta, showed pharmacists’ intervention in poorly controlled adults with type 2 diabetes within community pharmacies around Alberta, showed a significant A1c reduction of 1.8%.(19) Pharmacists are encouraged to look at managing hypoglycemia as a way to improve patient outcomes, demonstrate pharmacists’ value and encourage their own professional growth.

References are online at eCortex.ca.

FACULTY The pharmacist’s role in hypoglycemia in patients with diabetes treated with basal insulin

ABOUT THE AUTHOR

Esmond Wong is a clinical pharmacist working in the area of diabetes. He has a Bachelor of Science in Pharmacy from the University of Alberta (2006) and became a Certified Diabetes Educator and gained additional prescribing authorization in 2011. At his practice he prescribes/adjusts/refills medications and insulin, does foot screening, sends patients for lab work, and helps

set lifestyle goals with patients. His website www.cdestudycourse.com has helped more than 1,500 healthcare professionals across Canada become certified diabetes educators.

REVIEWERS

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

CE Project Manager: Rosalind Stefanac

CE Designer: Shawn Samson

This lesson is published by

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

NEW PRODUCTS

Kerendia for reducing cardiorenal risk finerenone 10 mg and 20 mg tablets, Bayer.

INDICATIONS An adjunct to standard therapy in adults with chronic kidney disease and type 2 diabetes. Used to reduce the risk of end-stage kidney disease and a sustained decrease in estimated glomerular filtration rate, and the risk of cardiovascular death, nonfatal myocardial infarction and hospitalization for heart failure.

within the first four weeks. The drug should not be started in patients with a serum potassium > 5.0 mmol/L or if the eGFR is < 25 mL/min/1.73m2. Take tablet at approximately the same time each day, with a glass of water, with or without food.

ADVERSE EFFECTS MOST COMMON: Hyperkalemia and decreased GFR. Hyperuricemia, hyponatremia, hypotension and pruritus have been reported. MOST SERIOUS: Hyperkalemia leading to hospitalization.

are candidates for systemic therapy or phototherapy.

ACTION A tyrosine kinase 2 (TYK2) inhibitor. Inhibits receptor-mediated activation of TYK2, which inhibits the release of proinflammatory cytokines and chemokines.

ACTION A nonsteroidal, selective mineralocorticoid receptor antagonist. Blocks the binding of aldosterone to mineralocorticoid receptors. Mechanisms by which finerenone helps to reduce renal and cardiovascular events are not completely understood, but may involve attenuation of inflammation and fibrosis (which are thought to be mediated by overactivation of mineralocorticoid receptors) and counteracting sodium retention in the kidneys and hypertrophic processes in the kidneys, heart and blood vessels. Has no significant affinity for androgen, progesterone, estrogen or glucocorticoid receptors; therefore, it is unlikely to cause sex hormone-related adverse events (e.g., gynecomastia).

DOSAGE Patients should be adequately treated with standard of care therapy before starting finerenone. Starting dose is 20 mg once daily if eGFR (estimated glomerular filtration rate) ≥ 60 mL/min/1.73m2, or 10 mg once daily if eGFR ≥ 25 to < 60 mL/ min/1.73m2. Should only be initiated when serum potassium is ≤ 4.8 mmol/L, but may be considered if serum potassium is > 4.8 to 5.0 mmol/L, provided that there is additional serum potassium monitoring

DRUG INTERACTIONS Contraindicated in patients receiving concomitant treatment with strong CYP3A4 inhibitors (e.g., itraconazole, ketoconazole, ritonavir, nelfinavir, cobicistat, clarithromycin). Use with weak CYP3A4 inhibitors (e.g., amiodarone, fluvoxamine) or moderate CYP3A4 inhibitors (e.g., erythromycin, verapamil) is expected to increase finerenone exposure; consider additional serum potassium monitoring, especially when starting or changing the dose of finerenone or the CYP3A4 inhibitor. Avoid concomitant use of moderate CYP3A4 inducers (e.g., efavirenz, phenobarbital) or strong CYP3A4 inducers (e.g., rifampin, carbamazepine, phenytoin, St John’s wort) as these agents are expected to markedly decrease finerenone plasma concentrations and result in reduced therapeutic effect. Avoid intake of grapefruit or grapefruit juice as this is expected to increase finerenone plasma concentrations.

Risk of hyperkalemia is increased if used concomitantly with medications that increase serum potassium. Avoid concomitant use with potassium-sparing diuretics (e.g., amiloride, triamterene), or other mineralocorticoid receptor antagonists (e.g., eplerenone, spironolactone). Use with caution and monitor serum potassium when taken concomitantly with potassium supplements, trimethoprim or trimethoprim–sulfamethoxazole; temporary discontinuation of finerenone may be necessary.

Sotyktu for psoriasis

deucravacitinib 6 mg tablets, Bristol-Myers Squibb.

INDICATIONS Treatment of moderate to severe plaque psoriasis in adults who

DOSAGE 6 mg orally once daily. No dosage adjustment is required in patients with mild, moderate or severe renal impairment or mild or moderate hepatic impairment. Not recommended in severe hepatic impairment.

ADMINISTRATION Can be administered with or without food. Swallow tablets whole; do not crush, cut or chew.

ADVERSE EFFECTS MOST COMMON: Upper respiratory tract infection (~19%), acneiform rash, herpes simplex infections, oral ulcers, folliculitis (all < 5%). Increases in creatine phosphokinase and liver transaminases (ALT, AST) have been reported.

MOST SERIOUS: Serious infections (< 1%). Should not be started in patients with any clinically important active infection until the infection resolves or is adequately treated. Consider risks and benefits before prescribing deucravacitinib in patients with a chronic infection or a history of recurrent infection. Evaluate patients for tuberculosis infection prior to initiating treatment. DRUG INTERACTIONS Avoid use of live vaccines. Consider completing all ageappropriate immunizations before starting deucravacitinib therapy. Safety and efficacy of combining deucravacitinib with immunosuppressants, including biologics, has not been evaluated in patients with psoriasis. Not recommended for use in combination with other potent immunosuppressants, due to the increased risk of infection during treatment.

COMMENTS First tyrosine kinase 2 inhibitor for psoriasis to be marketed in Canada.

Tabrecta for nonsmall cell lung cancer

capmatinib 150 mg and 200 mg tablets (as capmatinib hydrochloride), Novartis.

INDICATIONS Treatment of locally advanced unresectable or metastatic nonsmall cell lung cancer in adults harbouring mesenchymal-epithelial

transition (MET) exon 14 skipping alterations. Issued market authorization with conditions, pending the results of trials to verify the drug’s clinical benefit.

ACTION An inhibitor of the MET receptor tyrosine kinase, which leads to inhibition of the proliferation and survival of METdependent cancer cells.

DOSAGE 400 mg twice daily, with or without food. Continue until disease progression or unacceptable toxicity occurs. Dose reduction or modification may be required to manage adverse reactions.

ADVERSE EFFECTS MOST COMMON: Peripheral edema, nausea, fatigue, vomiting, dyspnea, decreased appetite. Risk of photosensitivity reactions; advise patients to limit direct ultraviolet exposure during treatment and to use sunscreen/protective clothing. MOST

SERIOUS: Dyspnea, pneumonia, pleural effusion, vomiting, interstitial lung disease/ pneumonitis, hepatotoxicity (alanine aminotransferase [ALT] and/or aspartate aminotransferase [AST] elevations). Liver function tests (ALT, AST, total bilirubin) should be performed before starting treatment, every two weeks during the first three months of treatment, then once a month or as clinically indicated. Elevations in amylase and lipase (acute pancreatitis may occur); monitor amylase and lipase at baseline and regularly during treatment. Some deaths have been reported (from hepatitis, treatment-related pneumonitis).

DRUG INTERACTIONS A substrate of CYP3A4. Coadministration with a strong CYP3A inhibitor (e.g., clarithromycin, indinavir, itraconazole, lopinavir/ritonavir, verapamil) may increase the incidence and severity of capmatinib adverse reactions. Coadministration with a strong or moderate CYP3A inducer (e.g., carbamazepine, phenobarbital, phenytoin, rifampin, St. John’s wort) may decrease capmatinib antitumour activity. Capmatinib is a moderate inhibitor of CYP1A2 and an inhibitor of transporters P-gp and BCRP. Coadministration with a CYP1A2, P-gp or BCRP substrate may increase the incidence and severity of adverse drug reactions of these substrates.

Ubrelvy for acute migraine

ubrogepant 50 mg and 100 mg tablets, AbbVie.

INDICATIONS Acute treatment of migraine, with or without aura, in adults.

ACTION A calcitonin gene-related peptide (CGRP) antagonist. CGRP is released from

sensory nerve endings during a migraine attack. Ubrogepant may relieve migraine by blocking CGRP-induced neurogenic vasodilation, halting the cascade of CGRPinduced neurogenic inflammation, and/or inhibiting the central relay of pain signals from the trigeminal nerve to the caudal trigeminal nucleus.

DOSAGE 50 mg or 100 mg, taken with or without food. If needed, a second dose may be taken at least two hours after the initial dose. Maximum daily dose is 200 mg. Limit doses to 50 mg (initial and optional second dose) in patients with severe hepatic impairment (Child-Pugh Class C) or severe renal impairment (CrCl 15–29 mL/min). The safety of taking more than 16 doses in a 30-day period has not been established.

ADVERSE EFFECTS MOST COMMON: Nausea, somnolence, and dry mouth (all < 5%).

MOST SERIOUS: Hypersensitivity (e.g., rash, urticaria, facial edema, dyspnea).

DRUG INTERACTIONS Metabolized primarily by CYP3A4. Contraindicated with strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, clarithromycin). Patients using moderate CYP3A4 inhibitors (e.g., ciprofloxacin, fluconazole, fluvoxamine, verapamil, grapefruit juice) should use only a single 50 mg dose of ubrogepant and avoid taking a second dose within 24 hours. Avoid use with strong CYP3A4 inducers (e.g., phenytoin, rifampin, St. John’s wort), as loss of ubrogepant efficacy is expected. Consider using the 100 mg dose of ubrogepant if co-administered with weak or moderate CYP3A4 inducers (e.g., modafinil, bosentan, efavirenz, primidone).

COMMENTS First oral CGRP antagonist to be marketed in Canada.

OTHER NEW PRODUCTS

Kirsty

insulin aspart solution for subcutaneous injection 100 units/mL; 3 mL disposable prefilled pen, BGP Pharma/Viatris.

INDICATIONS 1. Treatment of patients with diabetes who require insulin for the control of hyperglycemia. Should normally be used in regimens together with an intermediate or long-acting insulin.

2. Kirsty 10 mL vials (approved, but not yet marketed in Canada) may also be used for continuous subcutaneous insulin infusion (CSII) in pump systems that are licensed in Canada for insulin infusion.

DOSAGE Individualized; consult product monograph for details.

COMMENTS Second biosimilar to NovoRapid (Novo Nordisk) to be marketed in Canada, following Trurapi (Sanofi-Aventis).

Koselugo

selumetinib 10 mg and 25 mg capsules, AstraZeneca.

INDICATIONS Treatment of neurofibromatosis type 1 (NF1) in children two years of age or older who have symptomatic, inoperable plexiform neurofibromas.

DOSAGE 25 mg/m2, taken orally twice daily (about every 12 hours). Doses should be rounded to the nearest achievable 5 mg or 10 mg dose (up to a maximum single dose of 50 mg). Different strengths of capsules can be combined to provide the required dose.

ADMINISTRATION Take on an empty stomach with no food or drink other than water. Do not consume food within two hours before dosing and one hour after dosing. Swallow capsules whole with water; do not chew, dissolve or open capsules. Should not be administered to children who are unable to swallow a whole capsule.

Livtencity

maribavir 200 mg tablets, Takeda.

INDICATIONS An antiviral for the treatment of adults with post-transplant cytomegalovirus infection/disease. Intended for patients who are refractory (with or without genotypic resistance) to one or more prior antiviral therapies. DOSAGE 400 mg (two 200 mg tablets) twice daily, with or without food.

Semglee

insulin glargine (rDNA origin) solution for SC injection 100 units/mL; 3 mL disposable prefilled pen, BGP Pharma/Viatris.

INDICATIONS Once-daily SC administration in the treatment of patients > 17 years of

age with type 1 or type 2 diabetes who require basal (long-acting) insulin for the control of hyperglycemia. Also indicated in the treatment of children (> 6 years of age) with type 1 diabetes who require basal (long-acting) insulin for the control of hyperglycemia.

DOSAGE Individualized; consult product monograph for details.

COMMENTS Second biosimilar to Lantus (Sanofi-Aventis) to be marketed in Canada, following Basaglar (Eli Lilly).

Tavneos

avacopan 10 mg capsules, Otsuka Canada.

INDICATIONS Adjunctive treatment of adults with severe active antineutrophil cytoplasmic autoantibody (ANCA)associated vasculitis (granulomatosis with polyangiitis [GPA] and microscopic polyangiitis [MPA]). Intended for use in combination with standard background therapy, including glucocorticoids.

DOSAGE 30 mg (3 x 10 mg capsules) twice daily (morning and evening), with food. Swallow capsules whole with water; do not open, crush or chew.

NEW DOSAGE FORMS

• Lapelga Pre-Filled Autoinjector 6 mg/0.6 mL (pegfilgrastim preservative-free solution) Apotex, is now available, in addition to the original 6 mg/0.6 mL prefilled syringe.

• Nucala (mepolizumab solution for subcutaneous injection), GlaxoSmithKline. New single-use prefilled syringe containing 40 mg/ 0.4 mL (for use in children aged 6–11 years of age with severe eosinophilic asthma) joins the existing 100 mg/mL single-use prefilled syringe, 100 mg/mL prefilled single-use autoinjector and lyophilized powder for solution (100 mg vial).

• Skyrizi (risankizumab injection), AbbVie. New 600 mg/10 mL vial for intravenous (IV) use is now available (for induction

treatment of Crohn’s disease in adults). Also, a new 360 mg/2.4 mL (150 mg/mL) prefilled cartridge for subcutaneous use using the Skyrizi on-body injector (for maintenance treatment of Crohn’s disease in adults), joins the existing 150 mg/1 mL prefilled pen or syringe and the 75 mg/0.83 mL (90 mg/mL) prefilled syringe for subcutaneous use (for treatment of moderate to severe plaque psoriasis and active psoriatic arthritis). See also New indications

NEW GENERICS

• Jamp-Apremilast (apremilast 10 mg and 30 mg tablets), Jamp Pharma. Generic alternative to Otezla.

• pms-Apremilast (apremilast 30 mg tablets), Pharmascience. Generic alternative to Otezla.

• pms-Tofacitinib (tofacitinib 5 mg tablets), Pharmascience. Generic alternative to Xeljanz.

NEW INDICATIONS

Abevmy bevacizumab for injection, BGP Pharma/Viatris.

NEW INDICATION Treatment of first recurrence platinum-sensitive epithelial ovarian, fallopian tube or primary peritoneal cancer, in combination with carboplatin and gemcitabine. Patients should not have received prior VEGFtargeted therapy. (Also approved earlier for use in the treatment of metastatic colorectal cancer, locally-advanced, metastatic or recurrent nonsmall cell lung cancer, platinum-resistant recurrent epithelial ovarian, fallopian tube and primary peritoneal cancer, and malignant glioma/glioblastoma.)

DOSAGE Platinum-sensitive recurrent epithelial ovarian, fallopian tube and primary peritoneal cancer: 15 mg/kg by IV infusion every three weeks. Administered in combination with carboplatin and gemcitabine for six cycles (up to 10 cycles), followed by continued use of bevacizumab as a single agent until disease progression.

Abrilada

adalimumab SC injection, Pfizer.

NEW INDICATION Inducing and maintaining clinical remission in children five years of age or older with moderately to severely active ulcerative colitis. Intended for patients who have had an

inadequate response to conventional therapy, including corticosteroids and/ or azathioprine or 6-mercaptopurine, or who are intolerant to such therapies. (Also approved earlier for several other therapeutic uses; consult product monograph for details.)

DOSAGE Pediatric ulcerative colitis: Induction and maintenance doses are based on body weight; consult product monograph for details. Administer by SC injection.

Beovu

brolucizumab solution for intravitreal injection, Novartis.

NEW INDICATION Treatment of diabetic macular edema. (Originally indicated only for use in the treatment of neovascular [wet] age-related macular degeneration.)

DOSAGE Diabetic macular edema: 6 mg (0.05 mL) administered by intravitreal injection every six weeks for the first five doses. Thereafter, treatment intervals (e.g., every 8 or 12 weeks) are based on disease activity as assessed by visual acuity and/ or anatomical parameters.

Comirnaty Original & Omicron BA.4/BA.5 COVID-19 mRNA vaccine, bivalent (original and Omicron BA.4/BA.5), Pfizer.

NEW INDICATION Now indicated as a booster in children five years through < 12 years of age. (Originally indicated as a booster in individuals 12 years of age or older only.)

DOSAGE Booster in children five years through < 12 years of age: 0.2 mL administered intramuscularly at least six months after completing the primary twodose series with Comirnaty (COVID-19 vaccine, mRNA).

Ivozfo

fosfomycin for injection, Verity Pharmaceuticals.

REMOVED INDICATIONS No longer indicated for the treatment of osteomyelitis or nosocomial lower respiratory tract infections in adults or children (including neonates).

NEW INDICATIONS Treatment of the following infections in adults and children, including neonates: bone and joint infections, complicated intra-abdominal infections, complicated skin and soft tissue infections, hospital-acquired pneumonia, including ventilator-

associated pneumonia, and infective endocarditis. (Also approved earlier for use in the treatment of bacterial meningitis, bacteremia and complicated urinary tract infections.)

DOSAGE Varies according to the indication, severity and site of the infection, susceptibility of the pathogen(s) to fosfomycin and renal function. Dosage also varies according to age and body weight in children. Consult product monograph for details.

Nuvaxovid

COVID-19 vaccine (recombinant protein, adjuvanted), Novavax/Innomar Strategies.

NEW INDICATION Now approved for active immunization to prevent COVID-19 in adolescents 12 through 17 years of age.

(Originally indicated only for use in adults.)

DOSAGE Individuals ≥ 12 years of age: Primary series of two 0.5 mL doses, with the second dose administered three weeks after the first dose. Administer by intramuscular injection, preferably in the deltoid muscle of the upper arm.

NEW INDICATION A first booster dose in adults (≥ 18 years of age).

DOSAGE First booster dose in adults: 0.5 mL administered intramuscularly approximately six months after receiving the second dose of the primary two-dose series.

Polivy

polatuzumab vedotin for injection, Hoffmann-La Roche.

NEW INDICATION Treatment of adults with previously untreated large B-cell lymphoma (LBCL), including diffuse large B-cell lymphoma (DLBCL) not otherwise specified (NOS), high grade B-cell lymphoma, Epstein-Barr virus-positive (EBV+) DLBCL NOS, and T-cell/histiocyte rich LBCL. Used in in combination with rituximab, cyclophosphamide, doxorubicin and prednisone. (Also approved earlier [with conditions] for the treatment of relapsed or refractory DLBCL NOS in adults who are not eligible for autologous stem cell transplant and have received at least one prior therapy. Used in combination with bendamustine and rituximab.)

DOSAGE Adults with previously untreated LBCL: 1.8 mg/kg given as an IV infusion every 21 days for six cycles (in combination with rituximab, cyclophosphamide, doxorubicin and prednisone); see product monograph for details.

Skyrizi

risankizumab injection, AbbVie.

NEW INDICATION Treatment of moderately to severely active Crohn’s disease in adults who have had an inadequate response, intolerance or demonstrated dependence to corticosteroids; or an inadequate response, intolerance or loss of response to immunomodulators or biologic therapies. (Also approved earlier for use in adults for the treatment of moderate to severe plaque psoriasis and active psoriatic arthritis.)

DOSAGE Moderately to severely active Crohn’s disease in adults: 600 mg administered by IV infusion at Weeks 0, 4 and 8, followed by 360 mg administered by subcutaneous injection at Week 12, and every eight weeks thereafter. See also New dosage forms

Ultomiris ravulizumab for injection, Alexion/Innomar Strategies.

EXPANDED INDICATION Treatment of adults and children (1 month of age or older) with paroxysmal nocturnal hemoglobinuria. (Originally indicated for adults only.)

NEW INDICATION Treatment of adults and children (1 month of age or older) with atypical hemolytic uremic syndrome, to inhibit complement-mediated thrombotic microangiopathy.

DOSAGE Based on body weight; consult product monograph for details. Administer as an IV infusion.

Xeomin incobotulinumtoxinA for injection, Merz Pharma Canada.

NEW INDICATION Treatment of chronic sialorrhea associated with neurological disorders in children (age 2–17 years weighing ≥ 12 kg). (Also approved earlier for use in the treatment of chronic sialorrhea associated with neurological disorders in adults, hypertonicity disorders of the 7th nerve [e.g., blepharospasm, including benign essential blepharospasm and hemifacial spasm in adults], cervical dystonia [spasmodic torticollis] in adults, and spasticity of the upper limb in adults.)

DOSAGE Chronic sialorrhea associated with neurological disorders in children: Dosage varies according to body weight; consult product monograph for details. Injected into the parotid and submandibular glands, on both sides.

HEALTH CANADA ADVISORIES

Pfizer COVID-19 vaccine: avoid med errors

Health Canada has announced that the bivalent vaccine Comirnaty Original & Omicron BA.4/BA.5 (DIN 02533197) for use in children five to < 12 years of age will initially be supplied in vials and cartons with English-only labels with the name “Pfizer-BioNTech COVID-19 Vaccine, Bivalent Original and Omicron BA.4/BA.5.” This product has the same orange cap and label border as monovalent Comirnaty (COVID-19 Vaccine, mRNA), 10 µg/0.2 mL (DIN 02522454). Healthcare providers must pay careful attention to the vial and carton label to avoid medication errors.

Evusheld: risk of prophylaxis/treatment failure

Health Canada is warning that Evusheld (tixagevimab and cilgavimab for injection) may not be effective against certain SARS-CoV-2 Omicron subvariants when used for prophylaxis or treatment of COVID-19. Healthcare providers should consider local epidemiology and individual exposure to circulating SARS-CoV-2 viral variants when making decisions regarding the use of Evusheld. Patients who receive Evusheld should be warned about the potential lack of effectiveness against certain SARS-CoV-2 viral variants and instructed to seek medical advice if signs or symptoms of COVID-19 occur, persist or worsen.

Ocaliva: new contraindication

Health Canada has announced that Ocalvia (obeticholic acid) is now contraindicated for primary biliary cholangitis patients with advanced disease, such as those with Child-Pugh Class B or C decompensated cirrhosis or a prior decompensation event, as well as for patients with compensated cirrhosis who have evidence of portal hypertension.

Lu-Ann Murdoch, RPh, BScPhm, ACPR, 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://www.canada.ca/en/health-canada/ services/drugs-health-products/medeffect-canada/ safety-reviews.html

Practice Experts

Prescribing for minor ailments—a prime opportunity to advance our profession

Minor ailments—also known as common ailments, self-limiting conditions, ambulatory conditions, and low acuity conditions—are generally defined as health conditions that can be reliably selfdiagnosed (by a patient) and managed

with self-care strategies and/or minimal treatment, including prescription therapies.1 Pharmacists have a longstanding history of providing direct care to patients presenting with minor ailments. This involves patient assessment by the pharmacist and recommendation of nonprescription and prescription therapies, self-care strategies and referral to other healthcare professionals when required.

Canadian estimates show that 10%–30% of physician visits are for minor ailments. This is problematic due to

the escalating costs of care, as well as more limited access to these primary care providers. Pharmacists are wellpositioned and trained to address minor ailments. They can increase patient access to timely and quality care for these common conditions in the community, potentially reducing physician and emergency room visits/wait times, and ultimately reducing the burden on the healthcare system.2,3

Pharmacists in the United Kingdom have had the authority to prescribe drugs for minor ailment management for more than two decades. In Canada, all 10 provinces have adopted, or are currently pursuing, various degrees of prescriptive authority by pharmacists for specific conditions that fall under the minor ailment umbrella. However, there is no overarching national initiative for these minor ailment programs. The degree of prescriptive authority and scope of practice varies by province. Certain

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

MINOR AILMENT THERAPEUTICS By Nardine Nakhla / P. 25

PRACTICAL DIABETES By Shelley Diamond / P. 28

THERAPEUTIC ISSUES By Jillian Reardon / P. 30

MINOR AILMENT THERAPEUTICS

NARDINE NAKHLA PharmD

provinces permit prescribing for select minor ailments, while other provinces allow prescribing for any minor ailment, using any drug.4

Alberta, the first province to allow autonomous prescribing by pharmacists in 2007, did not limit scope to specific ailments or drugs.5 In contrast, pharmacists in Saskatchewan may prescribe Schedule 1 substances, but must follow a detailed protocol for each ailment. They are also restricted to a set formulary of medications specified per condition, as outlined in their provincial regulations.5 Pharmacists in Ontario are now authorized to prescribe for 13 minor ailments (this began January 1, 2023).6 Most recently, British Columbia announced plans to allow pharmacists to initiate therapy for minor ailments, with details expected to be formalized in 2023.7

Until recently, Alberta, Saskatchewan and Quebec were the only provinces where pharmacists were compensated by their provincial governments for prescribing treatments for select minor ailments. In 2022, Prince Edward Island, Nova Scotia and New Brunswick added funding for select ailments. Ontario community pharmacies are being reimbursed at a rate of $19 per in-person assessment and $15 per virtual assessment for all 13 ailments. This fee will be tied to the assessment itself, regardless of whether it results in a provision of a prescription, and will be capped at a maximum number of claims per ailment annually.8 Funding details have not yet been announced for British Columbia.

Why this is an important opportunity for the pharmacy profession?

Pharmacist prescribing for minor ailment (PPMA) programs are a significant milestone in the evolution of the pharmacy profession.9 Partaking in PPMA services will encourage pharmacists to practise to their optimal scope, take on a greater role within the healthcare system, and improve patient satisfaction.9 PPMA programs will also provide the pharmacy profession with important opportunities to promote efficiencies within the healthcare system by reducing the need for referrals to other healthcare professionals and improving access to timely care, which could lead to overall reductions in healthcare

costs across Canada.10 The benefits of pharmacist prescribing on health outcomes are well documented. For example, the RxOUTMAP study found that uncomplicated cystitis management by pharmacists in New Brunswick is effective and safe, and results in high patient satisfaction.11

Research in different parts of the world suggests that pharmacists generally have a positive attitude towards PPMA.12 PPMA may encourage pharmacists to seek continuing education and training, which promotes life-long learning and continuous improvement in clinical competencies. Expansion of scope to include PPMA services may also encourage schools of pharmacy to undergo curriculum revision, so that new pharmacy graduates have the confidence to partake in PPMA prior to licensure.13

Which minor ailments are included?

The minor ailments included in PPMA programs vary across the Canadian provinces (see Canadian Pharmacists Association’s summary available at https://www.pharmacists.ca/cpha-ca/ function/utilities/pdf-server.cfm?thefile=/ Common_Ailments_English_PDF. pdf ).14 In general, PPMA programs include dermatological, gastrointestinal, reproductive, genitourinary, respiratory, mouth, musculoskeletal, eye, psychiatric,

central nervous system, nutrition, lifestyle, travel immunizations, preventive and other conditions.14

How can pharmacists integrate minor ailment assessment and prescribing into their practice?

Successful integration of PPMA into a pharmacy practice depends on various factors such as pharmacist training, comfort level with assessment and prescribing for minor ailments, staffing, workload, remuneration, employer and/or managerial support, adequate workplace resources and access to clinical information.15 In addition to understanding the facilitators and barriers to implementing PPMA programs in your practice setting, the following three practical tips may be helpful for successful PPMA integration:15

1. Identify educational needs: Take your provincial college board-approved mandatory orientation module. This will assist with understanding, interpreting and applying PPMA implementation details and protocols in your practice, and help reinforce important practice expectations to support quality patient care.13 It is important for pharmacists to self-assess

their need for additional continuing education over time to ensure they have the current knowledge, skills and judgement necessary, so that their care is in accordance with existing clinical practice guidelines.13

2. Optimize workflow: Employ a team approach in the promotion and delivery of the service by conducting a pharmacy team training and orientation session and delegating various tasks (so everyone has a specific and clear role in the process). Hire/ enable pharmacy technicians in your pharmacy to practise to their full scope, to free up time for pharmacists to engage in more clinical tasks. It may be advisable to schedule appointments for patients wishing to access prescribing services when overlap in staffing is available. Manage patient expectations and build in buffers throughout the workday (e.g., extend your prescription wait times if possible) to allow for opportunities to conduct minor ailment assessments if they present.

3. Leverage technology: Adopt scheduling, assessment and/or documentation tools—especially if adapted to the regulations of your province. This can make the entire process more efficient and effective. For example, the Ontario Pharmacists Association has partnered with MAPflow, a cloud-based, clinical decision-making and implementation support tool designed specifically for the Ontario pharmacy practice environment.16 It features a series of conditional logic questions to guide assessment and facilitate development

of customized, evidence-based care plans for patients by providing first- and second-line in-scope therapeutic options. Documentation is automatically generated and ensures compliance with Ontario’s regulatory framework. Other platforms featuring dynamic and static questionnaires are also available nationally. (Disclosure: the author is the CEO and co-founder of MAPflow.)

How can you minimize friction and turf wars with other prescribers?

Successful integration of a formal minor ailment assessment and prescribing service into a given practice setting will require the development of interprofessional collaboration strategies with the relevant healthcare providers involved. Pharmacists are strongly encouraged to take a cautious approach to PPMA services by communicating with other clinicians regarding the PPMA program specifics, detailing the conditions included in the regulations (if applicable), reassuring the prescriber(s) of the timely notification of care plan they can expect to ensure continuity of care, and emphasizing that the patient’s best interest is always upheld and at the core of what we do.5 Educational sessions by pharmacists for physicians, nurse practitioners and other prescribers regarding PPMA specifics may be important, to ensure prescribers have adequate knowledge regarding pharmacist scope and training for PPMA service delivery. Interprofessional collaboration, shared decision making and ongoing discussions with patients and prescribers regarding PPMA treatment plans for a given patient may also help avoid friction and turf wars and solidify mutual trust.

Summary

The expanded role of pharmacists over the years has been beneficial in several services related to immunization, smoking cessation and diabetes. PPMA programs offer an opportunity for pharmacists to provide yet another valuable service to patients. Let’s take this collective opportunity to be proactive in the rebranding of our profession’s public image as care providers, and solidify our role as accessible and knowledgeable medication therapy experts.

Dr. Nardine Nakhla is a practising community pharmacist and a faculty member at the University of Waterloo School of Pharmacy. The author thanks Ali Syed, HBSc, PharmD, MSc, PhD candidate at the University of Waterloo School of Pharmacy for his coauthorship of this article.

REFERENCES

1. Paudyal V, Watson MC, Sach T, et al. Are pharmacybased minor ailment schemes a substitute for other service providers? A systematic review. Br J Gen Pract 2013;63(612):e472-81.

2. Ambizas EM, Bastianelli KM, Ferreri SP, et al; Nonprescriptions Medicine Academy Steering Committee. Evolution of self-care education. Am J Pharm Educ 2014;78(2):28.

3. Mansell K, Bootsman N, Kuntz A, et al. Evaluating pharmacist prescribing for minor ailments. Int J Pharm Pract 2015;23(2):95-101.

4. Taylor JG, Mansell K. Patient feedback on pharmacist prescribing for minor ailments in a Canadian province. Innovations in Pharmacy 2017 Feb 15;8(1). https://pubs.lib.umn.edu/index. php/innovations/article/view/497/491 (accessed November 30, 2022).

5. Taylor JG, Joubert R. Pharmacist-led minor ailment programs: a Canadian perspective. Int J Gen Med 2016;9:291.

6. Ontario Regulation 460/22. Government of Ontario. Updated May 3, 2022. https://www.ontario.ca/laws/ regulation/r22460 (accessed December 14, 2022).

7. Government of British Columbia. Expanded pharmacy services. Updated May 3, 2022. https:// www2.gov.bc.ca/gov/content/health/accessinghealth-care/pharmacy-services (accessed December 14, 2022).

8. Brady T. Update on Ontario’s minor ailment funding, December 16, 2022. https://www.canadianhealthcarenetwork. ca/update-ontarios-minor-ailmentfunding?oly_enc_id=5346G4950923I6Y&utm_ source=omeda&utm_medium=email&utm_ campaign=NL_CHN_Pharmacist_REG (accessed December 20, 2022).

9. Ontario Pharmacists Association. A decade in the making: minor ailments prescribing in Ontario. Updated June 7, 2022. https://opatoday.com/adecade-in-the-making-minor-ailments-prescribing-inontario/ (accessed November 30, 2022).

10. Famiyeh IM, McCarthy L. Pharmacist prescribing: a scoping review about the views and experiences of patients and the public. Res Soc Admin Pharm 2017;13(1):1-6.

11. Beahm NP, Smyth DJ, Tsuyuki RT. Outcomes of urinary tract infection management by pharmacists (RxOUTMAP): a study of pharmacist prescribing and care in patients with uncomplicated urinary tract infections in the community. Can Pharm J 2018;151:305-14. doi: 10.1177/1715163518781175.

12. McIntosh T, Munro K, McLay J, et al. A cross sectional survey of the views of newly registered pharmacists in Great Britain on their potential prescribing role: a cautious approach. Br J Clin Pharmacol 2012;73(4):656-60.

13. Nakhla N, Shiamptanis A. Pharmacist prescribing for minor ailments service development: the experience in Ontario. Pharmacy (Basel) 2021;9(2):96. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC8167622/pdf/pharmacy-09-00096.pdf (accessed November 30, 2022).

14. Canadian Pharmacists Association. Common ailment prescribing in Canada. Updated 2022. https:// www.pharmacists.ca/cpha-ca/function/utilities/pdfserver.cfm?thefile=/Common_Ailments_English_PDF. pdf (accessed November 30, 2022).

15. Jebara T, Cunningham S, MacLure K, et al. Stakeholders’ views and experiences of pharmacist prescribing: a systematic review. Br J Clin Pharmacol 2018;84(9):1883-905.

16. Ontario Pharmacists Association. Ontario Pharmacists Association launches new digital health tool to support minor ailments program. https://www. newswire.ca/news-releases/ontario-pharmacistsassociation-launches-new-digital-health-tool-tosupport-minor-ailments-program-838049492.html (accessed December 20, 2022).

Pharmacists in Ontario are now authorized to prescribe for 13 minor ailments (this began January 1, 2023).

Educate patients about changes to Canadian food package labels

What changes have been made to the nutrition facts table?

Key changes to the nutrition facts table on food package labels include the following:

• Making the serving size more consistent so that it’s easier to compare similar foods

• Adding the amounts in milligrams (mg) for potassium, calcium and iron

• Adding a footnote at the bottom of the table about % daily value to help consumers understand how much sugar and other nutrients (e.g., sodium) are in the food; the note will explain that 5% or less is “a little” and 15% or more is “a lot.”

More specific details regarding the changes are highlighted below.

Changes to serving size

As part of their Healthy Eating Strategy, Health Canada has made changes to the nutrition facts tables, and list of ingredients, on food package labels. The changes are designed to make labelling easier for Canadians to understand, so they can make informed choices. In 2016, industries were given a five-year transition period to make labelling changes to comply with the new recommendations, while allowing time for them to use existing label stock. The transition period was scheduled to end December 14, 2021, but was extended to December 14, 2022 as a result of the COVID-19 pandemic.

• Making the serving size more realistic so that it reflects the amount that Canadians typically eat in one sitting

• Increasing the print font size for the serving size and calories, and adding a bold line under the calories, to make them easier to find and read

• Revising the % daily values based on updated science

• Adding a new % daily value for total sugars

• Adding potassium to the list of nutrients, as it is important for maintaining healthy blood pressure and most Canadians do not get enough potassium in their diet

The new labelling will help ensure more consistent serving sizes, making it easier to compare similar foods and to know the calories and nutrients that will be consumed. The changes are based on regulated reference amounts, which are different for single-serving and multipleserving prepackaged foods.

Changes to the information on sugars

In order to compare sugar content of different foods and to identify sugary foods that should be limited (i.e., any food with a sugar daily value of ≥ 15%), the % daily value of sugar has been added, based on the daily recommended amount of 100 g. Previously, only the grams of sugar were required to appear on the label.

The changes are designed to make labelling easier for Canadians to understand, so they can make informed choices.

SHELLEY DIAMOND BScPhm

In addition, all sugar-based ingredients are now grouped together (in brackets) in descending order by weight after the name “sugars” to more easily find the sources of sugar that are added to the food and to understand how much is added compared to other ingredients.

Changes to information on sweeteners

New package label recommendations for Health Canada-approved highintensity sweeteners (neotame, sucralose, aspartame, acesulfame potassium) include:

• No requirement to list the sweetener on the front of the package

• No amount (i.e., mg) of sweetener is required

• Foods that are sweetened with aspartame must still include a warning statement that the food contains phenylalanine (for individuals with phenylketonuria) and this warning must appear in bold print at the end of the list of ingredients.

Front-of-package nutrition labelling changes are also coming

The food industry has been given until January 1, 2026 to add front-of-package

nutrition symbols for prepackaged foods that meet or exceed set levels for sodium, sugars or saturated fat. There are some exceptions. For instance, foods with a protective effect on health, such as fruits and vegetables without added sodium, sugars or saturated fat do not require a frontof-package nutrition symbol. For a more extensive list, visit the new guidelines at Health Canada’s website.1

What will the new front-of-package nutrition symbol look like?

The new bilingual black and white symbol (Figure 1) will feature a magnifying glass, highlighting which ingredient the product is high in: sodium, sugars, saturated fat or any combination of these. The words “Health Canada/Santé Canada” will also appear at the bottom of the symbol.

More than Skin Deep Compounding

in the management of atopic dermatitis

PRESENTERS

Aaron Sihota, BSc, BSc Pharm, RPh Community Pharmacist

Dr. Tiffany Wong, MD, FRCPC Pediatric Allergist

Dr. Malika Ladha, MD, FRCPC, FAAD

Double BoardCertified Dermatologist

Join our multidisciplinary panel to learn more about personalized therapeutic options for atopic dermatitis (AD). You will be better able to:

1. Describe the pathophysiology of AD and its manifestations in all skin colours.

2. Address special considerations in children and adults

3. Understand the benefits of compounding.

4. Educate patients to help them manage AD and improve their quality of life.

How can you help your patients living with diabetes understand these changes?

Nutrition labels provide useful information for patients looking to make healthier food choices. For most people living with diabetes, nutrition label reading is a part of daily life. Although these modifications will ultimately make their lives easier, they will still require your support in helping them to understand these changes. So as the revised labels roll out, spend just a few minutes to review them—for example, highlight the new recommended % daily values for sugar and what this means, as well as the new ‘front-of-package’ symbol to show that the product has added sugar. This may have a lasting impact on their diabetes journey!

REFERENCE

1. Government of Canada. Food label changes. https:// www.canada.ca/en/health-canada/services/foodlabelling-changes.html#shr-pg0 (accessed November 17, 2022).

Shelley Diamond, BScPhm, is a pharmacist and co-founder of www.diabetescarecommunity.ca, an extensive online resource for Canadians living with diabetes, their families and healthcare professionals.

FIGURE 1

Example of the front-of-package nutrition symbol

Inhaled Corticosteroids in COPD – A Closer Look

for patients without concomitant asthma is less clear cut and more nuanced.2

antagonist [LAMA]) versus dual LABA/ LAMA therapy, a 2021 systematic review and meta-analysis of six randomized controlled trials (n=13,579) found that triple therapy significantly decreased COPD exacerbations (rate ratio 0.73, 95% confidence interval [CI] 0.64–0.83), improved dyspnea and quality of life scores, FEV1 (forced expiratory volume in 1 second) and mortality (odds ratio 0.66, 95% CI 0.50–0.87) over six to 12 months.2 This analysis again demonstrated an increased risk of pneumonia with triple therapy compared to LABA/LAMA use (odds ratio 1.52, 95% CI 1.16–2.00).2 On average, participants were males in their 60s who were current or ex-smokers, with the two largest trials requiring two moderate or one severe exacerbation in the past year for study inclusion.2

Who is most likely to benefit from an ICS?

JILLIAN REARDON ACPR, PharmD, RPh

Chronic obstructive pulmonary disease (COPD), one of the leading causes of death globally, is characterized by progressive airflow limitation and lung tissue destruction.1 Bronchodilators are the mainstay of pharmacologic therapy and have been shown to improve dyspnea, quality of life and reduce exacerbations.1 While widely prescribed for COPD, the utility of inhaled corticosteroids (ICSs)

TABLE 1

COPD

Evidence summary

Several studies have demonstrated that compared to placebo, ICS monotherapy in COPD does not impact quality of life, exacerbations or mortality.1 The landmark TORCH study demonstrated that the combination of an ICS and long-acting beta agonist (LABA) did not reduce allcause mortality and increased the risk of pneumonia, in patients with moderate to very-severe COPD and at least one exacerbation in the previous year, when compared to LABA monotherapy.3 When examining the effect of triple therapy (ICS plus LABA plus long-acting muscarinic

stages and associated spirometry and symptoms

1 – Mild ≥ 80% predicted

*2 – Moderate 50%–79% predicted

*3 – Severe 30%–49% predicted

*4 – Very Severe < 30% predicted

1,8

Short of breath when hurrying on the level or walking up a slight hill

Walks slower than most people of the same age on the level because of breathlessness, or has to stop for breath when walking at own pace on the level OR

Stops for breath after walking about 100 metres or after a few minutes on the level

Too breathless to leave the house, or breathless when dressing or undressing

COPD–chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 second

*Patients in the moderate–very severe stages may benefit from addition of an inhaled corticosteroid (ICS) to long-acting beta agonist/long-acting muscarinic antagonist (LABA/LAMA) combination therapy depending on clinical status

The GOLD (Global Initiative for Chronic Obstructive Lung Disease) 2022 guidelines and the Canadian Thoracic Society recommend stepping-up to triple therapy with an ICS for patients with moderate to very-severe COPD who are on LABA/LAMA therapy and continue to be symptomatic with risk for frequent and/or serious exacerbations (≥ 2 per year, or ≥ 1 requiring hospitalization) (Table 1). 1,4 Interestingly, a positive correlation has been established between elevated blood eosinophils (> 300 cells/ μL) and responsiveness to ICSs in COPD patients; however, prospective trials are required to inform the usefulness of this marker in determining who may benefit from an ICS add-on.1,4 Patients with concomitant asthma should continue to receive an ICS as routine care.1

Can ICSs ever be stopped?

In patients who are on ICS/LABA/LAMA triple therapy and are clinically stable with no exacerbations or hospitalizations for at least a year, consideration should be given to stopping the ICS.1 This is supported by the WISDOM trial, which randomized 2,488 adults with severe to very-severe COPD and frequent exacerbations on triple therapy to gradual ICS withdrawal over 12 weeks and continuation of LABA/ LAMA or continuation of triple therapy; the study found no significant difference in COPD exacerbations, symptoms or

quality of life between groups.5

The subsequent SUNSET trial in adults with more stable COPD (compared to the WISDOM population) also found no difference in annual rates of moderate or severe exacerbations with abrupt ICS withdrawal and continuation of LABA/LAMA versus continuation of triple therapy.6 Finally, appropriateness of and need to continue ICS therapy should always be questioned in patients with repeated episodes of pneumonia.1

TABLE 2

Questions to assess if patients are obtaining meaningful symptomatic benefit from inhalers7

HAVE YOU NOTICED A DIFFERENCE SINCE STARTING THIS TREATMENT?

IF YES:

• Are you less breathless?

• Can you do more?

• Do you sleep better?

• Is this change worthwhile to you?

Pharmacist’s role

Prior to initiating an ICS, assess adherence as well as inhaler technique to ensure patients are fully optimized with LAMAs and LABAs.1,7 In patients who are prescribed an ICS (or any inhaler for COPD), follow-up every few months to see if they are noticing a meaningful symptomatic benefit (Table 2) 7 Those not noting any improvement in symptoms and/or a reduction in exacerbations may be candidates to consider for ICS deprescribing.1,7 If triple therapy is

Continuing Education PROGRAM

warranted, it should ideally be provided as a single inhaler or as a LAMA inhaler in combination with an ICS/LABA to prevent patients from inadvertently staying adherent to ICS monotherapy only.1 Cost and coverage must be considered as many insurers require patients to be optimized on a LABA and LAMA before triple therapy will be covered. Pharmacists can continue to support patients with COPD to quit smoking, partake in safe physical activity, keep up to date with influenza, COVID-19 and pneumococcal vaccines, and develop a written COPD action plan to manage acute exacerbations.8

REFERENCES

1. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2022 report. Available from: https://goldcopd. org/2022-gold-reports-2/ (accessed October 24, 2022).

2. Koarai A, Yamada M, Ichikawa T, et al. Triple versus LAMA/LABA combination therapy for patients with COPD: a systematic review and meta-analysis. Respir Res 2021;22(1):183. doi:10.1186/s12931-021-01777-x.

3. Calverley PMA, Anderson JA, Celli B, et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease (TORCH). N Engl J Med 2007;356:775-89. doi: 10.1056/ NEJMoa063070.

4. Bourbeau J, Bhutani M, Hernandez P, et al. Canadian Thoracic Society clinical practice guideline on pharmacotherapy in patients with COPD - 2019 update of evidence. Can J Resp Crit Care Sleep Med 2019;3:210-32. doi:10.1080/24745332.2019.1668652.

5. Magnussen H, Disse B, Rodriguez-Roisin R, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med 2014;371:128594. doi: 10.1056/NEJMoa1407154.

6. Chapman KR, Hurst JR, Frent SM, et al. Longterm triple therapy de-escalation to indacaterol/ glycopyrronium in COPD patients (SUNSET): a randomized, double-blind, triple-dummy clinical trial. Am J Resp Crit Care Med 2018;198:329-39. doi: 10.1164/rccm.201803-0405OC.

7. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2016 report. Available from: http://goldcopd.org/

8. McIvor RA. Chronic obstructive pulmonary disease. In: Therapeutics [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2016 [updated April 2021]. Available from: http://www.myrxtx.ca

Continuing Education PROGRAM

Gynecology Health Forum for Pharmacists

By Dr. Jamie Kroft, MD, FRCSC and Kerry Roberts, Pharmacist

Learning Objectives:

1. Determine the impact of uterine fibroids, endometriosis, and contraception on gynecologic health.

2. Direct patients on the appropriate use and potential side effects of pharmacotherapy for endometriosis and uterine fibroids.

3. Guide patients on the appropriate use, risks, and benefits of contraception, including combined oral contraceptives.

4. Understand how best to communicate with patients regarding the use of contraception and pharmacotherapy for uterine fibroids and endometriosis.

This program is made possible through funding from AbbVie Corporation

New therapies for the management of your patients with moderate to severe atopic dermatitis

By Michael Boivin, BSc. Pharm, Dan Tam Vu, B. Pharm and Melinda Gooderham, MD, FRCPC

Upon successful completion of this program, the pharmacist will be better able to:

1. Identify patients with moderate to severe atopic dermatitis (AD, eczema) who may require treatment adjustment or the addition of new agents to reach goals of therapy

2. Review the impact of moderate to severe AD on a patient’s quality of life (itching, sleep, etc.)

3. Discuss the limitations of topical therapies in managing patients with moderate to severe AD

4. Determine which patients with AD should be referred to their primary care provider for changes to the AD treatment plan or the potential addition of new therapy

5. Counsel patients on the different systemic therapy options for patients with moderate to severe AD

This learning activity has received financial support from Abbvie in the form of an unrestricted educational grant

Jillian Reardon, ACPR, PharmD, RPh, is a clinical pharmacist and lecturer at the Pharmacists Clinic, Faculty of Pharmaceutical Sciences, University of British Columbia.

#1044-2022-3479-L-P

Please consult this course online at eCortex.ca for expiry dates

By Suzanne Singh, BScPhm, ACPR, PharmD, RPh

Environmental stewardship and medication management

STEPS PHARMACISTS CAN TAKE TO REDUCE THE IMPACT OF CLIMATE CHANGE ON HEALTH OUTCOMES

Tackling a global crisis such as climate change as a frontline pharmacist may seem like an unexpected ask. I will share a personal story: during the COVID-19 pandemic, when I was invited to participate in a quality improvement project at my practice site on the use of inhalation devices as it related to climate change, my first reaction was, “Huh?” and my second reaction was, “am I not already busy enough?!” When I reflected on my core role as a pharmacist, I typically described it as ensuring medications are necessary, effective and safe for the patients under my care. I struggled to see the connection between my day-to-day clinical decisions as a pharmacist and climate change, felt resentful that having to think about the planet may add to my already lengthy list of clinical roles and responsibilities, and felt

skeptical that any “greener” pharmacotherapeutic decisions I made would be impactful enough to stem the tide of the climate crisis.

Any time I get asked to do something new that I am unfamiliar with, I try to learn more. To my surprise, the healthcare sector is a leading source of greenhouse gas emissions and is, in fact, 13% more polluting than the automotive industry.1 Medications account for approximately 25% of greenhouse gas emissions from the healthcare sector.2 Pharmacists may indeed have a role to play when it comes to environmental stewardship and medication management, and these two interests may be more interconnected than I previously assumed. This article highlights how climate change is already affecting pharmacists’ practice, and reviews four core areas where pharmacists may be able to help mitigate the impact of climate change on health outcomes: sustainable prescribing, sustainable dispensing, sustainable medication disposal, and greener pharmacy practice infrastructure and care-delivery at the practice level.

Climate change—

Already a threat to the health of Canadians

In February 2022, Health Canada released a 768-page report titled, Health of Canadians in a Changing Climate: Advancing our Knowledge for Action.3 Health Canada describes this as the “first comprehensive study of current and projected risks from climate change to the health of Canadians since 2008….It addresses the evolving knowledge needs of government decision-makers, civil society organizations, and individual Canadians by providing evidence-based and, where possible, quantitative information to help people understand how Canada’s climate is changing, and the effects on health and health systems, including implications for those most at risk in society.”3

KEY MESSAGES NOTED IN THIS REPORT ARE:

1. Climate change is already negatively impacting the health of Canadians.

2. Health risks will increase as global warming continues, and the greater the warming, the greater the threats to health.

3. Some Canadians are affected more severely by climate change, as exposure and sensitivity to hazards and the ability to take protective measures varies across and within populations and communities.

4. The effects of climate change on health systems in Canada— for example, damage to health facilities and disruptions to health services and operations—are already evident and will increase in the absence of strong adaptation measures.

5. Efforts to prepare for climate change are known to reduce risks and protect health. We must take action now.

6. The health impacts of climate change on First Nations, Inuit and Métis peoples are far-reaching, with disproportionate impacts on their communities, including food/water security and safety, air quality, infrastructure, personal safety, mental health and wellness, livelihoods, culture and identity.

7. To successfully protect all Canadians from the health impacts of climate change, decision-makers must pursue adaptation actions that are inclusive and equitable and consider the needs of racialized, marginalized and low-income populations.

8. Increased efforts to reduce greenhouse gas emissions are required to help protect the health of Canadians.

9. Reducing greenhouse gas emissions can provide very large and immediate health benefits to Canadians.3

The report highlights some examples of where pharmacy practice is already being impacted by climate change.3 It cites examples of where extreme weather and climate hazards have led to supply chain disruptions for medications and other healthrelated supplies. It mentions that having pharmacists work to full scope, including the ability to prescribe, particularly during environmental emergencies, adds value to the care of patients. The report also discusses illnesses related to climate change that pharmacists may be involved in managing (e.g., heat-related illnesses, infectious diseases including tick-borne diseases such as Lyme disease, and exacerbations of chronic health conditions).3

The report points out that in Ontario, the hottest days between 1986 and 2013 showed a 6% increase in hospitalizations for cardiovascular disease compared to optimal temperatures. During this period, about 1.2% of overall hospitalizations for cardiovascular disease could be attributed to heat; the majority of these admissions were related to moderate rather than extreme heat. The report also shares that Ontario data suggest that each 5°C increase in temperature during the summer from 1996 to 2010 was associated with a 2.5% increase in deaths, especially those related to cardiovascular disease.3

As pharmacists, we know that medication may increase an individual’s risk of extreme heat impacts by accelerating dehydration and body heat production.2,3 Certain medications affecting the central nervous system (e.g., anticonvulsants, antidepressants, anticholinergics, psychotropic drugs), as well as others may increase the risk of hyperthermia, while some medications (e.g., thiazide diuretics) may increase vulnerability to phototoxicity and skin cancer risk.4,5

What can pharmacists do about climate change?

Given the clear and present danger of climate change on the health of Canadians, what roles will emerge for pharmacists to help tackle these problems? What guidance and supports will frontline pharmacists receive from their employers, professional advocacy bodies and regulatory organizations to help in the fight against climate change? What will pharmacy trainees be learning about these issues in their curriculum? These are big questions, with no simple answers. I would, however, propose four areas to consider to advance environmental stewardship efforts by pharmacists. My recommendations are drawn from work being done by the Royal Pharmaceutical Society in the United Kingdom and have also been described in the Canadian context.2,6

1. Sustainable prescribing

2. Sustainable dispensing

3. Sustainable medication disposal

4. Greener pharmacy practice infrastructure and care-delivery at the practice level.

The healthcare sector is a leading source of greenhouse gas emissions and is, in fact, 13% more polluting than the automotive industry.

SUSTAINABLE PRESCRIBING

I define sustainable prescribing as participating in the prescribing process with an environmental stewardship lens. Practically, this involves two main components:

1. Prescribe medications only when they are necessary.2,6,7

Manufacturing and distribution of medications is associated with greenhouse gas emissions. If there is only one thing you take away from this article, it is this—perhaps the most important way to reduce the impact of pharmaceuticals on climate change is to prescribe medications only if they are necessary, and to deprescribe medications that are no longer indicated. Overprescribing is a complex topic, but we can all agree that pharmacists are well-positioned to address unnecessary medication use.

2. Select medications that have a lower impact on climate change, if feasible.2,6,8

Most of us have no idea what the carbon footprint is for atorvastatin as it makes its journey from being produced at a foreign facility to the patient’s hands for ingestion. As a pharmacist assessing that patient’s dyslipidemia, the carbon footprint of the various therapeutic options has never been on my radar. There is, however, emerging research looking at tools to support environmentally informed prescribing. The JanusInfo database (https://janusinfo.se/) was set up in 2009 in Sweden to allow physicians to check whether medications are

“green” before prescribing them, as part of Stockholm’s effort to reduce levels of environmentally hazardous medications in water.9,10 This “pharmaceuticals and environment” database rates pharmaceutical substances in terms of their toxicity, persistence and bioaccumulation potential based on data provided by pharmaceutical manufacturers.

While it is not practical to check this database each time a medication is prescribed, pharmacists in community- and hospital-based practices may focus their environmentally informed prescribing efforts on two therapeutic areas:

• Use dry-powder inhalers (DPIs) or soft-mist inhalers in place of metered-dose inhalers (MDIs) when clinically appropriate.

MDIs are pressurized devices that rely on liquefied-gas propellants to atomize medication for inhalation delivery. In the past, MDIs used chlorofluorocarbons (CFCs) as a primary gas propellant. CFCs, however, were banned under the 1987 Montreal Protocol as they possess significant ozonedepleting properties. Soon after, pharmaceutical companies began manufacturing MDIs that use more ozone-friendly hydrofluorocarbons (HFCs). Although HFCs do not deplete the ozone layer, they do have a high global warming potential (GWP). The UK National Institute for Health and Care Excellence (NICE) reports that MDIs containing 100 doses have a carbon footprint equivalent to a 180-mile (290 km) car journey. It is also thought that most of the propellant emissions from HFA inhalers occur at the user level, typically related to poor synchronization between patient actuation and inhalation. Pharmacists can visit the University of Toronto’s Sustainable Health Systems Community of Practice Sustainable Inhaler Initiative to learn more about this, and access some practical point-of-care tools that they may wish to implement in practice.11

The pharmacist’s role in hypoglycemia in patients with diabetes treated with basal insulin

By

After completion of this continuing education lesson participants should:

1. Know the prevalence of hypoglycemia in Canadians with type 1 and type 2 diabetes treated with insulin

2. Know the difference between mild, moderate, and severe hypoglycemia

3. Be comfortable with asking patients with diabetes if they are experiencing hypoglycemia

4. Know how much carbohydrate is used to treat hypoglycemia and know the two options for glucagon

• Promote less carbon-intensive inhaled anesthetics, such as sevoflurane in place of desflurane, as clinically appropriate, and reduce the unnecessary use of nitrous oxide.8 The anesthetic gases most noteworthy for greenhouse gas emissions are desflurane (2,540 times more detrimental than carbon dioxide) and nitrous oxide (less damaging than desflurane, but used in high volumes throughout health care). Sevoflurane is an alternate anesthetic gas that produces seven times less greenhouse gas emissions than desflurane. Pharmacists who work with teams that use these anesthetics in procedures may be able to facilitate a shift in anesthetic use.

SUSTAINABLE DISPENSING

As we reflect on how medications are dispensed, we should rethink aspects of this process that may be more environmentally conscious:

1. Re-evaluate use of plastic prescription vials.12-14 Plastic prescription vials are a staple found in most pharmacies. We tend to use a new vial anytime we fill a new prescription. I attempted (unsuccessfully) to find data on what patients do with these vials once they consume the medication (assuming they finish the medication!). Perhaps some patients reuse them or return them to the pharmacy. Perhaps they are put in the home recycling bin or the empty vials are tossed into a regular

garbage can. To what extent do these staples of our dispensing process end up in a landfill? Similarly, what do patients do with packaging of medication compliance packs once they have used them? How practical would it be to have alternatives to these plastic packages?

I read about two sisters who opened a pharmacy in Nova Scotia with an environmentally friendly mandate.13,14 The Teasdale Apothecary gives their patients a choice to use plastic vials from an environmentally friendly Canadian supplier (Ecolo-Vials), or opt-in to a reusable glass vial program. Ecolo-Vials are an example of a plastic vial alternative that uses 30% less plastic with a lower carbon footprint.14 I mused whether this program would be scalable. I also recently became aware of another option called “The Phill Box,” which is marketed as a fully recyclable and compostable alternative to plastic prescription vials.15

Canadian pharmacy practice is dominated by a handful of corporate oligopolies. Are these major pharmacy chains actively looking at greener strategies in the dispensing process? We have seen shifts over the years in the availability of plastic bags in retail spaces, with a federal mandate banning single-use plastic bags. Will pharmacists be instructed to ban the use of plastic prescription vials one day? It is important to proactively discuss the issue of sustainable dispensing within our profession and with key stakeholders, before we are told what to do by decisionmakers outside our profession.

In the interim, I would urge pharmacists to educate patients on the need to return medication packaging, including prescription vials, to the pharmacy for safe disposal. I encourage pharmacists to advocate for the use of eco-friendly vials or sustainable alternatives as it may become necessary in the future to phase out or minimize use of plastic prescription vials.

2. Manage supply chain disruptions.

Pharmacists are all too familiar with challenges in the drug supply chain. We have seen stockpiling and hoarding of medications during the COVID-19 pandemic, as well as drug shortages.16 This is something we will continue to face with the climate crisis.3 Some supply chain disruptions have been associated with extreme weather events (e.g., forest fires, hurricanes, floods), associated with climate change. Pharmacies should have an emergency plan that is enacted during disasters to help ensure patients have access to essential medications. This underscores the need for pharmacists being empowered to their full scope of practice to support patient access to appropriate therapeutics, and steward medications effectively.

SUSTAINABLE MEDICATION DISPOSAL

Proper disposal of unwanted medications protects our communities by preventing misuse and accidental ingestion, and safeguards our environment from contaminated landfills and waterways.2,17,18 Pharmacists should be familiar with their provincial medication return program policies and processes to dispose of pharmaceutically-generated waste, or contact their regulatory colleges for additional guidance. Pharmacy teams need to educate the public about medication disposal

programs so that they are used to their full potential. It is also important to recognize gaps within these programs. For example, as mentioned previously, pharmacists can preferentially recommend DPIs or soft-mist inhalers over MDIs, to minimize the effect on greenhouse gas emissions. However, we also have a responsibility to ensure that these DPIs and soft-mist inhalers are disposed of appropriately. These inhalation devices are comprised of a number of components and it may not always be a simple process to recycle them. Are current medication disposal systems adequate for this? Or should pharmaceutical manufacturers offer more support to facilitate this process via corporate “take-back” recycling programs? How do we incentivize appropriate recycling or medication disposal so that various stakeholders buy into this? And how do we make this accessible to the end-user (i.e., patients)? These are questions that need to be examined.

GREENER PHARMACY PRACTICE INFRASTRUCTURE AND CARE-DELIVERY AT THE PRACTICE LEVEL

When thinking about how we usually deliver care to patients at pharmacies, it may be useful to consider whether we have invested in digital infrastructure that will allow for more sustainable models of care provision.6 The COVID-19 pandemic led to a shift towards more virtual provision of care. Virtual care may reduce the environmental impact of travel, while still providing clinically appropriate care. Pharmacy teams may wish to capitalize on ways to maximize and optimize electronic platforms to enable patients to access care wherever they may be. Likewise, pharmacy teams may wish to consider work-from-home options for pharmacists in a meaningful way. Electronic transfer of prescriptions directly from prescribers to pharmacies may also be helpful to reduce use of paper, while respecting the patient’s autonomy and preferences around prescription self-management.6

Summary

In recent years, health care seems to be in a constant state of crisis. It may be challenging for frontline practitioners to tackle additional demands without supplemental resources. It is unquestionable, however, that the health of our planet is deeply woven into the health of Canadians. As there is increasing urgency to address the climate change crisis, pharmacists across all sectors need to seriously contemplate how our professional responsibilities may align with an environmentally conscious mandate.19 Pharmacists are encouraged to discuss sustainable prescribing, dispensing and medication disposal, and a greener approach to pharmacy practice within their teams, with patients and prescribers, and with their professional organizations. They can also implement some of the environmental stewardship ideas suggested in this article. The time to act is now.

Suzanne Singh (suzanne.singh@sinaihealth.ca) is a pharmacist at the Mount Sinai Academic Family Health Team and an Adjunct Lecturer at the Department of Family and Community Medicine at the University of Toronto. She is an advocate for enhancing the role of the pharmacist within integrated and innovative primary care practice models.

Pharmacy teams need to educate the public about medication disposal programs so that they are used to their full potential.

The Closer

CREATIVE THOUGHTS AND SMART IDEAS FOR PHARMACY OWNERS AND MANAGERS

A DOSE OF STRATEGY

Five common mistakes that hold us back

Mistake #3: Making incorrect attributions

AMY OLIVER MBA, BScPh, RPh, PMP, CLC

Community pharmacists are relentlessly hardworking and productive. Adept at task-switching, you have mastered the ability to perform skilled cognitive work despite constant distractions. And recent unpredictable seasons have only confirmed your agility. But while you’ve learned to manage the pivots and shifts required through a day, we have work to do to prepare you for the pivots and shifts of the decade.

After 10 years supporting and coaching practice owners in pharmacy and other community healthcare practices, I have put together a list of five common mistakes to avoid in your practice:

Mistake #1: Acting upon assumptions instead of facts Making strategic business decisions based solely on assumptions is poor practice. We tell ourselves stories all day long across all parts of our lives. For example, Jacinda is passionate about menopause and wants to launch a non-publicly-funded menopause service. But she assumes no one would pay $200 out-of-pocket for an hour-long consultation and therefore never launches the program. Ask, “Is this an assumption, or is it a fact?” Test the water. Ask your patients. Ask your friends. Find out if your assumptions are facts before you make decisions.

Mistake #2: Lacking broad perspective

You only see the world from where you stand. To design the best services, layouts, processes and programs, you need the perspective of all those who’ll be impacted (staff, patients, allied care providers, community). Top-down decisions may be faster, but that does not mean they are better. Discussion and healthy debate will result in more successful solutions. For example, as minor ailment prescribing rolls out more broadly in Canada, I wonder how many pharmacies will have posters and bag stuffers that say something about your services in “minor ailments.” Ask 10 of your non-pharmacy friends if they know what that means, and you will see how their perspective matters when planning your marketing.

Attribution error occurs when someone attributes their success to their skills, but their failures to bad luck. It’s classic human behaviour, but you can be coached to see that it may in fact have been a lack of skill or process, not bad luck. A successful practice is not a pass or fail exercise. It’s a learning journey where you must recognize what made something successful and then do more of that. Similarly, you need to understand what factors caused something to fail, and how to fix it and move forward.

Mistake #4: Risk management as an afterthought

Community pharmacy is chronically reactive. Your tasks are typically reactive to whatever/whoever walks in the door. Continuous improvement is typically reactive to incidents. When the systems and processes fail, then pharmacy teams replan. But while agility is important, many reactive actions could have been risk-managed before they became issues. When you develop your next service, process or protocol, ask, “What could go wrong here?” and then, if your answer is probable or highly impactful, plan a risk response BEFORE you need it.

Mistake #5: Taking continuing education that is solely clinical

It’s hard to imagine becoming a pharmacist without having learned core content in therapeutics, pharmacology, physiology and more. Yet many practice owners and managers expect to be great business owners and leaders without training in business or leadership. You don’t need an MBA to run a successful practice, but you should consider diversifying your professional development to include content on management and leadership so you can make your pharmacy and business aspirations come to life.

If any of these five common missteps resonate with you, it’s time to course-correct and implement best practices to ensure mistakes like these don’t hold your potential back any longer.

Amy Oliver is an experienced pharmacy executive and the founder of Amy Oliver + Co (www.amyoliver.ca), offering advisory services and certified business coaching to health leaders and practice owners looking to master their strategy, management and leadership on their journey to excellence.

Find out if your assumptions are facts before you make decisions.

Your usual pain reliever not working?

Try Combogesic®

COMBOGESIC ® (acetaminophen and ibuprofen) is analgesic which provides double action o medicines, acetaminophen and ibuprofen, in a single tablet.1

COMBOGESIC® contains 325 mg of acetaminophen and 97.5 mg of ibuprofen. 1 This 3.3:1 ratio has been clinically proven to provide superior efficacy and faster pain relief than the individual ingredients at equal doses. 1

COMBOGESIC® is indicated for: 1

• Short term management of mild to moderate acute pain

• Reduction of fever

For adults.

Please see product monograph for information on contraindications.

Acetaminophen works to stop the pain messages from getting through to the brain. It also acts in the brain to reduce fever. Ibuprofen is a non-steroidal anti-inflammatory medicine. It relieves pain and reduces inflammation.

The recommended adult dose of COMBOGESIC® is 1-2 tablets every 6 hours. 3 tablets may be taken at subsequent doses, on the advice of a healthcare professional. Do not exceed 12 tablets over a 24hour period.1

COMBOGESIC® tablets should not be taken for fever for more than three days or for pain for more than five days unless recommended by a physician. COMBOGESIC® tablets should not be taken with other acetaminophen or ibuprofen containing products. 1

• A combination of two trusted ingredients

• The double action of acetaminophen and ibuprofen provides fast and effective pain relief

• Simple dosing – no managing different dosing schedules

COMBOGESIC® is nonprescription, available behind the pharmacist's counter, and online. Visit www.combogesic.ca for more

MIND WEIGHT TH

w g g

PrCONTRAVE® is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of:1

• 30 kg/m2 or greater (obese) or

• 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., controlled hypertension, type 2 diabetes mellitus, or dyslipidemia).

PrCONTRAVE® (naltrexone and bupropion) may have effects on two separate areas of the brain involved in the regulation of food intake. The exact neurochemical effects of CONTRAVE leading to weight loss are not fully understood.1*

Consult the Product Monograph at https://pdf.hres.ca/ dpd_pm/00064902.PDF for important information about:

• Contraindications in patients with uncontrolled hypertension, seizure disorder or history of seizures, using other bupropion hydrochloride-containing products, diagnosis of bulimia or anorexia nervosa, using chronic opioid or opiate agonist or partial agonists, or acute opiate withdrawal, abrupt discontinuation of alcohol, benzodiazepines or other sedatives, and antiepileptic drugs, using monoamine oxidase inhibitors, using thioridazine, pregnancy, severe hepatic impairment, end-stage renal failure.

• The most serious warning and precaution regarding behavioural and emotional changes.

• Relevant warnings and precautions regarding opioid-containing drug products, opioid overdose, and opioid withdrawal, blood pressure and heart rate, dependence/tolerance, hypoglycemia, drugs metabolized by CYP2D6, hepatotoxicity, allergic reactions, lupus, seizures, serotonin toxicity, angle-closure glaucoma, mania and hallucinations, hepatic and renal impairment, nursing mothers, lactose.

The Product Monograph is also available by calling 1-800-361-4261.

* Clinical significance has not been established.