Pharmacy Practice + Business - October 2019

OCTOBER 2019

PLUS

5 TIPS FOR COUNSELLING THE GROWING IMMIGRANT POPULATION

Reefer MEDness:

A professional podcast about cannabis

YOUNG ADULTS AND DIABETES

HOW TO COMMUNICATE EFFECTIVELY WITH PATIENTS Are you speaking your patients’ language?

PAGE 43

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Contents

OCTOBER 2019 [VOL.6 NO.8] PAGES 17-24

PAGES 35-42

CE LESSON

CE LESSON

The pharmacist’s role in travel health: a guide to patient immunization assessment

Chronic Migraine: Comprehensive Management.

Collaborative Care.

1.5 CEUs

MADE POSSIBLE BY SANOFI PASTEUR LIMITED

1.5 CEUs

MADE POSSIBLE BY ALLERGAN INC.

PAGES 27-30 CE LESSON

Helping patients navigate an important paradigm shift in asthma management

1 CEU

MADE POSSIBLE BY ASTRAZENECA

43

5

EDITOR’S MESSAGE

7

DRUG NEWS

11

33

Health supplements in their natural habitat

BY VICKI WOOD

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

BY LU-ANN MURDOCH

PRACTICE EXPERTS

Geriatric Issues: Helping elderly patients manage orthostatic hypotension Practical Diabetes: Social issues in young adults with diabetes

31

THE INNOVATORS

Reefer MEDness: A cannabis story: Healthcare duo create unique way to educate on all things cannabis

BY ROSALIND STEFANAC

BY GRETA MAH

25

51

BY SHELLEY DIAMOND

FINDING YOUR NICHE

Oncology Care: An opportunity to bring comfort and hope, while practising to full scope

BY ROSALIND STEFANAC

43

ON THE COVER

51

NEW SERIES!

53 54

CLASSIFIEDS

Communicating effectively with patients BY KRISTI BUTT OTC Counselling Tip Sheet: Sweet relief: The buzz about honey and cough BY CÉLINE ST. PIERRE Employment opportunities and services

BACK TALK

Biz Talk: Ready to offer professional services? Here’s how to start

BY DEREK DESROSIERS ILLUSTRATION BY SPENCER FLOCK

5 TIPS

Counselling the growing immigrant population

BY ANNIE JALAL AND ELISE PARADIS

www.CanadianHealthcareNetwork.ca @Ppr_plus

@PharmacyPracticePlusBusiness

[Vol.6 No.8] OCTOBER 2019

3

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REMIND PATIENTS: The

ENTIRE laundry routine needs to be

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free

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EDITOR’S MESSAGE

Health supplements in their natural habitat IN SEPTEMBER, I attended the annual conference and trade show of the Canadian Health Food Association.

It’s been five years since I walked the aisles at CHFA East, partly because I felt it had less relevance to pharmacy than other pharmacy-specific events. It was an eye-opener to see how many of the natural health and wellness products from the 1,000+ companies exhibiting at the trade show are, or could be, at home in pharmacies.

I shouldn’t be surprised. As someone who spends plenty of time in drugstores, I see the growing real estate dedicated to supplements, functional foods and natural remedies. And I buy my vitamin B and probiotics at the pharmacy—unless the brand we use is on special at the grocery store. But I always get my “greens” supplement at a health food store; that is, except when it’s on sale at the pharmacy and I can use points to bring the price even lower.

I didn’t realize how typical my behavior was. Absolutely textbook, apparently.

PHARMACY PRACTICE + BUSINESS GROUP BRAND DIRECTOR, HEALTHCARE Donna Kerry dkerry@ensembleiq.com VICE PRESIDENT/ GENERAL MANAGER EVENTS Michael Cronin mcronin@ensembleiq.com EDITOR Vicki Wood vwood@ensembleiq.com

CONSULTING CLINICAL EDITOR Lu-Ann Murdoch, BScPhm VICE PRESIDENT, PRODUCTION Derek Estey CREATIVE DIRECTOR Nancy Peterman

PRODUCTION MANAGER Lisette Pronovost

It turns out that, when surveyed about their preferences and habits in shopping for natural health products, 1,244 Canadian female shoppers, aged 25-54, echoed my behavior to a T. Those insights were part of a fascinating overview of emerging shopper trends by Jessica Malach, VP, growth at SocialNature, Canada’s largest online panel of health and wellness consumers.

Malach described the women as “omni-channel” shoppers, because, when asked where they typically purchase these products, most mentioned three channels.

Just 45% regularly shop independent health food stores; 64% bought from large retailers (Walmart, Loblaw, etc.) and more than half (54%) shopped for their natural products at drugstores. Just over one in three (38%) purchase these products from online retailers.

When asked what keeps them coming back to their favourite store, half (46%) mentioned good prices and/or promotions.

Location was equally important (44%).

Shoppers also said they preferred retailers

DIRECTOR OF MARKETING Alex Voulu

ACCOUNT MANAGERS, QUÉBEC Ted Georgaros CONTINUING EDUCATION/ tgeorgaros@ensembleiq.com PROJECT MANAGER/PROOFREADER Nancy Dumont Rosalind Stefanac ndumont@ensembleiq.com WEB OPERATIONS MANAGER COLUMNISTS AND Valerie White CONTRIBUTING/CONSULTING AUDIENCE DEVELOPMENT EDITORS MANAGER Derek Desrosiers, BSc(Pharm), Lina Trunina RPEBC, RPh; Shelley Diamond, ltrunina@ensembleiq.com BScPhm; Sherilyn Houle, BSP, PhD; Sandra Knowles, BScPhm; SALES & EVENTS COORDINATOR Lu-Ann Murdoch, BScPhm; Nardine Claudia Castro Nakhla, PharmD; Carlene Oleksyn, BSP Pharm, CTH; Vikas Parihar, BRAND DIRECTOR BScBiochem, BScPharm, PharmD; Martin Rissin Jillian Reardon, BSc(Pharm), ACPR, mrissin@ensembleiq.com PharmD, RPh; Rosalind Stefanac; SENIOR ACCOUNT MANAGERS, Karen Welds TORONTO Norman Cook ncook@ensembleiq.com Scott Tweed stweed@ensembleiq.com

that are designed to be easy to shop quickly (41%) and those where they can browse for new natural products (40%).

So, what are these women buying?

Over three-quarters (76%) said they regularly take health supplements. Most (57%) do so to support their general health, as opposed to for a specific ailment or condition. About one in three (32%) purchase herbal or homeopathic health products. They spend, on average, $40 a month on supplements. (Yep.) No surprise, price is the most important consideration when buying supplements (cited by 73%). But being able to trust in the safety and quality of the brand was also important (65%). These two points are where drugstores have the edge over other retailers in the natural health products arena. With the trusted pharmacist nearby to offer advice, safety and quality are less of a worry. And with your buying power, pharmacies can price health supplements competitively. Plus, take it from Ms. Typical Shopper here: you can never go wrong with a sale.

vwood@ensembleiq.com @Ppr_plus @PharmacyPracticePlusBusiness

CORPORATE OFFICERS CHIEF EXECUTIVE OFFICER Jennifer Litterick CHIEF FINANCIAL OFFICER Dan McCarthy

CHIEF OPERATING OFFICER Joel Hughes

CHIEF INNOVATION OFFICER Tanner Van Dusen

CHIEF HUMAN RESOURCES OFFICER Ann Jadown EXECUTIVE VICE PRESIDENT, EVENTS & CONFERENCES Ed Several

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[Vol.6 No.8] OCTOBER 2019

5

DRUG NEWS

A REVIEW OF NEW LAUNCHES, NEW INDICATIONS, NEW DOSAGE FORMS AND HEALTH CANADA ADVISORIES

CLINICAL EDITOR

LU-ANN MURDOCH, RPh, BScPhm, ACPR, is a

consulting clinical editor for Pharmacy Practice +Business and drug information consultant for Pharmacist’s Letter.

NEW PRODUCTS Hemlibra: new SC antihemorrhagic for hemophilia A emicizumab subcutaneous (SC) injection; 30 mg/mL, 60 mg/0.4 mL, 105 mg/0.7 mL and 150 mg/mL single-use vials, Hoffmann-La Roche.

INDICATIONS

For hemophilia A (congenital factor VIII deficiency) patients with or without factor VIII inhibitors as routine prophylaxis to prevent bleeding or reduce the frequency of bleeding episodes.

Note: Limited clinical experience in patients with mild or moderate hemophilia A. No clinical efficacy or safety data in patients less than one year of age.

ACTION Emicizumab bridges activated factor IX and factor X to restore the natural function of activated factor VIII, which is missing in hemophilia A patients (and needed for effective hemostasis). Has no structural relationship or sequence homology to factor VIII; therefore, does not induce or enhance the development of direct inhibitors to factor VIII. DOSAGE Loading dose: 3 mg/kg SC once weekly for the first four weeks. Maintenance dose: Started one week after the last loading dose. Adolescents (12–17 years of age) and adults (≥ 18 years of age) who weigh ≥ 40 kg: 1.5 mg/kg SC once weekly, or 3 mg/kg SC every two weeks or 6 mg/kg SC every four weeks. Children (< 12 years of age) of any weight or patients of any age who weigh < 40 kg: 1.5 mg/kg SC once weekly or 3 mg/kg SC every two weeks.

ADMINISTRATION Recommended SC injection sites: abdomen, upper outer arms and thighs. Alternating injection sites

helps to prevent or reduce injection site reactions. Do not administer into areas where the skin is red, bruised, tender or hard, or areas with moles or scars. Patient and/or caregiver may be trained to inject the drug. Consult product monograph for recommended criteria for syringes, needles and vial adaptor to ensure correct and safe administration of Hemlibra.

ADVERSE EFFECTS MOST COMMON: Injection site reactions (erythema, pain, pruritus); most are mild to moderate in intensity and 95% resolve without treatment. Arthralgia, headache.

MOST SERIOUS: Increases coagulation potential. Thrombotic microangiopathy and thrombotic events (in patients also receiving activated prothrombin complex concentrate [aPCC]).

DRUG INTERACTIONS No studies conducted.

STORAGE Store at 2–8ºC. Keep vial in the outer carton to protect from light. Once removed from the refrigerator, unopened vials can be kept at room temperature (< 30ºC) for up to seven days. After storage at room temperature, unopened vials may be returned to the refrigerator.

Cumulative storage time at room temperature should not exceed seven days.

COMMENTS Currently available only to patients in Quebec (via Héma-Québec) for hemophilia A patients with factor VIII inhibitors; currently under review by Canadian Blood Services for all other Canadian jurisdictions. Hoffmann-La Roche is also working to make Hemlibra available through Canadian Blood Services and Héma-Québec for hemophilia A patients without factor VIII inhibitors.

OTHER NEW PRODUCTS Crysvita burosumab solution for SC injection; 10 mg/mL, 20 mg/mL and 30 mg/mL single-dose vials,

Kyowa Kirin (UK)/ Ultragenyx Pharmaceutical (US).

Canadian distributor: Innomar Strategies.

INDICATIONS Fibroblast growth factor

23 inhibitor for the treatment of X-linked hypophosphatemia in adults and children one year of age or older.

DOSAGE Discontinue oral phosphate and vitamin D analogs at least one week before starting burosumab treatment.

Fasting serum phosphorus concentration should be below the reference range for age before initiating treatment. Children (1 to < 18 years of age): Starting dosage is 0.8 mg/kg (rounded to the nearest 10 mg) administered SC every two weeks. Minimum starting dose is 10 mg; maximum dose is 90 mg. Adults: Starting dosage is 1 mg/kg SC (rounded to the nearest 10 mg) up to a maximum dose of 90 mg, administered every four weeks.

Pediatric and adult dosage is adjusted based on serum phosphorus levels (consult product monograph for details).

COMMENTS Contact the Innomar UltraCare program for assistance in gaining access to Crysvita in Canada: https://www.ultracaresupport. com/crysvita/canada/ (1-833-388-5872).

Mvasi bevacizumab 25 mg/mL solution for injection; 100 mg and 400 mg vials, Amgen.

INDICATIONS First-line treatment

of metastatic carcinoma of the colon or rectum (in combination with fluoropyrimidine-based chemotherapy); treatment of unresectable advanced, metastatic or recurrent nonsquamous nonsmall cell lung cancer (in combination with carboplatin/paclitaxel chemotherapy

[Vol.6 No.8] OCTOBER 2019

7

(Other new products continued)

regimen); and treatment of glioblastoma after relapse or disease progression following prior therapy (in combination with lomustine).

DOSAGE Varies according to therapeutic indication; consult product monograph.

Administered by intravenous infusion.

COMMENTS First biosimilar drug to Avastin to be marketed in Canada. Note: Pfizer’s Zirabev (bevacizumab 25 mg/mL solution for injection; 100 mg and 400 mg vials), the second biosimilar to Avastin, has also been approved by Health Canada, but the marketing date has yet to be announced.

Zeulide Depot leuprolide acetate for depot suspension; 3.75 mg (1-Month) and 22.5 mg (3-Month) vials, Verity Pharmaceuticals (416-800-7771).

INDICATIONS Palliative treatment of

advanced and/or metastatic prostate cancer.

DOSAGE 1-Month: 3.75 mg administered monthly as a single intramuscular (IM) injection. 3-Month: 22.5 mg once every three months as a single IM injection. Vials must be reconstituted with the ready-touse diluent prior to administration.

COMMENTS Alternative to 1-Month and 3-Month dosage forms of Lupron or Eligard.

NEW DOSAGE FORMS

Ibrance

(clozapine tablets), HLS Therapeutics. New 50 mg and 200 mg tablets join the original 25 mg and 100 mg tablets.

NEW INDICATIONS Genvoya (elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide tablets), Gilead Sciences.

EXPANDED INDICATION The indication

for use as a complete regimen to treat human immunodeficiency virus type 1 infection in adults has been expanded to include those with end stage renal disease on chronic hemodialysis. (Also indicated for use in children weighing ≥ 25 kg.)

DOSAGE One tablet once daily. No dose adjustment is required in adults with

on day 1. Etoposide is administered by IV infusion on days 2 and 3. This regimen is administered every three weeks for four cycles. Maintenance phase—atezolizumab 1200 mg by IV infusion every three weeks (no chemotherapy given).

NEW DOSAGE GUIDELINES Actemra (tocilizumab solution for SC injection), HoffmannLa Roche.

(palbociclib capsules), Pfizer.

EXPANDED INDICATION Now approved

for use in the treatment hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative locally advanced or metastatic breast cancer in combination with an aromatase inhibitor as initial endocrine-based therapy in postmenopausal women or men. It was originally approved for this use in postmenopausal women only.

(Also indicated for use in the treatment of hormone receptor-positive, HER2negative locally advanced or metastatic breast cancer in combination with fulvestrant in patients with disease progression after prior endocrine therapy.)

DOSAGE Administered in 28-day cycles: 125 mg orally once daily for 21 consecutive days, followed by seven days off treatment. Take with food at approximately the same time each day.

Tecentriq

Clozaril

8

estimated creatinine clearance (CrCl) ≥ 30 mL/minute or in adults with end stage renal disease (estimated CrCl < 15 mL/ minute) on chronic hemodialysis. Not recommended in patients with estimated CrCl ≥ 15 and < 30 mL/minute, or < 15 mL/minute who are not on chronic hemodialysis, as safety is not established.

No data available to make dosage recommendations for pediatric patients with renal impairment.

(atezolizumab concentrate for solution for infusion), Hoffmann-La Roche.

NEW INDICATION First-line treatment

of adults with extensive-stage small cell lung cancer, in combination with carboplatin and etoposide. (Other approved indications include treatment of locally advanced or metastatic urothelial carcinoma; first-line treatment for metastatic nonsquamous nonsmall cell lung cancer (NSCLC), with no EGFR or ALK genomic tumour aberrations, and no prior systemic chemotherapy treatment; and treatment of locally advanced or metastatic NSCLC with progression on or after platinum-based chemotherapy.)

DOSAGE Extensive-stage small cell lung cancer (first-line): Induction phase— atezolizumab 1200 mg administered by IV infusion, followed by carboplatin, and then etoposide administered by IV infusion

OCTOBER 2019 [Vol.6 No.8]

The SC formulation of Actemra is now indicated for the treatment of polyarticular juvenile idiopathic arthritis (pJIA) and systemic juvenile idiopathic arthritis (sJIA) in patients two years of age or older.

Formerly, only the intravenous infusion was approved for these indications. The recommended SC dosing regimen for patients with pJIA is 162 mg once every three weeks for patients weighing < 30 kg, and 162 mg once every two weeks for patients ≥ 30 kg (given in combination with methotrexate unless treatment with methotrexate is not appropriate). The recommended SC dosing regimen for patients with sJIA is 162 mg once every two weeks for patients < 30 kg, and 162 mg once weekly for patients ≥ 30 kg.

HEALTH CANADA ADVISORIES Tacrolimus: risks with switching formulations

Health Canada is warning about possible graft rejection and other adverse reactions caused by under- or over-exposure to tacrolimus when patients are switched to an alternate formulation of oral tacrolimus without appropriate dosing adjustments and monitoring. The three distinct oral tacrolimus formulations available in Canada are not interchangeable: immediate-release tacrolimus (Prograf and generics—tacrolimus 0.5 mg, 1 mg and 5 mg capsules); extended-release tacrolimus

NEW GENERICS

• Auro-Olmesartan HCT

(olmesartan/hydrochlorothiazide 20 mg/12.5 mg, 40 mg/12.5 mg and 40 mg/25 mg tablets), Auro Pharma.

Generic alternative to Olmetec Plus.

(Advagraf—tacrolimus 0.5 mg, 1 mg, 3 mg and 5 mg extended-release capsules); and prolonged-release tacrolimus (Envarsus PA—tacrolimus 0.75 mg, 1 mg and 4 mg prolonged-release tablets). Advagraf and Envarsus PA are not available generically. Health Canada suggests using brand/product names throughout the medication use cycle to specify the correct formulation for each patient. In addition, healthcare professionals should use prominent descriptors for the different formulations (e.g., IMMEDIATE release, EXTENDED release or PROLONGED release) to specify tacrolimus products on written orders, on the drug selection screens of prescribing and dispensing information systems, and in storage areas.

An automated alert should be considered for computerized prescriber and pharmacy order entry to warn that these formulations are not interchangeable; a dosing frequency reminder can also be included.

Hormonal birth control products: no direct link with suicidality

A Health Canada safety review examined the potential risk of suicidal thoughts and behaviours (suicidality) with the use of hormonal birth control products. The review followed a European Medicines Agency safety review that was based on a published study suggesting a higher risk of suicide/first suicide attempts among users of hormonal birth control products compared to non-users. However, Health Canada’s review concluded that there is currently insufficient evidence to support a direct link between the use of hormonal birth control products and the risk of suicidality. Hormonal birth control product safety information in Canada already includes warning statements about the risk of depression and mood changes. In addition, the risk of suicidality is specifically included in the product safety information for Depo-Provera (medroxyprogesterone acetate injectable suspension). No further labelling changes are warranted at this time.

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-healthproducts/medeffect-canada.html and https:// www.canada.ca/en/health-canada/services/ drugs-health-products/medeffect-canada/ safety-reviews.html.

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The pharmacist’s role in travel health: a guide to patient immunization assessment

Influenza in adults aged 65 and older: How to protect this vulnerable population

By Ajit Johal, B.Sc. (Pharm), BCPP, CTH, CDE

By Ajit Johal, B.Sc. (Pharm), BCPP, CTH, CDE and Jeffrey Habert, MD, CCFP, FCFP

Upon successful completion of this learning activity, pharmacists will be better able to:

Upon successful completion of this learning activity, healthcare providers will be able to: 1. Describe the medical implications and economic cost of influenza for adults aged 65 and older 2. Differentiate between available influenza vaccines for adults 3. Discuss vaccination options for adults aged 65 and older, based on the recent 2019-2020 Statement from the National Advisory Committee on Immunization 4. Address patients’ concerns in order to reduce the risk of vaccine hesitancy among adults aged 65 and older, their caregivers and loved ones

1. Describe the burden of illness of hepatitis A, typhoid fever, malaria, yellow fever and rabies based on the travel destination.

2. Assess travellers’ requirements for updating routine vaccinations prior to departure.

3. Raise awareness among millennial-age and younger travellers regarding their potential unique vaccination needs for hepatitis A and hepatitis B, compared to older travellers.

4. Discuss essential pharmacological and non-pharmacological prevention strategies to reduce the risk of food- and waterborne diseases, such as hepatitis A and typhoid fever, and to reduce the risk of vector-borne diseases, such as malaria and yellow fever.

5. Provide appropriate travel-related information to prevent and manage animal bites during travel.

Supported by educational funding from Sanofi Pasteur Limited

Supported by educational funding from Sanofi Pasteur Limited

[Vol.6 No.8] OCTOBER 2019

9

Advertising

Breakthrough technology inspires patient self-care What happens when people living with diabetes track their glucose levels over time? They see patterns, feel empowered, and change their behaviours for the better.i This detailed information is precisely what flash glucose monitoring delivers, according to Ken Burns—a Certified Diabetes Educator and Pharmacist at the Centre for Complex Diabetes Care at Health Sciences North/ Horizon Santé-Nord in Sudbury, Ontario.

In his 35-year career working with the diabetes community, Ken Burns identified a common theme: those who monitor their glucose patterns can readily adjust their habits to better manage their diabetes. For instance: Ken recalls that after starting a patient with the FreeStyle Libre system, the only flash glucose monitoring system available in Canada, it gave her a new understanding of what was going on with her glucose levels. It enabled her to make adjustments to her diet and lifestyle, and after using the system for a short time, she said that she “couldn’t imagine life without” the technology.

The FreeStyle Libre system reads glucose levels through a small sensor worn on the back of the upper arm for up to 14 days. With a one-second scan, the FreeStyle Libre reader or mobile application on a compatible iPhoneii shows users their real-time glucose readings and reveals how levels are trending at any time - and it’s now covered by the Ontario Drug Benefit

program for qualifying Ontario residents who manage their diabetes with insulin.

“I’ve seen a lot of medications and products come along, but I’ve never seen a product that can so drastically transform how people change their lifestyle habits and make healthier selfmanagement choices,” says Ken Burns.

Ken recounts one patient in his seventies, and his dramatic transformation. This patient regularly used fingerprick tests to check his glucose levels. The gentleman was always concerned about his sugar levels during the day, but Ken wanted to help him better understand what was happening overnight. The FreeStyle Libre system enabled them both to see what was happening 24 hours a day and work together to make needed changes.

“I’ve seen such positive outcomes in those using flash glucose monitoring, and I think it is a tool that could help all of my patients. I don’t know anyone I currently work with who would not benefit from using it,” Ken says. “Now that the FreeStyle Libre system is covered by the Ontario public health plan, I hope it results in more of my patients having access to the benefits of the technology.”

For another family, caring for a father with both diabetes and dementia, flash glucose monitoring gave them more visibility into their father’s glucose patterns and most importantly, some

“I’ve seen such positive outcomes in those using flash glucose monitoring, and I think it is a tool that could help all of my patients.”

MORE PATIENTS CAN DO IT

Ken Burns, Diabetes Educator and Pharmacist

peace of mind. On one occasion, their father was experiencing higher sugar levels during the day and his doctor wanted to increase his long-acting insulin. But the FreeStyle Libre system let Ken see that the patient’s levels were actually already low during the night and could be made lower by increasing the insulin dose. This insight allowed the family and the entire health team to safely make decisions for his care.

“People living with diabetes using flash glucose monitoring are seeing their patterns and are often coming to me directly with their own solutions for managing their glucose levels, completely unprompted,” says Ken. “It’s removing much of the guesswork about what glucose levels are doing that many people living with diabetes are accustomed to.

This is truly transformative care.”

To find out more information about the FreeStyle Libre system, visit freestylelibre.ca.

Now covered by ODB and RAMQ** for people managing diabetes with insulin

WITHOUT LANCETS*

™

The FreeStyle Libre flash glucose monitoring system is indicated for measuring interstitial fluid glucose levels in adults aged 18 years and older who have at least 2 years of experience in selfmanaging their diabetes. Always read and follow the label/insert for detailed instructions and indication of use.

This article was paid for by Abbott, a manufacturer of diabetes care products in Canada. Ken Burns is a consultant for Abbott Diabetes Care Canada. i Łuczynski W, Głowińska-Olszewska B, Bossowski A. . Empowerment in the Treatment of Diabetes and Obesity. J Diabetes Res. 2016;2016:5671492. doi:10.1155/2016/5671492.

ii The FreeStyle LibreLink app is compatible with NFC enabled phones on Apple’s iPhone 7 and later, running iOS 11 and later. * Scanning the sensor does not require lancets. ** Official Mark of the Régie de l’assurance maladie du Québec. The following three criteria must be met: intensive insulin therapy, frequent or severe hypoglycemia problems and the necessity of glycemia self-monitoring a minimum of eight times per day.

FreeStyle, Libre, and related brand marks are trademarks of Abbott in various jurisdictions.

Product images are for illustrative purposes only.

ADC-16094-V2.0

PRACTICE EXPERTS

OUR PHARMACIST EXPERTS SHARE INFORMATION AND IDEAS TO SUPPORT YOUR DAILY PRACTICE

GERIATRIC ISSUES

GRETA MAH, BScPhm, RPh, BCGP, is a clinical pharmacist for

the Geriatric Day Hospital & Geriatric Clinic for Parkinson’s, North York General Hospital in North York, ON, and an adjunct lecturer at the Leslie Dan Faculty of Pharmacy, University of Toronto.

Helping elderly patients manage orthostatic hypotension

O

rthostatic hypotension (OH) is associated with falls, fractures, myocardial infarction, stroke, and even death.(1,2) Prevalence increases with age—occurring in up to 30% of community-dwelling individuals older than 75 years of age and in up to 50% (or more) of frail nursing home residents.(2) OH is defined as a reduction in systolic blood pressure (BP) of ≥ 20 mmHg or a reduction in diastolic BP of ≥ 10 mmHg within three minutes of standing.(3)

Symptoms and causes

Symptoms of OH include light headedness, dizziness, weakness, clouded mentation, headache, syncope, nausea, coldness of extremities and recurrent or unexplained falls.(3) Almost immediately, when transitioning from a lying to upright position, there is a gravitational shift of nearly 500 mL of blood away from the chest to the venous capacitance system below the diaphragm. This fluid shift leads to a reduction in venous return, cardiac output and BP. Chronic OH occurs when the body cannot restore normal BP due to

TABLE 1

Age-related changes that impair blood pressure regulation(2) Reduced baroreflex sensitivity Reduced alpha-1 vasoconstrictor response Reduced parasympathetic activity Reduced renal salt and water conservation Reduced left ventricular diastolic filling Increased vascular stiffness

TABLE 2

Medications known to aggravate orthostatic hypotension(3,4)

multiple causes, including physiological changes with aging, medications and autonomic failure (Tables 1-3).

Management

Management should always start with minimizing orthostatic stressors (Table 4) and medications that may aggravate OH (Table 2), if possible. Patients can be empowered to adhere to lifestyle changes and treatment regimens when educated on how to recognize symptoms of OH, and actively measure sitting and standing BP at different times of the day (e.g., morning, after lunch and bedtime).

Nonpharmacologic Therapies(6,7)

Abdominal binder: Compression improves OH symptoms immediately by reducing peripheral pooling in the lower limbs and splanchnic region.(1) Abdominal binders can be purchased online or from home health supply stores, without a prescription. They are easier to apply than compression stockings and more effective at raising systolic BP (10 mmHg vs. 6 mmHg, respectively). This is because the splanchnic mesenteric bed accounts for a much higher blood volume (~ 25% of total blood volume) compared to venous capacitance of the calves and thighs.(3,7) The binder should be worn before rising from bed in the morning and taken off when lying down, to avoid discomfort and supine hypertension (see Supine Hypertension section).

Fluid and salt:(1,3,8) Fluid and increased salt intake are excellent volume expanders, especially in the morning after frequent nocturia. However, they are contraindicated if patients also experience heart or liver

Alpha-blockers Tricyclic antidepressants Anticholinergics Nitrates Diuretics Antihypertensive agents Beta-blockers

Parkinson’s medications (to a lesser extent with levodopa) TABLE 3

Medical conditions that can cause autonomic failure(1,2) CENTRAL NERVOUS SYSTEM

PERIPHERAL NERVOUS SYSTEM

Parkinson’s

Alcoholism

Sleep apnea

Multiple system atrophy

Diabetes

Amyloidosis

Lewy Body dementia Pernicious anemia Brain stem lesions Cerebral infarctions

Paraneoplastic syndrome

Myelopathy

failure and severe edema. Fluid intake of 1.5 L/day is generally recommended.

Rapidly drinking about 500 mL cold water increases systolic BP by > 20 mmHg for about two hours. If salting food is not desired, broth, salted soda crackers, pretzels or salt tablets (1–2 g tid) can be options.

Bed up: Raising the head of the bed by six inches will reduce supine hypertension, as well as natriuresis and nocturia caused by overnight recumbency.(5,9)

[Vol.6 No.8] OCTOBER 2019

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Pharmacologic therapies

Pharmacotherapy (Table 5) is necessary if OH symptoms are frequent and debilitating. The goal is to reduce symptoms and improve function without causing significant supine hypertension.

TABLE 4

Strategies to minimize orthostatic stressors(1,3,5)

Supine hypertension

Patients with autonomic failure often have supine hypertension while lying down. It is defined as a systolic BP ≥ 150 mmHg or diastolic BP ≥ 90 mmHg, despite a normal seated BP and low upright BP. Patients with significant supine hypertension may need to reduce or stop fludrocortisone and avoid fluid or salt late in the evening. Patients should also sleep with the head of the bed elevated. If supine BP is ≥ 180/110 mmHg, a short-acting antihypertensive agent should be considered (e.g., captopril 6.25–12.5 mg, or one-half of a nitroglycerin 0.2 mg/ hr transdermal patch qhs, removing it 30 minutes before rising from bed). Patients must be careful getting up during the night to prevent falls.(1,8,9)

Pharmacist’s role

Although OH is common among elderly patients, it is often overlooked until symptoms become debilitating or frequent unexplained falls occur. Pharmacists can play a significant role by: • Helping patients recognize OH symptoms and measuring sitting and standing BP.

ORTHOSTATIC STRESSORS THAT EXACERBATE OH

STRATEGIES

Dehydration

Avoid saunas or prolonged sun exposure

Prolonged motionless standing

Try muscle tensing, leg crossing or squatting

Early morning OH (after natriuresis and diuresis induced by overnight recumbency)

-Drink 2 cups of cold water 30 min before rising -Elevate head of bed - Wear an abdominal binder (see Nonpharmacologic therapies section) before rising

Physical exertion (skeletal muscle vasodilation)

Frequent rest during housework or exercise

Alcohol ingestion Postprandial OH often occurs within 0.5–1 hr after a heavy meal

Avoid alcohol. Avoid buffets; instead, eat small frequent meals to prevent splanchnic vasodilatation

Straining during micturition or defecation

Rising quickly from a chair or bed

Good bowel routine to prevent constipation Get up from sitting/lying position slowly

OH–orthostatic hypotension

• Screening for medications that may worsen OH and collaborating with physicians to reduce or stop them.

• Explaining to patients why certain medical conditions and/or orthostatic stressors cause rapid postural BP drop, and providing practical management strategies.

• Initiating discussions with physicians to implement appropriate drug therapies for managing severe symptoms when all other measures have failed.

• Ensuring both drug and nondrug treatment adherence.

• Monitoring for medication side effects and efficacy by assessing frequency and severity of orthostatic symptoms, maximum tolerable standing time, conditions under which symptoms occur, and whether symptoms interfere with daily activities.(8) • Educating patient to watch for supine hypertension and recommending management strategies.

TABLE 5

Pharmacologic therapies for orthostatic hypotension DRUG & MECHANISM OF ACTION

DOSAGE

SIDE EFFECTS & COMMENTS

Fludrocortisone(1,3,8) Mineralocorticoid—expands plasma volume and increases vascular alphaadrenoceptor sensitivity

0.05–0.2 mg daily

Supine hypertension, edema, hypokalemia Contraindicated in congestive heart failure and chronic renal failure

Midodrine(3,8,10,11) Direct-acting alpha-1 agonist Vasopressor effect occurs within 0.5–1 hour and lasts for 3–4 hours

2.5–10 mg tid (before getting out of bed, before lunch and mid-afternoon) Avoid lying down for 4 hours after taking a dose or administration after 6 pm to prevent supine hypertension.

Omit a dose if supine or sitting BP ≥ 150/90 mmHg

Pyridostigmine(1,3,8) 30 mg bid to 60 mg tid Cholinesterase inhibitor—improves neurotransmission in the sympathetic baroreflex pathway, which is activated only when standing

Paresthesias (e.g., scalp tingling, goosebumps)

Abdominal cramps, upset stomach, diarrhea May increase urination, sweating, saliva & mucus production Modest vasopressor benefit without aggravating supine hypertension

REFERENCES 1. Ricci F, De Caterina R, Redorowski A. Orthostatic hypotension. J Am Coll Cardiol 2015;66:848-60. 2. Gupta V, Lipsitz LA. Orthostatic hypotension in the elderly: diagnosis and treatment. Am J Med 2007;120:841-7. 3. Figueroa JJ, Basford JR, Low PA. Preventing and treating orthostatic hypotension: as easy as A,B,C. Cleve Clin J Med 2010;77:298-306. 4. Arnold AC, Raj SR. Orthostatic hypotension: a practical approach to investigation and management. Can J Cardiol 2017;33:1725-8. 5. Mathias CJ, Kimber JR. Treatment of postural hypotension. J Neurol Neurosurg Psychiatry 1998;65:285-9. 6. Freeman R. Current pharmacologic treatment for orthostatic hypotension. Clin Auton Res 2008;18(Suppl 1):14-8. 7. Newton JL, Frith J. The efficacy of nonpharmacologic intervention for orthostatic hypotension associated with aging. Neurology 2018;91:e652-6. 8. Low PA, Singer W. Update on management of neurogenic orthostatic hypotension. Lancet Neurol 2008;7:451-8. 9. Jordan J, Biaggioni I. Diagnosis and treatment of supine hypertension in autonomic failure patients with orthostatic hypotension. J Clin Hypertens 2002;4:139-45. 10. Wright RA, Kaufmann HC, Perera R, et al. A double-blind, dose-response study of midodrine in neurogenic orthostatic hypotension. Neurology 1998;51:120-4. 11. Izcovich A, Malla CG, Manzotti M, et al.

Midodrine for orthostatic hypotension and recurrent reflex syncope. Neurology 2014;83:1170-7.

12

OCTOBER 2019 [Vol.6 No.8]

An imbalanced cutaneous microbiome is linked to atopic dermatitis.

Proud sponsor of the ESC

LIP IK A R B AU M E AP+ Helps to rebalance the skin microbiome and space out flare-ups of severe dryness.

PROVEN TO FURTHER REBALANCE THE SKIN MICROBIOME

AT D28, DEMONSTRATES SUPERIORITY IN REDUCING STAPHYLOCOCCUS LEVELS VS. OTHER EMOLLIENT WITH CERAMIDES

AP+ n=30

Streptococcus

other emollient with ceramides 1000

2000

3000

4000

5000

6000

7000

8000

9000

% USERS IN RELAPSE

(OTU)

REDUCED FREQUENCY OF FLARE-UPS*

60% 30%

0% LI P I K A R BAUM E A P+

Other Emollient

P=0.0185

10000

Enhydrobacter

Staphylococcus[1]

MICROBIOME ANALYSIS AT D28 IN 30 USERS OF LIPIKAR BAUME AP+ AND 30 USERS OF AN EMOLLIENT WITH CERAMIDES, 2X /DAY.

% SCORAD WORSENING

[1]

0

50%

Acinetobacter

Others

n=30

100%

Xanthomonas

100% 50%

REDUCED SEVERITY OF FLARE-UPS*

79% P=0.0083

46%

0% LIPIK AR BAUME AP+

Other Emollient

*Due to skin dryness.

Using a specific emollient to manage skin dysbiosis. S. Seite, H. Zelenkova, R. Martin, N. Fierer. (2015). Poster presented at World Congress of Dermatology 2015.

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FLUZONE High-Dose: 73 (0.5%); FLUZONE standard-dose: 113 (0.7%) ®

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Postpone vaccination in case of moderate/severe febrile illness or acute disease.

Administer FLUZONE® High-Dose with caution in persons suffering from coagulation disorders or on anticoagulation therapy.

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Avoid vaccinating persons who are known to have experienced Guillain-Barré syndrome (GBS) within 6 weeks after a previous influenza vaccination.

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For more information: Consult the product monograph at http://products.sanofi.ca/en/ fluzone-hd.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 through our medical department. Call us at 1-888-621-1146.

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References: 1. FLUZONE® High-Dose vaccine. Product Monograph. Sanofi Pasteur Inc., April 24, 2019. 2. An Advisory Committee Statement (ACS)/National Advisory Committee on Immunization (NACI): Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2019-2020.

3. Legrand J, et al. Real-time monitoring of the influenza vaccine field effectiveness. Vaccine 2006; 24:6605–6611. 4. DiazGranados CA, et al. Efficacy of high-dose versus standard-dose influenza vaccine in older adults. N Engl J Med. 2014;371:635-645. 5. Statistics Canada. (2019). Canada's population estimates: Age and sex, July 1, 2018. https://www150.statcan.gc.ca/n1/en/daily-quotidien/190125/dq190125a-eng.pdf?st=KJGD2vFk. Accessed June 25, 2019. 6. Public Health Agency of Canada. (2013). FluWatch Report: August 11 to 24, 2013 (Weeks 33 & 34). http://publications.gc.ca/collections/ collection_2013/aspc-phac/HP58-1-2013-34-eng.pdf. Accessed: June 25, 2019. 7. Public Health Agency of Canada. (2014). FluWatch Report: 10 to 23 August, 2014 (weeks 33 & 34). http://publications.gc.ca/collections/collection_2014/aspc-phac/HP58-1-2014-34-eng.pdf. Accessed: June 25, 2019.

8. Public Health Agency of Canada. (2015). FluWatch Report: August 16 to August 29, 2015 (weeks 33 and 34). http://publications.gc.ca/collections/collection_2015/aspc-phac/HP58-1-2015-34-eng.pdf. Accessed: June 25, 2019. 9. Public Health Agency of Canada. (2016). FluWatch Report: August 14 to August 27, 2016 (Weeks 33-34). http://publications.gc.ca/collections/collection_2016/aspc-phac/HP58-1-2016-34-eng.pdf. Accessed: June 25, 2019. 10. Public Health Agency of Canada. (2017). FluWatch report: August 20 to 26, 2017 (Week 34). https://www.canada.ca/content/dam/canada/ public-health/services/publications/science-research-data/canadian-nosocomial-infection-summary/cnisp-aro-2011-2015%20report-final-en.pdf. Accessed: June 25, 2019. 11. Public Health Agency of Canada. (2018b). FluWatch Report: July 22, to August 25, 2018 (Weeks 30-34). http://publications. gc.ca/collections/collection_2018/aspc-phac/HP58-1-2018-34-eng.pdf. Accessed: June 25, 2019. 12. Schanzer DL, et al. Co-morbidities associated with influenza-attributed mortality, 1994–2000, Canada. Vaccine 2008;26:4697–4703.

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Influenza and vaccine effectiveness in 65+ year olds

This Counselling Corner is published by Ensemble IQ, 20 Eglinton Avenue West, Suite 1800, Toronto, ON M4R 1K8, Telephone: 416-256-9908. No part of this Counselling Corner may be reproduced, in whole or in part, without the written permission of the publisher. © 2019

PRACTICE EXPERTS

OUR PHARMACIST EXPERTS SHARE INFORMATION AND IDEAS TO SUPPORT YOUR DAILY PRACTICE

PRACTICAL DIABETES

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.

lower physical activity and increased risk for diabetes complications.(2) Itâ&#x20AC;&#x2122;s not known whether recreational drugs affect blood glucose levels, but their effects may disrupt normal management, including missed doses of insulin, increased or decreased physical activity and changes in appetite. The concern is that a resultant hypoglycemic episode may not be noticed due to impaired judgement. Diabetes Canada released a new position statement this year on recreational cannabis use in adults and adolescents with type 1 and type 2 diabetes.(3)

Social issues in young adults with type 1 diabetes nique challenges exist for young adults (defined as late teens and 20â&#x20AC;&#x2122;s) living with type 1 diabetes. In addition to changes in schools attended, living situation and work opportunities, there are also changes in social circles, romantic partners, and possible increased engagement in risky behaviours. In general, the vast majority of research in diabetes has focused on younger children with type 1 diabetes; very little attention has been given to young adults or older adults.

diabetes management routines on a university or college campus. In addition, access to healthy foods may be lacking, and schedule and work commitments may interrupt a previously well-maintained physical activity regimen. All of this can wreak havoc on blood glucose control.

College Diabetes Network (CDN) is a nonprofit organization whose mission is to provide young adults with type 1 diabetes with the peer connections they value, and the expert resources they need, to successfully manage the challenging transition to independence at college and beyond. CDN originated in the United States, but has started a chapter in Canada.

For more information, you can refer your patients to https://collegediabetesnetwork.org.

Education

Substance use

Getty Images

U

Many young adults are at a gateway for their continuing education where they may find themselves living outside of the home. They may be faced with changes in accommodations, diet and physical activity, as well as changes in relationships, among both family and friends. New peer relationships may encourage engagement in risky behaviours, including alcohol and drug use. It can be challenging to maintain

Young adults with type 1 diabetes have a similar incidence of substance abuse as those without diabetes.(1) Substance use can have important consequences for people with type 1 diabetes. Alcohol, for example, increases the risk for acute hypoglycemia, so it is important to know how to adjust insulin with alcohol use. Tobacco use has been found to be associated with poorer glycemic control,

Disordered Eating

Body dissatisfaction has been fueled by the media, and in recent years by social media. Since increased attention to food intake and carbohydrate counting is part of type 1 diabetes management, it is not

It is important to recognize the vulnerability of emerging adults with diabetes to loss of consistent health care and difficulties in adhering to diabetes management. surprising to learn that young adults with type 1 diabetes have a higher incidence of disordered eating (including manipulation of insulin related to food, binge eating or restricted eating) compared to the general population.(4) Therefore, it is important to screen for potential eating concerns in young adults with type 1 diabetes.

Relationships and dating

Since the majority of people with type 1 diabetes are diagnosed in childhood, young adults are, for the first time, faced with the challenge of communicating

[Vol.6 No.8] OCTOBER 2019

15

about their condition to people in new social environments. This includes romantic partners and the person with diabetes must make decisions regarding involving these people in their diabetes management. Research has shown that communal coping is related to positive relationship outcomes and positive health outcomes in the context of chronic illness, including type 2 diabetes.(5-7) Young adults should be advised that there is no best time to tell the person they are dating about their diabetes, but in general, the sooner, the better. Some circumstances may dictate the “need to know,” such as being able to recognize hypoglycemia, the need for insulin injections or altered mood states based on blood glucose levels. Diabetes may present an additional challenge in dating, but on the positive side, it can also be a useful determinant of the potential partner’s commitment.

What you can do to help

As mentioned previously, the paucity of research in the area of type 1 diabetes in

ce

young adults makes it more challenging to support this subgroup of patients. In addition to support and reinforcement of regular care for type 1 diabetes for patients of any age (e.g., blood glucose monitoring, regular appointments), opportunities specific to this population may warrant your intervention.

It is important to recognize the vulnerability of emerging adults with diabetes to loss of consistent health care and difficulties in adhering to diabetes management due to competing psychosocial, educational and vocational changes, potentially leading to deteriorating glycemic control. You can assist in providing support and links to resources (Box 1) that could benefit the patient.

Emerging adults with diabetes should be evaluated and treated for disordered eating behaviours and mood disorders. If you suspect or identify any of these issues, recommend that they discuss with their physician the need for a mental health referral to a source who understands the fundamentals of working with individuals with diabetes.

FREE! Approved for Answer online at ·ca www.eCortex.ca 1.5 Continuing Education CEUs L E S S O N CCCEP #1002-2019-2848-I-P • Please consult this course online at eCortex.ca for expiry dates

Chronic Migraine: Comprehensive Management. Collaborative Care.

By Karen Agro, BScPhm, PharmD, MSc Faculty: Rose Giammarco, MD, FRCPC, Nardine Nakhla, PharmD, RPh

At the completion of this program, pharmacists will be able to: 1. Recognize episodic versus chronic migraine and identify patients requiring prophylaxis.

2. Differentiate chronic daily headache disorders and their characteristic features.

3. Explore chronic migraine treatments, including self-management, natural health products, and prescription, both oral and injectable options when needed.

4. Identify self-management strategies to empower patients on appropriate medication use, including utilization of headache diaries and avoidance of medication overuse headache.

5. Discuss the elements of a comprehensive migraine management program, including the pharmacist’s role in self-management and collaborative care to optimize patient health outcomes.

Supported by educational funding from Allergan Inc.

16

OCTOBER 2019 [Vol.6 No.8]

BOX 1

RESOURCES FOR YOUNG ADULTS WITH TYPE 1 DIABETES • Beyond Type 1 (education, research and resources for type 1 diabetes) https://beyondtype1.org • College Diabetes Network (peer connections) https://collegediabetesnetwork.org • Insulin Nation (general diabetes news platform for type 1 diabetes) https://insulinnation.com • Type 1 Nation (online support network through JDRF) https://www.jdrf.org

Summary

As you build relationships with your young adult patients living with type 1 diabetes, let them know that you are also a resource for issues they are now responsible for themselves. These include birth control, pregnancy planning and risks, prevention of sexually transmitted illnesses, use of alcohol and drugs, smoking and driving.

Ensure that they understand how these may affect their management of diabetes.

When you feel that you don’t have the skills required, get to know the resources in your community so that appropriate referrals can be made. We are all still navigating how to support this group though their times of major life changes.

REFERENCES 1. Palladino DK, Helgeson VS, Reynolds KA, et al. Emerging adults with type 1 diabetes: a comparison to peers without diabetes. J Pediatr Psychol 2013;38:506-17.

2. Reynolds K, Liese AD, Anderson AM, et al. Prevalence of tobacco use and association between cardiometabolic risk factors and cigarette smoking in youth with type 1 or type 2 diabetes mellitus. J Pediatr 2011;158:594-601.

3. Bajaj HS, Barnes T, Nagpal S, et al. Diabetes Canada position statement on recreational cannabis use in adults and adolescents with type 1 and type 2 diabetes. Can J Diabetes 2019;43:372-6.

4. Young V, Eiser C, Johnson B, et al. Eating problems in adolescents with type 1 diabetes: a systematic review with meta-analysis. Diabet Med 2013;30:189-98.

5. Badr H, Carmack CL, Kashy DA, et al. Dyadic coping in metastatic breast cancer. Health Psychol 2010;29:169-80.

6. Berg CA, Wiebe DJ, Butner J, et al. Collaborative coping and daily mood in couples dealing with prostate cancer. Psychol Aging 2008;23:505-16.

7. Stephens MAP, Rook KS, Franks MM, et al. Spouses’ attempts to regulate day-to-day dietary adherence among patients with type 2 diabetes. Health Psychol 2013;32:1029-37.

ce October 2019

Approved for

Answer online at eCortex.ca

Continuing Education L E S S O N

1.5

CEUs Canadian Council on Continuing Education in Pharmacy

Approved for 1.5 CE units by the Canadian Council on Continuing Education in Pharmacy • CCCEP #1329-2019-2858-I-P • Please consult this course online at eCortex.ca for expiry dates

Learning Objectives

Upon successful completion of this learning activity, pharmacists will be better able to: 1. Describe the burden of illness of hepatitis A, typhoid fever, malaria, yellow fever and rabies based on the travel destination.

2. Assess travellers’ requirements for updating routine vaccinations prior to departure.

3. Raise awareness among millennial-age and younger travellers regarding their potential unique vaccination needs for hepatitis A and hepatitis B, compared to older travellers.

4. Discuss essential pharmacological and non-pharmacological prevention strategies to reduce the risk of food- and water-borne diseases, such as hepatitis A and typhoid fever, and to reduce the risk of vector-borne diseases, such as malaria and yellow fever.

5. Provide appropriate travel-related information to prevent and manage animal bites during travel.

The pharmacist’s role in travel health: a guide to patient immunization assessment

By Ajit Johal, B.Sc. (Pharm), BCPP, CTH, CDE recommended prevention and treatment options for travel-related illnesses are available without a prescription in pharmacies. Pharmacists should ideally provide travel medicine services during scheduled appointments, to ensure enough time is set aside, and for which pharmacists can appropriately charge since this is a nonpublicly funded service. With or without appointments, all pharmacists can assist their travelling patients with appropriate advice and referral to other healthcare providers, who can provide a more comprehensive service when necessary.

Instructions 1. After carefully reading this lesson, study each question and select the one answer you believe to be correct. Answer online at eCortex.ca.

2. To pass, a grade of at least 70% (11 out of 15) is required.

3. Complete the required feedback form for this lesson online at eCortex.ca.

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

DISCLOSURES The author discloses he has previously received funds from the company sponsoring this learning activity, for membership on an advisory board and speaking engagement.

He has also received funds from other commercial entities, including competitors to the sponsor, for membership on advisory boards, continuing education and speaking engagements. One expert reviewer has received funds from the sponsor and competitive entities, for membership on an advisory board and continuing education events. The second reviewer and the provider declare no real or potential conflict with the sponsor of this lesson.

Answer online at eCortex.ca

·ca

Introduction International travel continues to grow in Canada, with a projected growth of four percent per year until 2020.(1) Furthermore, travel to “less developed regions” of the world, including Southeast Asia and South America, continues to grow by six percent per year.(2) While the number of Canadian travellers continues to increase, many are not seeking crucial medical advice and appropriate vaccinations prior to travel. A Canadian survey indicated that only 27 percent of travellers reported plans to seek medical guidance prior to their trip.(3) Pharmacists are extremely well-positioned to improve travel health literacy among Canadians. This emerging role is made possible by an expanded scope of practice, which includes injection authority in many provinces for a wide range of vaccinations. In addition, many of the

Getting started: understand your scope of practice Pharmacists across the country have the authority to prescribe and administer a number of vaccinations, including travel vaccinations (Figure 1).(4) However, the regulations vary between provinces. In western Canada, pharmacists in British Columbia and Alberta may dispense and administer vaccinations independently using their own clinical assessment of the patient’s vaccination history and travel itinerary.(5) In Alberta, pharmacists with advanced prescribing authority can provide prescriptions for the oral medications that may be needed for preventing malaria, altitude sickness, and standby treatment for travellers’ diarrhea. The remaining provinces require a collaborative relationship, medical directive or a prescription from a physician to provide vaccinations and Schedule 1 medications necessary for travel.

Supported by educational funding from Sanofi Pasteur Limited

ce

Continuing Education L E S S O N

The pharmacist’s role in travel health: a guide to patient immunization assessment

CE2

BC Any drug (medication)

AB

SK

MB

✔

✔

✔

ON

TA B L E 1

QC

NB

P

✔

NS

NL

Intrinsic

✔

✔

• Past medical history • Conditions (i.e. chronic disease, immunosuppression) • Immunization history • Prior travel experience

✔

✔

✔

✔

✔

P

✔

✔

✔

✔

Travel vaccines

✔

✔

✔

✔

✔

P

✔

✔

✔

✔

Influenza vaccine

✔

✔

✔

✔

✔

P

✔

✔

✔

✔

All pharmacists are advised to consult their respective regulatory colleges and/or provincial pharmacy associations in order to obtain clarity on their scope of practice. P = Pending legislation, regulation or policy for implementation

Routine immunizations Primary care pharmacists should take the opportunity to update adult travellers on all of their routine immunizations. The growing shift of vaccine-preventable childhood diseases into adult populations illustrates that adult immunization rates in Canada fall short of recommended levels.(3) Travel to underdeveloped countries that do not have public immunization programs further increases the risk of infection for travellers. All Canadians, irrespective of age, should have immunity (by vaccination or documented natural exposure) to measles, mumps, rubella, tetanus, diphtheria, polio, pertussis and varicella. The National Advisory Committee on Immunization (NACI) itemizes recommended routine adult vaccinations for Canadians.(8) Furthermore, provincial immunization schedules can help pharmacists identify common immunization gaps in travellers.(9) Table 2 summarizes potential immunization gaps that pharmacists can address, keeping in mind there may

Factors for risk assessment(6)

PE

Vaccines

Travel health consultation = risk assessment Pharmacists who provide pre-travel health services conduct risk assessments in order to reduce the risk of preventable, travel-related illnesses occurring abroad. Primary care pharmacists must objectively assess their ability to provide travel health services on a caseby-case basis, based on the results of a risk assessment that considers intrinsic and extrinsic risk factors (Table 1). Both the traveller’s underlying medical conditions (intrinsic) and the risks related to their travel destination (extrinsic) will determine the complexity of the service. Primary care pharmacists can follow the travel health services pyramid (Figure 2) and the decision-making algorithm (Figure 3) to determine if they are competent and comfortable providing the service in their practice or if they should refer the traveller to a travel health specialist.

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be variations by province pertaining to publicly funded programs and pharmacist scope of practice.

Immunization assessment for millennials (born between 1981-2000) Pharmacists can address the unique immunization gap which may exist for millennial travellers, who are currently between the ages of 19 and 38 (or 20 and 39 in 2020). These travellers may have a unique vaccination status for hepatitis A and hepatitis B, compared to older travellers. During the 1990s, provincial vaccination programs began funding the hepatitis B vaccination for students in high school, which means that a combination hepatitis A and B vaccine, often routinely administered for adult travellers, would be redundant for millennials as well as Canadian travellers in subsequent generations. The age of the traveller, therefore, needs to be kept in mind to determine which publicly funded vaccinations they have received as part of the routine immunization schedule.

MEASLES MUMPS RUBELLA (MMR)

The measles virus is highly contagious and is spread from person to person in the form of aerosolized respiratory droplets. The western hemisphere experienced an interruption in the transmission of the measles virus in the early 2000s.(11) However, the measles virus continues to be imported into the region from other parts of the world, and the resulting outbreaks highlight the need to vaccinate travellers against this contagious disease prior to departure. International travelers (including those traveling to industrialized countries) who do not have presumptive evidence of measles immunity and who have no contraindications to MMR should receive MMR before travel, as outlined in Table 2.

TETANUS DIPHTHERIA ACELLULAR PERTUSSIS (TD/TDAP)

Tetanus can be a fatal disease and is endemic worldwide, especially in

Extrinsic • Travel destination • Trip plans (timing, itinerary, reason, style, activities) FIGURE 2

Travel health services pyramid

Travel health specialist services by pharmacists with advanced training Travel health advanced vaccination services by pharmacists with training

Intrinsic risk factors

Injection authority for pharmacists, by province(4)

Extrinsic risk factors

FIGURE 1

October 2019

Travel health generalist services by primary care pharmacists

developing countries with low immunization rates. Transmission usually occurs due to injuries from contaminated objects. Diphtheria is more of a concern for travellers since it is spread person-to-person through oral or respiratory droplets. The disease is endemic in many countries including Asia, the South Pacific, the Middle East, Eastern Europe and in Haiti and the Dominican Republic; diphtheria outbreaks in Indonesia, Thailand, Laos, South Africa, Sudan, and Pakistan have occurred in the past decade.(12) PERTUSSIS

Pertussis is endemic worldwide, even in areas with high vaccination rates.

In recent years a number of countries, including Canada, have experienced a resurgence in pertussis despite successful vaccination programs. Immunity from childhood vaccination and natural disease wanes with time; therefore, adolescents and adults who have not received a tetanus-diphtheria-pertussis (Tdap) booster can become infected.(13) Travelers are not at increased risk specifically due to international travel, but they are at risk if they come in close contact with infected people. Infants, especially those

The pharmacist’s role in travel health: a guide to patient immunization assessment

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FIGURE 3

October 2019

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Decision-making algorithm for provision of pre-travel care(7) WHO If any of the following…

PERSONAL INFORMATION: • Prior live immunization (past month) • Children (< 12 years old) • Pregnant / Breastfeeding • Elderly

Handle in pharmacy

MEDICAL STATUS • Immunocompromised - Immunosuppressant drugs (high-dose corticosteroids, anti-metabolites, etc).

• Disability • Psychiatric conditions • Seizures • Recent surgery / cardiopulmonary events • Chemotherapy / radiation • Organ / bone marrow transplant If none of the above…

WHEN < 2 weeks

> 2 weeks or long-term (> 6 months)

> 2 weeks

TIME OF DEPARTURE DURATION

1 – 2 weeks

HOW Rural (local homes, host family, tent)

Mexico (resort) Provide consultation on: • Routine vaccinations (e.g., MMR, Tdap) • Hepatitis A • Hepatitis B • LT-ETEC vaccination (labile toxin enterotoxigenic E. coli: a common cause of traveller’s diarrhea in many regions of the world) (discussion*) • Rabies discussion • OTC products (repellents, sunscreen,oral hydration salts, loperamide, first aid kit)

ACCOMMODATION Urban Air-conditioned, bed-nets / screens

WHY REASON FOR TRAVEL • Healthcare worker • Volunteering in rural communities • Seeking health care • Visiting family & friends (VFR)

Indonesia (< 2 weeks) (Bali - Denpasar, Ubud) China Japan Southern Thailand (resort < 2 weeks) Coastal Vietnam (< 2 weeks) (Hanoi) Provide consultation on topics listed above for Mexico (resort) (i.e., routine vaccinations, hepatitis A, hepatitis B, etc.) plus: • Typhoid fever • Japanese encephalitis (discussion*) *=Discussion based on specific traveller’s itinerary and risk profile

Disclaimer #1: Note that Northern Thailand, parts of Vietnam, and Indonesia may have malaria transmission (for comprehensive malaria risk assessment, advise the patient to consult with a travel health specialist)

If none of the above…

WHAT

Disclaimer #2: Risk of E.coli or Campylobacter jejuni mediated severe travelers diarrhea may occur – to obtain a standby treatment of antibiotics advise the patient to consult with a travel health specialist or see their doctor.

SPECIAL ACTIVITIES • Outdoor activities - Trekking - Diving / snorkelling - Swimming in fresh water If none of the above…

Refer to travel specialist

WHERE COUNTRY Africa, Asia, India, South America

who are too young to be protected by a complete vaccination series, are at highest risk for severe illness and death from pertussis. Immunization against pertussis can only be administered in conjunction with diphtheria and tetanus, as there is

China, Japan, Indonesia (Bali) Resorts: Mexico or Southern Thailand, Southern Vietnam (major cities)

no monovalent pertussis vaccination available in Canada. All provinces except B.C. fund the Tdap booster vaccination for adults. B.C. funds the Td booster vaccine only; therefore, adults have to pay out of pocket for the Tdap booster

vaccination in order to be immunized against pertussis.(14) HEPATITIS B

The hepatitis B virus (HBV) is transmitted by contact with contaminated

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TA B L E 2

October 2019

Potential gaps in routine immunizations

Immunization

Potential gap

Recommendations

Measles Mumps Rubella (MMR)

• No documented doses in childhood

• Administer 2 doses of the MMR vaccine 28 days apart

• Only 1 documented dose in child- • Administer a single MMR dose hood (Note: many Canadians born between 1970 and 1996 may have received only 1 dose of MMR)

Tetanus Diphtheria Acellular Pertussis (TDAP)

Hepatitis B

• Infants 6 through 11 months of age

• Should receive one dose of MMR vaccine.

Infants who get one dose of MMR vaccine before their first birthday should get two more doses (the first dose at 12 through 15 months of age and the second dose separated by at least 28 days).

• No documented doses in childhood

• Refer to provincial immunization catchup recommendations for adults starting immunization at 18 years and older

• 1 dose in Grade 9

• Administer booster dose of either TDAP or TD if >10 years since last TDAP dose

• No documented doses in childhood

• Administer 3 doses (0, 1, 6 months) or accelerated schedule of 4 doses (0, 7, 21 days, and 1 year)

• 3 documented doses in childhood, but high-risk travel itinerary

• May need blood test for hepatitis B surface antibodies (anti-HBs) if high-risk travel itinerary, and administration of booster dose if immune concentration is <10 IU/L(10)

blood, blood products and other body fluids (such as semen). Travelers may encounter poor infection control during medical or dental procedures, receipt of blood products, injection drug use, tattooing or acupuncture and unprotected sex.(10) The risk of contracting hepatitis B abroad depends considerably on the traveller’s itinerary and travel style.

High-risk travellers include those who will receive or perform medical procedures abroad and long-term travellers to high endemic regions. High endemic regions include Western Africa and the Western Pacific region (which includes countries such as Japan, Vietnam, Korea, and China), where the prevalence can be as high as six percent according to recent data from the World Health Organization.(13) Depending on the age of the traveller and immunizations received during childhood and adolescence, Canadian adult travellers may already have immunity to hepatitis B. Vaccination against hep B became part of publicly funded routine school-based vaccination programs in all provinces in the 1990s.(14) Travellers born after 1984 in most provinces, who received hepatitis B vaccination as part of the routine program, should have immunity.

Given the mode of transmission of HBV, and the fact that the many travellers will have already been vaccinated,

pharmacists should give greater consideration to vaccine-preventable contact diseases (i.e., measles, diphtheria, influenza, pertussis) and food- and water-borne diseases (e.g., hepatitis A, typhoid fever and traveller’s diarrhea).

Case studies of the “unfortunate traveller” The following cases illustrate some unfortunate outcomes for travellers who did not seek medical advice and receive appropriate vaccinations prior to departure. Pharmacists are encouraged to be proactive in promoting and advising their patients about the importance of pre-travel advice and vaccinations.

During consultations, pharmacists should not minimize the seriousness of the illnesses and their potential complications, which can be prevented through vaccination.

CASE # 1

The returned traveller: illness due to gap in routine immunizations

An 11-year-old boy travelling with his family began to experience a fever during his flight home from Southeast Asia. At home he developed a large rash spanning his entire back, which prompted his parents to take him to the emergency department.

His siblings began showing similar signs and symptoms, and after a blood test it was confirmed that they all had contracted measles while abroad.

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This case is based on a true story that occurred in B.C.(15) Due to the contagious nature of the measles virus, and the high propensity of unvaccinated travellers to “import” the disease from abroad, pharmacists must prioritize this vaccination in all pre-travel encounters. All best practice guidelines, including those of the U.S. Centers for Disease Control and Prevention (CDC) and the Canadian Committee to Advise on Tropical Medicine and Travel (CATMAT), state that “all adults must be up-to-date on their routine immunizations prior to travel.” Pharmacists should start their pre-travel consultation with a routine immunization assessment looking at potential immunization gaps (Table 2) and using their knowledge of the immunization schedule in their province.

In this case, all three children had not been immunized against measles in childhood, due to their parents’ vaccine hesitancy around the safety of the vaccine. If not immunized in childhood, they would have benefited from at least a single dose of MMR vaccination prior to departure to South East Asia. If pharmacists are unable to provide publicly funded vaccinations such as MMR, referral to the appropriate healthcare provider is advised.

CASE # 2

The returned traveller: illness due to foodand water-borne disease

A 31-year-old male returned home from a recent trip to Mexico and began to experience the following symptoms: fever, chills, pruritus and right upper quadrant pain.

He frequently visits Mexico throughout the year and owns a condominium in the Quintana Roo Tulum region. His symptoms continued to worsen, and when he looked in the mirror he observed yellowing of his sclera. He was diagnosed at the hospital with jaundice secondary to acute hepatitis A infection. He missed six months of work until his infection resolved.

Hepatitis A virus infects the liver and is transmitted via contaminated food and water. It is endemic in many parts of the world (Figure 4), and as a result the CDC recommends that all travellers leaving North America should be immunized against hepatitis A.(16) Travellers should be advised to avoid uncooked food products and to drink only hot beverages and sealed bottled water when abroad.

Hepatitis A vaccination is key to preventing food- and water-borne illnesses, which can spread even at all-inclusive resorts. Furthermore, since hepatitis A

The pharmacist’s role in travel health: a guide to patient immunization assessment

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TABLE 3

October 2019

Hepatitis A vaccine products(20)

Name of vaccine

Dosing schedule

Avaxim®

0.5 mL IM @ 0, 6-36 months

®

Avaxim Pediatric

0.5 mL Im @ 0, 6-36 months

Havrix® 1440

1.0 mL IM @ 0, 6-12 months

Havrix® Jr. 720

0.5 mL IM @ 0, 6-12 months

®

Vaqta

1.0 mL IM @ 0, 6-18 months

Vaqta® Pediatric

0.5 mL IM @ 0, 6-18 months

FIGURE 4

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World Health Organization Hepatitis A Epidemiology Map(17)

Combination vaccines Twinrix® Adult

1.0 mL IM @ 0, 1, 6 months

Twinrix® Junior

0.5 mL IM @ 0, 1, 6 months

®

Vivaxim

1.0 mL IM @ 0, 3-36 months*

*Booster doses can be either a hepatitis A (6-36 months) or the combination vaccine (month 36)

vaccination is not a routine vaccine in publicly funded school programs, it is a common immunization gap in travellers.

Hepatitis A vaccine is administered as two doses: the first dose at day zero and the second dose six to 36 months later, depending on the product.(18,19) The initial dose provides the traveller with levels of circulating antibody for their trip, and the second dose is administered after returning to ensure long-term immunity.

A number of vaccine options are available for hepatitis A (Table 3). Brands of monovalent Hepatitis A vaccination are considered interchangeable, in that a series started with one brand can be completed with another.(21) This principle can be useful for pharmacists, given the possibility of manufacturers’ vaccine shortages.

Combination vaccinations are also available: Twinrix® for hepatitis A and hepatitis B, and Vivaxim® for hepatitis A and typhoid fever. Twinrix® contains half the dose of hepatitis A vaccine (720 ELU) compared Havrix® (1440 ELU). As a result, a single dose of Twinrix® will not provide immunity for hepatitis A, as two doses are needed. Since most millennial-age (and younger) travellers will have completed their hepatitis B series of vaccination in childhood, and given the higher risk of transmission of hepatitis A through food and water, pharmacists can focus their recommendations for this age group to a monovalent vaccine or the combination-product Vivaxim®, which also immunizes against typhoid fever.

CASE #3

The VFR (visiting-friends-and-relatives) traveller: illness abroad due to food- and water-borne disease

A 51-year-old Canadian traveller returned to her country of origin, Pakistan, to visit friends and family. Three weeks into her

■ High prevalence (>90% have immunity by age 10) ■ Intermediate prevalence (>50% have immunity by age 15) ■ Low prevalence (~50% have immunity by age 30) ■ Very low prevalence (<50% have immunity by age 30) TA B L E 4

Typhoid fever vaccine products(25)

Injectable inactivated polysaccharide vaccine

Oral, live attenuated vaccine

Combined hepatitis A and inactivated typhoid vaccine

Typhim Vi® • ≥ 2 years of age • Protection in 14 days • One dose: 0.5 mL IM

Vivotif® • ≥ 5 years of age • Protection in 7 days following complete series • Total of 4 EC capsules – one capsule taken every second day (e.g., day 1, 3, 5, 7) • Live vaccine precautions (avoid in immunocompromised, pregnancy, GI conditions) • Not < 8 hours after ETEC-diarrhea vaccine or < 3 days after antibiotic

Vivaxim® • ≥ 16 years of age • Protection in 14 days • One dose: 1.0 mL IM

Reimmunization every 3 years

Reimmunization every 7 years

Boost with hepatitis A 6-36 months or if typhoid required, use combination

TA B L E 5

Minimizing risk of food- and water-borne diseases abroad(26)

Mode of transmission

Risk

Food

• Raw or undercooked meat, fish, • Avoid consuming salads, uncooked and shellfish can carry pathogens vegetables, unpasteurized fruit juices, • Raw fruits that are unpeeled, or not unpasteurized milk or cheese made from peeled by the traveller, can harbour unpasteurized milk. pathogens • Avoid raw fruits that are eaten unpeeled (e.g., strawberries). Fruits that require peeling (e.g., bananas, mangoes) should be peeled by the traveller who eats them.

Water

• Tap water may contain diseasecausing agents including viruses, bacteria and parasites, or chemical contaminants such as lead.

• Fountain drinks or other drinks made with contaminated tap water • Iced drinks with ice made from contaminated water

trip she began to experience high fever, headache and severe abdominal pain.

After no resolution of symptoms following courses of oral ciprofloxacin (five days), and cefi xime (four days), she was started

Advice to travellers

• Avoid consuming tap water. This includes avoiding tap water to prepare food and beverages, make ice, cook and brush teeth.

• Stick to sealed bottled water and hot beverages made from boiled water (i.e., coffee and tea).

• Request that beverages be served without ice.

on IV meropenem 1g IV every eight hours.

She began to respond to meropenem, and it was determined she was infected with extremely drug-resistant (XDR) typhoid fever.

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October 2019

The VFR traveller demographic Travellers visiting friends and relatives (VFRs) abroad are at a higher risk of acquiring travelrelated infections while abroad. Pharmacists should be aware that VFR travellers are more likely to feel they do not need pretravel advice and appropriate vaccinations. (27) Common misconceptions regarding immunity acquired abroad, combined with high-risk itineraries, put these travellers at higher risk.

• VFRs are eight times more likely than tourist travellers to be diagnosed with malaria. (28) • From 2008 through 2012 in the United States, 85 percent of typhoid cases occurred in VFRs, mostly from Southern Asia. (28) • A Canadian study found that 65 percent of hepatitis A cases were in VFRs under the age of 20.(29) • Other diseases, such as tuberculosis, hepatitis B, cholera and measles, occur more commonly in VFRs after travel. (30)

Typhoid and paratyphoid fever are caused by the Salmonella typhi bacteria.

Transmission results from consuming water or food that has been contaminated by the feces of an ill person or a chronic, asymptomatic carrier. The majority of cases occur in Southern Asia (i.e., India, Pakistan, Sri Lanka). Other areas of risk include East and Southeast Asia, Africa, the Caribbean, and Central and South America. Fever, which is typically lowest in the morning and peaks in the late afternoon or evening, is a defining symptom.(22) Serious complications of typhoid fever include life-threatening intestinal hemorrhage or perforation.

A growing concern is the emergence of extremely drug resistant (XDR) typhoid fever in certain regions of South East Asia such as Pakistan. The bacterium Salmonella enterica serovar typhi haplotype H58 has been identified as a common cause of multi-drug resistant (MDR) typhoid fever across Asia and Africa.(23) The H58 haplotype has acquired an extended spectrum betalactamase (CTX-M-15) conferring resistance to third-generation cephalosporins , as well as a mutation that causes resistance to fluoroquinolones, and on occasion azithromycin.(24) Treatment options for XDR strains of typhoid fever like H58 are azithromycin PO or IV carbapenems.

Vaccines against typhoid fever include the Typhim Vi® capsular polysaccharide vaccine, the Vivotif® oral live attenuated vaccine and the combination Vivaxim® hepatitis A and typhoid fever vaccine (Table 4).

Typhoid vaccines protect 50 to 80 percent of recipients; pharmacists should remind travelers that typhoid immunization is not 100 percent effective, and typhoid fever could still occur.(22) Safe food and water precautions (Table 5) and frequent hand washing (especially before meals and after going to the bathroom) are vital even for vaccinated travellers.

Finally, the traveller in this case is classified as a visiting-friends-and-relatives (VFR) traveller. VFRs are at a higher risk of acquiring travel-related illness (see sidebar, “The VFR traveller demographic”).

CASE 4

Illness and eventual death from vector-borne illness

A 46-year-old man from the Netherlands began to experience fever, malaise and headache on the last day of his three-week trip to Sao Paulo, Brazil. Upon returning home to the Netherlands, his symptoms worsened and he experienced jaundice and internal bleeding. He was diagnosed with yellow fever. At the hospital, his kidneys began to fail and he died soon after.(31) The mosquito acts as a prominent vector in transmitting numerous infectious diseases abroad, including (but not limited to) chikungunya, dengue fever, Japanese encephalitis (JE), malaria, yellow fever and Zika virus. Many of these diseases do not have preventative immunizations or medications, therefore it is important for travellers to minimize vector exposure. Pharmacists can advise travellers on how to minimize their exposure by recommending products that are available without a prescription in the pharmacy. For three of these diseases (JE, malaria and yellow fever) pharmacists should also recommend additional prevention strategies, including vaccination and appropriate medications.

TA B L E 6

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Minimize vector exposure Mosquito repellents are applied to the skin every six to 12 hours depending on the product. Health Canada recommends the use of a repellent containing diethyltoluamide (DEET), with a maximum concentration of 30 percent available in Canada, or icaridin (picaridin). The concentration of icaridin must be 20 percent for a 12-hour duration of protection.

Permethrin is an insecticide applied to clothing in order to repel insect vectors such as mosquitos. Clothes can be treated with permethrin spray or come pretreated with the insecticide. Currently permethrin spray is available in the United States only; however, permethrintreated clothing is available for adults in Canada. Permethrin-treated clothing is effective through several wash cycles.

The feeding behaviour of mosquito vectors differs between species. For example, mosquito species that transmit dengue, yellow fever and Zika are most active during the day (from dawn until dusk). Mosquito species that transmit malaria and JE are most active in the evening (dusk to dawn). Travellers can take precautions to protect themselves from vector exposure during peak times by covering exposed areas during the day and using screens and bed nets at night.

All of the above non-pharmacological advice and products when used appropriately can minimize mosquito bites and therefore considerably reduce the risk of vector-borne diseases.

Disease-specific immunizations and chemoprophylaxis JAPANESE ENCEPHALITIS (JE)

JE is a rare but serious mosquito-borne illness endemic in many parts of Southeast Asia. Travellers can reduce their risk by minimizing exposure, particularly during the evening and night, and by receiving the Health Canada-approved Ixiaro vaccination against JE. The vaccine is administered as two doses seven to 28

Adult dosing and timing of malaria chemoprophylaxis medications(34)

Medication

Dose

Timing

Atovaquoneproguanil

1 tablet daily with food

1 to 2 days before, while in the endemic region, and 7 days after leaving the malaria-endemic region

Chloroquine

2 tablets weekly

1 to 2 weeks before, while in the endemic region, and 4 weeks after leaving the malaria-endemic region

Doxycycline

100 mg daily

1 day before, while in the endemic region, and 4 weeks after leaving the malaria-endemic region

Mefloquine

250 mg weekly

2 to 3 weeks before, while in the endemic region, and 4 weeks after leaving the malaria-endemic region

The pharmacist’s role in travel health: a guide to patient immunization assessment

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October 2019

days apart, with the second dose at least one week before departure to the endemic area. For future travel to endemic areas a booster vaccination given one to two years after the primary two-dose series provides protection for 10 years.(32) MALARIA

Malaria is a parasitic infection transmitted via the bite of an infective female anopheles mosquito. Transmission patterns change rapidly from year to year, therefore pharmacists who provide malaria risk assessments need to have upto-date global transmission data. Travel medicine software, such as Travax (www. travax.com), is useful to stay up-to-date.

Malaria risk is variable across the globe but high-risk areas include West Africa, parts of Asia, Southeast Asia and parts of Central and South America. Once it has been determined that the traveller will be entering a malaria endemic area, the choice of chemoprophylaxis depends on a number of factors, including: resistance patterns in the region, time to departure, adverse effect profi le and cost. Table 6 summarizes the names, doses and directions of medications available.

Pharmacists should suspect malaria in febrile patients who have travelled to malaria-endemic regions within the past year (particularly within the past three months), regardless of chemoprophylaxis.(33) This should be considered a medical emergency. Pharmacists should advise all returned travellers presenting with fever to go to their local emergency department immediately.

YELLOW FEVER

The yellow fever virus is transmitted via the bite of an infected Aedes or haemagogus mosquito. While most individuals infected with yellow fever virus remain asymptomatic, those who do show symptoms experience fever, malaise and fatigue. Fifteen percent of symptomatic individuals will go on to manifest the “toxic” form of the disease characterized by jaundice, organ failure and possibly death.(35) Transmission of the disease is localized in two distinct regions of the world: sub-Saharan Africa (i.e., 46 out of 54 countries in Africa, south of the Sahara desert, such as Nigeria, Ivory Coast and Kenya) and South America. Yellow fever immunization is recommended, and in some cases required, for people who travel to regions with yellow fever.

The World Health Organization, through the international health

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regulations, has mandated proof of yellow fever vaccination upon entry into certain countries. Some countries require proof of immunization upon entry regardless of the country of origin. Most countries require proof only if the traveller arrives directly from a region with yellow fever transmission. Pharmacists must ask travellers about the specific details regarding their itinerary, including the specific countries/cities they are visiting, and the order in which they will be visiting them.

Pharmacists administering yellow fever vaccination (YF-VAX) in their practice have received advanced training and certification. Travel to yellow fever endemic regions is typically a complex itinerary, and many times yellow fever and malaria transmission coexist in the same region. To obtain the vaccine needed to immunize travellers against yellow fever, pharmacies must register with the Public Health Agency of Canada (PHAC) in order to become a designated site. Registered pharmacies will receive copies of the international certificate of vaccination prophylaxis (ICVP), which is issued to travellers as proof of immunization. Pharmacists need to be aware of the precautions and medical contraindications of the live attenuated yellow fever FIGURE 5

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vaccination and issue medical certificates of contraindication where appropriate.

Pharmacists unable to provide yellow fever vaccinations in their practice can refer travellers to the designated sites listed on PHAC’s website (https://www. canada.ca/en/public-health/services/ travel-health/yellow-fever.html).

Yellow fever vaccination must be administered on the same day as other live attenuated vaccinations (such as the MMR vaccine) or spaced at least 30 days apart to avoid interference.(35) CASE 5

Medical evacuation for rabies immunoglobulin

A stray dog bit a 25-year-old traveller in Ubud, Bali. The traveller was not vaccinated for rabies, and was advised by his friends to seek medical attention for the bite.

At the local hospital in Ubud he received a tetanus vaccination, and was advised to travel to Singapore to obtain human rabies immunoglobulin and rabies vaccination due to lack of supply in Bali.

Rabies is endemic throughout the world, with higher rates of animal to human transmission in Africa, Asia and South America. The rabies virus comes from the family of neurotropic viruses

Rabies post-exposure protocol(36)

Scenario 1: Travelers who received pre-exposure vaccination • Extensive wound washing for 15 minutes with soap and water, detergent, povidone iodine or other substances that kill the rabies virus.(37) • Two doses of vaccine: one dose on day zero and the second dose three days later • The booster doses do not have to be the same brand as the one used during the original pre-exposure immunization series.

Benefits of pre-exposure vaccination • Pre-exposure vaccination does not eliminate the need for additional medical attention after a rabies exposure, but it simplifies post-exposure prophylaxis.

• Pre-exposure vaccination may also provide some protection when an exposure to rabies virus is unrecognized and post-exposure prophylaxis might be delayed.

• Travelers who have completed a 3-dose pre-exposure rabies immunization series or have received full post-exposure prophylaxis are considered pre-exposure immunized and do not require routine boosters.

• Periodic serum testing for rabies virus-neutralizing antibody is not necessary in most international travelers, unless at high risk (working with animals at risk, cave diving).

Scenario 2: Travelers who did not receive pre-exposure vaccination • Extensive wound washing for 15 minutes with soap and water, detergent, povidone iodine or other substances that kill the rabies virus.(37) • Post-exposure protocol for a previously unvaccinated patient consists of injections of 1. Rabies immunoglobulin (RIG) (20 IU/kg) 2. A series of four injections of rabies vaccine over 14 days Issues with rabies immunoglobulin (RIG) • Patient discomfort since as much of the total volume as possible (20 IU/kg body weight) should be administered at the bite site (if anatomically possible), and the remainder administered in large intramuscular sites (gluteal and deltoids).

• Some countries still stock unpurified anti-rabies serum of equine origin. Unpurified anti-rabies serum is associated with higher rates of serious adverse reactions, including anaphylaxis and transmission of bloodborne pathogens.

• The variability of potency of RIG preparations may limit effectiveness and increase the risk of adverse reactions.

• RIG is difficult to access in many countries.

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TA B L E 7

October 2019

Rabies vaccine products(36)

Name of vaccine ®

HDCV, Imovax

TABLE 8

1.0 mL IM @ 0, 7, 21 or 28 days ®

PCEC, RabAvert

Summary of preventative vaccinations and medications for international travel

Travel-related Mode of illness transmission

Dosing schedule

1.0 mL IM @ 0, 7, 21 or 28 days

Destination

Preventative vaccination/medication

Measles

Person to person Routine immunization MMR vaccination 2 doses 28 days apart

Diphtheria

Person to person Routine immunization TDAP or TD vaccination every 10 years

Hepatitis A

Food and water

Outside of North America (including all-inclusive resorts)

2 doses 0, 6-36 months (depending on product)

Typhoid fever

Food and water

Asia, Africa, Central and South America

1 dose 2 weeks prior to departure (duration of protection depends on product, see Table 4)

Japanese encephalitis

Vector

Parts of Asia

2 doses (7-28 days apart) 1 week prior to departure

Yellow fever

Vector

South America, Sub-Saharan Africa

1 dose 10 days before departure from Public Health Agency of Canada designated site

Malaria

Vector

Asia, Africa, Central and South America

Oral medication as chemoprophylaxis (timing depends on medication product)

HDCV=human diploid cell vaccine; IM=intramuscular; PCEC=purified chick embryo cell

and is transmitted via the bite of an infected animal. Once tissue trauma occurs, the virus travels through the neuromuscular junction and travels through the nervous system to the brain. Once the virus reaches the brain and the patient becomes symptomatic (anxiety, paralysis and other signs of encephalitis), the infection is almost always fatal.(36) Travellers can reduce their risk of rabies infection by avoiding animal bites and being aware of the disease and their surroundings. Travellers should refrain from touching and feeding animals, including bats, dogs and monkeys, when abroad.

Individuals travelling with their children should be particularly cautious, due to the high propensity for children to engage with animals, and the high probability that they could be bitten in the neck/head region, which gives the virus faster access to the central nervous system.

If bitten, travellers should immediately seek medical attention and appropriate treatment for potential rabies exposure.

Due to the high case fatality ratio of rabies, all animal bites abroad should be treated for rabies. Treatment of rabies exposure depends on whether the traveller was immunized with a series of rabies vaccination prior to travel (Figure 5). If a traveller received three doses of rabies vaccination (Table 7), the post-exposure protocol for rabies is simplified, and the traveller has more time to seek medical attention.

Brands of rabies vaccines are considered interchangeable, in that a series

Answer online at eCortex.ca

started with one brand can be completed with another.(21) During all travel health consultations, pharmacists should discuss the seriousness of rabies and give advice on how to avoid animal bites and how to seek appropriate treatment. While preexposure vaccination greatly simplifies management following the bite of an animal, cost and time to departure may be barriers that prevent travellers from choosing rabies vaccination.

Conclusion In light of the growing popularity of global travel, pharmacists are accessible healthcare providers who can help mitigate the risk of travel-related illnesses.

Pharmacists should initiate their vaccination assessments by focussing on key routine immunizations, regardless of patients’ travel destination. The next step is a risk assessment to determine the need for vaccination and/or medication against food-, water-, and vector-borne diseases based on the travel destination. Table 8 summarizes the preventative vaccinations

and medications that can be utilized to protect against travel-related diseases, based on the destination. Pharmacists are well-positioned to provide helpful nonpharmacological advice and recommend over-the-counter products that reduce the risk of food-, water- and vector-borne diseases. Pharmacists must objectively determine both their competency and level of comfort in providing travel health services in their practice. Competency can be demonstrated with advanced certification in travel medicine through accredited organizations such as the International Society of Travel Medicine (ISTM).

References for this CE lesson are available online at www.ecortex.ca.

Find the questions for this CE lesson online at www.ecortex.ca.

Quick Search CCCEP # 1329-2019-2858-I-P

Faculty: The pharmacist’s role in travel health: a guide to patient immunization assessment ABOUT THE AUTHOR Ajit Johal is the Clinical Services Coordinator at Wilson Pharmacy and CEO of Travel Rx Education and Next Level Medication Management. Ajit has been providing immunizations and developing clinical education since 2012. Ajit is a clinical instructor for the University of

Answer online at eCortex.ca

British Columbia Faculty of Pharmaceutical Sciences, where he teaches about vaccinations and gaps in immunization.

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

CE Project Manager: Karen Welds CE Designer: Shawn Samson

CE queries: email ecortex@canadianhealthcarenetwork.ca

This lesson is published by EnsembleIQ: 20 Eglinton Ave. West, Suite 1800 Toronto, ON M4R 1K8 Phone: 877.687.7321 Fax: 888.889.9522

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

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FINDING YOUR NICHE:

ONCOLOGY CARE AN OPPORTUNITY TO BRING COMFORT AND HOPE, WHILE PRACTISING TO FULL SCOPE

BY ROSALIND STEFANAC

ike many pharmacists who work in oncology, Melissa Lo never set out to make cancer care her career focus.

After all, cancer is still a scary word associated with complicated medication regimens and severely ill patients. But after seven years as a clinical pharmacist at Toronto’s Princess Margaret Cancer Centre (PMCC), Lo says the job is only getting more fulfilling.

“Working at a world-class tertiary centre like this one where we treat the rarest of cancers, I have gotten to see drugs enter into preliminary research and clinical trials all the way to standard of care,” she says. “It’s very exciting to be part of this journey.” Being involved at the drug discovery level has also given Lo the unique opportunity to manage patients on new treatments and get a first-hand look at medication effects, which she has been able to share with other healthcare teams dealing with cancer patients. “We can’t bring everyone here so we support our community hospitals, either with one-onone training, or by providing expertise to provincial programs to standardize care across the board.”

Now as both a clinical pharmacist in outpatient malignant hematology/bone marrow transplant, and an ambulatory oncology pharmacist at the University Health Network’s PMCC, Lo is also involved in helping patients manage their diseases at home. That includes helping them navigate access to needed drugs.

“My typical day is a combination of

RESOURCES FOR CANCER CARE Cancer Care Ontario

(www.cancercareontario.ca)

BC Cancer Agency

(www.bccancer.bc.ca)

Alberta Health Services: Cancer Guidelines

(www.albertahealthservices.ca/info/ cancerguidelines.aspx)

Canadian Association of Pharmacy in Oncology (www.capho.org)

“It’s a terrible diagnosis but I can help to improve their quality of life, and every extra good day I can give them is a win for me.”

Melissa Lo, clinical pharmacist, Princess Margaret Cancer Centre, Toronto, ON.

outpatient work with leukaemia patients, as well as preparing chemo and infusions for all the other cancers out there.”

Lo says it was important for her to change her mindset around cancer in general to make the most out of her career choice. “The majority of the population will be affected by cancer in their lifetime, and as depressing as it is to see people so sickly sometimes, anything I can do to

The Centre for Pharmaceutical Oncology

(www.pharmaceuticaloncology.com)

National Comprehensive Cancer Network (www.nccn.org) American Society of Clinical Oncology (www.asco.org) International Association of Oncology Pharmacy Practitioners (isopp.org)

European Society for Medical Oncology (www.esmo.org)

[Vol.6 No.8] OCTOBER 2019

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“Having an expertise or taking the time to educate yourself on these therapies means you can ensure patients know how to use them safely, while helping them find novel ways to improve adherence.”

Lauren Hutton, clinical co-ordinator, oncology pharmacy, Queen Elizabeth II Health Sciences Centre, Halifax

make their day better goes a long way,” says Lo. “It’s a terrible diagnosis but I can help to improve their quality of life, and every extra good day I can give them is a win for me.”

Lauren Hutton, who provided palliative oncology care at Princess Margaret earlier in her career, says it’s about getting to know patients and what their goals are so you can find novel ways to support them.

That could mean something as simple as changing the time of a sedative or nausea medication so a patient can participate in a Skype call or attend a wedding. “Those patient-centred successes should be celebrated as you’re working to make the life expectancy these patients do have as meaningful as possible,” she says.

Hutton admits that dealing with cancer on a regular basis can be “emotionally taxing,” so having access to a support network of colleagues and friends for a safe and open discussion is invaluable to maintaining good mental health as a practitioner.

Now, as a clinical co-ordinator, oncology pharmacy at the Queen Elizabeth II Health Sciences Centre in Halifax, Hutton spends two full days a week supporting patients who are receiving oral anti-cancer therapy (either in person or on the phone), collaborating with nurses and physicians as needed.

“This really is an area of practice where pharmacists can advance their clinical knowledge and innovate within their scope,” she says. Her non-direct patient care time is spent working on overall

How do I specialize?

oncology program development, providing front-line staff support, conducting research and helping educate health profession learners of various levels.

In the community setting, Hutton says pharmacists have a huge opportunity because of their accessibility to cancer patients on a daily basis. “With oral anticancer therapies in particular, there is no good catch-all in the hospital system and sometimes patients are going directly from their physicians to the commuting pharmacy,” she says. “Having an expertise or taking the time to educate yourself on these therapies means you can ensure patients know how to use them safely, while helping them find novel ways to improve adherence.”

From her current job perspective in helping develop innovative clinical pharmacy programs in oncology, Hutton says the evidence for pharmacists having a positive impact on cancer patients is only growing. “Just working to expand pharmacy services in oncology to meet patient care needs is going to keep me busy for many, many years.”

Both Lo and Hudson advise new grads and community pharmacists not to be intimidated by this growing field for patient care, but rather to see it as a huge opportunity to be able to practise to their full scope. “There is such a demand for what we do as pharmacists in this area, and so many of my colleagues are enjoying the challenge,” says Lo.

Given that some pharmacy schools don’t have oncology as a therapeutic topic, and residencies in cancer care are limited during undergraduate training, consider taking additional courses through the University of Toronto’s Centre for Pharmaceutical Oncology. There you can find bi-monthly seminars featuring speakers from academia and industry, as well as an annual oncology-related symposium that is free for members. The Canadian Association of Pharmacy in Oncology offers an Oncology Fundamentals Day every year, which is a full-day of online learning, in addition to education and resources available throughout the year. You can also get certified in Oncology Pharmacy through the US Board of Pharmacy Specialties, however, you do need experience working in the field for several years prior to applying.

26

OCTOBER 2019 [Vol.6 No.8]

ce October 2019

Approved for

Answer online at eCortex.ca

Continuing Education L E S S O N

1

CEU Canadian Council on Continuing Education in Pharmacy

Approved for 1 CE unit by the Canadian Council on Continuing Education in Pharmacy • CCCEP #1329-2019-2841-I-P • Please consult this course online at eCortex.ca for expiry dates

Learning Objectives

After completion of this learning activity pharmacists will be better able to: 1. Describe the prevalence and consequences of short-acting betaagonist (SABA) overuse in asthma 2. Identify patients at increased risk of asthma exacerbation 3. Review the evidence for the use of symptom-driven (as-needed) inhaled corticosteroid (ICS)/ formoterol reliever therapy in mild asthma and beyond to reduce the risk of asthma exacerbation 4. Recommend as-needed ICS/formoterol reliever therapy across all severities of asthma for appropriate patient candidates 5. Educate and empower patients in the transition to as-needed ICS/formoterol for reliever with or without maintenance for asthma management through the use of effective communication and practical tools

Instructions 1. After carefully reading this lesson, study each question and select the one answer you believe to be correct. Answer online at eCortex.ca.

2. To pass, a grade of at least 70% (6 out of 8) is required.

3. Complete the required feedback form for this lesson online at eCortex.ca.

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

DISCLOSURES The author discloses that in the past he has received funds from the company sponsoring this learning activity, for participation in an advisory board meeting and speaking engagements. One expert reviewer discloses the receipt of funds from the sponsor and other commercial entities for membership on advisory boards, continuing education work and speaking engagements. The second expert reviewer discloses the receipt of funds from other entities for continuing education work.

The provider declares no real or potential conflict with the sponsor of this lesson.

Answer online at eCortex.ca

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Helping Patients Navigate an Important Paradigm Shift in Asthma Management

By Tom Smiley BScPhm, PharmD, CTE

“The most important change in asthma management in 30 years” —Global Initiative for Asthma (GINA)(1) Many baby boomers who are current or former asthma sufferers remember the 1960s, when the only asthma symptom relief available was through the use of an inhaled bronchodilator containing a shortacting beta agonist (SABA) and/or an anticholinergic agent.(2,3) The relief was almost instant, but short-lived. Well-controlled asthma was virtually unattainable for most.(1,2) Moreover, through observational study, researchers suspected that overuse of bronchodilator therapy was associated with increased risk of asthma death.(2) In the 1970s, clinical research uncovered the important relationship between inflammation and its role in bronchial hyperresponsiveness to irritant stimuli.(3) As confirmed by clinical trials, maintenance treatment with an inhaled corticosteroid (ICS) to reduce bronchial inflammation associated with asthma symptoms and exacerbations was deemed to be the cornerstone of asthma therapy.(4) Subsequent studies found that ICS/long-acting betaagonist (LABA) combination therapy as maintenance treatment plus SABA as needed (prn) increased the percentage of

patients achieving total asthma control and reduced the risk of exacerbation compared to ICS alone plus prn SABA therapy.(5) Finally, several clinical trials that included over 16,500 patients showed that use of budesonide/formoterol inhaler therapy as a single maintenance and reliever therapy (SMART) for moderate-severe asthma reduced time to first severe exacerbation, frequency of exacerbations and steroid load compared to budesonide/formoterol maintenance therapy or high dose budesonide therapy or high dose fluticasone/salmeterol therapy plus SABA as needed.(6-12) Inhaled ICS therapy has not previously been recommended by guidelines such as GINA for patients with asthma of mild severity. However, recent randomized placebo-controlled trials (SYGMA 1 and SYGMA 2) as well as a “real-world” study (NovelSTART) have demonstrated that, as shown in patients with more severe disease, inhaled ICS therapy (budesonide) combined with the fast-acting LABA (formoterol), significantly reduces the rate of asthma exacerbation in these patients.(13-15) As a result, the 2019 GINA management strategy now recommends the use of symptom-driven, as-needed ICS/formoterol as the preferred reliever therapy across the entire spectrum of asthma severity for adults and adolescents aged 12 years and older.(1) Moreover, GINA no longer recommends treatment with SABA alone and supports this recommendation with the following statement: • “There is strong evidence that SABAonly treatment, although providing short-term relief of asthma symptoms, does not protect patients from severe exacerbations, and that regular or frequent use of SABAs increases the risk of exacerbations.”(1) The 2019 GINA Strategy Report describes this evolution in therapy recommendations as “the most important change in asthma management in 30 years.”(1)

This program was supported in part by an educational grant from AstraZeneca

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Helping Patients Navigate an Important Paradigm Shift in Asthma Management

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FIGURE 1

October 2019

2019 GINA treatment strategy(1)

Answer online at eCortex.ca

to 95 percent. Peak expiratory flow (PEF) > 50 percent predicted or best.

• Severe exacerbation: Patient talks in words, sits hunched forwards, agitated.

Respiratory rate > 30/min (normal rate is 12 to 20/min). Accessory muscles in use. Pulse rate > 120 bpm. Oxygen saturation (on air) < 90 percent. PEF ≤ 50 percent predicted or best.

From a quality of life perspective, it is important to note that asthma exacerbations are physically threatening and emotionally significant for patients, with onethird of patients reporting symptoms that resulted in them feeling that their life was in danger.(17) Exacerbations in mild asthma

LTRA = leukotriene receptor antagonist; Anti-IgE = Anti-immunoglobulin E; Anti-IL5/5R = anti-interleukin 5/anti-interleukin 5 receptor; Anti-IL4R = Anti-interleukin 4 receptor; OCS = Oral corticosteroid; HDM SLIT = House dust mite sublingual immunotherapy; FEV = forced expiratory volume

Case: Carly has had an exacerbation Carly, 16, is in the pharmacy with her mother. She presents a prescription received in the hospital because her asthma was acting up. Carly’s mother interjects: “It was more than ‘acting up.’

She could hardly breathe!” The mother adds that she is confused because she had been told by her family doctor that Carly had only mild asthma.

The prescription is for budesonide/ formoterol 200/6 mcg and states: “Use 1 inhalation as needed to a maximum of 8 inhalations a day.”

Carly seems anxious. “The doctor said that I shouldn’t use my blue inhaler when I use this one, is that true?” she asks. “I take my blue inhaler with me wherever I go. I usually don’t use it very often, but if I don’t have it, I get really stressed and I need to go home and get it. In the past few days I have needed it more often, until finally my asthma got so bad that we had to go to the hospital.”

You tell Carly that it is important to carry her inhaler with her at all times and that it’s not unusual to feel stressed without it. You explain that that this new inhaler uses the same type of medication as her blue inhaler and acts just as quickly—and even better, the effects of opening up the breathing passages last for a much longer period of time. In addition, there is another drug in the inhaler that calms the airways down so that wheezing and other asthma symptoms occur less often. This new medication has been shown to reduce the number of times that people need to visit the hospital for “flareups” of asthma, or asthma that is “acting up,” as Carly put it.

Treatment strategy and asthma severity The 2019 GINA guidelines state that asthma severity assessment is based retrospectively on the level of treatment required to control symptoms and exacerbations.(1) Figure 1, reprinted with permission from the GINA Pocket Guide, summarizes the 2019 GINA Asthma Treatment Strategy for Adults and Adolescents 12 years and older.

Well-controlled asthma is defined as asthma with the following over the past four weeks: • daytime symptoms occurring two times or less per week; • no night-time wakening due to asthma; • reliever needed twice per week or less; and • no activity limitation due to asthma.

Asthma treatment strategy, based on severity, is as follows: • Mild asthma is asthma that is well controlled with Step 1 or Step 2 treatment in Figure 1 (low-dose ICS therapy plus LABA or prn SABA).(1) • Moderate asthma is asthma that is well controlled with Step 3 therapy.(16) • Severe asthma is asthma that requires Step 4 or Step 5 therapy.(16) The underlying cause of asthma exacerbation is increased airway inflammation. The GINA guidelines define asthma exacerbations as follows (1) • Mild or moderate exacerbation: Patient talks in phrases, prefers sitting to lying, not agitated. Respiratory rate increased. Accessory muscles not used.

Pulse rate 100-120 beats per minute (bpm). Oxygen saturation (on air) 90

Severe exacerbations may occur in patients of all ages and with asthma severity ranging from mild to severe. In fact, an estimated 19 percent to 36 percent of all patients with mild asthma experience an asthma exacerbation every year. (13,14,17-21)

The GINA guidelines suggest that asthma exacerbations be referred to as asthma “flare-ups” since the term is simpler, and reinforces the idea that asthma is present even when symptoms are absent.(1) Issues associated with overuse of SABA Patients with asthma rely on SABA reliever for quick relief of symptoms. The almost-immediate gratification often leads to overuse of these inhalers and non-adherence to controller medications in the majority of patients.(2) Additionally, increased use of SABA is a sign of worsening symptoms, which are associated with increased risk for asthma exacerbation secondary to airway inflammation.(16) Evidence has shown that utilization of three of more canisters of a SABA in a year increases the risk of severe exacerbations by two-fold and that utilization of 12 or more canisters per year is associated with an increased risk for asthmarelated death.(1) A retrospective study of the medical records of 343,520 patients with asthma living in B.C. between the years 1997 and 2014 found that 7.3 percent of person-years (percent of aggregate number of years that participants were in study) were associated with inappropriate SABA use and 0.9 percent of personyears were associated with excessive use.

Inappropriate SABA use was associated with a 45 percent increase in risk of asthma-related hospitalization and a 25 percent increase in risk of emergency department visits.(22) Primary care health professionals should act collaboratively to educate patients about the expected level of

Helping Patients Navigate an Important Paradigm Shift in Asthma Management

Answer online at eCortex.ca

October 2019

asthma control and regularly ask patients about their asthma. Given that a SABA inhaler should last at least six months, pharmacists have an excellent opportunity for education and intervention when encountering a patient who is asking for an early refill of this reliever medication.

Armed with the knowledge that the GINA guidelines recommend the replacement of symptom-driven SABA reliever therapy with ICS/formoterol as-needed reliever therapy +/- maintenance for all severities of asthma, pharmacists have a perfect opportunity to educate the patient about the benefits of the regimen while engaging in a discussion about the current level of asthma control. In collaboration with the patient, the pharmacist can send a recommendation to the prescribing healthcare professional to change from the SABA to the combination ICS/LABA for reliever therapy as the next step in the patient care continuum for asthma control.

Symptom-driven use of budesonide/ formoterol: the rationale Figure 2 illustrates that asthma exacerbations develop over a period of time, with reductions in peak expiratory flow (PEF), increases in day and night symptoms, and increased reliever medication use over a period of days before exacerbation onset.

Identification of the sequence of events preceding an exacerbation presents a window of opportunity to intervene with anti-inflammatory therapy (i.e., inhaled ICS) before asthma control is lost.(23) With the use of combination budesonide/formoterol as reliever therapy for all steps of asthma treatment (Figure 1), increasing doses of inhaled ICS are administered earlier than when SABA is used alone, thereby taking advantage of that early window of opportunity to address the underlying airways inflammation. It is important to note that formoterol must be the LABA used in the symptom driven ICS/LABA regimen, as it is the only LABA that relieves bronchospasm as quickly as SABA.(1) In addition, budesonide/formoterol is the only combination proven to be effective through clinical trial as a reliever for all asthma severities.

The use of budesonide/formoterol as symptom-driven reliever therapy instead of a SABA has been extensively studied in seven clinical trials involving more than 16,500 patients 12 years or older with moderate to severe asthma.(6-12) Highlights from these studies include: • In each study, the rate of severe exacerbations was reduced compared to every other regimen used (e.g., increased maintenance dose of ICS or ICS/LABA plus SABA prn), • In five of the studies, time to first severe exacerbation against all comparators increased.

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Continuing Education L E S S O N

• Asthma symptoms, lung function and reliever use improved compared to all budesonide regimens across all studies.

• Steroid burden was reduced in most studies.

As mentioned, severe asthma exacerbations also occur in patients with mild asthma, and the same circumstances lead to the worsening of symptoms.(1) With that in mind, researchers have conducted clinical trials to determine the efficacy of symptom-driven ICS/ formoterol therapy in place of prn SABA therapy, or in place of ICS maintenance therapy in patients who are not 80 percent adherent, for the management of mild asthma.(13-15) Overview of clinical trials resulting in a paradigm shift for asthma management The two “Symbicort Given as Needed in Mild Asthma” (SYGMA 1 and SYGMA 2) clinical trials and the Novel Symbicort Turbuhaler Asthma Reliever Treatment (Novel START) real-world study have demonstrated the value of initiating the combination of budesonide/formoterol therapy prn in patients with mild asthma to lower the risk of asthma exacerbation risk and reduce exposure to inhaled corticosteroids over time.(13-15) Figure 3 shows the clinical trial designs of SYGMA 1 and SYGMA 2.

SYGMA 1 AND SYGMA 2 STUDIES

In patients with mild asthma, budesonide/formoterol as needed:(13,14) • reduced severe exacerbation rate vs. those using SABA as needed; • increased the odds of a well-controlled asthma week compared to terbutaline as needed (OR 1.14) but not compared to budesonide maintenance therapy when used at a high adherence rate.(2) • resulted in a comparable rate of severe exacerbations as maintenance budesonide + terbutaline as needed;(2,3) • demonstrated efficacy with a ≥75 percent lower steroid load than the budesonide maintenance arm;(2,3) • resulted in fewer days with high reliever use; and • reduced the short-term (21-day) risk of exacerbation versus as-needed terbutaline following a day of high reliever use.(1) Adverse effects such as upper respiratory tract infection, viral upper respiratory tract infection and asthma associated with use of as-needed budesonide/formoterol were equivalent to or less than the comparative therapies.(13,14) NOVEL START REAL WORLD STUDY(15)

The Novel START study was a randomized, 52-week, open-label, parallel-group, controlled trial with 668 patients randomized to:

CE3

• Salbutamol 100 µg, two inhalations prn • Budesonide 200 µg, one inhalation twice daily plus salbutamol 100 µg prn (budesonide maintenance group) • Budesonide-formoterol 200 µg/6 µg, one inhalation prn In patients with mild asthma, budesonide/formoterol as needed:(15) • reduced the exacerbation rate compared to salbutamol group by 51 percent; • did not significantly reduce ‘any’ exacerbation rate compared to budesonide maintenance group; • reduced the number of severe exacerbations by 60 percent (nine versus 23) compared to the salbutamol group and by 56 percent (nine versus 21) compared to the budesonide maintenance group; and • reduced the mean inhaled dose compared to the budesonide maintenance group (107 +/- 109 µg vs. 222 +/- 113 µg per day).

Case (continued): Convincing Carly Carly is still looking anxious and tells you once again that she is really attached to her blue inhaler. You seek to calm her concerns through additional education, demonstration and reassurance. First, you respond that you understand that the blue inhaler gives her almost instant relief, but that this new inhaler will do the same thing with the added benefits of keeping the airways open for a longer period of time and reducing the risk of having to go to the hospital for another flare-up.

Carly’s mother, who has asthma that has been categorized as moderate-severe, wonders why Carly is taking the same medication as she is taking. You explain that while Carly’s mother is using her budesonide/formoterol turbuhaler regularly (daily) and as needed, Carly will use the medication only as needed (not regularly). In both cases, when the budesonide/formoterol turbuhaler is used as a reliever, the controller component of the medication works to reduce inflammation earlier and reduce the risk of flare-ups, while the reliever medication opens up the airways.

After the prescription is fi lled you invite Carly and her mother into the counselling area to show Carly how to use the budesonide/formoterol turbuhaler and review her asthma action plan, including when to seek medical help.

You ask Carly to record in a small diary the dates and times she needs to use the budesonide/formoterol turbuhaler over the next two weeks and inform her that you will call in a week to see how she is doing. You also ask Carly to be sure that she gives the pharmacy a call if she has any more questions or concerns about her

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budesonide/formoterol turbuhaler or her asthma condition. After the counselling, Carly and her mother thank you for helping them feel more at ease about using the new medication.

Answer online at eCortex.ca

F I G U R E 2 Changes in peak expiratory flow rate (PEF), symptoms and use of rescue inhaler leading to an asthma exacerbation.(23)

Key Learnings • Nineteen to 36 percent of patients with mild asthma experience a severe exacerbation each year.

• The overuse of a SABA is associated with an increased risk of severe exacerbation, regardless of asthma severity.

• The risk of severe exacerbations exists irrespective of disease severity.

• ICS plus formoterol (the only LABA that works quickly enough to use as a reliever) used instead of SABA is associated with significantly reduced incidence of asthma exacerbations (evidence only with budesonide-formoterol).

• The 2019 GINA guidelines recommend ICS/formoterol as the preferred reliever across all severities of asthma (evidence only with budesonide-formoterol).

• In patients 12 years and older with asthma, pharmacists have an important role to play in recommending budesonide/formoterol as reliever therapy, particularly for those who are overusing a SABA and in new patients being prescribed inhaled therapy for the first time.

FIGURE 3

Study designs of SYGMA 1 and SYGMA 2 (E= Enrolment)(13,14)

SYGMA 1 (N = 3,849)

SYGMA 2 (N=4,215)

References for this CE lesson are available online at www.ecortex.ca.

Find the questions for this CE lesson online at www.ecortex.ca.

Quick Search CCCEP # 1329-2019-2841-I-P

Inclusion criteria (both studies): Patients aged ≥12 years with asthma (GINA 2012 criteria) for ≥6 months and assessed by investigator as needing GINA Step 2 treatment (see Figure 1) for 30 days prior to Visit 2; use of the SABA terbutaline as-needed on ≥3 days of last week of run-in.

Faculty: Helping Patients Navigate an Important Paradigm Shift in Asthma Management ABOUT THE AUTHOR

REVIEWERS

Tom Smiley, founder of Pharmavision consulting firm, has developed clinical education programs for pharmacists and other healthcare providers for more than 20 years in many areas, including respiratory care, diabetes and cardiovascular disease. He has co-authored a program designed to prepare health professionals to challenge the Certified Respiratory Educator (CRE) exam.

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

Answer online at eCortex.ca

CE Project Manager: Karen Welds CE Designer: Shawn Samson

This lesson is published by EnsembleIQ: 20 Eglinton Ave. West, Suite 1800 Toronto, ON M4R 1K8 Phone: 877.687.7321 Fax: 888.889.9522 CE queries: email ecortex@canadianhealthcarenetwork.ca

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

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5 TIPS

PEARLS YOU CAN USE IN YOUR PRACTICE NOW

COUNSELLING THE GROWING IMMIGRANT POPULATION ANNIE JALAL, PharmD and ELISE PARADIS, PhD

Getty Images

H

ealthcare providers are increasingly faced with the challenge of encountering patients who speak different languages, have different illness perceptions or beliefs, and different healthcare expectations. As front-line healthcare providers, pharmacists play a fundamental role in counselling patients to ensure the safe and effective use of medications. With increasing rates of international immigration, however, linguistic and cultural barriers might be limiting pharmacists’ abilities to provide counselling. This highlights the importance of developing a pharmacy system that is culturally sensitive and linguistically accessible. To begin meeting the needs of new migrants to Canada, pharmacists can employ the following five tips to facilitate encounters with these patients.

1

Acknowledge different cultural beliefs and address myths and misconceptions.

As a diverse population, we all hold different cultural beliefs, including beliefs regarding drug use, drug therapy and the healthcare system overall.(1) Commonly identified, but misconceived, beliefs held by some new immigrants include the perception that generic medications are of lower quality than brand name products,(1) and the expectation that prescription medications should be obtainable from the pharmacy without a prescription.(2) As all medications are not readily available without a prescription, some migrants have medications sent to them from their home country.(2) This undocumented use of medications has been identified as a medication safety issue, for which a solution remains undetermined.(2) However, a step forward is to work towards achieving a certain level of understanding about ethnic minority patients.

This can be achieved by conducting surveys of the local population regarding their common beliefs about medications, and offering information sessions to dispel any myths or at least start a discussion. With limitations in time and staffing, this could be a community outreach project for a pharmacy student or intern.

2

Mitigate language barriers through communication aids.

Language barriers are a frequent challenge during encounters with international migrants.(1-7) This raises concerns about illiteracy and uncertainty regarding whether the patient understands the written and verbal instructions you provide.(1) Language barriers can lead to closedended questions and hamper engaging discussions or participatory interactions.(3) Consequently, pharmacists’ interactions with immigrants may be of lower quality, where only sparse information is provided.(3) Based on a survey, prescription labels that pharmacists deemed simple to understand were misinterpreted by immigrant customers.(4) These included commonly used instructions such as “avoid sunlight,” “take two tablets twice daily” and “take with food.”(4) Given the complexity of medication regimens and potential for errors, language barriers become an important consideration.

To mitigate language barriers, several resources are currently available. The International Pharmaceutical Federation has free pictogram software (www.fipfoundation. org/pictograms-support/ pictogram-software) that uses illustrations to enhance

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patients’ understanding. It enables printing of pictogrambased medication labels and drug information sheets.

Counselling aids, such as pictograms can be a useful method of engaging patients and imparting information that may be better understood.

Several other resources are provided by the Agency for Healthcare Research and Quality (AHRQ). The AHRQ Health Literacy Tools for Use in Pharmacies (www.ahrq.gov/ professionals/quality-patientsafety/pharmhealthlit/tools. html) contain a health literacy assessment tool, a training program for pharmacy staff on communication, and explicit and standardized prescription medicine instructions (translated into Chinese, Korean, Russian, Spanish and Vietnamese), among other useful tools.

3

Use translational software.

Children or family members are often used as interpreters to facilitate communication with immigrants. However, pharmacists may feel uneasy speaking to nonprofessional interpreters to impart health information because it is unclear whether child interpreters can relay information correctly.(1) In addition, pharmacists often have valid concerns about patient privacy, and thus

may provide only minimal information to children, to protect their parents’ privacy.(1) Perhaps the simplest resource at our fingertips to assist with translation is Google Translate (https://translate. google.ca). After selecting the patient’s language and turning on “translate by voice,” patients can speak their native language and have it translated on screen into English, and vice versa. It is easy to use, quick, and can be used during counselling sessions without added cost or training for pharmacy personnel.

4

Be mindful in interpreting nonverbal communication.

Nonverbal communication poses yet another avenue for miscommunication. It includes a person’s expression, tone, pitch and body language, as well as their appearance.(1) For example, some immigrant patients may speak in a pitch that listeners might associate with anger, when in fact they are not angry.(1) This can impede the conversation and affect the quality of the counselling session. Moreover, some pharmacists have expressed that traditional cultural garments, such as the burqa, hamper their ability to communicate.(1) We must be aware of our biases and reflect on how we think or feel about other people who look

or sound different from us, and how our beliefs influence our actions towards others.

Some resources to improve cultural competency are available, such as LIAASE: A General Cultural Competency Tool & Self Assessment Tool for Primary Healthcare Providers (mycna.ca/~/media/ nurseone/page-content/ pdf-en/cultural_competence_ guide_for_primary_health_ care_professionals.pdf) and the Cultural Competency e-learning Module Series from the Hospital for Sick Children (www.sickkids.ca/patientfamily-resources/childfamily-centred-care/HealthEquity-Cultural-Competence/ Cultural-Competence-ELearning-Module-Series/ Cultural-Competence-ELearning.html).

5

Advertise your multicultural services.

Multilingual written and verbal communication is not always readily available from many pharmacies. In pharmacies where these services do exist through bilingual staff members or translated prescription labels, studies show that patients are often unaware of the availability of these services.(5) If pharmacies offer such services, they should actively inform patients of these services through promotional signs and advertisements.

CONCLUSION

The five tips outlined here can be used to improve interactions between pharmacists and immigrants, and help pharmacists increase awareness of their own behaviours and perceptions.

Assessment of cultural disparities in pharmacies is important to improve medication use and the quality of encounters with patients of all cultural backgrounds.

While we are often faced with time constraints and limited staff, we should nevertheless strive to provide information to patients in a language that they can understand, and work with our minority populations to foster greater cultural respect.

Since ethnic minority groups tend to be the most vulnerable populations from a healthcare perspective,(8,9) it is particularly important for pharmacists to consider their needs.

ANNIE JALAL (annie.jalal@mail.utoronto.ca) is a pharmacist with a strong interest in identifying cultural and linguistic challenges to assess cultural disparities in pharmacies, with the aim to improve medication safety and the quality of encounters with patients of all cultural backgrounds.

ELISE PARADIS (elise.paradis@utoronto.ca) holds the Canada Research Chair in Collaborative Healthcare Practice.

She is an award-winning researcher, mentor and speaker who studies collaborative healthcare practices and aims to transform how teams work together and improve patient outcomes.

REFERENCES: 1. Håkonsen H, Lees K, Toverud EL. Cultural barriers encountered by Norwegian community pharmacists in providing service to non-Western immigrant patients. Int J Clin Pharm 2014;36:114451. 2. Cleland JA, Watson MC, Walker L, et al. Community pharmacists’ perceptions of barriers to communication with migrants. Int J Pharm Pract 2012;20:148-54. 3. Mygind A, Espersen S, Nørgaard LS, et al. Encounters with immigrant customers: perspectives of Danish community pharmacy staff on challenges and solutions. Int J Pharm Pract 2013;21:139-50. 4. Lee EJ, Riley AC. Understanding of medication directions: assessment of native Korean older adults. Consult Pharm 2015;30:671-7. 5. Weiss L, Gany F, Rosenfeld P, et al. Access to multilingual medication instructions at New York City pharmacies. J Urban Health 2007;84:742-54. 6. Green JA, Brown K, Burgess J, et al. Indigenous and immigrant populations’ use and experience of community pharmacies in New Zealand. J Immigr Minor Health 2013;15:78-84.

7. Väänänen MH, Lyles A, Airaksinen M. Finnish immigrants’ experience of community pharmacy services in Spain: an example of a developing E.U. issue. Int J Health Serv 2008;38:293-312. 8. Syed HR, Dalgard OS, Hussain A, et al. Inequalities in health: a comparative study between ethnic Norwegians and Pakistanis in Oslo, Norway. Int J Equity Health 2006;5. doi:10.1186/1475-9276-5-7. 9. Jenum AK, Holme I, Graff-Iversen S, et al. Ethnicity and sex are strong determinants of diabetes in an urban Western society: implications for prevention. Diabetologia 2005;48:435-9.

32

OCTOBER 2019 [Vol.6 No.8]

THE INNOVATORS

“Cannabis is out there and people are going to recreational stores when they should be coming to a healthcare professional.”

Reefer MEDness

Take a nurse and a community pharmacist who love to banter, throw in some cannabis-related hot topics, and the result is a podcast that is helping people navigate the still green world of medical cannabis.

A cannabis story

Reefer MEDness (https://reefermed.ca/) is the brain child of Kirk Nyquist, a community health nurse working in remote First Nation communities, and Trevor Shewfelt, a community pharmacist at Dauphin Clinic Pharmacy in Manitoba. The two met 18 years ago at a local social club and have been engaging in (sometimes heated) discussions ever since. And while neither had any prior on-air interview experience, they’re now producing two podcasts a month on top of their day jobs.

“Cannabis is out there and people are going to recreational stores when they should be coming to a healthcare professional,” says Shewfelt, a pharmacist for 22 years. “Our mission is to educate our audience on issues pertaining to people’s use and perception

Healthcare duo create unique way to educate on all things cannabis

BY ROSALIND STEFANAC

ABOVE: Trevor Shewfelt (left), community pharmacist at Dauphin Clinic Pharmacy, and Kirk Nyquist, a community health nurse working in remote First Nation communities.

[Vol.6 No.8] OCTOBER 2019

33

“As a nurse, I focus on the humanities while Trevor goes after the science, and we both have our nuances in the types of stories we bring to the series.”

34

of cannabis so they can make good decisions.” Since launching the podcast in January 2018, the pair have produced 34 episodes to date, covering everything from cannabis as a treatment for sexual dysfunction to cannabis for kids. “As a nurse, I focus on the humanities while Trevor goes after the science and we both have our nuances in the types of stories we bring to the series,” says Nyquist. “We prepare for our stories of course, but there is no script and we’re not always prepared for the questions we fire off to each other, which keeps it interesting.”

Their listeners think so too. While most people tuning into Reefer MEDness come from Manitoba, there are also listeners in 50 countries on every continent.

Shewfelt said the idea first came to him in 2017 when he discovered that medical cannabis was going to Dauphin Pharmacy patients at five care homes. “We wouldn’t even know they were on cannabis unless the doctors told us; they were getting us to fill out paperwork to get cannabis mailed to these patients and I kept thinking that it would make so much more sense for us to be dealing with the care homes directly,” he says. “But our regulatory College wouldn’t allow us to touch anything cannabis-related.”

This led to a discussion with Nyquist who agreed that a podcast would be a good forum for education. “I did some research and discovered there weren’t any other healthcare professionals doing anything on this topic [in such a format] and it was a way to get our voices out there to share our learnings with other people,” says Nyquist, who has 35 years of nursing experience under his belt.

Fortuitously, Shewfelt had a connection at the local radio station who offered them free use of the studio during off-hours.

These days, the duo spends three hours of prep time for each hour of audio, which they do outside of work hours.

Sometimes they bring in topic experts to join an episode and occasionally they travel to cannabis-related events or retailers. “We’re also getting lot of feedback from the public about what they want to hear,” says Shewfelt. Listeners are also encouraged to share their stories by emailing a one-minute voice memo talking about their experiences with cannabis that can be shared on future podcasts.

With no budget, Shewfelt and Nyquist rely on a couple of local sponsors

OCTOBER 2019 [Vol.6 No.8]

to cover costs related to equipment, transportation, audio production and social media promotion. (Their key sponsor is medical cannabis data company called Strainprint Technologies based in Toronto.) “Somewhere in the podcast world there is money but we’re not making it yet,” says Shewfelt. “This is a passion project for the both of us.”

The pair have several new topics in the works, delving into things such as the craft grower phenomenon, as well as the experiences of a professional cyclist using cannabis to recover from a shoulder fracture. In the future, Shewfelt says he’d also love to interview his pharmacy college registrar to get further clarification on why pharmacists aren’t allowed to dispense medical cannabis.

“On a good note, we haven’t had any feedback from our Colleges yet so I think we are doing this [podcast] at the right level of professionalism,” adds Nyquist.

While Shewfelt says it’s hard to measure if his new-found fame has brought in business for his employer, he certainly does get more cannabis-related questions since Reefer MEDness started airing. He says his long-term goal is for the podcast to count towards continuing education credits for pharmacists and other healthcare professionals, given its clinical content.

In the meantime, he advises other pharmacists to educate themselves so they can better serve patients in this area. “Lots of patients are using cannabis and they may benefit from a pharmacists’ advice,” he says. “If we can talk to our patients about fentanyl, it’s ridiculous that we’re not talking to them about cannabis.”

ROSALIND STEFANAC is a Toronto writer specializing in pharmacy and business topics.

ce October 2019

Approved for

Answer online at eCortex.ca

Continuing Education L E S S O N

1.5 CEUs Canadian Council on Continuing Education in Pharmacy

Approved for 1.5 CE units by the Canadian Council on Continuing Education in Pharmacy • CCCEP #1002-2019-2848-I-P • Please consult this course online at eCortex.ca for expiry dates

Learning Objectives

At the completion of this program, pharmacists will be able to: 1. Recognize episodic versus chronic migraine and identify patients requiring prophylaxis.

2. Differentiate chronic daily headache disorders and their characteristic features.

3. Explore chronic migraine treatments, including self-management, natural health products, and prescription, both oral and injectable options when needed.

4. Identify self-management strategies to empower patients on appropriate medication use, including utilization of headache diaries and avoidance of medication overuse headache.

5. Discuss the elements of a comprehensive migraine management program, including the pharmacist’s role in selfmanagement and collaborative care to optimize patient health outcomes.

Chronic Migraine: Comprehensive Management.

Collaborative Care.

By Karen Agro, BScPhm, PharmD, MSc Faculty: Rose Giammarco, MD, FRCPC, Nardine Nakhla, PharmD, RPh

Instructions 1. After carefully reading this lesson, study each question and select the one answer you believe to be correct. Answer online at eCortex.ca.

2. To pass, a grade of at least 70% (11 out of 15) is required.

3. Complete the required feedback form for this lesson online at eCortex.ca.

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

DISCLOSURES The author, faculty and expert reviewers disclose that they have received funds from the company sponsoring this learning activity and/or from other commercial entities for membership on advisory boards, speaking engagements and/or participation in research.

Answer online at eCortex.ca

·ca

What is the impact of migraine on the health of Canadians?

Migraine is a common primary headache disorder, ranked as the second-highest cause of disability worldwide.(1) A 2010/2011 Health Canada survey found an 8% prevalence of migraine in Canada, which is likely an underestimate as many migraine sufferers never seek medical attention.(2-4) Although prevalence statistics vary widely, episodic migraine and chronic migraine are estimated to affect approximately 14% and 2% of the population, respectively.(5,6) Migraines often begin in childhood, adolescence or early adulthood.(7) Females are more than twice as likely to report migraine.(4,8) Migraines affect people in their prime working years, with the highest prevalence at ages 30 to 49.(4) They prevent usual activities, increase feelings of being left out, prevent driving, affect sleep, limit job opportunities and affect workplace productivity.(4) People with migraines have physical, emotional and functional impairment

during their attacks and between their attacks, affecting work, relationships and family life.(9) Compared to episodic migraine, chronic migraine sufferers visit primary care providers, neurologists or headache specialists, pain clinics, and emergency rooms three to four times more often; and are almost twice as likely to use preventative headache medications.(10-13) Chronic migraine sufferers are also nearly twice as likely to be affected by depression, anxiety and chronic pain when compared to those with episodic migraines; and they are more likely to miss days of work, school or household work, become occupationally disabled, and experience lower levels of household income.(12,14,15) The familial burden of migraine has also been reported to be higher among adolescents of parents with chronic migraine than episodic migraine measured across various domains, including loss of parental support/reverse caregiving, emotional experience, interference with school, and missed activities and events.(16) Migraine sufferers are also prone to developing medication overuse headache (MOH), often co-existing with migraine in 60-80% of cases, caused by overuse of abortive or pain-relieving medications.(17) MOH is a costly headache disorder for individuals and society in terms of both the direct and the indirect costs of reduced productivity.(18) It is best to prevent it rather than attempting to treat it. Pharmacists can play a leading role in identifying and helping prevent MOH as over-the-counter (OTC) medications are often the culprit.

Supported by educational funding from Allergan Inc.

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Continuing Education L E S S O N

Chronic Migraine: Comprehensive Management. Collaborative Care.

CE2

TA B L E 1

October 2019

Diagnostic Criteria for Migraine – Episodic and Chronic(20)

Migraine Diagnostic Criteria

Answer online at eCortex.ca

TA B L E 2 Secondary Headache and Medication Overuse Headache

Possible Indicators of Secondary Headache(21) 1. Headache attacks lasting 4-72 hours (when untreated or unsuccessfully treated) AND 2. Headache has ≥2 of the following characteristics: • Unilateral location • Moderate to severe pain intensity • Pulsating • Interference with, or aggravated by, routine physical activity AND 3. Accompanied by ≥1 of the following: • Nausea and/or vomiting • Photophobia and phonophobia

+ Episodic Migraine Requiring Prophylaxis <15 headache days/month (3, 21)

Chronic Migraine Requiring Prophylaxis ≥15 headache days/month(20)

• Moderate to severe headache >3 days/month when abortive medications are not effective, OR • Headache >8 days/month and at risk of medication overuse headache (MOH), OR • Recurrent migraine attacks causing considerable disability despite optimal abortive therapy.

Headache on ≥15 days per month: • For >3 months, AND • Where ≥8 days/month the headaches are migraines.

TA B L E 3

Red Flags & Details(3,32-34)

Systemic signs or symptoms: Fever, weight loss, rash, headache with fever and neck stiffness Secondary risk factors: HIV, cancer, immunosuppression, Lyme disease Neurologic signs or symptoms: Altered consciousness, visual disturbances, slurred speech, hemiparesis Onset: “Worst headache of life”; Abrupt, peak intensity reached in seconds to minutes (e.g. thunderclap headache) Older: New onset headache over 50 years of age and/or signs or symptoms of acute angle-closure glaucoma, temporal arteritis, or elderly with new headache and subacute cognitive change

• Unexplained focal signs • Atypical headaches (not consistent with migraine or tension-type headache) • Unusual headache precipitants • Unusual aura symptoms • Onset after age 50 • Aggravation by neck movement; abnormal neck examination findings (consider cervicogenic headache) • Jaw symptoms; abnormal jaw examination findings (consider temporomandibular joint disorder) Medication Overuse Headache (MOH)(3,20,21, 29-31) Consider MOH in patients with chronic daily headache (i.e., ≥15 headache days/month) who are using: • Simple analgesics (e.g., acetaminophen, NSAIDs) on ≥15 days/month* for >3 months; or • Ergots, triptans, opioids, or combination analgesics with an opioid or barbiturate (e.g., acetaminophen with codeine and caffeine) on ≥10 days/month† for >3 months.

Note: Total use of several different drugs without overuse of any single drug on ≥15 days/month* for simple analgesics or ≥10 days/month† for ergots, triptans, opioids or combination analgesics is considered overuse.

F I G U R E 1 PPPOUND: Acronym for Remembering the Features of Migraine

Pulsating pain Photophobia

Previous headache history: New (first headache ever), or change in quality, location or frequency of existing headaches

Phonophobia

Postural, positional: Changes with exertion, or worsens with Valsalva maneuver

One day duration of severe untreated attacks

Papilledema: Fleeting disturbances in vision, headache, vomiting or a combination

Unilateral pain Nausea +/- vomiting

How does chronic migraine differ from other forms of chronic daily headache?

Migraine is a primary headache disorder, meaning it is not caused by any underlying condition or disorder. Primary headache disorders are diagnosed clinically, which may include the use of diagnostic criteria (Table 1), without traditional diagnostic studies to verify the diagnosis.(19) Secondary headaches, on the other hand, are caused by an underlying disorder and can be diagnosed by identifying that condition (Table 2).(19,20) Migraine is characterized by a unilateral, throbbing or pulsating headache with moderate to severe pain intensity, interference with activities, and at least one of nausea or light and sound sensitivity.(21) An easy acronym for remembering the features of a migraine is PPPOUND (Figure 1).(22) Migraines without aura, formerly called “common migraine,” are the most prevalent type. Migraines with aura, formerly called “classic migraine,”

will have reversible focal neurological symptoms, which may precede or accompany the headache.(20,23) Episodic and chronic migraine are distinct from the perspective of disease manifestation, impact and diagnosis; and are recognized as unique medical entities by the Classification Committee of the International Headache Society.(20) Episodic migraine is diagnosed in patients with headache occurring on <15 days/ month (Table 1). The transformation from episodic to chronic migraine is reported to occur in approximately 3% of patients with episodic migraine annually.(14) Chronic migraine is diagnosed in patients with headache occurring on ≥15 days/month for >3 months, which, on ≥8 days/month, has the features of a migraine headache (Table 1).(20) It is differentiated from episodic migraine by headache frequency, pathophysiology, etiology, headache severity, disease burden, and impact on health-related quality

Disabling intensity Adapted from Harvard Health Publishing (22).

of life (HRQoL).(6,12,15,20,24-28) Chronic migraine is considered to be one of four subtypes of chronic daily headache disorders, each with their own distinguishing features (Figure 2).

In assessing headaches, practitioners should rule out red flags requiring immediate medical attention (Table 3) and consider secondary causes (Table 2).

MOH is considered a secondary headache, which is potentially treatable and preventable (Table 2).(3,21) Although it is not part of the diagnostic criteria for chronic migraine, when there is concomitant MOH, both diagnoses are given.(20) What are the risk factors for developing chronic migraine?

Risk factors for developing chronic migraine include genetic predisposition,

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Chronic Migraine: Comprehensive Management. Collaborative Care.

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FIGURE 2

October 2019

CE3

Characteristics of Primary Chronic Headache Disorders

Chronic daily headache ≥15 d/mo

Headache on ≥15 d/mo, ≥ 3 mo, ≥ 8 d/mo migrainous*

Yes

*Lasting 4-72 hours Unilateral, Pulsating, Nausea, Light and Sound Sensitivity, Interference with Activities

Chronic migraine

No

Continuous headache, strictly unilateral pain with autonomic features† and an indomethacin response

†

Yes

Tearing, Nasal congestion, Lid Edema, Forehead Sweating, etc. on same side as headache; Restlessness; Agitation

Hemicrania continua

No

Continuous headache‡, clearly remembered onset on a remembered day

Yes

New daily persistent headache

‡

May have Migraine and/or Tension-Type Headache Features

No

Headache on ≥15 d/mo for >3 mo with chronic tension-type headache features¶

Yes

Chronic tension-type headache

¶

Lasting Hours to Days, or Unremitting Bilateral, Steady, Non-pulsating

Note: Assumes patients have normal neurologic examination findings. Treatment of primary chronic daily headache disorders will require referral to an appropriately trained physician.

Adapted from Bigal & Lipton(35), Becker(31).

female gender, depression, anxiety, obesity, smoking, sleep apnea, low socioeconomic status and education, head trauma, and stressful life events.

(13,15) Overuse of abortive migraine medication, ineffective acute treatment and high migraine attack frequency also increase the risk of developing chronic migraine by shortening the period between attacks and reducing the amount of time where a patient’s sensory threshold for an attack is at baseline, thus potentiating the onset of another attack.(13) Who is a candidate for prophylactic therapy?

Chronic migraine is underdiagnosed and under treated. Of patients who meet the criteria for chronic migraine, approximately 36% of patients consulting a headache specialist, and 16% consulting a non-headache specialist, receive a diagnosis of chronic migraine.(36) Research estimates that 25% of migraine sufferers are candidates for prophylaxis, but prophylaxis is underutilized, creating a gap in care.(37) Criteria for prophylaxis of episodic and chronic migraine are provided in Table 1.

What are the goals of chronic migraine prophylaxis?

The main goal of chronic migraine treatment is to reduce headache burden and improve quality of life.(21,31) Key considerations to remember: • Headache attacks will not likely be abolished completely.

TA B L E 4

Self-Management Strategies for Migraine(3, 21, 30, 31, 38)

Use a headache diary to monitor headache frequency, intensity, triggers and medication use.

Headache diaries available online e.g., www.migrainecanada.org Triggers

Strategies

Diet • Delayed, missed or inadequate meals • Dehydration • Caffeine excess or withdrawal • Alcohol

• Eat ≥3 x per day • Eat breakfast • Avoid >4 hours without eating during the day

• Drink water

• Limit coffee to ≤1 cup (or equivalent) per day

• Limit alcohol

Exercise • Lack of regular exercise • Intense exercise • Obesity

• Maintain a healthy BMI

• Exercise 3-5 x per week

Stress & Psychological • Irregular or lack of sleep • Stressful lifestyle

• Sleep ≥7-8 hours per night • Maintain good sleep habits

• Use stress management skills, relaxation therapy, pacing, biofeedback therapy, cognitive behavioural therapy

Environment & Hormone Changes • Lights, smells, weather changes • Hormone changes in menstruation or menopause

• Avoid specific triggers, such as bright or flickering lights, strong smells

• A reduction in headache frequency of 50% or more is usually considered successful. In chronic migraine, a smaller improvement may still be worthwhile.

• A reduction in intensity and duration

• Manage hormone changes, where possible

of headache attack may improve productivity/quality of life, which can also be considered successful.

• Goals of therapy should be jointly established with the patient to set realistic expectations.

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Chronic Migraine: Comprehensive Management. Collaborative Care.

CE4

How is episodic and chronic migraine treated?

October 2019

TA B L E 5

Answer online at eCortex.ca

Determining if Abortive Therapy is Adequate

WHAT IS THE OVERALL APPROACH TO EPISODIC AND CHRONIC MIGRAINE TREATMENT?

Use the following questions to help determine if abortive therapy is adequate. If the answer to all four questions is yes, the regimen does not need to be changed. If the answer is no to any one question, consider a change in the acute migraine medication:(3)

The overall approach to episodic and chronic migraine therapy is to optimize self-management strategies (Table 4), treat individual attacks with appropriate abortive therapy and use prophylaxis when indicated. Key questions to determine if abortive therapy is adequate are provided in Table 5. MOH should be identified and management should be done with the knowledge and/or supervision of the prescribing physician, especially if the patient is overusing high dose opioids or barbiturates.

A number of drugs have shown efficacy for migraine prophylaxis. Choice of pharmacologic prophylaxis should be individualized to the patient, taking to account the patient’s previous medication experience(s) and therapy beliefs/preferences, as there is not one single ideal first-line agent.

Consideration should also be given to the strength of evidence, patient disability, migraine pain severity, contraindications, tolerability, and the presence of co-existing medical and/or psychiatric disorders, in which an agent could be chosen to manage both the migraine and comorbidity.(30) Guiding principles for pharmacologic prophylaxis are provided in Table 6.

1. Do you have significant relief within 2-hours of taking the medication?

WHAT SELF-MANAGEMENT STRATEGIES SHOULD BE CONSIDERED?

All migraine sufferers can benefit from self-management strategies, which include keeping a headache diary, adjusting lifestyle factors and developing stress management techniques (Table 4).(3,21) Keeping a headache diary allows patients to monitor headache frequency, intensity, triggers and medication use.

Self-monitoring to identify factors influencing migraine and modifications to manage specific triggers should be encouraged (Table 4).(3,21) A wide variety of diaries exist, many of which are available online, including www.migrainecanada.org.

Modifying lifestyle factors will overlap with specific trigger management; however, clinicians consider some overall lifestyle factors (i.e., diet, exercise, stress, environment) to be important (Table 4), regardless of the availability of supporting scientific data. Multidisciplinary care across all of these areas is recommended.(3) WHAT NATURAL HEALTH PRODUCTS ARE USED FOR MIGRAINE PROPHYLAXIS?

Several natural health products (NHPs) (i.e., vitamins, minerals and herbal

2. Are you able to tolerate the medication, with few or no side effects?

3. Do you take only one dose per episode?

4. Can you resume normal occupational, social, and family activities within 2-hours after taking the medication?

TA B L E 6

Guiding Principles for Migraine Pharmacologic Prophylaxis(39)

Guiding Principles

Exceptions for Injectables

• Use evidence-based treatments • Start low & titrate* • Reach a therapeutic dose • Give an adequate trial (≥ 8 weeks) at titrated therapeutic dose • Establish realistic expectations • Consider co-existent medical conditions • Maximize adherence

• No need for gradual dose increase • Rapid onset & favourable tolerability with onabotulinumtoxinA & erenumab Place in chronic migraine (CM) therapy: • OnabotulinumtoxinA - Only drug specifically indicated in CM - May be used first-line or after oral migraine prevention agents • Erenumab (i.e., Calcitonin Gene Receptor Peptide [CGRP] inhibitors) - After 6-week trial of ≥ 2 oral migraine prevention agents, OR - Minimum 2 quarterly injections (6 months) of onabotulinumtoxinA

*Note: Exceptions where slow titration is not required: onabotulinumtoxinA, try for 3-4 cycles over 8-12 months; erenumab, two dose options with no titration; candesartan, start with 8 mg daily for 1 week then 16 mg daily.

TA B L E 7

Natural Health Products for Migraine Prophylaxis*(3, 30, 40-43)

Drug

Dose †

Butterbur (Petasites hybridus extract )

75-150 mg/day, once daily or divided BID

Coenzyme Q10

100 mg TID

Riboflavin (vitamin B2)

400 mg/day, once daily or divided BID

Magnesium citrate‡

300 mg elemental magnesium BID

Vitamin D

2000 IU once daily

*Based on evidence for episodic migraine prophylaxis. † Use products labelled as free of hepatotoxic pyrrolizidine alkaloids (PA). ‡ Controversial for continuous use in pregnancy. Used for acute treatment of toxemia and headaches.

compounds) are recommended for migraine prophylaxis, and are preferred by some patients (Table 7).(3,21) All have demonstrated efficacy in reducing migraine attack frequency with minimal side effects.(30) No head-to-head studies have been conducted comparing the prophylactic efficacy of NHPs versus prescription agents, but the NHPs are generally considered to be less efficacious.(3) Butterbur (Petasites hybridus extract) has the strongest body of evidence (moderate quality) supporting its use in migraine prophylaxis.(30) However, patients should be cautioned to only use butterbur products certified and labelled as hepatotoxic pyrrolizidine alkaloid (PA)-free.

The most common NHPs in headache practices are magnesium 300 mg elemental twice daily, riboflavin (vitamin B2) 200 mg twice daily and vitamin D 2000 IU daily, which are sometimes used in a triple regimen. Riboflavin has limited side effects. Patients with sleep issues can

be counselled to take the magnesium as a single dose at bedtime. If the magnesium is associated with diarrhea, reduce the dose to once a day, then gradually try to increase over a 2-week period if tolerated.

Patients with gastrointestinal issues (e.g., inflammatory bowel syndrome, gastroesophageal reflux disease) may wish to start with one agent at a time, introducing the next after 3 months.

WHAT PRESCRIPTION AGENTS ARE USED FOR EPISODIC MIGRAINE PROPHYLAXIS?

A number of agents have established efficacy and/or are indicated for episodic migraine including metoprolol, propranolol, timolol, flunarizine, divalproex sodium, topiramate, amitriptyline and erenumab. Other antihypertensives, antiepileptics and antidepressants have also been used, but evidence to support their use is limited (Table 8).(3,44) Choice of prescription episodic migraine prophylaxis should be individualized to the patient,

Chronic Migraine: Comprehensive Management. Collaborative Care.

Answer online at eCortex.ca

October 2019

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Continuing Education L E S S O N

TA B L E 8 Maintenance Doses - Episodic and Chronic Migraine Prophylaxis Prescription Therapies(3, 29, 30, 40, 41, 45-48)

Episodic Migraine

Maintenance Dose

Beta-Blockers Atenolol

100-150 mg/day

Metoprolol

100-200 mg/day (divided BID; SR form once daily)

Nadolol

80-160 mg/day

Propranolol*

40-120 mg BID (or 80-160 mg LA form once daily)

Timolol

10 mg BID or 20 mg once daily

Calcium Channel Blockers Flunarizine

10 mg HS

Verapamil

240 mg/day (divided TID; SR divided BID)

Angiotensin Receptor Blockers Candesartan†

16 mg/day

Antiepileptics Divalproex sodium†

750-1,500 mg/day (divided BID)

†

Gabapentin

1,200-1,500 mg/day (divided TID), up to 1,800 mg/day

†

Topiramate

100-200 mg/day (divided BID)

Antidepressants Amitriptyline‡

20-40 mg HS; up to 100-150 mg/day

Nortriptyline

20-40 mg HS; up to 150 mg/day

Venlafaxine

150 mg/day; up to 225 mg/day

Calcitonin Gene Receptor Peptide (CGRP) Blocker Erenumab†

70-140mg SC monthly

Chronic Migraine

Maintenance Dose †

OnabotulinumtoxinA †

155-195 Allergan Units IM every 12 weeks

Erenumab

70-140mg SC monthly

Topiramate†

100-200 mg/day (divided BID)

Note: Drugs in bold face have established efficacy and/or are indicated. *Propranolol is the preferred agent during pregnancy or lactation. † Not for use in pregnancy. Divalproex sodium: neural tube defects if used in pregnancy. Gabapentin: may cause fetal harm.

Topiramate: oral clefts if used in 1st trimester. ‡ Amitriptyline may be considered for use during pregnancy or lactation if propranolol is contraindicated or ineffective.

LA = long acting; SR = sustained release.

strength of evidence, comorbidities, contraindications, and tolerability.(30) WHAT PRESCRIPTION AGENTS ARE USED FOR CHRONIC MIGRAINE PROPHYLAXIS?

Three agents (i.e., onabotulinumtoxinA, erenumab and topiramate) are supported by data in the prophylaxis of chronic migraine headaches (Tables 8, 9).(3,13,31,45,49) While the other agents have been used in chronic migraine, the evidence of their efficacy in this patient population is less robust.(3,44) Given the evidence that episodic migraine and chronic migraine are distinct diseases with differing clinical and epidemiological profi les, therapeutic response patterns can be different between disease states.(6) OnabotulinumtoxinA is thought to inhibit the release of neuropeptides [e.g.,

calcitonin gene-related peptide (CGRP), glutamate, substance P] implicated in migraine pathophysiology from sensory neurons, blocking peripheral sensitization directly and central sensitization indirectly.(47) It is indicated for the prophylaxis of headaches in adults with chronic migraine (≥15 days per month with headache lasting 4 hours a day or longer).(47) In a pooled analyses of data from the Phase 3 PREEMPT 1 and 2 trials, onabotulinumtoxinA significantly reduced the frequency of headache days compared to placebo in patients with chronic migraine, as well as the frequency of moderate/severe headache days and the total cumulative hours of headache on headache days.(50,51) In addition, patients experienced significant improvements in health-related quality of life and overall functioning as measured

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by the Headache Impact Test (HIT)-6 and Migraine-Specific Quality of Life (MSQ) scales.(50,51) Adverse effects were generally mild to moderate in severity.

OnabotulinumtoxinA is administered as an intramuscular injection by a trained clinician every three months.(47) Erenumab is a recombinant human monoclonal antibody that competes with CGRP for binding to the CGRP receptor, inhibiting the function of the neuropeptide implicated in migraine pathology.(46) It is indicated for prevention of migraine in adults who have at least 4 migraine days per month.(46) Erenumab 70 mg and 140 mg have been shown to significantly reduce monthly migraine days compared to placebo in patients with chronic migraine in one Phase 2 trial.(45) Erenumab was considered safe, and adverse effects were generally mild to moderate in severity.(45,46) Data on the long-term safety and efficacy of erenumab is limited.(45) Erenumab is self-administered by subcutaneous injection every month.(46) Some patients may require 140 mg/month, which may impact cost of therapy.

Topiramate has the best evidence of efficacy of the oral agents for chronic migraine prophylaxis.(3) Topiramate has been shown to reduce monthly migraine days, frequency of associated symptoms and achieve a 25% reduction in monthly migraine attacks in patients with chronic migraine.(52) In the FORWARD study, treatment with onabotulinumtoxinA resulted in a higher proportion of patients with a 50% or greater reduction in headache frequency compared to topiramate with higher tolerability; only 3.6% of the onabotulinumtoxinA group dropping out due to intolerable adverse effects versus 50.7% of the topiramate group.(53) Side effects are common with use of topiramate, especially at higher doses (i.e., 200 mg).(30) Some clinicians will avoid topiramate in patients with concurrent depression, as mood disturbances, including depression, are a known side effect and suicidal ideation has been reported with antiepileptic agents in several indications.(48) Caution also needs to be taken due to its interaction with oral contraceptives, potential to predispose to renal calculi and, rarely, acute angle closure glaucoma.(30) While there is limited evidence for the use of other prescription agents in chronic migraine, they may be used based on extrapolation of data for their efficacy in episodic migraine prophylaxis.(44) Amitriptyline, candesartan, divalproex sodium, tizanidine, and gabapentin have higher levels of evidence (i.e., at least one randomized control trial) for efficacy

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Chronic Migraine: Comprehensive Management. Collaborative Care.

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TA B L E 9

October 2019

Chronic Migraine Prophylaxis Prescription Therapies*(3, 29, 30, 40, 41, 45, 46, 48, 54)

Drug / Dose

Points to Consider

OnabotulinumtoxinA injection of 50, 100 & 200 Allergan units† 155-195 Allergan units† IM to multiple sites in the head and neck as per injection protocol, can be repeated every 12 weeks if necessary

• Indicated, and evidence for use, in chronic migraine prophylaxis.

• Evidence for efficacy in associated medication overuse headache.

• Adverse effects: pain at injection sites, neck pain, muscle weakness, brow ptosis, lid ptosis (rare), dysphagia (rare).

• Avoid in pre-existing dysphagia, breathing difficulties or muscle weakness and myasthenia gravis (or other neuromuscular transmission disorder).

• Avoid in pregnancy. Some clinicians will use onabotulinumtoxinA if the benefits outweigh the risks.

• Administer by a trained injector: www.mychronicmigraine.ca

Erenumab 70 mg/mL injection 70 mg/month, up to 140 mg/month by SC injection

• Evidence for efficacy in chronic migraine prophylaxis. Indicated for prevention of migraine in adults who have at least 4 migraine days per month.

• Adverse effects: injection site reactions, nausea, upper respiratory tract infection, constipation, muscle spasms.

• Avoid in pregnancy. Some clinicians recommend using an effective method of contraception in patients of childbearing potential, and stopping erenumab 6-months before considering pregnancy.

• May be self-administered.

Topiramate 25, 100 & 200 mg tablets and 15 & 25 mg sprinkle capsules Start with 25 mg/day; increase slowly up to 100 mg/day, divided BID (up to 200 mg/day divided BID can be used, but with greater risk of adverse effects)

• Evidence for efficacy in chronic migraine and associated medication overuse headache. Indicated in adults for the prophylaxis of migraine headache.

• Adverse effects: CNS effects (e.g., fatigue, dizziness, tremor, sedation, cognitive impairment, word finding difficulty), GI effects (e.g., nausea, anorexia), weight loss, paresthesia, renal calculi.

• Drug interactions (e.g., carbamazepine, phenytoin, CNS depressants, CYP2C19 inhibitors, oral contraceptives, divalproex).

• Avoid in kidney stones, renal failure, and angle-closure glaucoma.

Caution use in depression and in patients with cognitive concerns.

• Avoid in pregnancy. Topiramate is contraindicated in pregnancy and patients of childbearing potential must use an effective method of contraception.

CNS = central nervous system; GI = gastrointestinal. *Drugs used in episodic migraine prophylaxis (e.g., beta-blockers, antidepressants, etc.) may be considered in chronic migraine prophylaxis without specific evidence, and may be considered if co-morbidities such as hypertension or anxiety exist. † The term “Allergan unit” is a specific measurement of toxin activity that is unique to Allergan’s formulation of onabotulinumtoxinA.

in chronic migraine prophylaxis.(3,13,31) However, any of the prescription episodic prophylactic options may be trialed for a particular patient based on clinical experience, a favorable tolerability profi le, patient preference, and/or the ability to treat both the migraine and another comorbid condition.(30) How can pharmacists contribute to chronic migraine self-management?

Below are 7 critical ways pharmacists can contribute to optimal chronic migraine management, where the migraine diagnosis is established and red flags and secondary causes have been ruled out.

1. Identify triggers and recommend selfmanagement strategies, where possible (Table 4).

2. Identify potential or actual MOH (Table 2).

3. Ensure abortive therapy is appropriate (Table 5).

4. Identify patients in need of prophylaxis (Table 1).

5. Set the patient up with a diary (e.g., visit www.migrainecanada.org) and, if appropriate, recommend a regimen of NHPs prior to the next physician visit (Table 7).

6. Review migraine prophylaxis options with the patient, considering comorbidities (Tables 8, 9).

7. Assess appropriateness and adherence to prophylaxis regimens, and follow-up.

Migraine is a chronic medical disorder and management is complex.

Comprehensive migraine management requires a team approach, within which pharmacists can add significant value and where patients’ active participation is of utmost importance.(3) A clinical practice tool for pharmacists, highlighting the major aspects of this continuing education lesson, is available at: http:// agrohealth.com/practicetools Summary case study Joan is a regular patient at your pharmacy.

Over the past few months, she has been purchasing and using multiple bottles of over-the-counter combination analgesics with codeine, along with naproxen, both of which she has been taking for headaches. Your staff has been increasingly concerned with the frequency of her analgesic purchases. As Joan also has other chronic medical conditions

Answer online at eCortex.ca

for which she is receiving prescription therapy, you suggest a medication review.

During the review, you learn that Joan has had migraines without aura for 10 years. She suffers with headaches an average of 15 days per month and, on about 10 of these days each month, the criteria for migraine appears to be fulfi lled. She is currently taking combination analgesics on 20 days each month.

HOW WOULD YOU CHARACTERIZE JOAN’S HEADACHES?

• Joan is suffering from chronic migraine (≥15 headache days per month; migraine criteria fulfi lled ≥8 days per month) with medication overuse headache (combination analgesics ≥10 days per month).

WHAT OPTIONS ARE POSSIBLE FOR JOAN?

• Educate Joan on migraine, and on the differences between acute and prophylactic options.

• Discuss the need to see her primary healthcare provider for assessment.

• Set Joan up with a headache diary, and review triggers and lifestyle modifications.

• Discuss NHPs and suggest a regimen that can be tried prior to seeing her primary caregiver and/or headache specialist, if she is agreeable.

• Educate Joan on medication overuse headache and the appropriate use of abortive therapy, and discuss a plan to gradually taper off her OTC analgesics.

• Recommend Joan follow-up with her physician to see which prophylactic medication may be right for her.

References

1. Stovner LJ, Nichols E, Steiner TJ, Abd-Allah F, Abdelalim A, Al-Raddadi RM, et al. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2018;17(11):954-76.

2. Bigal ME, Lipton RB, Stewart WF. The epidemiology and impact of migraine. Current neurology and neuroscience reports.

2004;4(2):98-104.

3. Towards Optimized Practice (TOP) Headache Working Group.

2016 September. Primary Care Management of Headache in Adults: Clinical Practice Guideline: 2nd edition. Edmonton AB: Toward Optimized Practice. Available from: http://topalbertadoctors.org/cpgs/10065.

4. Ramage-Morin PL, Gilmour H. Prevalence of migraine in the Canadian household population. Health reports. 2014;25(6):10-6.

5. Burch RC, Loder S, Loder E, Smitherman TA. The prevalence and burden of migraine and severe headache in the United States: updated statistics from government health surveillance studies. Headache. 2015;55(1):21-34.

6. Manack AN, Buse DC, Lipton RB. Chronic migraine: epidemiology and disease burden. Curr Pain Headache Rep. 2011;15(1):70-8.

7. Mayo Clinic. Migraine. Available from: https://www. mayoclinic.org/diseases-conditions/migraine-headache/ symptoms-causes/syc-20360201.

8. O’Brien B, Goeree R, Streiner D. Prevalence of migraine headache in Canada: a population-based survey. International journal of epidemiology. 1994;23(5):1020-6.

9. Buse DC, Rupnow MFT, Lipton RB. Assessing and managing all aspects of migraine: migraine attacks, migraine-related functional impairment, common comorbidities, and quality of life. Mayo Clin Proc. 2009;84(5):422-35.

10. Buse DC, Manack AN, Fanning KM, Serrano D, Reed ML, Turkel CC, et al. Chronic migraine prevalence, disability, and sociodemographic factors: results from the American

Chronic Migraine: Comprehensive Management. Collaborative Care.

Answer online at eCortex.ca

October 2019

Migraine Prevalence and Prevention Study. Headache.

2012;52(10):1456-70.

11. Munakata J, Hazard E, Serrano D, Klingman D, Rupnow MF, Tierce J, et al. Economic burden of transformed migraine: results from the American Migraine Prevalence and Prevention (AMPP) Study. Headache. 2009;49(4):498-508.

12. Blumenfeld AM, Varon SF, Wilcox TK, Buse DC, Kawata AK, Manack A, et al. Disability, HRQoL and resource use among chronic and episodic migraineurs: results from the International Burden of Migraine Study (IBMS). Cephalalgia.

2011;31(3):301-15.

13. May A, Schulte LH. Chronic migraine: risk factors, mechanisms and treatment. Nat Rev Neurol. 2016;12(8):455-64.

14. Bigal ME, Lipton RB. Concepts and mechanisms of migraine chronification. Headache. 2008;48(1):7-15.

15. Buse DC, Manack A, Serrano D, Turkel C, Lipton RB. Sociodemographic and comorbidity profiles of chronic migraine and episodic migraine sufferers. J Neurol Neurosurg Psychiatry.

2010;81(4):428-32.

16. Buse DC, Powers S, Gelfand A, al e. Adolescent perspectives on the burden of a patient’s migraine: results from the CaMEO study. Headache. 2018;58:512-24.

17. Alstadhaug KB, Ofte HK, Kristoffersen ES. Preventing and treating medication overuse headache. Pain Rep. 2017;2(4):e612.

18. Kristoffersen ES, Lundqvist C. Medication-overuse headache: epidemiology, diagnosis and treatment. Ther Adv Drug Saf. 2014;5(2):87-99.

19. Stern SD, Cifu AS, Altkorn D. 20: Headache 2015 Available from: https://accessmedicine.mhmedical.com/content.aspx?bookid =1088&sectionid=61698969.

20. International Headache Society. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition.

Cephalalgia. 2018;38(1):1-211.

21. Becker WJ, Findlay T, Moga C, Scott NA, Harstall C, Taenzer P. Guideline for primary care management of headache in adults.

Can Fam Physician. 2015;61(8):670-9.

22. Harvard Health Publishing. Headache: When to worry, what to do: Harvard Medical School; Available from: https://www.health. harvard.edu/pain/headache-when-to-worry-what-to-do.

23. Worthington I, Pringsheim T, Gawel MJ, Gladstone J, Cooper P, Dilli E, et al. Canadian Headache Society Guideline: acute drug therapy for migraine headache. Can J Neurol Sci. 2013;40(5 Suppl 3):S1-S80.

24. Katsarava Z, Buse DC, Manack AN, Lipton RB. Defining the differences between episodic migraine and chronic migraine.

Curr Pain Headache Rep. 2012;16(1):86-92.

25. Bigal ME, Serrano D, Reed M, Lipton RB. Chronic migraine in the population: burden, diagnosis, and satisfaction with treatment.

Neurology. 2008;71(8):559-66.

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26. Adams AM, Serrano D, Buse DC, Reed ML, Marske V, Fanning KM, et al. The impact of chronic migraine: The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study methods and baseline results. Cephalalgia : an international journal of headache.

2015;35(7):563-78.

27. Bigal ME, Rapoport AM, Lipton RB, Tepper SJ, Sheftell FD. Assessment of migraine disability using the migraine disability assessment (MIDAS) questionnaire: a comparison of chronic migraine with episodic migraine. Headache. 2003;43(4):336-42.

28. Messali A, Sanderson JC, Blumenfeld AM, Goadsby PJ, Buse DC, Varon SF, et al. Direct and Indirect Costs of Chronic and Episodic Migraine in the United States: A Web-Based Survey.

Headache. 2016;56(2):306-22.

29. Towards Optimized Practice (TOP) Headache Working Group.

2016 September. Primary Care Management of Headache in Adults: Clinical Practice Guideline, Quick Reference: 2nd edition. Edmonton AB: Toward Optimized Practice. Available from: http://topalbertadoctors.org/cpgs/10065.

30. Pringsheim T, Davenport W, Mackie G, Worthington I, Aube M, Christie SN, et al. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012;39(2 Suppl 2):S1-59.

31. Becker WJ. The Diagnosis and Management of Chronic Migraine in Primary Care. Headache. 2017;57(9):1471-81.

32. Davies MB. How do I diagnose headache? J R Coll Physicians Edinb 2006;36:336-42.

33. Holle D, Obermann M. The role of neuroimaging in the diagnosis of headache disorders. Ther Adv Neurol Disord. 2013;6(6):369-74.

34. Martin VT. Simplifying the Diagnosis of Migraine Headache.

Advanced Studies in Medicine. 2004;4(4):200-9.

35. Bigal ME, Lipton RB. The differential diagnosis of chronic daily headaches: an algorithm-based approach. The Journal of Headache and Pain. 2007;8(5):263-72.

36. Buse DC. Chronic Migraine May be Underdiagnosed and Undertreated 2014. Available from: https://www.mdedge. com/neurologyreviews/article/86210/headache-migraine/ chronic-migraine-may-be-underdiagnosed-and.

37. Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF, et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68(5):343-9.

38. World Health Organization and European Headache Federation.

Aids for Management of Common Headache Disorders in Primary Care. J Headache Pain. 2007;8:S1-S47.

39. American Headache Society. The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. Headache: The Journal of Head and Face Pain. 2019;59(1):1-18.

40. RxTx. Canadian Pharmacists Association. [Accessed December 13, 2018]. Available from: www.e-therapeutics.ca.

41. RxFiles [Accessed December 13, 2018]. Available from: www. rxfiles.ca.

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42. Natural Medicines Comprehensive Database. [Accessed January 29, 2019]. Available from: https://naturalmedicines.therapeuticresearch.com/.

43. Buettner C, Nir R-R, Bertisch SM, Bernstein C, Schain A, Mittleman MA, et al. Simvastatin and vitamin D for migraine prevention: A randomized, controlled trial. Annals of Neurology.

2015;78(6):970-81.

44. Scottish Intercollegiate Guidelines Network (SIGN).

Pharmacologic Managment of Migraine. Edinburgh: SIGN; 2018. ISBN 978 1 909103 62 7.

45. Tepper S, Ashina M, Reuter U, Brandes JL, Doležil D, Silberstein S, et al. Safety and efficacy of erenumab for preventive treatment of chronic migraine: a randomised, double-blind, placebo-controlled phase 2 trial. The Lancet Neurology.

2017;16(6):425-34.

46. Novartis. Aimovig (erenumab injection) Product Monograph.

July 30, 2018.

47. Allergan. Botox (onabotulinumtoxinA for injection Ph. Eur.) Product Monograph. October 16, 2018.

48. Janssen. Topamax (topiramate tablets sprinkle capsules) Product Monograph. November 13, 2018.

49. Herd CP, Tomlinson CL, Rick C, Scotton WJ, Edwards J, Ives N, et al. Botulinum toxins for the prevention of migraine in adults.

Cochrane Database of Systematic Reviews. 2018. https://doi. org/10.1002/14651858.CD011616.pub2 50. Dodick DW, Turkel CC, DeGryse RE, Aurora SK, Silberstein S, Lipton RB, et al. OnabotulinumtoxinA for Treatment of Chronic Migraine: Pooled Results from the Double-Blind Randomized, Placebo-Controlled Phases of the PREEMPT Clinical Program.

Headache. 2010;50:921-36.

51. Aurora SK, Winner P, Freeman MC, Spierings EL, Heiring JO, DeGryse RE, et al. OnabotulinumtoxinA for Treatment of Chronic Migraine: Pooled Analyses of the 56-Week PREEMPT Clinical Program. Headache. 2011;51(9):1358-73.

52. Shamliyan TA, Kane, RL, Taylor, FR. Migraine in Adults: Preventive Pharmacologic Treatments. Comparative Effectiveness Review No. 103. (Prepared by the University of Minnesota Evidencebased Practice Center under Contract No. 290-2007-10064-I) AHRQ Publication No. 13-EHC068-EF. Rockville, MD: Agency for Healthcare Research and Quality; April 2013. www.effectivehealthcare.ahrq.gov/reports/final.cfm.

53. Rothrock JF, Adams AM, Jo E, Zhao X, Blumefeld AM. A Multicenter, Prospective, Randomized, Open-Label Study to Compare the Efficacy, Safety, and Tolerability of OnabotulinumtoxinA and Topiramate for Headache Prophylaxis in Adults with Chronic Migraine: The FORWARD Study. Poster presented at the International Headache Congress (2017), Vancouver, B.C.; 2017 September 7 - 10, 2017.

54. Allergan. Botox (onabotulinumtoxinA for injection Ph. Eur) Product Monograph, October 16, 2018.

Questions Answer online at eCortex.ca. Quick Search CCCEP #1002-2019-2848-I-P Note: The order of the responses may differ in the version of this course posted online.

Please read carefully when you answer your test questions at eCortex.ca.

1. Select the correct statement about the prevalence of migraines in Canada: a) Males are more likely to report migraine. b) Prevalence is likely underestimated. c) Migraine sufferers seek medical attention as soon as symptoms occur. d) All of the above.

2. Compared to episodic migraine, chronic migraine sufferers: a) Are almost twice as likely to be affected by depression, anxiety and chronic pain. b) Visit their healthcare

providers three to four times more often. c) More likely to miss work or school. d) All of the above.

3. When assessing headaches, it is important to: a) Rule out red flags. b) Consider secondary causes. c) Screen for medication overuse headache. d) All of the above.

4. Select the correct statement regarding primary chronic headache disorders: a) Primary chronic headache disorders require diagnostic tests to verify the clinical

diagnosis. b) Primary chronic headache disorders are due to an underlying disorder. c) Primary chronic headache disorders are characterized by headache occurring on ≥ 15 days per month, but each type is defined by their unique clinical criteria. d) Primary chronic headache disorders only include chronic migraine and new daily persistent headache.

5. Select the correct definition of chronic migraine requiring prophylaxis: a) Headache on > 8 days/ month and at risk of

medication overuse headache. b) Headache on > 3 days/ month, when abortive medications are not effective. c) Headache on ≥ 15 days/ month, for > 3 months, where ≥ 8 days/month the headaches are migraines. d) Headache on < 15 days/ month where > 3 days/ month abortive medications are not effective, or > 8 days/month and at risk of medication overuse headache, or migraines causing significant disability despite optimal abortive therapy.

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6. Select the statement that is most consistent with medication overuse headache.

Over the past 3 months, Susan uses: a) Ergots or a codeinecontaining combination analgesic on 5 days/month. b) Acetaminophen 10 days/ month and ibuprofen 10 days/month. c) Ibuprofen 4 days/month and sumatriptan 4 days/month. d) Acetaminophen 4 days/ month and sumatriptan 2 days/month.

7. Paul comes into the pharmacy complaining of headaches. Upon questioning, he tells you that he takes acetaminophen with codeine on at least four days per week for the past 6 months, leading you to suspect medication overuse headache. What advice will you give Paul? a) Advise Paul to continue his current therapy. b) Advise Paul to stop taking acetaminophen with codeine right away. c) Advise Paul of the risks of MOH and to seek the supervision of a physician to create a plan to taper off regular abortive therapy. d) Advise Paul to try naproxen in addition to acetaminophen with codeine.

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8. Select the correct statement. Headache diaries: a) Allow patients to selfmonitor headache frequency, intensity, triggers and medication use. b) Can be initiated by a pharmacist, to enable the patient to gather headache data for their physician. c) Can be found online (e.g., www.migrainecanada.org). d) All of the above.

9. Select the correct statement regarding goals of therapy for chronic migraine prophylaxis: a) A reduction in headache frequency of 50% is usually considered successful. b) Substantial benefits may take 2-4 weeks to occur. c) Improvement in quality of life. d) a and c 10. Carol has been diagnosed with chronic migraine, but her appointment with the specialist is in three months.

She comes into the pharmacy asking if there is anything she can do while she waits for her appointment. Your advice includes: a) Setting consistent times for her to wake up and go to bed, even on weekends. b) Keeping a headache diary and monitor her

acute medication intake in preparation for her appointment. c) Continue natural health products as suggested for prophylaxis. d) All of the above.

11. Which of the following prophylactic agents have a Health Canada approved indication for chronic migraine? a) Propranolol. b) OnabotulinumtoxinA. c) Amitriptyline. d) Gabapentin.

12. Select the correct statement regarding factors guiding choice of injectable chronic migraine prophylactic agents: a) Gradual dose increases are needed for all migraine prophylaxis therapies. b) OnabotulinumtoxinA may be used first line or after oral migraine prevention agents. c) Erenumab may be used after a 6-week trial of ≥ 2 oral migraine prevention agents or a minimum of 2 quarterly injections (6 months) of onabotulinumtoxinA. d) Both b and c 13. Select the correct statement regarding choice of therapy in chronic migraine.

Answer online at eCortex.ca

a) Topiramate may be a suitable choice in patients with dementia. b) Venlafaxine may not be a suitable choice in patients with chronic migraine and unipolar depression. c) Propranolol is the preferred agent during pregnancy or lactation. d) Topiramate is a suitable choice in pregnancy.

14. Select the option(s) that could help an otherwise healthy 30-year old patient diagnosed with chronic migraine who has tried propranolol and topiramate with suboptimal success: a) OnabotulinumtoxinA physician-administered. b) Erenumab self-administered. c) Trained OnabotulinumtoxinA injectors may be found at www.mychronicmigraine.ca. d) All of the above.

15. Pharmacists may impact patient care for chronic migraine by helping patients: a) Develop and maintain good sleep hygiene strategies. b) Start a headache diary. c) Understand how acute medication overuse can contribute to medication overuse headache. d) All of the above.

Faculty: Chronic Migraine: Comprehensive Management. Collaborative Care.

ABOUT THE AUTHOR Karen Agro is Director, Agro Health Associates Inc. She holds a BScPhm and a PharmD from the University of Toronto and a MSc from McMaster University. Karen started her career in community pharmacy before moving into the pharmaceutical industry, and subsequently into healthcare consulting.

Karen has taught at the University of Toronto and University of Waterloo. Her research interests are around the costeffective use of pharmaceuticals and the effective delivery of pharmacy services.

Answer online at eCortex.ca

She maintains her active pharmacy license and has been a requested speaker and moderator throughout North America.

Karen established Agro Health Associates in 1996, providing Market Access and Strategic Marketing Support, Healthcare Communications and Continuing Education Program development to the pharmaceutical industry, pharmacy and healthcare communities.

FACULTY Rose Giammarco, MD, FRCPC Nardine Nakhla, PharmD, RPh

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

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

CE Project Manager: Rosalind Stefanac CE Designer: Shawn Samson This lesson is published by EnsembleIQ: 20 Eglinton Ave. West, Suite 1800 Toronto, ON M4R 1K8 Phone: 877.687.7321 Fax: 888.889.9522 CE queries: email ecortex@canadianhealthcarenetwork.ca

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COVER FEATURE

COMMUNICATING EFFECTIVELY WITH PATIENTS

BY KRISTI BUTT, BMSc, PharmD

T

he ability to communicate effectively is a nonnegotiable skill for pharmacists. As per the National Association of Pharmacy Regulatory Authorities’ (NAPRA) Model Standards of Practice for Canadian Pharmacists, pharmacists are expected, at a minimum, to “use effective verbal, nonverbal, listening and written communication skills” and “demonstrate sensitivity, respect and empathy when communicating with diverse groups,” irrespective of the role they are fulfilling.(1) Communicative performance influences patients’ ratings of quality of care, satisfaction with service encounter, and trust in the pharmacist.(2) Effective communication is essential for establishing trusting therapeutic relationships, providing care that is patient-centered and uses shared-decision making, and improving patient understanding of safe and effective medication use for optimal therapeutic outcomes.(3) This article describes general strategies for facilitating communication with patients, including recommendations for mitigating unique challenges that select populations may present.

Population-specific resources should be consulted for more detailed recommendations on communicating with these groups.

Although beyond the scope of this discussion, it is also important to recognize the role of effective communication in establishing successful collaborative relationships with non-patient groups, including other healthcare professionals (HCPs) and pharmacy staff.

1. USE PATIENT-FRIENDLY LANGUAGE

Using patient-friendly language when communicating facilitates patient understanding and helps establish rapport. This includes employing communication strategies that reflect health literacy levels. Health literacy is defined by the Canadian Public Health Association (CPHA) as “the ability to access, understand and act on information for health.”(7) According to a 2008 CPHA publication, only 40% of all Canadians and 12% of older adults have adequate health literacy skills.(4) Low health literacy has been linked to poor treatment adherence, more medication errors, higher hospitalization rates, and a poorer health status overall.(5) Using patient-friendly language when communicating, especially with older adults, may help to mitigate the negative consequences of low health literacy. Health Canada has recognized this with their Plain Language Labelling initiative, which requires that the Facts Table on nonprescription drugs and natural health products be written at a grade 6-8 reading level.(6) The CPHA is less stringent in their recommendations, suggesting a grade 8-10 literacy level be targeted when providing health information.(7) To achieve such targets, replace medical jargon with plain language that is action-oriented. Plain language is direct, clear and concise—avoid redundancies, ambiguous acronyms, artificial words, and intensifiers that do not add value to your message (Table 1). Other strategies for overcoming poor health literacy include limiting the number of messages delivered, repeating

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important information, speaking slowly, and using pictures or videos to support key messages. Many drug manufacturers and other organizations publish patient-friendly videos online that can be accessed to provide information on medications and/or delivery devices. The Canadian Lung Association, for example, offers instructional videos on various inhalers through their website.(8) Employing patient-friendly language also includes using terminology that is audience-sensitive. Language should reflect patient preference and be free of assumption and bias. For example, when communicating with members of the LGBTQ+ community, heteronormative language should be avoided and efforts should be made to learn and use patients’ preferred names and pronouns (e.g., “he”, “she”, “they”). Communication should also be void of preconceived notions (e.g., it should not imply that a man will have a wife, or that a woman identifying as a lesbian will not be pregnant).

Such strategies help to create a safe and welcoming environment for marginalized populations. Patient-friendly and audience-sensitive language should also be used when communicating with culturally diverse populations. For example, care should be provided in the patient’s preferred language to facilitate understanding. Other recommendations for providing culturally safe care are discussed in the next section.

2. PROVIDE CULTURALLY SAFE CARE

According to the 2016 Census, more than one in five Canadians are born outside of Canada.(12) As such, Canadian pharmacists are providing care to culturally diverse populations, in which health disparities often exist due to differences in determinants of health, including socioeconomic status, education and food security.(13) The prevalence of diabetes, for example, is higher among First Nations adults living off reserve and those who have not completed high school than it is among non-Indigenous adults and university graduates.(13) Culturally diverse populations may also be more fearful and mistrusting of HCPs due to a history of enduring discriminatory treatment and racism at the hands of our healthcare system.

Studies suggest that providing culturally competent care enhances patient satisfaction and may improve patient health outcomes.(14,15) Cultural competency in healthcare is defined as “the ability to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural and linguistic needs.(21)” Culturally competent care also fosters cultural safety, which is “based on respectful engagement that recognizes and strives to address power imbalances inherent in the health­ care system. It results in an environment free of racism and dis­ crimination, where people feel safe when receiving health care.(16)” As previously mentioned, culturally safe care includes providing information in patients’ preferred language. Pharmacists who are not fluent in a particular language may ask a pharmacy staff member who is to act as an interpreter or use a reputable translation service or app (e.g., Google Translate, Canopy Speak). In general, family members should not be used as interpreters, as patients may not feel comfortable disclosing certain information.(17) Pictures and videos may also be valuable in cross-cultural communication to support key messages. Visual aids like USP Pictograms, for example, are standardized images for conveying medication instructions, precautions, and/or warnings to patients for whom English is a second language.(18) Several pictograms are available for download from the USP’s website (https://www.usp.org/healthquality-safety/usp-pictograms). Caution is warranted when using pictograms however, as limited evidence suggests that some lack 44

OCTOBER 2019 [Vol.6 No.8]

TABLE 1: Language traps to avoid when

communicating with patients(9-11) EXAMPLES • • • •

REDUNDANCIES

Past experience Absolutely essential 12 noon Advance warning

• BID, TID, QID • PRN • PO, PR, PV • QHS

AMBIGUOUS ACRONYMS

ARTIFICIAL WORDS

INTENSIFIERS NOT ADDING VALUE

• Commence • Anticipate • Accomplished • Circumvent • Very • Really • Definitely • Particularly

universality and are prone to cross-cultural misinterpretation.

For example, using a sunrise and/or sunset image to represent dosing times has created misunderstanding in areas where the sun does not set during certain months.(19) Caution must also be exercised when using nonverbal communication strategies (e.g., gesturing) due to potential differences in meaning across cultures.

The American “OK” gesture, for example, is similar to gestures meaning “money” in Japan and “zero” in France.(20) However, when used appropriately, nonverbal cues foster effective communication.

Specific recommendations for nonverbal communication are described in the next section.

Perceptions of illness and treatment also vary greatly across cultures and an understanding and respect of these beliefs is central to providing culturally safe care. For example, recognizing that complementary and alternative medicines (e.g., herbal preparations, acupuncture) are often preferred in African and Asian cultures, and including these as options (if appropriate) when discussing treatment, will help to establish trust and rapport.(17) Models such as the LEARN model (Figure 1) have been developed TABLE 2: Practical tips for nonverbal communication(3,25) 1) USE VARIED EYE CONTACT

(do not stare, but do not avoid eye contact) 2) MAINTAIN A RELAXED POSTURE (do not cross arms, relax shoulders) 3) LEAN IN SLIGHTLY

(but respect personal space)

4) MAINTAIN AN ERECT BODY POSITION (do not slouch)

5) DO NOT FIDGET

6) MIRROR THE SPEAKER

7) USE PARALANGUAGE EFFECTIVELY

(appropriate tone, pitch, volume when speaking; avoid vocal fillers [e.g., “um”, “ah”, “eh”]) 8) USE CULTURALLY APPROPRIATE GESTURES

FIGURE 1: The LEARN model for

cross-cultural clinical encounters(17)

L

E

A R

N

Listen with sympathy & understanding to the patient’s perception of the problem Explain your perceptions of the problem Acknowledge and discuss differences & similarities Recommend treatment Negotiate a mutually agreed upon treatment plan

FIGURE 2: Stages of listenings(31) Receiving (hear the message) Responding (provide feedback on the message)

Evaluating (judge the value of the message)

Understanding (learn the meaning of the message)

Remembering (commit the message to memory)

to facilitate cross-cultural communication and understanding, specifically in healthcare.(17) Other useful strategies in cross-cultural communication include using open-ended questions (i.e., ones that require more than a simple yes/no or single word answer) to encourage disclosure and the teach-back method (described later) to verify understanding.(17) Culture-specific resources, including community leaders, should be consulted for more detailed recommendations on cross-cultural communication. Courses that aim to improve cultural safety should also be considered (e.g., San’yas: Indigenous Cultural Safety Training [Provincial Health Services Authority], Aboriginal Relationship and Cultural Competency Courses [Cancer Care Ontario], Leadership in Clinical Cultural Competency [York University]).

(For additional ideas on communicating with patients from various cultural backgrounds and who speak different languages, see the article 5 Tips: Counselling the growing immigrant population, pages 31-32.)

3. USE NONVERBAL COMMUNICATION EFFECTIVELY

Nonverbal communication is a key component of interpersonal communication and has been shown to be especially important when communicating attitudes and feelings. Psychologist Albert Mehrabian showed that in these situations, over 90% of the message communicated is conveyed through nonverbal cues

(tone of voice and facial expression) and only 7% is in the words spoken.(22) This means that when verbal and nonverbal messages are inconsistent, people will be more likely to trust nonverbal cues.(22) As such, pharmacists must be conscious of the nonverbal messages they are conveying and ensure congruency with verbal messages to support effective communication with patients.

Successful nonverbal communication also helps to establish empathy and form trusting therapeutic relationships.(23) Nonverbal communication includes kinesics (body movement), proxemics (distance between individuals communicating), and the physical environment in which communication is occurring.(3) To increase approachability and encourage disclosure from patients, pharmacists should maintain an open posture. This includes facing the patient fully, placing arms and legs comfortably apart (not crossed), and displaying an attentive facial expression.(3) In some situations, however (e.g., when dealing with an overly talkative patient), a closed posture that discourages further interaction may be necessary.(3) When interacting with patients, pharmacists should communicate at a distance that respects the patient’s personal space, but also maintains privacy. A general rule of thumb is to be about 1.5 feet away from the patient;(23) however, pharmacists should use their professional judgment in deciding an appropriate distance. For example, when communication involves a more sensitive topic (e.g., therapy for erectile dysfunction, emergency contraception), closer positioning or relocation to a secluded area is likely warranted.(3,24) Pharmacists should also be cognizant of cues from patients that suggest more/less space is needed. If a patient is leaning in, for example, the pharmacist should consider moving closer; if they are leaning away or have stepped backward, the pharmacist should create distance.(3) The physical environment is also an important consideration for successful communication. Physical barriers to communication, like the prescription counter, should be eliminated. Moving from behind the counter when communicating with patients reflects interest and helps establish rapport.(3) A clean and organized pharmacy, with staff who are dressed appropriately, demonstrates professional competency and increases patients’ trust in the care they receive.(3,24) Further recommendations for nonverbal communication are summarized in Table 2. As alluded to in the cultural safety section, certain nonverbal cues have drastically different meanings across cultures—examples are provided in Table 3 (see online version of article). It is essential that pharmacists are aware of these cultural differences and adjust their nonverbal communication appropriately.

4. ENGAGE IN ACTIVE LISTENING “Listen to your patient, he is telling you the diagnosis” -Sir William Osler (27)

Much of the discussion thus far has focused on communication strategies to enhance patient understanding. However, being a successful communicator also necessitates pharmacists be effective listeners and understand the messages patients are trying to convey. To do this, pharmacists must engage in active listening. The general stages of listening are described in Figure 2. Hallmarks of active listening include being attentive, summarizing and/or paraphrasing what was said, and responding empathetically.(3) By being attentive, pharmacists show interest in hearing what the patient has to say. Displays of attentiveness include eliminating distractors (e.g., moving to a quiet area of the pharmacy) and using nonverbal cues that demonstrate listening (e.g., eye contact, nodding, interested facial expression).(28,29)

[Vol.6 No.8] OCTOBER 2019

45

Summarizing and/or paraphrasing shows that listening occurred and enables pharmacists to verify their understanding of what the patient said.(24) If there has been a misunderstanding, the pharmacist and patient have an opportunity to rectify this before proceeding. In these cases, pharmacists should ask questions— generally open-ended ones—to clarify their understanding.(28) An accurate understanding is essential for pharmacists to respond empathetically and appropriately to the situation. Reflective statements are often used to convey empathy; stems of such statements are found in Table 4.(24) Empathetic responses help patients to feel understood and aid in establishing trusting therapeutic relationships.(3) Potential barriers to listening include preconceived notions or assumptions, time constraints, language barriers or speech disorders, interruptions (i.e., not allowing the patient to speak), and distractions (e.g., phones ringing, other patrons in the pharmacy).(30) Strategies discussed above can be used to minimize the impact of such barriers on listening and the overall communicative process.

5. IDENTIFY & LEVERAGE PATIENTS’ LEARNING STYLE

It is important to bear in mind that no one communication style or approach will be effective for all patients encountered. This may be especially important when providing education, such as during prescription or nonprescription drug counselling. In fact, some evidence suggests customizing education to literacy level and learning style improves patients’ retention of health information.(32) As such, having a general understanding of different learning styles and leveraging this knowledge appropriately can facilitate patient understanding and may improve health outcomes.

Broadly speaking, learning styles can be broken down into three categories: auditory, visual, and kinesthetic. Key characteristics of each learning style are provided in Table 5; examples for targeting education to these styles are also provided. Learning styles can generally be identified by simply asking patients how they prefer to receive information (e.g., verbally vs. written vs. hands-on).

TABLE 5: Learning styles and examples of targeting

education for each

(34)

LEARNING STYLE

Visual

KEY CHARACTERISTICS

• Learn by seeing and reading

• Traditional verbal counselling on medications may not be effective

EXAMPLES OF TARGETING EDUCATION

• Providing written medication information • Using diagrams or figures to communicate information • Showing the patient how to use devices (e.g., live demonstration, online video)

• Describing colour and shape when referencing medications Auditory

Kinesthetic

• Learn by listening and speaking • Traditional verbal counselling on medications is generally effective

• Learn by touching and doing

• Traditional verbal counselling on medications is often ineffective 46

• Providing medication information and instructions for use verbally • Encouraging patients to verbalize their understanding of instructions for medication use • Allowing patients to touch and try devices while you are providing counselling on their use

OCTOBER 2019 [Vol.6 No.8]

TABLE 4: Example stems for reflective statements

“So, in other words…”

“It seems like you…”

“Let me see if I understand…”

“Sounds like you’re…”

“So, you believe…”

“What I think I hear you saying is…”

“So, you were feeling…”

TABLE 6: Summary of recommendations for

communicating with patients, including select populations 1) EMPLOY PATIENT-FRIENDLY LANGUAGE

2) PROVIDE CULTURALLY SAFE CARE

• Target a grade 8-10 literacy level

• Use patient’s preferred language

• Use plain language that is action-oriented

• Use visual aids (e.g., USP Pictograms) to support key messages, but be cautious of potential cross-cultural misinterpretations

• Be cautious of language traps (Table 1)

• Limit number of messages delivered, speak slowly, repeat key information

• Be mindful of differences in perceptions of illness & treatment

• Recommendations are especially relevant, as only 12% have adequate health literacy skills

• Consider using the LEARN model to facilitate cross-cultural communication & understanding

• Ensure language is free of assumption & bias

• Consult community leaders for guidance

• Use preferred pronouns

• Complete courses to improve cultural safety

• Provide information in patients’ preferred language

3) USE NONVERBAL COMMUNICATION EFFECTIVELY

4) ENGAGE IN ACTIVE LISTENING

• Maintain an open posture • Communicate at a distance that respects patients’ personal space, but maintains privacy • Eliminate physical barriers to communication • Ensure pharmacy is clean & organized, and staff are dressed appropriately • Be cautious of differences in meaning across cultures (Table 3) • See Table 2 for additional recommendations

• Be attentive (eliminate distractors, use nonverbal cues to demonstrate listening) • Paraphrase or summarize what was said to show listening occurred & check understanding • Ask open-ended questions to clarify understanding • Use reflective statements to convey empathy (Table 4)

5) IDENTIFY & LEVERAGE PATIENTS’ LEARNING STYLE

• Attempt to identify patients’ learning style (Table 5) • Provide written information and/or diagrams for visual learners (most of the general population) • Relay information verbally for auditory learners • Allow kinesthetic learners to demonstrate device use • Use the teach-back method to verify patient understanding • Remember that most children are kinesthetic learners General population;

Older adults;

Pediatric population;

LGBTQ+ community;

Culturally-diverse population

The teach-back method gives pharmacists the opportunity to correct misunderstandings and add counselling points that may have been missed initially.

Formal tools also exist for identifying learning styles, however, the use of these may not be feasible depending on practice setting.

Visual learners are reported to make up the majority of the general population (65%), followed by auditory learners (30%), and finally, kinesthetic learners (5%).(33) An exception to this may be in the pediatric population, where the kinesthetic learning style often dominates, especially in younger children. Also note that learning style may not be static—it can change depending on the nature of the education being provided and/or over time. For example, a patient may better understand how to use an inhaler by demonstrating how they will use the device, but only understand potential adverse effects of a drug after reading a handout. In providing education, pharmacists should consider using strategies like the teach-back method to assess patient understanding. With the teach-back method, patients are asked to repeat instructions or information provided by the pharmacist (e.g., they are asked to explain how they will take the medication prescribed). This

PATIENTS GOING ON VACATION? TALK TO THEM ABOUT – A DRINKABLE VACCINE – BEFORE THEY TRAVEL.

strategy is most valuable when used to verify understanding of critical instructions or information; it is unreasonable and of no benefit to ask patients to recall all information provided. The teach-back method gives pharmacists the opportunity to correct misunderstandings and add counselling points that may have been missed initially. Nonverbal cues, such as facial expressions, are also valuable indicators of patient understanding and should not be overlooked.

Pharmacists must be effective communicators, not only to meet standards of practice, but also to establish trusting therapeutic relationships with patients to improve health outcomes and enhance the overall care experience. Practical tips for improving communication with patients have been summarized in Table 6, with special reference to select patient populations. Although effort has been made to include the most important communication strategies here, recommendations described are by no means exhaustive. Additional resources should be consulted for a more detailed and comprehensive discussion of this topic.

KRISTI BUTT, BMSc, PharmD, practises full-time as designated manager at Michael’s Pharmasave in Clinton, ON. She is also course coordinator for PHARM127: Professional Communication Skills in Pharmacy Practice at the University of Waterloo School of Pharmacy. The author would like to thank Elaine Lillie and Nardine Nakhla for their contributions to this article.

TABLE 3 AND REFERENCES are available in the online version of this article. Visit CanadianHealthcareNetwork.ca/pharmacists

ce

FREE! Approved for Answer online at ·ca www.eCortex.ca 1 Continuing Education CEU L E S S O N CCCEP #1329-2019-2841-I-P • Please consult this course online at eCortex.ca for expiry dates

Helping Patients Navigate an Important Paradigm Shift in Asthma Management

By Tom Smiley BScPhm, PharmD, CTE

DUKORAL® [Oral, Inactivated Cholera and ETEC Diarrhea Vaccine] is indicated for the prevention of and protection against cholera and enterotoxigenic Escherichia coli (ETEC)-producing heat-labile enterotoxin (LT) (either LT alone or both LT and heat stable enterotoxin (ST) together).

Cholera: The vaccine is recommended for adults and children from 2 years of age who will be visiting areas with an ongoing or anticipated epidemic or who will be spending an extended period of time in areas in which cholera infection is a risk.

ETEC-diarrhea: The vaccine is recommended for adults and children from 2 years of age who will be visiting areas posing a risk of diarrheal illness caused by LT-producing ETEC. DUKORAL® should not replace standard preventative hygiene measures.

Rehydration measures must be taken in case of diarrhea.

After completion of this learning activity pharmacists will be better able to: 1. Describe the prevalence and consequences of short-acting beta-agonist (SABA) overuse in asthma 2. Identify patients at increased risk of asthma exacerbation 3. Review the evidence for the use of symptom-driven (as-needed) inhaled corticosteroid (ICS)/formoterol reliever therapy in mild asthma and beyond to reduce the risk of asthma exacerbation 4. Recommend as-needed ICS/formoterol reliever therapy across all severities of asthma for appropriate patient candidates 5. Educate and empower patients in the transition to as-needed ICS/formoterol for reliever with or without maintenance for asthma management through the use of effective communication and practical tools

Consult the DUKORAL® product monograph at https://health-products. canada.ca/dpd-bdpp/index-eng.jsp for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The product monograph is also available through our medical information department. Call us at 1-855-356-0831.

DukoralCanada.com

This program was supported in part by an educational grant from AstraZeneca

[Vol.6 No.8] OCTOBER 2019

47

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• FLUZONE® High-Dose is not indicated for persons less than 65 years of age.

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For more information: Consult the product monograph at http://products.sanofi.ca/ en/fluzone-hd.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 through our medical department.

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This Q&A is published by Ensemble IQ, 20 Eglinton Avenue West, Suite 1800, Toronto, ON M4R 1K8, Telephone: 416-256-9908.

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‡ The pre-specified statistical superiority criterion for the primary endpoint (lower limit of the 2-sided 95% CI of the vaccine efficacy of FLUZONE® High-Dose relative to FLUZONE® > 9.1%; p-value against H0:VE ≤ 9.1% = 0.022 one-sided) was met. ¥ In a multicentre study (FIM12) conducted in the United States and Canada, adults 65 years of age and older were randomized (1:1) to receive either FLUZONE® High-Dose or FLUZONE® Trivalent. The study was conducted over two influenza seasons (2011–2012 and 2012–2013). FLUZONE® High-Dose contained 60 μg of HA per strain while FLUZONE® Trivalent contained 15 μg of HA per strain. The per-protocol analysis set for efficacy assessments included 15,892 FLUZONE® High-Dose recipients and 15,911 FLUZONE® Trivalent recipients. The primary endpoint of the study was the occurrence of laboratory-confirmed influenza, defined as a new onset (or exacerbation) of at least one of the following respiratory symptoms: sore throat, cough, sputum production, wheezing, or difficulty breathing; concurrent with at least one of the following systemic signs or symptoms: temperature > 37.2°C, chills, tiredness, headaches or myalgia. ¶ In the first year of the study, the influenza B component of the vaccine and the majority of influenza B cases were of the Victoria lineage; in the second year, the influenza B component of the vaccine and the majority of influenza B cases were of the Yamagata lineage. § Laboratory confirmation by culture or polymerase chain reaction. £ Randomized, double-blind, multicentre comparative trial with FLUZONE® High-Dose or FLUZONE® vaccine (2006-2007 formulation).

Randomized, double-blind multicentre, efficacy trial with FLUZONE® HighDose or FLUZONE® vaccine (2011–2012 and 2012–2013 formulations).

References 1. FLUZONE® High-Dose vaccine. Product Monograph. Sanofi Pasteur Inc., April 24, 2019. 2. DiazGranados CA, et al. Efficacy of high-dose versus standarddose influenza vaccine in older adults. N Engl J Med. 2014;371:635-645.

3. Schanzer DL, et al. Co-morbidities associated with influenza-attributed mortality, 1994–2000, Canada. Vaccine 2008;26:4697–4703. 4. Public Health Agency of Canada (PHAC). FluWatch. May 3 to May 9, 2015. 5. An Advisory Committee Statement (ACS)/National Advisory Committee on Immunization (NACI): Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2019-2020. 6. Statistics Canada. (2019). Canada's population estimates: Age and sex, July 1, 2018. https://www150.statcan.gc.ca/n1/en/daily-quotidien/190125/dq190125a-eng. pdf?st=KJGD2vFk. Accessed June 25, 2019. 7. Public Health Agency of Canada.

(2013). FluWatch Report: August 11 to 24, 2013 (Weeks 33 & 34). http:// publications.gc.ca/collections/collection_2013/aspc-phac/HP58-1-201334-eng.pdf. Accessed: June 25, 2019. 8. Public Health Agency of Canada.

(2014). FluWatch Report: 10 to 23 August, 2014 (weeks 33 & 34). http:// publications.gc.ca/collections/collection_2014/aspc-phac/HP58-1-201434-eng.pdf. Accessed: June 25, 2019. 9. Public Health Agency of Canada.

(2015). FluWatch Report: August 16 to August 29, 2015 (weeks 33 and 34). http://publications.gc.ca/collections/collection_2015/aspc-phac/HP58-12015-34-eng.pdf. Accessed: June 25, 2019. 10. Public Health Agency of Canada. (2016). FluWatch Report: August 14 to August 27, 2016 (Weeks 33-34). http://publications.gc.ca/collections/collection_2016/aspc-phac/ HP58-1-2016-34-eng.pdf. Accessed: June 25, 2019. 11. Public Health Agency of Canada. (2017). FluWatch report: August 20 to 26, 2017 (Week 34). https://www.canada.ca/content/dam/canada/public-health/services/ publications/science-research-data/canadian-nosocomial-infection-summary/ cnisp-aro-2011-2015%20report-final-en.pdf. Accessed: June 25, 2019.

12. Public Health Agency of Canada. (2018b). FluWatch Report: July 22, to August 25, 2018 (Weeks 30-34). http://publications.gc.ca/collections/collection_ 2018/aspc-phac/HP58-1-2018-34-eng.pdf. Accessed: June 25, 2019. 13. Gozalo PL, et al. The impact of influenza on functional decline. Am Geriatr Soc. 2012 July;60(7):1260–1267. 14. Canadian Lung Association. Influenza. https:// www.lung.ca/lung-health/lung-disease/influenza. Last updated: February 21, 2017. Accessed: June 25, 2019. 15. Centers for Disease Control and Prevention: Flu Symptoms & Complications. https://www.cdc.gov/flu/about/disease/ complications.htm. Accessed: June 25, 2019. 16. CDC: The Pink Book: Course Textbook - 13th Edition (2015). Chapter 12 Influenza. https://www.cdc.gov/ vaccines/pubs/pinkbook/downloads/flu.pdf. Last updated: May 16, 2018.

Accessed: June 25, 2019. 17. Udell JA, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis.

JAMA 2013;310(16):1711-1720. 18. Grau AJ, et al. Influenza Vaccination Is Associated With a Reduced Risk of Stroke. Stroke 2005;36(7):1501-1506.

19. CDC Morbidity and Mortality Weekly Report. August 26, 2016; 65 (5).

Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices — United States, 2016–17 Influenza Season. https://www.cdc.gov/mmwr/volumes/65/rr/rr6505a1.htm.

Last updated: June 16, 2017. Accessed: June 25, 2019. 20. Husein N, et al.

Influenza and Pneumococcal Immunization. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Journal of Diabetes 2013;37 (Suppl 1):S93. 21. Legrand J, et al. Real-time monitoring of the influenza vaccine field effectiveness. Vaccine 2006; 24:6605–6611. 22. Sanofi Pasteur Inc. Data on file. Fluzone High-Dose. Claim Confirmation Letter.

December 11, 2015. 23. Sanofi Pasteur Inc. Data on file. Fluzone High-Dose. Doses Distributed Letter. January 8, 2019.

FLUZONE® is a trademark of Sanofi Pasteur. Sanofi Pasteur 1755 Steeles Avenue West, Toronto, Ontario M2R 3T4.

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FLUZONE® High-Dose vaccine is the only vaccine demonstrated, through a large randomized study, to be more efficacious than FLUZONE® standard-dose vaccine in preventing influenza in adults over 65. 22

Technology has changed most forms of collaboration.

Why not prescribing?

PrescribeIT® is modernizing the way prescriptions are sent and received in Canada. A national e-prescribing service, it enables pharmacies to receive electronic prescriptions directly into their pharmacy management system. It also improves communication while enhancing medication safety and protecting patient privacy. PrescribeIT® is today’s answer for the future of health care collaboration.

A new era for prescribing.

For more, visit PrescribeIT.ca

OTC COUNSELLING TIPS

This is the first in a series of OTC Counselling Tip Sheets created for Pharmacy Practice + Business by final year pharmacy students at the University of Waterloo.

SWEET SWEET RELIEF RELIEF THE BUZZ ABOUT HONEY AND COUGH

BY CĂ&#x2030;LINE ST. PIERRE

Pharmacies are often the first stop when patients develop a cough. Among the many options available for cough syrups, few have convincing efficacy, and even fewer are available for use in children. Honey can be a satisfying and effective choice for certain patients, especially those looking for a natural remedy. It has been used for centuries and should not be overlooked.(1-3)

THE FACTS

Cough is the most common reason for seeking medical care(1)

Pharmacists are primary healthcare providers sought to manage cough(4)

Over 70% of Canadians use natural health products, with a projected 10-20% global annual increase(5)

There is little to no efficacy in current over-the-counter regimens for cough management(6,7)

Dry vs. productive cough - let it bee One of the first questions we ask our patients is to describe the nature of their cough: dry or productive.

This archaic classification dates back to a time where identifying a phlegmy cough was critical in avoiding the development of tuberculosis.(4) With todayâ&#x20AC;&#x2122;s modern-day medicine rendering this question obsolete, our assessment should shift to focus on duration and ruling out potential red flags, including a persistent cough lasting over three weeks, or a cough accompanied by altered breathing, such as wheezing or shortness of breath.(4,8) Treatment should be aimed at addressing the cough itself, rather than overmedicating with multi-drug cough and cold products. Not only are these nonprescription products cautioned for use in children, many have failed to show benefit in either symptom improvement or duration.(6,7) Among the drugs with limited evidence supporting their use, both dextromethorphan and codeine carry abuse potential, and are restricted to use in children over six and 12 years of age, respectively.(9) Addressing the cough symptom individually allows us to provide a more targeted and effective therapy while avoiding the potential rare, but serious, adverse events associated with OTC drug use in this population, including seizures, altered mental status and abnormal heart rates.(9)

[Vol.6 No.8] OCTOBER 2019

51

A Cochrane review comparing honey to dextromethorphan and diphenhydramine for cough in children revealed honey to be superior to diphenhydramine, and non-inferior to dextromethorphan in children aged 12 months to 18 years.

What’s all the buzz about honey

ADDITIONAL BENEFITS TO HONEY INCLUDE:

(2,10,11)

• Availability & accessibility—you can find honey anywhere • Low cost • Naturally occurring, no added ingredients needed • Targets a wider demographic – Can be used in >1 years old (pasteurized only to kids) – Safe use in diabetics and pregnancy • Few drug interactions; limited to moderate interactions with phenytoin and anticoagulants • No abuse potential

DOSING

CHILDREN’S DOSING: (>2 years old): 0.5 to 2 teaspoons of honey at bedtime (2,13)

How does it work? (2,12)

1. Stimulation of salivation lubricates the airway 2. Sweet taste promotes innate analgesic system 3. Demulcent effect contributes to antitussive action

ADULT DOSING: 20.8g of honey/2.9g coffee/tea dissolved in warm water (14)

( When referring honey for cough, counsel on maintaining good oral hygiene, such as brushing teeth after use )

The bee’s knees: honey’s global history as a healer

(15-17)

Honey has long been recognized for its medicinal properties, and embraced throughout ancient history by cultures and civilizations across the globe. With growing scientific evidence supporting its therapeutic benefit, along with its appealing safety profile, Canadians should be following suit, and recognizing honey for more than its natural sweetening properties.

Honey was the most prominent drug in ancient Egypt, present in nearly all therapies of that period, with widespread use including wound healing and cough remedy.

Staying innovative in the changing landscape of pharmacy(5)

The Indian Vedic civilization regarded honey most notably for its use in relieving irritating coughs and digestive complications.

It was the Chinese Xin Dynesty to first introduce honey as a medicinal product, and one still being used in today’s society to treat coughs.

Hippocrates, the ancient greek scientist, utilized honey in various combinations to treat conditions such as eye disease, baldness and coughs.

Think towards the future. Our population is trending towards higher natural health product use, with women and those with higher formal education among the main drivers of this increase. We should be utilizing this movement to promote a cough treatment that is supported by scientific evidence, and one which addresses an underserved population, currently lacking in safe and effective products to manage cough.

As pharmacists continue to be valued among the most trustworthy healthcare professionals, let us uphold this title by recommending the most evidence-based practices, whether those be drug products or otherwise.

“YES, HONEY” is often the safest, and most appropriate answer

CÉLINE ST. PIERRE is in her final months of study at the University of Waterloo’s PharmD program and looks forward to developing her business and professional skills, starting with community pharmacy practice.

REFERENCES 1. McGarvey LPA Cough • 6: Which investigations are most useful in the diagnosis of chronic cough? Thorax 2004;59:342-346. 2. Oduwole O, Udoh EE, Oyo‐Ita A, Meremikwu MM. Honey for acute cough in children. Cochrane Database of Systematic Reviews 2018, Issue 4. Art. No.: CD007094. DOI: 10.1002/14651858.CD007094.pub5. 3. Peterson RG, Cran B, Knoppert D et al. Scientific Advisory Panel on nonprescription pediatric cough and cold medications (SAP-NPCCM). Ottawa: Health Canada; March 20, 2008. 4. Morice AH. Its time to change the way we approach coughs in community pharmacy. The Pharmaceutical Journal. March 2016. doi:10.1211/cp.2016.20200821. 5. Health Canada and the Public Health Agency of Canada. Evaluation on the Natural Health Products program 2010-2011 to 2014-2015. https://www.canada.ca/content/dam/canada/health-canada/migration/department-ministere/health-sante/transparency-transparence/corporatereporting-rapports-gestion/evaluation/2016-2017/natural-health-products-produits-sante-naturels/alt/nat-health-prod-eng.pdf. Published March 2016. Accessed July 13th, 2019. 6. Schroeder K, Fahey T. Systematic review of randomised controlled trials of over the counter cough medicines for acute cough in adults. BMJ2002;324:329-31. 7. Smith SM, Schroeder K, Fahey T. Over-thecounter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev 2014;11:CD001831. 8. Acute Cough. In: RxTx. Ottawa, ON: Canadian Pharmacist Association. [Updated May 2018, Accessed March 12, 2019]. https://www.e- therapeutics.ca/search 9. Government of Canada. Health Canada releases decision on the labelling of cough and cold products for children. Available from: http://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2008/13267a-eng.php. Accessed July 13, 2019. 10. Sukriti and Garg, S. K. Influence of honey on the pharmacokinetics of phenytoin in rabbits. Ind J Pharmacol 2002;34(147). 11. Abdulrhman, M. M., El-Hefnawy, M. H., Aly, R. H., Shatla, R. H., Mamdouh, R. M., Mahmoud, D. M., and Mohamed, W. 10.S.Metabolic effects of honey in type 1 diabetes mellitus: a randomized crossover pilot study. J Med Food 2013;16(1):66-72. 12. Eccles R. Mechanisms of the placebo effect of sweet cough syrups.

Respir Physiol Neurobiol 2006;152:340-8. 13. Paul IM, Beiler J, McMonagle A, et al. Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Arch Pediatr Adolesc Med 2007;161:1140-6. 14. Raeessi MA, Aslani J, Raeessi N, Gharaie H, Karimi Zarchi AA, Raeessi F. Honey plus coffee versus systemic steroid in the treatment of persistent post-infectious cough: a randomised controlled trial. Prim Care Respir J. 2013 Sep;22(3):325-30. 15. Eteraf-Oskouei T, Najafi M. Traditional and modern uses of natural honey in human diseases: a review. Iran J Basic Med Sci. 2013;16(6):731–742. 16. Macedonian Journal of Medical Sciences. 2012 Jul 31; 5(2):205-214. doi:10.3889/MJMS.1857-5773.2012.0213 17. Altman, Nathan.

The Honey Prescription: The Amazing Power of Honey as Medicine. Rochester, Vermont. Healing Arts Press; 2010. ccessed July 13, 2019.

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OCTOBER 2019 [Vol.6 No.8]

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

pharmacy

[Vol.6 No.8] OCTOBER 2019

53

BACK TALK

CREATIVE THOUGHTS AND SMART IDEAS FOR PHARMACY OWNERS AND MANAGERS

BIZ TALK

DEREK DESROSIERS, BSc(Pharm), RPEBC, RPh, has accrued more than 37 years of

Do not overwhelm yourself by trying to do too much at once.

Start slow, and grow as you go.

READY TO OFFER PROFESSIONAL SERVICES? Here’s how to start (Part 1) Professional services, such as in-depth medication reviews, medication management, chronic disease management and point-of-care testing require resources­­— including time, expertise, staff, technology and money, to implement. If you do not have these resources available, it’s next to impossible to execute the offering of such services for your patients.

54

We will examine the issue of resources (especially time management) in part 2 of this series, but first, let’s take a step back.

It’s important to start this process by assessing your market to ensure there is a demand for the service(s) you plan on offering. Check in with patients, other healthcare professionals (especially physicians), and even

OCTOBER 2019 [Vol.6 No.8]

caregivers.

Next, keeping in mind the feedback you have gathered, ensure that you and/or your staff members are passionate about the specific service(s) you plan on offering. If you are not enthusiastic and passionate about something, it shows, and your patients will pick up on that. It’s a recipe for failure.

Do not overwhelm yourself by trying to do too much at once. Start slow, and grow as you go. Sometimes things are better sooner than perfect; this is not one of those times.

You do not have to get it perfect, but you have to be very good at what you do. A mediocre service offering is not only likely to fail in itself, but may also have negative consequences and reflect badly on the rest of your business.

Once you know where you want to go with your new service(s), your next task is to create a business plan which includes an assessment of the following: • legality from a legislative

and regulatory perspective (is the service within your scope of practice?)

• competition in the area relative to that service • resource requirements, including financial, equipment, training and personnel • marketing plans • economics, including how you will price the service • key performance indicators to measure success • growth plans • exit plans if the offering is unsuccessful.

If you are already offering some professional services, payer-funded or not, having a specific business plan is still a great idea. If you are uncomfortable with writing a business plan, engage professional help. It’s important to have a business plan for a number of reasons, not the least of which is that the bank will require it if you are going to approach them for funding related to the new service offering. Another good reason for a business plan is that it provides you with a record of what you planned and how you implemented it, so that you do not repeat mistakes in the future.

You may feel uncomfortable with all of this, given that many pharmacies cite a lack of time and other resources as being problematic for them. Stay tuned: in part 2 of this series (December) we will bring you some time and resource solutions.

Illustration by Spencer Flock

experience as a community pharmacist, pharmacy manager and pharmacy owner. He was also CEO of a regional pharmaceutical wholesale company and banner program, and recently director of pharmacy practice support at the BC Pharmacy Association. Feedback and topic ideas are welcome at Derek@dessonconsulting.com.

Do something amazing ®

Help them quit – for good – with the latest in smoking cessation delivered right to your inbox

Sign up at HelpThemQuit.ca

82% One study found that 82% of smokers wanted their physician to talk about smoking often, or at every visit.1 In fact, seeing a GP but not getting advice to quit can significantly decrease their odds of quitting.2

Even 3 minutes of your time can boost their odds by 30%.3 Get quick counselling tips, NRT dosing information, NICORETTE® & NICODERM® sample ordering opportunities and more in your inbox.

NRT=nicotine replacement therapy NICORETTE® and NICODERM® are smoking cessation aids that can reduce withdrawal symptoms and nicotine cravings in adults 18 years and older. For cautions and warnings, please visit https://www.helpthemquit.ca/treatment/overview. Always direct the patient to read the label.

References: 1. Quinn VP, et al. Tobacco-cessation services and patient satisfaction in nine nonprofit HMOs. Am J Prev Med 2005;29(2):77-84.

2. West R. The science, economics and politics of tobacco control. University College London clinical presentation 2013. 3. Fiore MC, et al. Clinical practice guideline: Treating tobacco use and dependence: 2008 update. © Johnson & Johnson Inc. 2019

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Visit us at subarufleet.ca 1. Safety ratings are awarded by the Insurance Institute for Highway Safety (IIHS). Please visit www.iihs.org for testing methods. 2. ALG named Subaru the Top Mainstream Brand for Residual Value in the 2019 Canadian Residual Value Awards. ALG is the benchmark for residual value projections in North America, publishing residual values for all vehicles in the United States and Canada. For more information, visit www.alg.com. 3. Based on IHS Markit Vehicles in Operation as of June 30, 2018 for Model Years 2009 to 2018 vs Total New Registrations of those vehicles.