KEEPING TABS
Volume 4 | Issue 2
University of Florida College of Pharmacy
Table of Contents
Hydroxychloroquine, Miracle Mineral Solution and Everything in Between: The Pharmacist's Quick Guide to the Drugs of COVID-19
Page 4
CODE BLUE! The Pharmacist's Role in an Emergency Situation
Page 6
Precision Medicine: The Future of Pharmacy
Page 8
How Food Affects You: Summer Edition
Page 10
2020 Legislative Update
Page 12
Operation Heart
Page 15
Mental Health During COVID-19 WICked Resources for Women, Infants and Children
Page 16
Page 18
Congratulations TO
OUR
NEW
OFFICERS,
President: Oore Morakinyo President-Elect: Gaby Gonzalez Patient Care VP: Amy Cirelli Policy VP: Kelli Herin Policy VP Elect: Monica Bennett International VP: Wendy Caba Piloto International VP Elect: VIctoria Walker Communications VP: Brenda Echevarria Membership VP: Brandon Lane FInance VP: Mustafa Kamal Member-at-Large: Moya Reid Fundraising Chair: Maria Reilly Historian: Travis Hong
CHAIRS
AND
CO-CHAIRS
Operation Diabetes: Hannah Davis*, Lauren Hoggart, and Victoria Walker Operation Heart: Megan Miller* and Vivian Cai Operation OTC Med Safety: Moya Reid* and Ambra Malshi Operation Immunization: Dominic Santos* and Logan Langley Operation Mental Health: Christi Reinman* and Justin Sta.ana Generation Rx: Alex Litvintchouk* and Brandon Uzice Operation Women's Health: Madison Conway* and Ariel Williams Operation Pride: Rachel Cufferi* and Jade Nanan IPSF: Irissel Rodriguez Industry Liaison: *indicates chair Ali Patron
Thank you to our outgoing officers and chairs this year would not have been the same without you.
Hydroxychloroquine, Miracle Mineral Solution and Everything in Between: The Pharmacist’s Quick Guide to the Drugs of COVID-19 Written by: Alex Litvintchouk and Brandon Uzice
These are unprecedented times we are living in with the arrival of the Novel Coronavirus Disease 2019 (COVID-19) and our patients are afraid. In the U.S. alone there have been 1.12 million confirmed cases and 65,000 deaths. With so much uncertainty surrounding COVID-19 treatment and prevention, patients will understandably be looking to the most accessible health care provider for advice, care, and support. What follows is a succinct summary of deceptive medications advertised for COVID-19 and their place in practice. Patients looking to take their healthcare into their own hands may stumble across sodium chlorite containing products that claim to be a suitable treatment for COVID-19. Some common products include Master Mineral Solution, Miracle Mineral Supplement, and Chlorine Dioxide Protocol. Many of these products require the solution to be mixed with an acid prior to consumption which often comes pre-packaged with the solution. The resulting mixture, chlorine dioxide, is a bleaching agent that is typically used as an active ingredient within industrial disinfectants. Sodium chlorite and chlorine dioxide are not intended for human consumption and patients should be advised against taking any supplements with these agents. If a patient were to ingest chlorine dioxide some known symptoms include nausea, vomiting, diarrhea, and severe dehydration. In the event of adverse reactions, patients should contact the Poison Control Center and seek immediate medical attention. Patient’s may also come to you asking about other drugs in the news, specifically, hydroxychloroquine and chloroquine. Due to the increase in the number of prescriptions being dispensed of the two, the FDA has released a cautionary statement to patients being administered the drugs outside of a
hospital or clinical trial setting. Namely, hydroxychloroquine and chloroquine have not been shown to be safe or effective in the treatment or prevention of COVID19. Within clinical trials, these drugs have also been shown to cause abnormal heart rhythms, such as QT prolongation and ventricular tachycardia. These risks are being compounded in some as azithromycin (an unapproved drug to fight COVID-19) is also known to prolong QT interval. Therefore, when confronted by a patient or provider, the practicing pharmacist should follow the current advice set forth by the FDA and recommend against its use. Currently, there are no FDA approved medications being used for COVID-19 treatment, however, there are combinations of antivirals that are being investigated to curb and fight off the infection in extreme inpatient settings. In these cases, supportive care such as oxygen or mechanical ventilation may be required. However, for the majority of patients that are not at risk for lifethreatening symptoms, the advice from the FDA and CDC is as follows: that patients stay hydrated, get plenty of rest and take pain relief medications as needed for comfort and under the supervision of their provider. These are strange times we are living in, but as the pharmacy experts in the healthcare field and the most trusted and accessible healthcare provider, it is up to us to provide our patients (and fellow providers) with the most up to date and accurate information of this ever-evolving situation. References: CDC Cases, Data and Surveillance. “Cases in the U.S.” Centers for Disease Control and Prevention, May 2020. www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Office of the Commissioner. “Danger: Don’t Drink Miracle Mineral Solution or Similar Products.” U.S. Food and Drug Administration, FDA, www.fda.gov/consumers/consumer-updates/danger-dontdrink-miracle-mineral-solution-or-similar-products. FDA Safety Communication. “FDA cautions against use of hydroxychloroquine or chloroquine for COVID-19 outside of the hospital setting or a clinical trial due to risk of heart rhythm problems.” Food and Drug Administration, April 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-cautions-against-use-hydroxychloroquine-or-chloroquine-covid-19-outside-hospital-setting-or Harvard Health Publishing. “Treatments for COVID-19: What Helps, What Doesn't and What's in the Pipeline”. Harvard Medical School, March 2020. https://www.health.harvard.edu/diseases-andconditions/treatments-for-covid-19.
Alexander M. Litvintchouk
Brandon Uzice
Code Blue! The Pharmacist's Role in an Emergency Situation Written by: Jourdan Boyle-Taylor
Whether you have worked in a hospital or watched Grey’s Anatomy you have heard the phrase “code blue” being said. Now, what does code blue actually mean? According to an article from NCBI, the code is defined as any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital alert. Where does a pharmacist fit in these types of situations? There are many different ways a pharmacist can be included on the code team such as dosing recommendations, preparing the medications to be used, and making sure the timing of doses is correct. An example of when this is important is when administering epinephrine, which should be done every 3-5 minutes. If administered too quickly the patient can experience unfavorable outcomes after cardiopulmonary resuscitation (CPR) (Wang et.al). Pharmacists also can prepare infusions at the bedside, provide information on drugs to nurses and doctors when necessary, and perform CPR. Being able to execute all of these actions make pharmacists key players in the role of emergency medicine, especially in a code. What about the medications used in a resuscitation, that we may need to provide further clarification on?
Adenosine: antiarrhythmic used for the treatment of supraventricular tachycardia - Do not use in 2nd or 3rd-degree heart block Amiodarone: antiarrhythmic used for the treatment of unstable ventricular tachycardia, ventricular fibrillation, and ventricular tachycardia with no pulse unresponsive to shock - Do not use in 2nd or 3rd-degree heart block Atropine: anticholinergic used for symptomatic bradycardia and overdoses/toxicities - Doses lower than 0.5 mg may worsen bradycardia Dopamine: catecholamine vasopressor and inotrope used in bradycardia after administration of atropine - Do not mix in alkaline solutions or with sodium bicarbonate Epinephrine: catecholamine vasopressor and inotrope used in cardiac arrest, anaphylaxis, symptomatic bradycardia after atropine - Do not give in cocaine-induced ventricular tachycardia Lidocaine: antiarrhythmic used to treat cardiac arrest from ventricular fibrillation or ventricular tachycardia wide complex tachycardia - Do not give for wide complex bradycardia - Do not use prophylactically in acute myocardial infarction Magnesium Sulfate: electrolyte and bronchodilator used for torsades de pointes, hypomagnesemia, and digitalis toxicity - Calcium chloride is the antidote to reverse hypermagnesemia Vasopressin: antidiuretic hormone analog used as an alternative to epinephrine for pharmacists ventricular fibrillation, asystole, and pulseless electrical activity In conclusion, can be a shock resource in these high-stress valuable
situations when information about medication needs to be provided quickly.
References: “Commonly Used Medications in ACLS.” ACLS Medical Training, ACLS Medical Training, www.aclsmedicaltraining.com/commonly-used-medications-in-acls/. Eroglu, Serkan E et al. “Blue code: Is it a real emergency?.” World journal of emergency medicine vol. 5,1 (2014): 20-3. doi:10.5847/wjem.j.issn.19208642.2014.01.003 The Pharmacist's Role in Advanced Cardiac Life Support (ACLS) Pharmacist Objectives Background Pharmacists in the ER Wang, Chih-Hung, et al. “The Influences of Adrenaline Dosing Frequency and Dosage on Outcomes of Adult in-Hospital Cardiac Arrest: A Retrospective Cohort Study.” Resuscitation, vol. 103, 2016, pp. 125–130., doi:10.1016/j.resuscitation.2015.12.008.
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Precision Medicine: The Future of Pharmacy Written by: Wendy Caba Piloto
Historically, the practice of medicine has generally been sensitive to changes. Today, it is known that in order to treat or cure a disease we usually have to wait until the onset of symptoms. So, it is presumed that every patient regardless of their age or genetic characteristics receive the same medical treatment. This is because even the world’s most recognized scientists and doctors do not entirely understand how the development of disease and response to treatments vary per individual. Consequently, the use of traditional practice which is commonly based on a “one-size-fitsall” approach to medicine, can make our intentions to treat disease inaccurate, variable, and sometimes unsuccessful. This conventional practice regularly fails to recognize how each person’s genetic make-up is somewhat different from everyone else’s, which can often impact our health in very significant ways.
While the concept of “precision medicine” is fairly new, the term has been used in the healthcare system for several years. Blood transfusion is a good example, as the donor’s blood type has to be matched to the recipient to avoid any risks or complications. In 2015, President Barack Obama declared that the United States would be part of a government funded precision medicine initiative, in which over 1 million people would be registered. This is what is now called "All of US.” The arrival of precision medicine is leading us to more predictable and powerful health care that is better adapted for the specific patient. Therefore, the developing knowledge of genomics and genetics — and knowing how impactful they can be in disease and drug responses— is allowing healthcare professionals to come up with more accurate diagnosis and enhanced disease prevention, as well as more effective medical treatments and safer drug administration. Preventive and therapeutic interventions are then to be focused on those who will be favored, reducing cost and adverse events for those who are not. As the definition proposes, the potential benefit of precision medicine has to do with its power to direct health care decisions concerning the most effective treatments for a particular patient, and hence, reduce the need for diagnostic testing and treatment while improving quality of care. There is currently insufficient research data on the application of precision medicine, however, new initiatives are starting to encourage the need for the creation of evidence. Therefore, it is crucial that we as healthcare professionals advocate for this revolutionary approach that tailors care to each patient’s unique genetic make-up, socioeconomic status, and other lifestyle factors.
References: Ginsburg, Geoffrey S, and Kathryn A Phillips. “Precision Medicine: From Science To Value.” Health Affairs (Project Hope), U.S. National Library of Medicine, May 2018, www.ncbi.nlm.nih.gov/pmc/articles/PMC5989714/. “What Is Personalized Medicine?” The Jackson Laboratory, www.jax.org/personalizedmedicine/precision-medicine-and-you/what-is-precision-medicine.
VOL 4 ISSUE 2
How Food Affects You: Summer Edition WRITTEN BY JULIA LESSING
Summer is finally here, and that means barbecues and camping trips are in full swing. Enjoying a grilled burger or a charred chicken breast may seem harmless, but there are two chemicals - polycyclic aromatic hydrocarbon (PAH) and heterocyclic amines (HCA) - which should make you consider how you cook your proteins. PAH and HCA are formed when meat such as beef, pork, poultry and fish are cooked at high temperatures like grilling directly over an open flame. When fat from cooking the meat drips down onto the hot coals, the smoke that forms contains PAH, and the charred exterior (or interior, if you like things very well-done) contains HCA. Both of these chemicals have been linked to higher rates of colorectal cancer in a study done by the National Cancer Institute in 1999 and have been added to the Department of Health’s official list of carcinogens. PAH and HCA are capable of damaging DNA only once metabolized or “bioactivated” by specific enzymes in the body, and these enzymes are being researched for their possible risk of causing cancer with exposure to these substances.
While this information sounds scary and may lead you to stay away from the grill, there is currently no official calculated quantity that deciphers these chemicals as being carcinogenic. So, as with most things, eating them in moderation is your best bet. Here are some other tips to cut down the amount of PAH and HCA in your grilled meat: 1. Try not to char your meat or you can cut off charred pieces, along with avoiding prolonged cooking times (this lowers the amount of HCA). 2. Avoid flare ups of the grill with grease dripping by either placing punctured foil on the grates or cooking using indirect heat, meaning not over the open flame (thereby lowering the amount of PAH). 3. Researchers at the University of Hawaii found that marinating your meat for even just an hour before grilling could significantly reduce the amount of these chemicals created. The marinade adds moisture to prevent charring and makes the surface less sticky for PAH-filled smoke. 4. A study in 2010 found that adding rosemary to your meat before grilling could cut down the HCA content by up to 90 percent! It is thought that the antioxidants in rosemary correlate with these findings, and similar studies have found that garlic, onion, tart cherries, and honey also block these chemicals from forming. There are currently no Federal guidelines addressing the consumption of foods containing PAH and HCA, but there are several research investigations ongoing in the United States and Europe. This summer educate your friends and family and try out some of these tips for reducing the formation of these chemicals!
References:
Chemicals in Meat Cooked at High Temperatures and Cancer Risk - National Cancer Institute. https://www.cancer.gov/about-cancer/causesprevention/risk/diet/cooked-meats-fact-sheet. Accessed 4 May 2020. Dean, Sam. “Is Grilling Good for You? Or Bad? Here’s What Science Says.” Bon Appétit. www.bonappetit.com, https://www.bonappetit.com/test-kitchen/cookingtips/article/is-grilling-good-for-you-or-bad-here-s-whatscience-says. Accessed 4 May 2020.
2020 Legislative Update BY DIMPLE PATEL
Below are the various bills that were either passed or died during the 2020 Legislative Sessions where numerous pharmacists and pharmacy students advocated for the future of pharmacy.
SB714/HB389: PASSED Testing For and the Treatment of Influenza and Streptococcus Signed into law by Governor DeSantis on March 11. 2020 Effective Date: 07/01/2020 Intent of bill: Increase patient access to acute illness point of care testing
This is the third year that FPA was advocating for this bill. The bill authorizes a pharmacist to enter into a collaborative pharmacy practice agreement (CPPA) with a physician to manage chronic health conditions if the pharmacist meets certain qualifications. A CPPA must meet certain terms and specify the health conditions, treatments, and tests governed by the CPPA. It also authorizes a pharmacist to test or screen for and treat minor, non-chronic health conditions within the framework of a written protocol with a supervising physician. The conditions are limited to: Influenza Streptococcus Lice Skin conditions Minor, uncomplicated infections The bill includes authorization for a pharmacist to use certain laboratory or clinical tests, as well as any established screening procedures for which no test is available. Prohibitions: Collaborating pharmacist cannot initiate, modify or discontinue any medication that is prescribed by a health care practitioner who does not have a CPPA with the pharmacist. Collaborating pharmacists cannot prescribe a controlled substance. Update: This bill has been broadened to include any acute testing due to COVID-19
LAW UPDATE
SB1094/HB599: PASSED Consultant Pharmacists (Collaborative Practice Agreements) Signed into law by Governor DeSantis on March 11. 2020 Effective Date: 07/01/2020 Intent of bill: Takes pharmacist practice in hospitals to primary clinics and in‐
patient hospice The bill expands consultant pharmacist scope of practice by authorizing a consultant pharmacist to enter into a written collaborative practice agreement to provide medication management services with a healthcare facility medical director or Florida-licensed allopathic physician, osteopathic physician, podiatric physician, or dentist to: Order and evaluate laboratory and clinical testing Conduct patient assessments Administer medications Modify or discontinue medicinal drugs pursuant to a patient-specific order or treatment protocol. Training needed: Consultant pharmacist training and licensure with 3 hours of lab and clinical testing CE training - 12 hours of consultant CE per year/24 hours per biannual cycle
SB708/HB59: PASSED (FPA/FSHP against this bill) Automated Dispensing Systems Has not be signed by the governor yet Effective date: 07/01/2020 Authorizes community pharmacy to use automated pharmacy system Provides certain medicinal drugs stored in automated pharmacy system for outpatient dispensing Concerns: This legislation restricts the opportunity for the patient to interact with the pharmacist Considering current technology advances, internet stability in remote areas may not support this pharmacy model Without a pharmacist on the premises, this legislation presents significant patient safety and confidentiality concerns
For the three passed bills above: pharmacists cannot perform the authorized activities until the FLBOP completes the rule-making process.
LAW UPDATE
SB1444/HB961: DIED Prescription Drug Benefits Died on 3/14/2020 Intent of bill: Increase access to prescription medications while lowering cost Pharmacists May Order and Administer COVID-19 Tests Emergency Order 20-006 was filed to suspend: Section 483.813: Requires a pharmacist to be separately licensed to perform a clinical laboratory test Section 465.003(13): Prohibits a pharmacist from ordering, administering, or reporting the results of COVID-19 tests, including serology tests This suspension applies until the expiration of Executive Order 20-52.
Reference: Florida Board of Pharmacy. (n.d.). Licensing, Renewal, Resources, Meetings and Information. Retrieved May 03, 2020, from https://floridaspharmacy.gov/
APHA-ASP
OPERATION HEART
Written by Megan Miller and Vivian Cai Operation Heart is one of the many important committees that the APhAASP chapter focuses on. As student pharmacists, we aim to gain awareness and understanding for cardiovascular issues, the number one cause of death globally. Cardiovascular issues include hypertension, heart attack, and arrhythmias to name just a few. We are looking forward to holding many events in order to help educate different populations about heart healthy lifestyles, advise the public on heart healthy behaviors, and monitor the health status of the local community through blood pressure screenings. We have many exciting events planned for this upcoming year, and look forward to working with other operations within APhA-ASP, as well as community organizations, in order to help promote cardiovascular health! We look forward to a productive and engaging year ahead!
Mental Health During COVID-19 Written By: Jason Acevedo, Christi Reinman, and Justin Sta.ana There have been many changes during the COVID-19 pandemic and it can be hard to keep your head clear sometimes. Operation Mental Health wanted to take this opportunity to talk to readers about the importance of practicing good mental health and what steps to take during this time of uncertainty. Things you should do: Try to follow your normal routine.There are plenty of useful tools to help you continue your usual schedule such as FaceTime and Zoom to stay in touch with family and friends. In addition, there are apps, such as the Nike Training Club that you can utilize to stay active while gyms are closed. Continue what you can and make modifications where necessary. Don’t forget you can safely go outdoors in nature while still practicing social distancing.
Things you should NOT do: It’s easy to get caught up watching too much news because you want to know the latest information. However, it’s important to take breaks from watching the news. It can be stressful to repeatedly hear and see images about the pandemic. Use the news for periodic updates. Try to maintain your normal life and provide yourself with positive activities that you enjoy in order to not dwell on the crisis. Taking care of children and others As a parent or caretaker, those who you take care of look towards you for comfort and support. By handling situations calmly and confidently you can reassure those close to you that things will be okay. Setting a good example, such as eating healthy, exercising, as well as avoiding drugs and alcohol can influence others to do the same. Breaking stigmas During trying times people often look for someone or something to blame. It is important to remember that people who have not recently visited an area of active spread of COVID-19 or have not been in contact with someone with a confirmed case of COVID-19 are not at an increased risk of spreading the virus. The Bottom Line During times of uncertainty practicing good habits will help you to think clearly in stressful situations. By conducting social distancing you might feel alone, but there are ways to still be connected with family and friends. Make sure to stay in contact with loved ones and don’t be afraid to reach out to those who might be isolated. If you need additional help coping with anxiety or other mental health conditions don’t hesitate to seek it. You do not need to feel isolated with your struggle and there is nothing wrong with obtaining help from a professional. Resources to use include doctors, counselors, church leadership, and the SAMHSA helpline at 1-800-985-5990. Just remember that things will return to normal.
Wicked Resources for Women, Infants,and Children WRITTEN
BY:
ARIANNE
BARGAS
What is WIC? Since 1974, the Women, Infants, and Children (WIC) Program has provided supplemental nutrition for low-income women, infants, and children up to 5 years old who are at nutritional risk. This governmentfunded program is available in 50 states, with 184 clinics here in Florida. It is a great resource for well-informed pharmacists/student pharmacists to provide for their patients requiring additional assistance. Services that WIC provides Most people who know about the WIC program, know that participants receive food benefits as long as it is WIC approved, which provides healthy and nutritious options. Foods such as fruits, vegetables, baby food, eggs, milk, peanut butter, cheese, whole wheat bread, and many more items that can be found on your state government’s website¹. Some larger chain stores also provide information on their shelves if a food item is eligible for WIC, so next time you are out grocery shopping, keep an eye out for these labels. In addition to food benefits, participants who qualify can also have access to health screenings, immunization screenings, referrals, nutrition and breastfeeding counseling sessions.As well as breastfeeding aids such as breast pumps, breast shells, substance abuse referrals, and many more.
I W
C
Who qualifies? For any state, there are four categorical requirements participants must meet to qualify for WIC benefits. To be categorically eligible you have to be a woman (pregnant, postpartum, breastfeeding) with/without an infant, or a child up to 5 years of age who is struggling to provide food for yourself or the family. Applicants must live in the state they apply to, meet the residency requirement, and have low-level income requirements determined by the state government/agency. Lastly, the applicant must be deemed a “nutritional risk” meaning the applicant or individual has medical or dietary based conditions such as anemia, low weight, poor diet, or has a history of poor pregnancy outcome. To make the eligibility process easier, there is an online web application prescreening tool to determine if individuals qualify for WIC benefits². How can student pharmacists/pharmacists provide education to patients regarding WIC?As student pharmacists/pharmacists, we are at a unique advantage in being an accessible resource to our community. In addition to providing information about medications and counseling patients, we can encourage patient’s self-advocacy and lead them to the right resources for additional assistance to improve their overall well-being. We must always provide the best care for our patients and that includes being knowledgeable about one of the many public health resources available. So next time, when you have the opportunity to counsel a patient with concerns regarding their pregnancy, you can potentially alleviate some of their stress and anxiety by providing helpful information about a service for women that can aid them during and after their pregnancy. WICked cool, right? References: https://www.fns.usda.gov/wic/about-wic¹ http://www.floridahealth.gov/programs-and-services/wic/_documents/fl-wic-foods-eng.pdf² https://wic.fns.usda.gov/wps/pages/preScreenTool.xhtml
Thank you. to our writers
to our designers
Arianne Bargas Wendy Caba Piloto Julia Lessing Jason Acevedo Justin Sta.ana Christi Reinman Dimple Patel Megan Miller Vivian Cai Brandon Uzice Alex Litvintchouk
Jourdan Boyle-Taylor Hannah Davis Brenda Echevarria Lucy Phipps