Since the COVID pandemic began in 2020, Green Tree Pharmacy has helped supply and administer over 11,000 COVID vaccines.
Highlights
Hot Topics: Updates/ New Products p1
New Products / Supply Issuesp1
Operations Tips and Tricks p1
Agitation in Dementia p2
Regulatory Update / Review p2
Clinical Focus: Osteoporosis p2
Rumor…
Bisphosphonates can be administered with other medication.
Truth…
Bisphosphonates should be administered first thing in the morning and at least 30 minutes before the first food, beverage (except water) or other medications of the day. Patients should be instructed to stay upright (not to lie down) for at least 30 minutes and until after the first food of the day (to reduce esophageal irritation).
Suggestions/Comments…
We’d love to hear how we are doing and are always open to your feedback to improve our services.Please call1-800-913-8174 or visit our websitegreentreepharm.com and click “contact us” to submit the request / comment.
COVID updates:
Initially, the manufacturer stated Paxlovid must be swallowed whole, due to lack of data to support alternative administration. A review of the literature of both ritonavir and nirmatrelvir (components of Paxlovid) shows they can be split or crushed and mixed with applesauce , pudding, or any common food or liquid. Paxlovid can also be crushed and mixed with water for administration via feeding tubes.
Effective 1/26/23: Evusheld is no longer authorized for use in the United States.
New Products:
1-23-23 FDA announced approval of a SGLT2 inhibitor, Brenzavvy (bexagliflozin) for use to improve glycemic control in adults with type 2 diabetes.
Brenzavvy is available in 20 mg oral tablets, with recommendations to be taken once daily in the morning with or without food.
Brenzavvy is contraindicated in end stage kidney disease with eGFR < 30 mL/min or who are receiving dialysis.
Pharmacy Team Spotlight: Becky Reynolds, Consultant Pharmacist
Becky joined our team in January of 2016. She is a consultant pharmacist, and she shows her “Happy to Oblige” by her dedication and willingness to go wherever she is needed.
She has provided multiple flu/COVID vaccines during the pandemic with an astonishing 42 clinics for the 2022 season. She did these clinics on top of her regular consultant responsibilities. She consults for Carlinville, Fairview Haven, Gillespie, Litchfield, Mattoon, Mt. Zion, Pana, Staunton, and Villa East/West. You are a rock star, Becky, and a very much appreciated part of our team!
Operations Tips and Tricks
Be sure to communicate with pharmacy when medications from the convenience boxes have been used to ensure timely replenishment and eliminate the need for utilizing a back-up pharmacy due to stock-outs.
Upcoming Events
April – Parkinson’s Awareness month
April 22 – DEA Drug Take Back Day
May – Mental Health Month & National Osteoporosis Awareness & Prevention month
May 6 – National Nurses Day
On 1-18-2023, CMS issued a memorandum advising of audits of schizophrenia coding in the MDS data & quality measure rating adjustments for erroneous schizophrenia coding.
Quality measures (QM) constitute 1 of 3 domains of 5 star quality rating system. One such QM is the percentage of long stay residents receiving antipsychotic drugs. This measure excludes residents diagnoses of schizophrenia, Huntington’s disease, or Tourette syndrome.
CMS states concern that some nursing homes have erroneously coded residents as having schizophrenia, masking their true rate of antipsychotic medication use. Therefore, CMS will conduct offsite audits of schizophrenia coding and based upon the results, adjust the quality measure star ratings for facilities whose audit reveals inaccurate coding.
ABH is the acronym of the components: Ativan, Benadryl, & Haldol. It is not commercially available and is compounded by specialty pharmacies. Although ABH gel is used occasionally in terminal agitation at the end of life, there is a lack of evidence. Application of ABH gel is typically to the thin areas of skin including wrists or behind ears.
Remember, Haldol is an antipsychotic, so this medication if being used PRN would need to be limited to 14 days with no exception.
Clinical Focus: Osteoporosis
Osteoporosis is a systemic skeletal disease identified by decreased bone mass & deterioration of bone tissue. This leads to an increased risk for bone fragility and fracture.
The American College of Physicians (ACP) has issued an update of its guideline with clinical recommendations for treatments of primary osteoporosis outlined below:
Bisphosphonates (ie: alendronate) are recommended as initial pharmacologic treatment in both males & females. Current evidence suggests increasing the duration of bisphosphonate therapy to longer than 3 to 5 years reduces risk for new vertebral fractures, but not risk for other fractures. There is increased risk for long term harms (osteonecrosis of jaw). Clinicians should consider stopping bisphosphonate treatment after 5 years. A limitation of this class is there are no large-scale safety data in patients with CKD or CrCl < 35 mL/min, so this medication is generally avoided in this population.
The RANK ligand inhibitor (Prolia) is recommended as second-line therapy with contraindications or adverse effects from bisphosphonates in both males & females.
The sclerostin inhibitor (Evenity) or the recombinant PTH (Forteo) are commended “conditionally” only for women with osteoporosis and very high fracture risk, for 1 to 2 years respectively, and should be followed by a bisphosphonate.
For women over 65 years of age with osteopenia, decisions to start bisphosphonates should be individualized according to risk factors.
Please remember that long term steroid use can lead to drug induced osteoporosis. Evaluate for falls, fractures, and frailty.
Adequate calcium & vitamin D intake should be a part of fracture prevention in all adults with osteoporosis or low bone mass.
Agitation in Dementia:
Agitation affects up to 7 in 10 dementia patients. Non-drug measures are critical (daily routine, socialization, calming music, touch/massage therapy, etc.).
Address possible causes of agitation including pain, constipation, remove upsetting items, medication (anticholinergics, steroids, etc.).
Consider trial of SSRI first if medication is needed. In those over 60 years, citalopram max dose: 20mg/day and escitalopram max dose: 10mg/day due to QT prolongation and torsades risk.
Antipsychotics have a black boxed warning due to being linked to increased mortality in older patients with dementia. Antipsychotic medications should only be utilized in cases of emergency or when agitation/symptoms of psychosis are severe, dangerous, or cause significant distress.
Anticonvulsants have been used off-label for dementia behaviors. Depakote is not well supported by evidence and has risk of side effects.
Singulair (Montelukast):
The FDA announced March 2020 that Singulair requires a boxed warning to strengthen an existing warning about the risk of neuropsychiatric events associated with the drug, which is used to treat asthma and allergic rhinitis. There are continued reports including agitation, depression, insomnia, hallucinations, disorientation, and suicidal thoughts and actions while taking Singulair.
Risks vs benefits and mental health history should be considered when Singulair is prescribed.
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