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Archive for January, 2022

Covid-19 Outpatient Treatment in 2022. By Our Student Pharmacist, Connor Glasgow.

In the early stage of the Covid-19 pandemic, significant developments in containing, preventing, and mitigating spread of Covid-19 were at the forefront of healthcare development. This can be most obviously seen with the rapid production of effective vaccines and subsequent vaccination campaigns.

As of this month, approximately 63% of the population is vaccinated, and among the vaccinated population there is a sharp decline of hospitalizations and death due to Covid-19. That being said, due to variant strains such as Omicron, mild to moderate breakthrough cases are not uncommon and the need for effective outpatient therapy remains high.

This article will list available treatments and their place in therapy. It is of note that most prescription medications provided to treat Covid itself and not symptomatology are reserved for those who are at risk of developing severe symptoms.

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Novel oral antivirals:

  • Nirmatrelvir-ritonavir
    • First-line option for non-hospitalized patients
    • Inhibitor of Sars-Cov2 main protease and pharmacokinetic enhancer
    • Dose is two tablet regimen, 300 mg (nirmatrelvir) and 100 mg (ritonavir) twice a day for five days within five days of symptom onset
    • Contraindicated in patients on CYP3A4 metabolized medications with high risk of severe adverse effects and those with kidney function issues and an eGFR under 30ml/min
      • Caution in patients with hepatic impairment
      • Caution in patients with uncontrolled HIV due to resistance concerns
    • Requires renal adjustment to 150 mg-100 mg (respectively) twice daily if eGFR is between 30 and 60ml/min
    • Allowed for patients 12 and older with a body weight of 40 kg or more
  • Molnupravir
    • Second-line option for non-hospitalized patients
    • Cytidine nucleotide analog
    • Dose is 800 mg every 12 hours for five days
    • Contraindicated in pregnancy and for those under 18
      • Cartilage and bone toxicity reported in animal studies
      • No formal studies on pregnant patients or those under 18
      • Pregnancy test recommended before administration
    • No known drug interactions
      • Studies are limited
    • Seemingly well tolerated
      • Most common adverse events were diarrhea, dizziness, and nausea
      • Occurred in under 2% of patients
    • Specific variant coverage has not been studied
    • Generally considered lower efficacy compared to nirmatrelvir-ritonavir

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Monoclonal antibodies:

  • Sotrovimab
    • First-line for non-hospitalized patients in areas where Omicron is primary variant or Omicron is confirmed variant
    • Recombinant human IgG1 antibody binds to preserved epitope on Sars-Cov2 spike protein
    • Dose is single 500 mg IV infusion within 10 days of infection
    • Contraindicated in patients with history of hypersensitivity or those hospitalized
    • Reproductive effects not studied
    • Adverse reactions:
      • Diarrhea, rash, chills, and dizziness
    • Only drug interaction is with Covid-19 vaccine, which may reduce effectiveness
      • If previously vaccinated, must wait 90 days from vaccination to administer for treatment.
  • Casirivimab-indevimab
    • First-line for non-hospitalized patients in areas where Omicron is NOT primary variant or confirmed variant is NOT Omicron
    • Recombinant human IgG1 antibody binds to two seperate epitopes on Sars-Cov2 spike protein
    • Dose is 600-600 mg (respectively) single IV dose within 10 days of exposure
    • Contraindicated if hypersensitivity to drug product
    • Adverse reactions:
      • Nausea, vomiting, and pain at site of injection
    • Only drug interaction is with Covid-19 vaccine, which may reduce effectiveness
      • If previously vaccinated, must wait 90 days from vaccination to administer for treatment.
  • Bamlanivimab-etesevimab
    • First-line for non-hospitalized patients in areas where Omicron is NOT primary variant or confirmed variant is NOT Omicron
    • Recombinant human IgG1 antibody binds to two seperate epitopes on Sars-Cov2 spike protein
    • Dose is 700 mg and 1,400 mg (respectively) single IV dose as soon as possible following exposure
    • No current contraindications. Research is limited.
    • Adverse reactions:
      • Rash, dizziness, fever, and nausea
    • Only drug interaction is with Covid-19 vaccine, which may reduce effectiveness
      • If previously vaccinated, must wait 90 days from vaccination to administer for treatment.

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Parenteral antiviral:

  • Remdesivir
    • First-line option for both hospitalized and non-hospitalized patients
    • Adenosine triphosphate analog
    • Dose is 200 mg IV loading dose, then 100 mg IV for five days
    • Only contraindication is hypersensitivity to drug product
    • Adverse reactions
      • Nausea, rash, increased ALT/AST, and possible bradycardia
    • Efficacy can be reduced by concurrent administration of hydroxychloroquine
      • Combination is not recommended
    • Caution in patients with kidney function issues and eGFR under 30ml/min
    • Not recommended in patients with AST levels over 10 times ULN
    • While studies are small and preliminary, use in pregnant women is possible under physician guidance.

References:

  • Fact sheet for healthcare providers: Emergency use … (2021, December 22). Retrieved January 26, 2022, from https://www.fda.gov/media/155050/download
  • Fact sheet for healthcare providers: Emergency use … (2021, December 23). Retrieved January 26, 2022, from https://www.fda.gov/media/155054/download
  • Fact sheet for healthcare providers: Emergency use … (2021, November 30). Retrieved January 26, 2022, from https://www.fda.gov/media/149533/download
  • Fact sheet for healthcare providers: Emergency use … (2021, November 1). Retrieved January 26, 2022, from https://www.fda.gov/media/145611/download
  • Fact sheet for healthcare providers: Emergency use … (2022, January 1). Retrieved January 26, 2022, from https://www.fda.gov/media/145802/download
  • Fact sheet for healthcare providers: Emergency use … (2020, October 1). Retrieved January 26, 2022, from https://www.fda.gov/media/214787/download
  • COVID-19: Outpatient evaluation and management of acute illness in adults. UpToDate. (2022, January 24). Retrieved January 26, 2022, from https://www.uptodate.com/contents/covid-19-outpatient-evaluation-and-management-of-acute-illness-in-adults#!

Ivermectin and Covid-19: Does it Work? By Our Student Pharmacist, Connor Glasgow.

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The Covid-19 pandemic has presented a unique challenge to the healthcare community. The novel disease spread like wildfire and, with it, the need for information followed just as swiftly.

In response, we developed vaccines to help prevent the spread, and continued to develop treatments for the disease, which were lacking early on. As a result, novel medications were tried and created.

Alongside synthesis of novel Covid-19 treatments, other research has focused on finding effective antiviral treatment in existing and unconventional medications. Unfortunately, few pilot studies have yet to produce robust data supporting use of such medications. However, interest in these medications has remained at the forefront of discussion, often due to political motivations and cost-considerations compared to novel medications.

These factors have propelled small pilot studies to the forefront of discussion and granted enough of a platform to persuade a portion of the population to believe in the efficacy of these medications. While there have been previous examples of these medications, namely hydroxychloroquine, the most recent example is the medication ivermectin.

Ivermectin is approved as an antiparasitic used in a variety of organisms including hookworm, scabies, lice, and more exotic parasites, and has noted antiviral, antibacterial, and antineoplastic properties. In addition, the safety profile of ivermectin makes the large-scale use of the medication feasible.

Proposal of ivermectin as a treatment for Covid-19 began as a study performed by Monash Biomedicine Institute in Australia, led by Kylie Wagstaff. The study involved in vitro exposure of Sars-Cov2 infected cells over a period of 48 hours, which demonstrated a decrease in viral load compared to the control group.

The cell-line used in the experiment was Vero/hSLAM, which had previously been used as a receptacle for measles and related viruses. The scope of the trial was limited and was presented as a proof-of-concept about the use of ivermectin as a novel Sars-Cov2 treatment and was unable to demonstrate clinical efficacy in vivo. The study instead suggested clinical trials be performed.

Since that point, multiple trials have been performed to test the efficacy of ivermectin in vivo. The results of those trials have themselves been subject to a meta-analysis review to determine significance of the data.

One such meta-analysis performed concluded that the evidence for use of Ivermectin remains a low certainty of evidence. Of note, this meta-analysis included mostly pre-prints, or studies that have not yet been subject to peer review, represented the most optimistic data for the use of ivermectin.

On paper, the proposal of ivermectin for Sars-Cov2 treatment is reasonable and is reinforced by in vitro data. However, multiple clinical trials, both approved and pre-approved, have failed to yet demonstrate the efficacy required for clinical use.

Use of ivermectin itself may have limited safety concerns, however, evidence-based medical practice should dictate other options be preferred, such as novel therapies. Use of poorly evidenced medication can lead to patients receiving suboptimal therapy and should be avoided if at all possible.

With our current data, use of ivermectin is not optimal at this time, and more robust data is required for clinical use.

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References: 

  1. Caly L, Druce JD, Catton MG, Jans DA, Wagstaff KM. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antiviral Res. 2020 Jun;178:104787. doi: 10.1016/j.antiviral.2020.104787. Epub 2020 Apr 3. PMID: 32251768; PMCID: PMC7129059.
  2. Deng J, Zhou F, Ali S, Heybati K, Hou W, Huang E, Wong CY. Efficacy and safety of ivermectin for the treatment of COVID-19: a systematic review and meta-analysis. QJM. 2021 Dec 20;114(10):721-732. doi: 10.1093/qjmed/hcab247. PMID: 34570241; PMCID: PMC8500108.
  3. Deng J, Zhou F, Ali S, Heybati K, Hou W, Huang E, Wong CY. Efficacy and safety of ivermectin for the treatment of COVID-19: a systematic review and meta-analysis. QJM. 2021 Dec 20;114(10):721-732. doi: 10.1093/qjmed/hcab247. PMID: 34570241; PMCID: PMC8500108.
  4. Zein AFMZ, Sulistiyana CS, Raffaelo WM, Pranata R. Ivermectin and mortality in patients with COVID-19: A systematic review, meta-analysis, and meta-regression of randomized controlled trials. Diabetes Metab Syndr. 2021 Jul-Aug;15(4):102186. doi: 10.1016/j.dsx.2021.102186. Epub 2021 Jun 27. PMID: 34237554; PMCID: PMC8236126.

Smoking Cessation: Now is the Best Time to Quit. By Our Student Pharmacist, Connor Glasgow.

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Is it the right time to quit smoking?

Am I able to quit smoking?

Where do I even start?

It’s understandable to be hesitant when quitting smoking. The initial cravings, headache, shaking, fatigue, and cough can come on quickly, but so can the benefits to your health.

In a matter of minutes after stopping smoking, your heart rate will return to a normal rhythm.

After several days, the level of carbon monoxide in your blood drops to the same as a non-smoker.

Make it a whole year and your risk of heart attack drops drastically.

At three to six years, your risk of a cardiac event drops by half.

After ten years, your risk of lung cancer drops by half.

After twenty years, your risk for cardiac events and various cancers including esophageal, pancreatic, and throat cancers drops to the same as a person who never smoked.

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With those benefits in mind, there really is no time to waste on the road to recovery.

Here are some steps to get started:

  1. Discuss the decision to stop smoking with your primary care physician or local pharmacist. Make sure to bring a list of your medications with you.
  2. Choose a date to quit.
  3. Have a plan to quit ahead of your date including medication or counseling service support.
  4. Initiate your plan to quit on that date, and continue to periodically follow-up with your primary care physician or local pharmacist.

When it comes to quitting smoking, some of the best aids are found over-the-counter (OTC).

Nicotine replacement therapy (NRT) is the gold standard in smoking cessation and is readily accessible in multiple forms.

Here are some NRT OTC medications to help you quit:

  • Nicotine patches
    • Come in 21 mg, 14 mg, and 7 mg patches
    • Starting dose is determined by number of cigarettes smoked per day
      • Over 10 cigarettes per day: Start with 21 mg patch daily for six weeks, then 14 mg patch daily for two weeks, then 7 mg patch daily for two weeks
      • At or under 10 cigarettes per day: 14 mg patch daily for six weeks, then 7 mg patch daily for two weeks
    • Possible adverse effects
      • Abnormal or vivid dreams (can be alleviated by removing patch a few hours prior to sleep)
      • Skin rash at site of application
    • When removing, ensure to fold the patch inward. Wash hands before and after applying patches.
  • Nicotine gum or lozenges
    • Come in 4 mg or 2 mg gum and lozenges
    • Starting dose is based on when you have the first cigarette of the day
      • If first cigarette is within 30 minutes of waking: Use 4 mg
      • If first cigarette is after 30 minutes of waking: Use 2 mg
    • Dose incrementally by week
      • Week 1 to 6: Use one lozenge or gum piece every one to two hours as needed for cravings (max 20 pieces per day, max of 5 pieces in 6 hours)
      • Week 7 to 9:  Use one lozenge or gum piece every two to four hours as needed for cravings (max 20 pieces per day, max of 5 pieces in 6 hours)
      • Week  10 to 12:  Use one lozenge or gum piece every six to eight hours as needed for cravings (max 20 pieces per day, max of 5 pieces in 6 hours)
    • Possible adverse effects:
      • Irritation of the mouth or throat
      • Jaw ache
      • Dry mouth
      • Hiccups
      • Heartburn
    • Can be used concurrently with patches for breakthrough cravings.
    • Use proper technique with gum which includes biting down until flavorful, then resting between cheek and gum until flavor fades, before repeating until flavor is gone.
    • For the lozenge, do not use if allergic to soybeans.

In addition to NRT, other smoking cessation options are available and require consulting with your primary care physician. These options can include referral for counseling services and prescription medications.

Now is the best time to quit smoking and some of the best smoking cessation aids are available immediately without a prescription at your local pharmacy.

References: 

  1. A clinical practice guideline for treating tobacco use and dependence: 2008 update. (2008). American Journal of Preventive Medicine, 35(2), 158–176. https://doi.org/10.1016/j.amepre.2008.04.009
  2. U.S. Department of Health and Human Services. The Health Consequences of Smoking: What It Means to You. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004 [accessed 2022 January 7].
  3. Lexi-Drugs: Nicotine. Wolters Kluwer. Updated 12/29/2021. https://online.lexi.com. Accessed January 7, 2022.

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Please Welcome Connor Glasgow Our Student Pharmacist for the Month of January from The Ohio State University.

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This month, we are joined at Plain City Druggist by Connor Glasgow, a fourth-year pharmacy student from The Ohio State University’s College of Pharmacy.

Connor will graduate in May 2022 with his PharmD degree and will then take the test to become a registered pharmacist. Connor will be with Tayler and the staff here in Plain City throughout January, so please stop by and meet him while he is here.

Here is what Connor tells us about himself:

My name is Connor Glasgow, and I am a current fourth year APPE student at The Ohio State University’s College of Pharmacy.

I am a long time Ohio resident who grew up in Worthington, where I graduated from Thomas Worthington High School. Following graduation, I started my undergraduate career at Ohio Wesleyan University, where I graduated with a Pre-Medicine major with a Chemistry minor.

Taking courses in biochemistry and human physiology led me to be especially interested in the relationship between chemicals and the human body. However, I still wanted to directly help patients. Given that, I was naturally drawn to pharmacy because of the face-to-face interactions pharmacists have with patients, while also providing quality healthcare. As such, the primary focus of my career has been in the retail community pharmacy setting.

My career in pharmacy began prior to entering OSU, when I applied to be a pharmacy technician with Kroger Pharmacy in Delaware. After a year, I was a certified technician, and after another year with Kroger I was in their intern program. After four years at Kroger, my passion for community pharmacy has only increased after completing their internship program. In some ways, my time there has been unique given the advent of Covid-19 and the need of healthcare professionals to assist in mitigating the spread of the pandemic.

Aside from helping immunize patients at Kroger, I have also assisted in a large-scale immunization clinic at the Schottenstein Center for several weeks. Both these experiences have only further demonstrated to me the utility and need of pharmacists at the community level in helping improve community health in ways that no other profession can.

In addition to my time at Kroger, my APPE rotations have given me skills and perspectives from all areas of pharmaceutical practice. These rotations have included time at a home-infusion clinic observing a rapidly growing sector of pharmacy, outpatient infusion services and compounding; assisting the pharmacy director of SUN Acute Behavioral hospital to help patients in urgent mental health assistance; as well as spending time with Equitas administrative offices, a local clinic and pharmacy specializing in community outreach.

I have even seen how pharmacists handle animal patients and compounding for such patients while a student at OSU Veterinary Hospital. However, despite all these experiences I still feel most at home and satisfied with community pharmacy.

If anything, I feel my career has been preparing for work in a community setting, and this newest rotation at Plain City Druggist is all the better preparing me for my future career. Though the majority of my career has been in a large chain community setting, I am excited to see how a local, independent pharmacy operates day-to-day, and what makes an independent pharmacy different from a large chain pharmacy. Independent pharmacies often form the backbone of healthcare, especially in rural areas that may be underserved. These pharmacies in many ways represent the peak of community practice and improving the healthcare of the community, not just the customer.

I am beyond excited to observe and learn what I can from Plain City Druggist.

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