Jeannette Wick , RPH, MBA, FASCP

Many community pharmacists work with patients with 

 who are underserved or whose health literacy is low.

Most health care organizations track errors, but the data they collect are often part of their performance and quality improvement programs and are rarely available publicly. Recent discussions with certified diabetes educators identified 8 areas where pharmacists should be more aware about the possibility of error.

1. Injecting insulin after meanls when it should be injected before.

Giving insulin before a meal ensures that its onset matches the absorption of glucose consumed during the meal.

 Clinicians use different types of insulin for mealtime doses. Compared with regular insulin, rapid-acting analog (RAA) insulins aspart, glulisine, and lispro act within minutes of administration. Patients must administer regular insu- lin 30 to 45 minutes before a meal and RAA insulin 5 to 15 minutes before or immediately after they begin eating. They should not wait until they have finished eating.

2. Using mealtime insulin even when they do not eat.

Administering insulin with no food consumption can cause uncontrolled blood glucose and unpredictable glycemic control. Hypoglycemia is a preventable adverse event, and pharmacists should periodically remind patients of that fact.

3. Injecting insulin into the front of the arm, possibly intramuscularly, instead of into the subcutaneous tissue in the back of the arm.

Remembering all the details about insulin can be difficult for patients. They should be reminded that insulin must be injected into the fat just underneath the skin, not into muscle, and that the correct injection sites are the buttocks, rear upper arms, stomach, and thighs.

 These sites have a high fat content. The needle is usually not long enough to reach muscle, but injecting insulin into muscle is painful, and the insulin will be absorbed faster, increasing the risk of hypoglycemia.

4. Reusing lancets and needles for insulin and/or glucagon-like peptide-1 agonists.

The results of an international study showed that on average users of disposable syringe needle devices reused needles 3.3 times

 and on average reused insulin pen devices an 3.6 times. A whopping 26.6% of insulin pen users reused needles more than 5 times.

 The results of a 2021 study in the United States showed that about 50% of individuals reused lancets and needles, with lancet reuse more common than needle reuse.

 Reusing needles reduces copayments, especially for patients who multiple daily injections. But needle reuse for subcutaneous insulin injection is not recommended.

 It may be associated with cutaneous lipodystrophy, infection, and more painful punctures, but little evidence available regarding these adverse events. 

A 2016 meta-analysis that looked at 25 studies showed that infection at injection sites was studied most often, but reusing needles was not associated with local infection.

 Findings showed a statistically significant association between lipohypertrophy and needle reuse but found the data inconclusive because the studies had been structured very differently. Needle reuse was also associated with more pain.

 Sometimes, the smallest quantity the pharmacy can dispense is more than the patient will use before it expires. The high cost of the products sometimes force patients to choose between using expired medication or going without. Furthermore, once in use, injectables for diabetes have a finite expiration date, even if the manufacturer’s expiration date is still good. Patients may not know that. Using expired insulin increases the risk of poor glycemic control.

6. Adjusting medication doses without involving the primary care provider.

Although patients can self-adjust some insulins for diabetes, they should not self-adjust all medications for diabetes.

 Clinicians often see patients taking medication once a day when the label says twice daily or taking extra doses when they experience hyperglycemia at the maximum daily dose. Monitoring refill history and questioning patients when they need refills too soon can identify these nonadherence issues.

7.  Not scanning the sensor often enough when using continuous glucose monitoring (CGM).

This prevents the provider from interpreting data and adjusting doses. Higher rates of CGM scanning have been linked to increased time in the glycemic target range and less hyper- and hypoglycemia. Frequent scanning also helps patients see how carbohydrate intake, exercise, illness, medication, or stress
affect blood glucose.

Pharmacists should remind patients to scan at the frequency that their primary care physicians (PCPs) recommend. For complete data capture, they should scan the sensor at least 3 times a day, 8 hours apart.

8. Testing blood glucose with a glucometer because the PCP said to do so, but making no meaningful changes.

Testing for the sake of testing helps no one and wastes money on costly supplies. Patients should know the threshold for checking blood glucose more often, checking ketones, drinking plenty of fluids, restricting carbohydrates, and adjusting insulin. For example, a patient who has a random reading of 400 mg/dL should retest to verify the reading and take medication if that is part of the medication plan or the patient skipped a dose. Taking a walk can sometimes bring the reading down, as can avoiding food and drinking plenty of water.

Knowing common mistakes is a wonderful way to prevent them. Asking a few simple questions when patients pick up refills and stressing points that are apt to cause confusion, such as expiration dates, is helpful for low-literacy patients.

, is the assistant director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy in Storrs.

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Articles

Here are 8 diabetes areas where pharmacists should be more aware of error.

Monitoring for Mistakes in Patients With Low Health Literacy Is Crucial

 pandemic drags on, Americans are still arguing, debating, and discussing vaccinations.

This is a good time for pharmacists to review the general principles behind the COVID-19 

, extra doses, and booster shots, which are different things.

 First, they should protect against disease and/or infection caused by a pathogen during postvaccination exposure. Second, they should prevent infection transmission, a concept related to herd immunity. Live (attenuated) or nonlive (inactivated) vaccines and protein or polysaccharide antigen(s) have been successful for many years. In response to the pandemic’s dire consequences, pharmaceutical companies developed new vaccines based on nucleic acid (DNA and RNA) and viral vector technology.

After vaccination, 3 biologic activities occur first.1 Dendritic cells activate and present antigens. B cells produce antibodies, T cells work on cellular immunity and immune memory, and T helper cells relay signals that stimulate B cells and cytotoxic T cell production. Finally, cytotoxic T cells kill infected cells.

The most important step is B cell production of circulating antibodies because it drives sterilizing immunity, the situation in which the immune system stops a pathogen completely.

 T cell response is an additional contributing factor. T helper cells can drive cellular immunity, B cell development and antibody production, and mucosal surface immunity. Finally, cytotoxic T cells seem to prevent progression to more severe disease.

 lists other factors that improve protection.

Other factors are vaccine specific. Virologists have examined various measures of efficacy for the COVID-19 vaccines. Although it would be ideal if the vaccines protected from any SARS-CoV-2 infection, it appears that the current vaccines protect from most infections, especially life-threatening and severe ones. Virologists also look at each pathogen’s incubation period and infection process.

 In addition, they examine circulating body concentrations and elimination half-life, with specific attention to whether the amount of antibody varies among individuals.1 Although it usually takes 3 to 4 days for individuals to develop some immune memory or reactivate antibody production, virologists look at each vaccine’s individual profile.

Next, virologists must look at the vaccine’s real-world performance so they can determine whether patients need booster shots or extra doses.

 The decision to recommend either is based on whether patients develop an adequate response to an initial vaccination series, associated with long incubation-period infections, or a less optimal response to an initial vaccination series, associated with short incubation-period infections.

Almost everybody who has been approved for a COVID-19 vaccine needs an additional dose or booster shot to maintain immunity.

 Certain factors drive that need. The circulating SARS-CoV-2 viral variants are relatively resistant to antibody neutralizing activity.

 This means they have an efficient, fast infection process. Virologists have documented declining circulating antibody levels in individuals who have had an adequate response to primary vaccination but who have high-exposure risk, a high risk of severe disease, and/or a low initial response. Another contributing factor has been insufficient herd immunity.

Boosters are recommended when the response to the primary series of any vaccine is sufficient but immunity wanes over time.

Virologists measure waning immunity via declining antibody titers in vaccinated individuals or epidemiologic evidence of increased infections or severe disease.

Additional doses are recommended when the patient’s immunity is inadequate or the response to the originally designed primary series of the vaccine is insufficient.

 In the former case, epidemiologic evidence indicates that vulnerable populations have no or limited protection from infections or severe disease or that patients have low or unmeasurable antibody titers.

 lists factors that influence response to the initial vaccine series.

Immunizers should be aware of the CDC’s recommendations for additional doses of mRNA vaccines. As of January, the CDC recommends additional doses for moderately to severely immunocompromised people, meaning individuals who are actively taking high-dose corticosteroids or immunosuppressants, are receiving active cancer treatment, have advanced or untreated HIV infection, have a moderate to severe primary immunodeficiency, or received a stem cell transplant within 2 years or an organ transplant and are taking immunosuppressants.

Patients who mount no detectable serum anti-body response to the COVID-19 vaccines still have an approximately 50% protection from infection compared with unvaccinated individuals.

 CDC recommendations change, and the astute immunizer should bookmark CDC pages and visit them often. Research is evolving continually, and the need for a booster shot does not mean these vaccines do not work; they work well.

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Explain to patients that research Is continually evolving and the need for booster shots does not mean the vaccinations do not work.

Change Is the Operative Word When Discussing COVID-19 Vaccines

The traditional formula for weight loss is simple: induce a negative energy balance by increasing physical activities and reducing caloric intake.

 Yet obesity is not a simple health problem. Individuals who struggle with obesity report difficult life changes, few ways to lose weight and keep it off, and yo-yo dieting.

Guidelines call weight loss of at least 5% from baseline clinically significant, indicating that it improves cardiometabolic risk factors.

 That seems like good news. For instance, that would mean a 200-lb individual who loses just 10 lb should see significant improvements. However, most 1 individuals with obesity lose little weight with lifestyle changes alone. Approximately one-third who lose more than 5% of their weight return to their original weight within 1 year. More than half return to their starting weights at 2 years and almost all do so within 5 years.

When lifestyle interventions are unsuccessful, most obesity control guidelines recommend adjunct medication.

 Because central and peripheral hormonal signaling controls energy intake,

 investigators have targeted numerous mechanisms to develop medications. FDA-approved antiobesity medications for chronic weight management include 5 options. Potential mechanisms for obesity medications include appetite/energy intake reduction, calorie absorption reduction, and promotion of energy expenditure.

Glucagon-Like Peptide 1 Receptor Agonists

The FDA approved the injectable glucagon-like peptide 1 (GLP-1) receptor agonists liraglutide (Saxenda) in 2014 and semaglutide (Wegovy) in 2021
for long-term weight management (Table

). GLP-1 regulates blood glucose after meals by inhibiting glucagon secretion and enhancing insulin secretion from pancreatic β-cells in a glucose-dependent manner.

 It induces postprandial satiety and fullness, reduces appetite and food consumption, and slows gastric emptying.

 Three randomized controlled trials (RCTs) found weight loss of 4.7% to 8% in liraglutide-treated patients.

 In clinical trials, semaglutide treated was associated with an approximate 15% weight loss over a 68-week period.

Naltrexone/bupropion (Contrave) combines an opioid antagonist with an antidepressant. Four large RCTs documented weight loss of 5% to 6.1%
in naltrexone/bupropion-treated patients.

 Contraindications include abrupt alcohol discontinuation, anorexia or bulimia nervosa, benzodiazepines, monoamine oxidase inhibition during the first 14 days of use, seizure, uncontrolled hypertension, and use of antiepileptic drugs or barbiturates. This medication also requires gradual dose escalation, starting with 1 tablet (8 mg/90 mg) for 1 week, and ultimately reaching 2 tablets twice daily (the maximum dose) at week 4. Common adverse effects (AEs) include constipation, dizziness, dry mouth, headache, nausea, and vomiting.

 Clinicians should monitor for depression or suicidal ideation.

The FDA approved orlistat (Xenical) in 1999, and it is available as an OTC formulation (Alli) for individuals 12 years or older.

 Orlistat inhibits gastrointestinal and pancreatic lipases, blocking absorption of approximately one-third of consumed fatty acid and triglyceride hydrolysis but having no effect on appetite.

 In a large RCT, participants had a total body weight loss of 2.4% after 4 years. Orlistat decreased type 2 diabetes (T2D) risk in the treatment arm (9%) compared with the placebo arm (6.2%).

 It also improved blood pressure, insulin sensitivity, and lipid profiles.

Patients should take orlistat with or within 1 hour of meals.

 Because nonabsorbed fats remain in the intestine, almost all patients will report some fecal incontinence, flatus with discharge, frequent bowel movements, and steatorrhea. Using a fiber-contain- ing supplement such as psyllium, can reduce gas- trointestinal AEs. Orlistat prevents the lipid-soluble vitamins from being absorbed, so patients may need vitamin A, D, E, and K supplementation with long-term use.

The FDA approved phentermine/topiramate extend- ed release (Qsymia), a schedule IV-controlled sub- stance, for long-term obesity management in 2012. It suppresses appetite through mechanisms that remain unclear. Three RCTs found significant mean weight reduction ranging from 7.8% to more than 10% over 1 to 2 years. It was also associated with improved blood pressure, fasting glucose and insulin levels, lipid profiles, and waist circumference.

Patients take phentermine/topiramate once daily in the morning to avoid drug-related insomnia. Clinicians gradually escalate the dose from 3.75 mg/23 mg for 2 weeks to 7.5 mg/46 mg in the following weeks. After 3 months, they may increase the dose to 15 mg/92 mg if patients have not lost 3% of baseline weight. If patients lose less than 5% of weight or are intolerant to the drug, clinicians should gradually discontinue phentermine/topiramate to avoid seizure risk.

 Common AEs are constipation, dizziness, dry mouth, dysgeusia, insomnia, and paresthesia. Clinicians must periodically monitor creatinine, electrolytes, and heart rate.

 Contraindications observed are uncontrolled cardiovascular disease, chronic kidney disease, glaucoma, hypertension, hyperthyroidism, and inhibition of monoamine oxidase within 14 days. Women of childbearing age should avoid pregnancy, as the drug is linked to fetal oral clefts.

With 5 drugs available to manage obesity, clinicians should consider each drug’s mechanism of action before prescribing. Orlistat is more suitable for individuals who tend to eat fatty foods. The GLP-1 receptor agonists have no neuropsychiatric safety concerns and may be options for patients with comorbid mental disorders or T2D.

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14. Garvey WT, Ryan DH, Look M, et al. Two-year sustained weight loss and metabolic benefits with controlled-release phentermine/topiramate in obese and overweight adults (SEQUEL): a randomized, placebo-controlled, phase 3 extension study. 

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19. O’Neil PM, Aroda VR, Astrup A, et al. Neuropsychiatric safety with liraglutide 3.0 mg for weight management: results from randomized controlled phase 2 and 3a trials. 

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Increasing physical activities and reducing caloric intake isn’t always enough to conquer obesity.

Approved Medications Can Stimulate Weight Loss

Driven by the graying of America, more than 75% of all newly diagnosed cancers occur in people aged 55 or older. Oncology—and oncology pharmacists&mdash;are changing hats swiftly.

Traditionally, inpatient or outpatient oncology pharmacists checked and dispensed medication.

 This pivotal responsibility has since evolved. Pharmacists are progressively swapping their dispensing hats for clinical caps, thanks to technician assistance, technology advancements, and practice progression.

Jon Jankun, RPh, of Hallmark Health, indicates that his institution uses a 3-tiered review process. Pharmacists review chemotherapy orders, monitor pertinent tests, and send recommendations to prescribers if necessary. These functions exploit oncology pharmacists’ specialized knowledge of antineoplastics and supportive care for comorbidities as some begin to work in remarkably progressive roles.

Jay Patel, PharmD, of Banner MD Anderson Cancer Center in Gilbert, Arizona, reports, “I work with oncologists to decide what chemother- apy regimens and supportive care are required for patients based on specific factors—organ function, age, cancer stage, etc&mdash;and the evidence in the literature.”

With more than 800 drugs, biologics, and vaccines in development for cancer, the “drug expert” label keeps oncology pharmacists learning constantly.

 In 2016 alone, the FDA approved or modified indications for 18 agents (online table 1

), with some being subject to multiple actions. These ongoing developments create considerable formulary management responsibilities. For example, at Hallmark Health, oncology phar- macists are integral to the Oncology Pharmacy and Therapeutics (P&T) Committee. Like general P&T committees, this committee develops policies and procedures, periodically reassessing them. Pharmacists also present comprehensive information about new drugs proposed for possible formulary addition and evaluate ongoing uses of approved drugs.

The unprecedented numbers of oncology agents approved in the past few years translate to complex, targeted therapy. Qualified oncology pharmacists who practice in this field have become a treatment team’s critical drug information source. Because drug interactions are a serious concern,

 Dr. Patel indicates that he often collaborates with providers. For example, prescribers will typically ask the oncology pharmacist if antibiotics will cover infections without precipitating interactions in these heavily medicated patients.

Only 65% of patients nationally reported receiving education about their medications, according to the 2015 Hospital Consumer Assessment of Healthcare Providers and Systems survey.

 This large void can lead to poor outcomes. Lisa Holle, PharmD, of the University of Connecticut’s Neag Comprehensive Cancer Center, works directly with oncologists to promote patient care involvement. A quick review of online table 1 shows that new agents have novel mechanisms and narrow indications and that these agents are often approved with companion diagnostic or monitoring kits.

 Many also have boxed warnings. Oncology pharmacists need to be prepared to deal with cancer treatment’s increased complexity and to help patients as they receive more combination therapies and progressive lines of therapy.

Because cancer treatment increasingly relies on oral agents, Dr. Holle reminds us that patients sometimes carry their chemotherapy home, taking it without supervision. Therefore, Dr. Patel and Dr. Holle conduct medication therapy management (MTM) in the clinic and by phone. The intensive education delivered through MTM addresses drug interactions, food interactions, and adherence. This last item is especially important because missed doses could cause cancer recurrence or resistance. The results of a retrospective cohort study indicate that pharmacist monitoring contributes to suc- cessful treatment.

) have produced similarly positive results.

Dr. Holle reports that lacking prescriptive authority, oncology pharmacists cannot bill for services independently as midlevel providers do. Currently, only pharmacists who execute collaborative practice agreements can see patients independently. Legislature is the only alternative solution to this challenge.

 Ongoing role expansion will rely on the accumulation of data that show that pharmacists improve individual systemic outcomes.

Mr. De Lena is a 2017 PharmD candidate at the University of Connecticut. Ms. Wick is a visiting professor at the University of Connecticut.

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Pharmaceutical Research and Manufacturers of America. Medicines in development for cancer 2015 report. PhRMA website. phrma.org/report/medicines-in-development-for-cancer-2015-report. Published September 11, 2015. Accessed December 20, 2016.

Hospital Consumer Assessment of Healthcare Providers and Systems. Summary of HCAHPS survey results, January 2015 to December 2015 discharges. HCAHPS website. hcahpsonline.org. Accessed December 20, 2016.

FDA. Hematology/oncology (cancer) approvals & safety notifications, 2016. FDA website. www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm279174.htm. Updated December 19, 2016. Accessed December 21, 2016.

Buffery D. The 2015 oncology drug pipeline: innovation drives the race to cure cancer. 2015;8(4). American Health & Drug Benefits website. ahdbonline.com/issues/2015/june-2015-vol-8-no-4/1940-the-2015-oncology-drug-pipeline-innovation-drives-the-race-to-cure-cancer. Published June 2015. Accessed December 20, 2016.

Patel JM, Holle LM, Clement JM, Bunz T, Niemann C, Chamberlin KW. Impact of a pharmacist-led oral chemotherapy-monitoring program in patients with metastatic castrate-resistant prostate cancer. 

Simons S, Ringsdorf S, Braun M, et al. Enhancing adherence to capecitabine chemotherapy by means of multidisciplinary pharmaceutical care. 

 2011;19(7):1009-1018. doi: 10.1007/s00520-010-0927-5.

Edwards SJ, Abbott R, Edwards J, et al. Outcomes assessment of a pharmacist-directed seamless care program in an ambulatory oncology clinic. 

 2014;27(1):46-52. doi: 10.1177/0897190013504954.

Wong SF, Bounthavong M, Nguyen C, Bechtoldt K, Hernandez E. Implementation and preliminary outcomes of a comprehensive oral chemotherapy management clinic. 

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Lam MS, Cheung N. Impact of oncology pharmacist-managed oral anticancer therapy in patients with chronic myelogenous leukemia. 

Driven by the graying of America, more than 75% of all newly diagnosed cancers occur in people aged 55 or older. Oncology&mdash;and oncology pharmacists&mdash;are changing hats swiftly.

The Oncology Pharmacist: Taking the Helm in Medication Management

Taxis may not only be a reliable mode of transportation for urbanites—they may also be frequent transmitters of the flu virus.

Around 12% of New York City taxi riders are older than 70, sedentary, and at high risk for chronic disease and influenza. With 233,000 of these US taxi drivers having close contact with riders, taxis may be breeding grounds for communicable diseases.

Thus, immunizing taxi drivers could protect the drivers and their riders.

Researchers have not conducted intervention-based studies targeting influenza vaccination among taxi drivers—until now. A team from the University of Chicago published the results of their vaccination efforts of taxi drivers in the 

The researchers targeted taxi drivers at Chicago-area airport taxi holding lots. They were assisted by Spanish translators and had materials in English, Spanish, and Arabic.

The study used volunteer clinicians, and clinic support staff included nursing staff, physicians, physician residents, marketing personnel, and administrative support from the University of Chicago.

Taxis may not only be a reliable mode of transportation for urbanites-they may also be frequent transmitters of the flu virus.
