Marilyn N. Bulloch, PharmD, BCPS, FCCM

In 2008, the United Nations recognized June 19 as World Sickle Cell Disease Day with the goal of increasing awareness of a prevalent genetic disease at the international level, sickle cell disease (SCD). Although millions of people worldwide have SCD, there are approximately 100,000 Americans currently diagnosed and roughly 1 in 13 African Americans carry the sickle cell trait.

Notably, the role of the pharmacist in SCD management revolves around appropriate pain management, because the disease is known for its episodes of pain, as well as preventative therapy against sickle cell crisis. SCD manifests due to a single base substitution found in the beta-globin gene of chromosome 11, which results in valine replacing glutamic acid producing sickle shaped hemoglobin S instead of the typical disk-shaped hemoglobin A.

The altered shape subsequently triggers the vaso-occlusive events (sickle cell crisis) that lead to the acute and chronic pain of these patients. Because pain is so subjective and variable among these patients, it makes management difficult in this population, allowing pharmacists to step-in to optimize treatment regimens.

In acute management, pharmacists can ensure adequate dosing, medication, and administration routes because these patients typically have developed drug tolerance requiring higher doses of IV pure opioids, and their hypoxemic state, combined with poor venous access, suggests these patients may get more benefit from oral or subcutaneous administration.

Following acute treatment, pharmacists can be essential in managing these patients’ chronic pain medications by ensuring they effectively treat the pain while using the safest long-term option. A few examples include making sure patients are tapered off opioid treatment following acute attacks to avoid withdrawal symptoms, completing frequent monitoring of hepatic and kidney function due to potential weakening from compensating for hematologic abnormalities to ensure appropriate dosing, use of adjuvants for additional symptom relief, and management of long-term use of opioids, such as constipation.

Furthermore, with the opioid crisis making access to these necessary medications much more difficult for this patient population, pharmacists should serve as advocates for improved access as well as educators to prescribers that are hesitant.

 Management of SCD generally should also include measures to prevent sickle cell crisis.

Hydroxyurea has been the mainstay treatment option for the prevention of pain episodes, acute chest syndrome hospitalization, and blood transfusions, due to its ability to prevent vaso-occlusive events.

 Patients who have 3 or greater pain episodes in a year should be considered for initiation of hydroxyurea.

The pharmacist should confirm doses are optimized based on weight, age, hemoglobin F levels, and level of myelosuppression.

 Adherence with hydroxyurea may be a challenge in some patients.

Pharmacists can help improve adherence through several traditional methods. Routine counseling sessions following hospital initiation of hydroxyurea on the importance of medication adherence for optimal results and the education on what to practically expect based on the medication’s adverse effect profile can increase understand expectations of the treatment to hopefully improve adherence rates.

In turn, this may help reduce sickle cell crisis and subsequent hospitalizations and/or opioid use. Because hydroxyurea is classified as pregnancy category D, all patients initiated on it, other health care providers, and potentially pregnant women should be counseled on the risks of this medication to fetal development and address other treatment options following discontinuation of hydroxyurea.

Considering the age demographics of SCD include more patients of a younger age than many common comorbidities, the recognition of the risk in pregnancy is vital. Although there is some literature that provides more optimistic data on hydroxyurea in pregnancy, the severity of the teratogenic effects, particularly in early pregnancy, are profound enough that some experts recommend stopping the medication before the patient becomes pregnant.

On the other hand, hydroxyurea therapy may be considered in rare cases during the second and third trimesters in which the risk of not being on the medication is thought to substantially outweigh the risk to the baby.

More recently in 2017, the FDA approved an additional prevention medication, 

 (L-glutamine oral powder), for SCD patients older than 5 years of age, which can be added on to hydroxyurea to prevent sickle cell crises.

 Although pharmacist counseling points and management is similar to hydroxyurea, administration counseling is more important because the medication must be taken twice a day and dissolved in a liquid.

Endari is much more expensive than hydroxyurea, making access to this medication significantly difficult. Because SCD patients may pay significant out-of-pocket costs for their treatment even with private insurance, pharmacists can play a huge role in advocating for improved affordability of care.

While pharmacologic management is essential in SCD pain management and preventative options, nonpharmacologic management is a key role pharmacists play in this population as well. Some examples of this include cognitive behavioral therapy, massage therapy, acupuncture, participation in social support groups.

In all patient care settings, pharmacists can discuss and connect patients with resources to improve and prevent severe pain episodes. Furthermore, pharmacists are optimally placed to provide patient-specific counseling to parents of young individuals diagnosed with SCD because management can be difficult.

SCD is one of the most common genetic diseases in the world. With treatment options being minimal and medication adherence rates typically being low, there is a clear need for intervention and improvement in the management of this patient population.

Pharmacists can address these gaps by increasing patient counseling on preventative medications, managing acute and chronic pain regimens, and arguably the most important, providing thorough education to patient, caregivers, and other health care team members.

World sickle cell day - friday 19th june 2020 // Sickle Cell Society

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Opioid crisis adds to pain of sickle cell patients

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The Cost of Living with Sickle Cell Disease

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Sickle Cell Disease: A Review of Nonpharmacological Approaches for Pain: Review Article 

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Articles

The role of the pharmacist in sickle cell disease management revolves around appropriate pain management.

World Sickle Cell Day: The Pharmacist’s Role in Medication Management 

 awareness is globally recognized every year during the month of June to illuminate the second most common disability in the world.

 Although head pain only accounts for fewer than 5% of acute medical care, migraines impact more than 1 billion people worldwide.

Migraines can result in an invisible struggle in which 1.3 years of the patient’s life is lost to debilitating discomfort.

 Migraines are often multifactorial and patient-specific, which causes accessible patient care and efficacious treatment to be sparce and overlooked.

Unfortunately, patients suffering from chronic headaches have a 2.49-fold higher risk of suicidal ideation and are 3 times more likely to suffer from depression.

 The increased negative health outcomes associated with migraines provide an opportunity for pharmacists in both the inpatient and outpatient setting to support patients suffering from this complex disability.

Within the outpatient setting, misuse of OTC headache agents, such as Excedrin, is frequent among patients and can cause a vicious cycle of chronic headache pain because of overuse. While medication overuse headaches (MOH) are a common topic of discussion within pharmacy, a questionnaire study in 2014 displayed that continuing education centered around MOH may be needed for pharmacy staff.

Out of 228 questionnaires dispersed to 44 pharmacies’ staff members, 90.6% of the respondents rated themselves as knowledgeable in MOH due to professional education, yet only 8.6% correctly indicated which medications can cause MOH.

 This discrepancy between self-perceived knowledge and actual knowledge can negatively impact migraine recommendations in retail pharmacies.

Therefore, continued education surrounding MOH can create a great learning opportunity for pharmacy staff to provide appropriate OTC advice to prevent MOH in the future.

Pharmacists practicing within acute care settings can also play a major role in improving migraine management. The American Headache Society’s guidelines for the Management of Adults with Acute Migraine in the Emergency Department recommends avoiding the use of injectable morphine and hydromorphone; however, opioids continue to be used in more than 50% of migraine emergency department (ED) visits.

A meta-analysis examining the relative efficacy of frequently used meperidine compared to nonopioid comparators displayed that dihydroergotamine is more effective than meperidine (odds ratio 0.3), with meperidine having the most similar efficacy to ketorolac (odds ratio 1.75).

 The increased opioid use in migraine management is associated with several negative outcomes, such as chronic migraines, prolonged acute care visits, and increased disabling episodes without increased efficacy in abortive treatment.

Consequently, inpatient pharmacists can share these data with other providers and promote the use of nonopioid agents in the abortive treatment of migraines to prevent the harm associated with opioid use in this patient population. The direct and indirect health expenses of migraine management in the United States is estimated to cost $14 billion annually, and this estimation does not include each patient’s additional economic burden that results from their many missed workdays.

This economic loss creates an incentive for the creation of new migraine treatment options that all pharmacists should be aware of. New preventative agents like 

 have novel mechanisms that can provide more patient-specific care when first-line treatment fails.

In an observational study of participants who had failed 2 or more preventative treatments, 69.7% of those who had received 3 doses of erenumab had a 50% decrease in monthly migraine days and 71.9% no longer suffered from MOH.

 These recent advances in migraine pharmacology provides pharmacists with another weapon to recommend from their drug arsenal when all other migraine options are exhausted.

Altogether, the detrimental impact that migraines have on health costs and personal burden creates several opportunities for pharmacists to adopt an expanding role in its management within both inpatient and outpatient settings. As the most accessible health care provider, pharmacists should strive to remain competent in MOH treatment through migraine-focused continued education to properly recommend patients on appropriate OTC agents.

To follow the ethical duty of “Do No Harm,” pharmacists should promote evidence-based nonopioid treatment for abortive therapy within the ED. Pharmacists should be proactive and remain up to date on recent literature and novel agents to better aid physicians with complex patient cases.

All these roles are critical factors in helping to advocate for the appropriate management of debilitating headaches while assisting patients in decreasing the disabling impact of migraine attacks and recurrent treatment failure.

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Doretti, A., Shestaritc, I., Ungaro, D. 

 Headaches in the emergency department –a survey of patients’ characteristics, facts and needs. 

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Hedenrud T, Babic N, Jonsson P. Medication overuse headache: Self-perceived and actual knowledge among pharmacy staff. 

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Dodson H, Bhula J, Eriksson S, Nguyen K. Migraine Treatment in the Emergency Department: Alternatives to Opioids and their Effectiveness in Relieving Migraines and Reducing Treatment Times. Cureus. 2018 Apr 6;10(4):e2439. doi: 10.7759/cureus.2439. PMID: 29881652; PMCID: PMC5990028.

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Bonafede M, Cai Q, Cappell K, Kim G, Sapra SJ, Shah N, Widnell K, Winner P, Desai P. Factors Associated with Direct Health Care Costs Among Patients with Migraine. J Manag Care Spec Pharm. 2017 Nov;23(11):1169-1176. doi: 10.18553/jmcp.2017.23.11.1169. PMID: 29083975.

Ornello, R., Casalena, A., Frattale, I. et al. Real-life data on the efficacy and safety of erenumab in the Abruzzo region, central Italy. 

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The increased negative health outcomes associated with migraines provide an opportunity for pharmacists in both the inpatient and outpatient setting to support patients.

Migraine Awareness Month: A Pharmacist’s Role in Dynamic Management

, recognizing a disease that can be both acute or chronic as well as infectious and non-infectious.

Hepatitis can have a widespread impact on the health

 and pharmaceutical needs of patients. It also carries a stigma that may make patients hesitant to seek treatment or disclose their condition.

As a result, providers may not be aware of unique pharmacotherapy requirements these patients may have. Prevention, optimal disease state management, and appropriate pharmacokinetic and therapeutic attention are all part of the holistic approach to hepatitis care.

Many of patients with hepatitis that pharmacists encounter have viral hepatitis, which can be easily remembered as the ABCs of hepatitis. Starting with the A for hepatitis A virus (HAV), the Centers for Disease Control and Prevention’s Division of Viral Hepatitis has noted an increasing number of HAV cases since March 2017.

This is thought to be linked to imported foods that had been contaminated, causing primary infection continuing to spread from person-to-person. HAV infection can be prevented through a vaccine, good hygiene, and patients decreasing their risk factors.

Promoting the HAV vaccine to patients, especially those at high risk of HAV infection, can be arguably the best preventative measure to ensure a patient’s safety, as HAV can result in cholestatic hepatitis, relapsing hepatitis, autoimmune hepatitis or even liver disease. Just one dose of inactivated HAV vaccine can provide protection from HAV for up to 11 years.

Risk factors for contracting HAV include illicit drug use, sexual contact with a person infected with HAV, contact with a person infected with HAV, homelessness, and travel to countries where HAV is prevalent including, Saudi Arabia, Syria, Turkey, and Eygpt.

 The spread of HAV can be reduced through good hand hygiene after using the restroom following contact with body fluids or stool, and through avoiding unsanitary food and water sources.

The role of the pharmacist has been highlighted in various HAV outbreaks across the United States. Once such pharmacist, Dr. Monica Payne, a pharmacist from Section, Alabama, was on the front lines of fighting HAV in her community during an outbreak in 2019.

“The hepatitis A outbreak in 2019 was a trying time for our community, but it was also an excellent opportunity for pharmacists to show what we can do as the most accessible healthcare providers,” Payne said

In late 2018, North Alabama, including Jackson County and Section, saw the start point of an outbreak that eventually made its way through the entire state by the end of 2020.

 Payne’s community pharmacy, Section Pharmacy, worked with the Alabama Department of Public Health to provide vaccine clinics in rural areas near Section where many patients did not have adequate transportation to a pharmacy or prescriber's clinic.

“We vaccinated hundreds of individuals across Jackson County to help control the outbreak, and we were proud to do our part in protecting the health of our community,” Payne said.

In contrast to HAV, there has been a steady decrease in hepatitis B virus (HBV) cases over the past 10 years. HBV prevalence has decreased in correlation with an increased vaccine prevalence. From 1999 to 2018, infection rates decreased from 5.7% to 4.3% with higher rates in men and non-Hispanic, Asian adults.

HBV can be contracted through sexual contact, contaminated blood, or be passed from mother to newborn. Due to this, vaccination was advocated for newborns and is correlated with today's decreased past and current cases of HBV.

It is important to continue to advocate for the HBV vaccine to all patients as severe complications can lead to cirrhosis, liver failure or kidney disease. During the years of 2015-2018, 25.2% of adults over 18 years of age had been vaccinated for HBV.

 Women had a higher prevalence of vaccination history, which would correlate with women having a lower prevalence for being infected.

These numbers and correlations of infections to vaccinations clearly depict a linear relationship of vaccinations lowering the number of infections and is why pharmacists should advocate for all patients to be fully vaccinated.

 A study published in 2020 showed clinically significant data that clinical pharmacists improved the attitude of patients living with HBV toward their infection and increased their knowledge about HBV through interviews.

During these interviews the pharmacists elicited what the patient currently knew about the disease, corrected any misinformation, and then further educated them about HBV. After the interviews, patients indicated that their attitudes toward HBV had improved now that they had gained more knowledge about the disease.

Also, as a rule, the better educated a patient is about their condition, the more likely they are to be adherent to their medication and non-pharmacological recommendations, improving patient outcomes.

Unlike HAV and HBV, hepatitis C virus (HCV) is more common in the United States. An estimated 2.4 million Americans are currently living with HCV.

In 2018, a conservative estimate of 14,242 deaths in the United States were reported as a result of chronic HCV.

Although this number continues to decline each year, pharmacists still need to promote the importance of risk reduction and frequent testing of those at high risk because complications of HCV can result in cirrhosis or liver cancer.

HCV is spread through contact with blood from an infected person and no vaccine is currently available for prevention. Pharmacists should encourage patients to get tested for HCV, because it often has no signs or symptoms and can lead to liver cancer if left untreated.

One population of high risk that pharmacists should recommend screening for are those born between the years 1946-1964, also known as the Baby Boomers. Risk reduction and early diagnosis are the best ways to increase the patient’s chances of a positive prognosis.

Talk with your peers about their comfortability level of performing point-of-care testing and providing basic education about HCV. A survey in 2019 was sent out to pharmacists in community settings that inquired about their comfortability level of performing point of care testing and patient education for HCV.

This survey concluded that the pharmacists surveyed were in support of the implementation of HCV point of care testing and that they would be willing to provide basic patient education.

 Having community pharmacists available for HCV testing could open the door for many patients who may feel more comfortable not going to a physician’s office and feel more comfortable with their pharmacist.

In the same mindset, National Hepatitis Testing Day is May 19. Use this day as an opportunity to discuss the importance of testing with patients to help protect themselves and others around them.

One study illustrated the impact clinical pharmacists have on the outcomes of patients with HCV and HIV coinfections. The most notable roles the pharmacist played within the study included HCV medication adherence counseling, HCV drug-drug interaction counseling and screening, HCV medication counseling regarding common adverse events (AEs), HCV counseling regarding HCV treatment outcomes and risk of reinfection, ordering laboratory tests, and interpreting the HCV laboratory values.

The study was conducted to compare AEs and outcomes between groups of patients who had contact with a clinical pharmacist versus those who did not. The results were in favor of a clinical pharmacist’s expertise as part of a multidisciplinary care team to decrease AEs, increase favorable outcomes, and have better drug management for patients living with HCV/HIV coinfections.

Studies such as these show the importance of pharmacists caring for patients with special pharmacokinetic indications, like hepatitis.

In addition to HAV, HBV, and HCV, there is also acute non-viral hepatitis. Acute non-viral hepatitis can stem from exposure to some medications, illegal drugs, alcohol overuse, and toxins.

Some autoimmune diseases can also lead to acute hepatitis, especially when they go uncontrolled for a prolonged period of time.

 These autoimmune diseases include thyroiditis, type 1 diabetes, hemolytic anemia, and celiac disease.

This illness results in inflammation of the liver that could progress to liver disease. In 2021, cases of acute non-viral hepatitis with unknown etiologies were suspected to have been derived from “Real Water” alkaline water, a brand that was recalled due to lack of compliance with the FDA.

Pharmacists can counsel patients to not consume products not approved by the FDA, help control any other comorbid conditions patients have, and to watch for signs and symptoms, such as fatigue, fever, abdominal pain, and joint pain.

Take time to educate patients on all-things hepatitis during the month of May. Educate patients on available vaccines, regular testing, and risk factors for contracting HAV, HBV, and HCV, as well as non-viral hepatitis.

Promote patient testing and immunizations, educate yourself on ways to promote hepatitis awareness, new testing procedures, and new treatment methods when available. Aside from educating patients, take the time to educate other health care professionals around you about the importance of hepatic dose adjustments for patients who have liver diseases.

It is instinct for many providers to double-check renal dose adjustments, but many may be unaware of the need for modifying the dose of drugs that are hepatic cleared to keep the patient safe and the drug at therapeutic concentrations. Overall, pharmacists hold a unique role in fighting hepatitis because of their extensive knowledge of pharmacokinetics and pharmacodynamics when treating hepatitis and preventing further liver damage.

Pharmacists are also the most easily accessible health care provider and can provide a safe and convenient space for patients to get tested and vaccinated against hepatitis.

“Widespread Outbreaks of Hepatitis A Across the U.S.” 

Centers for Disease Control and Prevention

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Bahap, M., Kara, E., Cagla Sonmezer, M., Inkaya, A. C., Aydin-Hakli, D., Unal, S., & Demirkan, K. (2021). Pharmacist intervention to improve patients' knowledge and attitude towards hepatitis B infection. 

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Learn more about hepatitis C and about getting tested

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Table 3.7 of 2019 Viral Hepatitis Surveillance Report

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Investigation of Acute Non-Viral Hepatitis of Unknown Etiology Potentially Associated with an Alkaline Water Product. 

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Many of patients with hepatitis that pharmacists encounter have viral hepatitis, which can be easily remembered as the ABCs of hepatitis.

Hepatitis Awareness Month: Help Your Patients Live(r) Longer

March is Bleeding Disorders Awareness Month, which gives pharmacists the opportunity to advocate for and honor patients with bleeding disorders. Having a bleeding disorder can put a patient at risk of a hemorrhage and death.

There are approximately 3 million people nationwide who are affected by bleeding disorders.

 Approximately 30,000 people in the United States are thought to have hemophilia, whereas approximately 1 in every 100 people are affected by von Willebrand disease.

One of the most important roles a pharmacist can play in the treatment of patients with bleeding disorders is counseling on the symptoms of bleeding, which include but are not limited to easy bruising, bleeding gums, heavy bleeding from small cuts, and nosebleeds. Making sure patients are aware of these signs can be lifesaving.

Another important role pharmacists can play in bleeding disorders is providing medication counseling and reconciliation for patients with bleeding disorders and individuals taking high bleed risk medications. Through medication counseling, pharmacists can warn these patients about the risk of using medications that may cause bleeding.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are found in most households and can pose the risk of bleeding when used inappropriately. Pharmacists can counsel patients on how to safely use NSAIDs and identify which patients should not use them.

In 2018, a study was done on the effect of a pharmacist-driven monitoring program and electronic health record on bleeding log completeness, documentation in an electronic health record (EHR) and pharmacist-driven clinical interventions.

 During this pharmacist-driven monitoring program, a pharmacist was placed in a hemophilia treatment center (HTC) 4 hours per week to provide patient education and help build interdisciplinary relationships with the care team.

While bleeding logs have been the standard of care for determining adherence in patients with bleeding disorders, the study showed that implementation of this program improved bleeding log completeness and documentation in the EHR among the HTC patients with bleeding disorders.

Another study developed by pharmacists focused on a Hemophilia Management Program. This program was designed to improve care, reduce spending, and expand clinical pharmacy services.

In total, implementation of the Hemophilia Management Program resulted in a net savings of 2.7 million for the fiscal year 2017. Some of this cost savings is attributed to the pharmacist’s early identification of patients needing clotting factors and use of the 340B Drug Pricing Program, which also effectively reduced the need for blood transfusions per patient.

Pharmacists can close the gap in care for patients with high-risk diseases, leading to better outcomes, patient education, and cost savings. As a pharmacist, whether in the clinical or the community setting, take the time to educate yourself and your patients on the risks of bleeding and early recognition of a possible bleed.

1. Bleeding Disorders. American Society of Hematology https://www.hematology.org/education/patients/bleeding-disorders Accessed February 7, 2022.

2. Shay B, Kennerly-Shah J, Neidecker M, et al. Effect of a Pharmacist-Driven Monitoring Program and Electronic Health Record on Bleeding Log Completeness and Documentation. 

. 2018;24(10):1034-1039. doi:10.18553/jmcp.2018.24.10.1034

3. Slocum, GW, Peksa, GD, Webb, TA, Lat, I. Implementation of a hemophilia management program improves clinical outcomes. 

. 2019; 2: 236– 242. https://doi.org/10.1002/jac5.1061

Pharmacists are an important part of the care team for patients with bleeding disorders, providing services such as medication counseling and reconciliation.

The Pharmacist’s Role in Bleeding Disorders

Birth defects affect approximately 3% of all babies born in the United States each year, affecting roughly 1 baby born every 4 and a half minutes, which makes birth defects the leading cause of infant death in the United States.

To raise awareness of this issue, March 3 was recognized as National Birth Defects Awareness Day. Because approximately 1 in 10 birth defects are caused by the use of teratogenic medications, pharmacists have multiple roles in prevention of these birth defects.

Roughly 6% of pregnancies in the United States are exposed to potentially teratogenic medications because of various reasons, such as 1 in 6 women being prescribed a teratogenic medication each year, approximately half of US pregnancies are unplanned, and there is a lack of pre-pregnancy health counseling.

Based on these statistics, it is essential that women are informed of these risks anytime they take a potentially teratogenic medication because most birth defects are likely to happen early in pregnancy before women become aware they are pregnant. Pharmacists are in a prime position to meet this education and counseling demand because they are the most accessible health care provider to aid in safe OTC therapy in the community as well in dispensing of medications.

More than 90% of women take at least 1 OTC or prescription medication while pregnant, and in the past 40 years, the number of women using 4 or more medications during pregnancy has more than doubled.

 Some examples of common teratogenic OTC medications are aspirin, guaifenesin, and pseudoephedrine.

In contrast, there are also certain vitamins and minerals necessary for appropriate fetal development, and if intake is not adequate, it can lead to birth defects. For example, inadequate folic acid intake during pregnancy increases the risk of neural-tube defects.

With the increasing amount and complexity of medication regimens of the general population, it is also necessary to increase access to preconception and pregnancy care, which pharmacists can do in all practice settings. For example, in the community setting, pharmacists can intervene when pregnant patients are selecting aspirin as a pain reliever when acetaminophen may be a safer option.

A prescription medication of current importance is molnupiravir because of its evolving role in COVID-19 treatment. Molnupiravir has been found to have fetal harm concerns based off findings from animal reproduction studies, including malformation of the eye, kidney, and axial skeleton, as well as rib variations.

 This risk is transmitted through both females and males of reproductive age.

Because COVID-19 treatment is constantly changing and management can be complex, pharmacists are in an ideal position to notify providers and patients of this risk and how to avoid potential harm. In an inpatient and ambulatory care setting, pharmacists can serve as essential managers of complex drug regimens directly. Pharmacists can also assist through the development of educational handouts on how to minimize medication-induced birth defects, conducting a periodic review of medications stocked on obstetrician floors, and using the most up-to-date information when developing or modifying order sets to make sure they align with recommended guidelines and pose the lowest risk of fetal harm.

A group of medications associated with birth defects that pharmacists have vast potential to address in the prevention of fetal harm are opioids. In 2019, the National Survey on Drug Use and Health documented that approximately 6.6% of pregnant women reported using a prescription opioid and 21% of them reported opioid misuse.

Furthermore, 31.9% of women reported that they never received information about how the use of opioids could affect a fetus. This gap could be addressed by pharmacists in community settings, office visits, and even discharge counseling from the hospital by providing education on opioids and their potential fetal effects, monitoring for substance misuse, and providing awareness for social support services.

A more unique role that pharmacists can be involved in for the prevention of birth defects is being aware of and informing other health care providers about rarer drug-induced birth defects, such as the association between lithium use early in pregnancy with an increased risk of Ebstein’s anomaly, as well as management of these medications during pregnancy.

For example, if a pharmacist was presented with a situation in which a pregnant patient was picking up a prescription for a psychotropic with minimal potential risk of fetal harm, such as olanzapine, and the patient was concerned about the switch from lithium, this is a prime opportunity to counsel on why it was necessary to switch medications, what other options may be needed in the future, as well as general pregnancy health education.

Lastly, it is important to note that vaccine hesitancy is a significant barrier in pregnant women receiving recommended 

 Tdap vaccines because the passive immunity significantly reduces the risk of influenza and pertussis illness among infants during the first few months.

 Pharmacists need to be familiar with these vaccines to appropriately address pregnant women's concerns, recommend necessary vaccines, and provide accurate counseling to help increase vaccination rates in pregnant women to help prevent infectious diseases that result in birth defects.

With nearly 120,000 babies born with birth defects each year in the United States, which has an unusually high infant mortality rate for a developed nation, it is imperative steps be taken to reduce the rate of these events.

 Although pharmacists have had a major role in counseling on common teratogenic medications and appropriate alternatives, their expertise and diverse positions in the community places them in a key position to fill in the counseling and education gap on potentially teratogenic medication to other health care members and the general population, assist in contraceptive needs, administer recommended vaccinations, and provide preconception and pregnancy care in order to reduce these risks.

Centers for Disease Control and Prevention. (2021, December 8). 

. Centers for Disease Control and Prevention. Retrieved December 13, 2021, from https://www.cdc.gov/ncbddd/birthdefects/index.html.

Drug-induced birth defects - teratogenic drugs - causes - effects - faqs

. Medindia. Retrieved December 13, 2021, from https://www.medindia.net/patients/patientinfo/drug-induced-birth-defects.htm.

Schwarz, E. B., Parisi, S. M., Handler, S. M., Koren, G., Shevchik, G., & Fischer, G. S. (2013). Counseling about medication-induced birth defects with clinical decision support in primary care. 

It is essential that women are informed of the risks of potentially teratogenic medications because most birth defects are likely to happen early in pregnancy before women become aware they are pregnant.