Natalie Espeso

Migraine headaches are a leading cause of disability that affect 1 in 6 Americans. Migraines negatively impact quality of life, daily functioning, and productivity.

Prophylactic treatment can reduce the frequency, severity, and duration of migraine attacks. Patients may benefit from prophylaxis if they routinely suffer from migraines (e.g., they have more than 6 headache days per month), are unresponsive to or unable to tolerate abortive therapies, or experience severe disability.

Guidelines recommend discontinuing prophylactic treatment if headaches are under control for at least 6 to 12 months.

 Examples of FDA-approved drugs for migraine prophylaxis include beta-blockers propranolol and timolol; anticonvulsants divalproex sodium and topiramate; and injectable calcitonin-gene related peptide (CGRP) inhibitors erenumab (Aimovig), galcanezumab (Emgality), and fremanezumab (Ajovy).

 published a prospective, longitudinal cohort study to evaluate 61 patients for changes in health-related quality of life after discontinuing a CGRP inhibitor for migraine prophylaxis.

Patients completed a headache-specific questionnaire (i.e., Headache-Impact-Test 6) and generic questionnaires (i.e., EuroQol-5-Dimension-5-Level, Short-Form 12) at the time of last monoclonal antibody injection, 8 weeks later, and 16 weeks later. Results revealed that after CGRP inhibitor discontinuation, the impact of headache increased, and general wellbeing declined.

Additionally, after treatment discontinuation, monthly migraine days (MMDs) increased. At the time of last injection, the mean MMDs was 8.59. At 16 weeks after the last injection, it increased to 12.84, a number similar to baseline MMDs prior to treatment.

Surprisingly, researchers found that patients can suffer from impaired quality of life during treatment discontinuation, even without a worsening of migraine frequency. This suggests that headache frequency is not the only factor influencing quality of life in patients with migraines. Fear of another attack, avoidance of certain activities, and social stigmatization are additional factors that can negatively impact patients’ lives.

Researchers observed that discontinuing erenumab led to a greater impairment of quality of life compared to discontinuing galcanezumab or fremanezumab. The exact reason is unknown, but it may be due to erenumab’s shorter elimination half-life of 21 days, as opposed to 27 days for galcanezumab and 30 days for fremanezumab.

The cessation of CGRP inhibitor treatment can negatively impact patients with migraines. Pharmacists must understand the value of monitoring changes in quality of life and headache frequency to help facilitate the decision to continue, discontinue, or restart migraine prophylaxis.

Natalie Espeso is a 2022 PharmD candidate at the University of Connecticut.

Peters GL. Migraine overview and summary of current and emerging treatment options. 

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https://www.ajmc.com/view/migraine-overview-and-summary--of-current-and-emerging-treatment-options

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https://www.aafp.org/afp/2019/0101/p17.html

Terhart M, Mecklenburg J, Neeb L, et al. Deterioration of headache impact and health-related quality of life in migraine patients after cessation of preventive treatment with CGRP(-receptor) antibodies. 

. 2021;22(1):158. doi:10.1186/s10194-021-01368-7

Articles

Pharmacists must understand the value of monitoring changes in quality of life and headache frequency to help facilitate the decision to continue, discontinue, or restart migraine prophylaxis.

The Consequences of Discontinuing CGRP Inhibitors in Migraine Patients 

HIV infects and destroys the immune system after being spread through contact with HIV-infected bodily fluids. In the United States, it most commonly spreads by anal or vaginal sex or by sharing drug injection equipment.

When thinking about ways to reduce the risk of HIV infection, what often comes to mind is to engage in safe sex practices and never share drug injection equipment.

However, many patients aren’t aware of another prevention option: pre-exposure prophylaxis (PrEP).

PrEP involves taking emtricitabine/tenofovir (Truvada or Descovy) to prevent high-risk individuals from contracting HIV. When taken as indicated, PrEP is highly effective, reducing the HIV risk from sex by 99% and from injecting drugs by at least 74%.

In a study published in the January 2022 issue of 

, a team of researchers from the Division of Infectious Diseases at Washington University School of Medicine evaluated baseline knowledge, opinions, and interest in PrEP among persons who inject drugs (PWID). More specifically, they interviewed 30 PWID hospitalized for serious injection-related infections (e.g., endocarditis, osteomyelitis).

Researchers found low overall awareness of PrEP. Only 2 study participants were already on PrEP and only 5 had heard about it previously.

Participants didn’t view HIV as a significant threat. They associated injection drug use (IDU) with a minimal risk of HIV transmission, perceiving it to be primarily a sexually transmitted infection (STI) that mostly affects men who have sex with men (MSM).

Researchers educated participants about HIV risk from IDU and PrEP as a valuable prevention method. However, participants expressed no interest in PrEP. 

Many believed PrEP was exclusive to MSM. They mentioned other methods, such as abstaining from IDU or using clean needles, were more effective in lowering their HIV risk. Notably, all participants had access to opioid use disorder treatments and needle exchange programs, which may have skewed their overall perception.

Despite high knowledge of harm reduction techniques with needle use, participants had a high STI rate (17%). This suggests that not all STIs among PWID are directly related to injecting but could be related to sexual behaviors and impaired judgement. None of the participants made the connection that a prior STI increases their risk of HIV infection.

This study found PWID had low baseline knowledge of PrEP, high stigma with PrEP, and little interest in starting PrEP even after education. This highlights the need to incorporate PrEP education more effectively in PWID. Pharmacists are well-positioned to address questions, concerns, and misconceptions that patients have about PrEP.

HIV and AIDS: The Basics. HIVinfo.NIH.gov. Updated August 16, 2021. Accessed January 13, 2022. 

https://hivinfo.nih.gov/understanding-hiv/fact-sheets/hiv-and-aids-basics

Pre-Exposure Prophylaxis. HIV.gov. Updated January 07, 2022. Accessed January 13, 2022. 

https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/pre-exposure-prophylaxis

Sayood S, Marks LR, Patel R, Nolan NS, Liang SY, Durkin MJ. Low Knowledge of HIV PrEP Within a Midwestern US Cohort of Persons who Inject Drugs. 

. 2022;9(1):ofab541. doi:10.1093/ofid/ofab541

PrEP involves taking emtricitabine/tenofovir (Truvada or Descovy) to prevent high-risk individuals from contracting HIV.

Low Knowledge of HIV PrEP Among Injection Drug Users

Maintaining oral health is essential to general health and well-being.

 Oral conditions affect more than just the mouth and teeth. Poor oral health increases the risk of developing chronic conditions, such as cardiovascular disease and diabetes.

The most common oral health problems include dental caries (tooth decay), periodontal disease (gum disease), and tooth loss. In the United States, more than one-fourth of adults have untreated tooth decay, and nearly half who are 30 years or older show signs of periodontal disease, which can lead to tooth loss if left untreated.

 Additionally, poor oral health can cause bad breath, dehydration, erosion of self-esteem, malnutrition, speech problems, and trouble eating and swallowing.

Dental caries develops when bacteria in the mouth metabolize sugars and produce acid that demineralizes the tooth’s hard tissues, causing a breakdown of the surface. Initial stages may be symptomless, but disease progression is associated with dark spots, toothache, and tooth sensitivity. Periodontal disease develops because of bacteria in dental plaque. The immune system attempts to eliminate the bacteria by releasing inflammatory substances, resulting in bleeding, swollen gums.

Acidic and sugary foods, poor oral hygiene, certain medications, and tobacco use can contribute to the development and progression of oral diseases. Pharmacists can help patients incorporate good oral hygiene practices into their routines, such as properly brushing their teeth twice daily with a fluoride toothpaste, flossing daily, and replacing toothbrushes at least every 3 months.

 Rinsing with a mouthwash can provide additional benefit, but it should not replace optimal brushing and flossing.

 Many OTC oral care products are available to meet patients’ needs (Table 1

). Additionally, both manual and powered toothbrushes are effective with proper technique, but individuals with limited dexterity may find it easier to use powered toothbrushes.

When applied topically and ingested systemically, fluoride prevents tooth decay. Water naturally contains fluoride but at levels too low for dental benefit. Many communities fluoridate their drinking water, which is a highly effective practice. Individuals should contact their water utility provider to determine local fluoride levels.

Those without fluoridated water should talk to their doctor about taking systemic fluoride supplementation, including oral lozenges and tablets.

In terms of diet, pharmacists should reinforce healthy eating habits, such as limiting acidic and sugary beverages and foods, which are the main culprit
behind tooth decay and erosion. Sugar may hide in several liquid medications, so it is imperative to read the label and suggest sugar-free alternatives if possible.

 For example, patients could easily swap Robitussin Cough and Chest Congestion DM, which contains 2.3 g of sugar per 5 mL, 12 with its sugar-free alternative.

Smoking cessation is another area for pharmacist intervention. Smoking cessation decreases the risk of oral cancers, periodontal disease, poor oral wound healing, and premature tooth loss.

Some OTC and prescription medications have unintended adverse effects (AEs) that affect oral health. The most common medication-induced oral condition is xerostomia (dry mouth), and more than 400 medications are known to cause dry mouth (Table 2

). Insufficient saliva secretion dries the oral tissues and reduces buffering capacity, which alters normal flora. This leads to an array of problems, including increased susceptibility to infection, tooth decay, and trouble chewing and swallowing.

Medication-induced dry mouth is often reversible. Pharmacists can recommend discontinuing the offending agent and switching to one with less potential to cause dry mouth.

 Furthermore, pharmacists can advise patients to chew sugar-free gum or suck on sugar-free candies to promote saliva flow, frequently sip water, and limit intake of alcohol, caffeinated beverages, and tobacco.

Other medication-induced oral conditions include altered taste, gingival hyperplasia, and infections (Table 2

). To develop strategies to manage and prevent these AEs, pharmacists must be able to identify the offending agents.

To maintain good oral health, referrals to a dentist when warranted and regular dental checkups are crucial. Unfortunately, many patients have barriers to dental care, and pharmacists may be the first or only contact with a health professional. Pharmacists are well positioned to help patients take care of their dental needs and promote oral health awareness.

 at the University of Connecticut School of Pharmacy in Storrs.

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6. Mouthrinse (mouthwash). American Dental Association. Updated December 1, 2021. Accessed January 5, 2022. https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/mouthrinse-mouthwash

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8. Toothbrushes. American Dental Association. Updated February 26, 2019. Accessed January 5, 2022. https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/toothbrushes

9. Community water fluoridation. CDC. Updated April 1, 2016. Accessed January 6, 2022. https://www.cdc.gov/fluoridation/faqs/community-water-fluoridation.html

10. Fluoride: topical and systemic supplements. American Dental Association. Updated July 15, 2021. Accessed January 6, 2022. https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/fluoride-topical-and-systemic-supplements

11. Pharmacy. Oral Health Foundation. Accessed January 5, 2021. https://www.dentalhealth.org/pharmacy

12. Donaldson M, Goodchild JH, Epstein JB. Sugar content, cariogenicity, and dental concerns with commonly used medications. 

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13. Lam A. Medications and oral health. Aging Well. Accessed January 5, 2021. https://www.todaysgeriatricmedicine.com/archive/083109p22.shtml

14.ADA Division of Medications. For the dental patient. How medications can affect your oral health. 

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15.Higgs G. Medications and their effects on oral health. Guidelines for Nurses. June 17, 2019. AccessedJanuary 5, 2021. https://www.guidelines.co.uk/expert-articles/medications-and-their-effects-on-oral-health/455380.article

Tooth decay and loss, periodontal disease increase the risk of developing chronic conditions.

Maintaining Oral Health Is Essential to Well-Being

The lifetime risk of developing shingles, a viral infection characterized by a painful rash, is 20%-30%. After varicella zoster virus causes chickenpox, it remains dormant in the central nervous system and can later reactivate to cause shingles.

The rash will eventually clear, but complications may be long-term or permanent. These complications include postherpetic neuralgia (PHN), skin necrosis, bacterial superinfection, and ocular problems.

 published a retrospective study that analyzed the medical records of 355 shingles patients treated at the University Hospital of Basel, Switzerland between 2005 and 2019.

 The researchers found that complications and hospitalizations are the main drivers of shingles-related treatment costs.

The study population had a complication rate of 30% (with PHN as the most common complication), a hospitalization rate of 19%, and a mortality rate of 0.85%. Complications increased costs by a factor of 4.3 in outpatients and 6.6 in inpatients. Hospitalization increased costs by a factor of nearly 27.

Consistent with findings from other studies, researchers found age to be a significant risk factor for shingles complications. For each additional year of age, the odds for a complication increased by 3.5%.

Even more concerning, for each additional 10 years of age, the odds for a complication increased by 40%. A large spike in cases and complications occur in adults 50 years of age and older, suggesting this age group would benefit the most from shingles vaccination. This aligns with the US Advisory Committee on Immunization Practices (ACIP) recommendations.

Cancer, including both solid and hematological cancers, is another risk factor significantly associated with a higher complication rate. This was true even in younger patients, suggesting an age-independent association. Swiss vaccine guidelines have yet to incorporate this fact.

But interestingly, in October 2021, the US ACIP unanimously voted to expand shingles vaccine recommendations to adults 19 years of age and older with immunocompromising conditions (e.g., cancer). This recommendation is still pending review and approval.

Shingrix, the recombinant shingles vaccine, is more than 95% effective in preventing shingles infection, which will subsequently prevent shingles-related complications and hospitalizations, and thus drive down treatment costs. This study supports the notion that older adults and patients with cancer are at increased risk for complicated shingles. Thus, they should be the focus of vaccination efforts.

Pharmacists must stay up to date with current immunization recommendations and clinical studies to help patients make informed decisions about getting vaccinated.

Ms. Espeso is a 2023 PharmD candidate at the University of Connecticut.

Bongers LD, Navarini A, Berger CT, Mueller SM. Complications and cost estimations in herpes zoster – a retrospective analysis at a Swiss tertiary dermatology clinic. 

. 2021;151:w30081. Published 2021 Dec 28. doi:10.4414/smw.2021.w3008

Hicks L. ACIP Recommends Shingrix for Younger Immunocompromised Adults; Updates Pneumococcal Vaccine Guidance. Medscape. 2021. Accessed January 10, 2022. 

https://www.medscape.com/viewarticle/961385

After varicella zoster virus causes chickenpox, it remains dormant in the central nervous system and can later reactivate to cause shingles