 clinical forum on hemophilia A, panelists discussed effective management of hemophilia A and considerations for specialty pharmacy.

The panelists started the discussion by addressing how to identify the ideal patient for prophylactic factor VIII.

Atta Chowdhry, director of the hemophilia program and regional director of operations at Amerita Inc, said individuals who are more active are ideal patients for factor VIII. Panelist Natalie Watkins, PharmD, clinical manager at CVS Health, added that patients who self-infuse are also ideal, and Becca Moorman, PharmD, RPh, noted that individuals who have heart stents are good candidates for factor VIII.

The ideal patients for initiation of emicizumab include individuals who are tired of self-infusing and are looking for a more convenience, said Mahdi Al Hallaq, RPh, pharmacist-in-charge at SandsRx. Before the COVID-19 pandemic, there  was a trend toward switching patients to emicizumab-kxwh (Hemlibra; Genentech), although he said the pandemic may have interrupted this shift.

“Once the pandemic hit, we saw a halt at BioMatrix in general,” said Kim Epps, PharmD, CSP, vice president and general manager for bleeding disorders at BioMatrix Specialty Pharmacy. “Patients weren’t going to clinic; they were doing virtual visits and they weren’t ready to switch in that environment.”

About 1 or 2 out of every 10 patients per month have a conversation about switching, Hallaq said.

Moorman said when counseling patients who want to switch medications, pharmacists should remind patients to reach out to their care team whenever they have bleeds, even if they are not as frequent or severe as before starting the medications.

Watkins added that it is important to remind patients and their caregivers to keep factor VIII on hand for any potential emergencies, even if they are close to their local hospital. The panelists also discussed common dosing regimens for emicizumab-kxwh. Chowdhry said receiving treatment every 2 weeks is the most common, although some patients may switch to every-4-week dosing. However, he said patients tend to feel more comfortable with 2-week dosing.

Physicians and pharmacists must also be able to communicate effectively and work closely together, the panelists said, particularly because patients with hemophilia A require close monitoring and collaboration with the care team.

“Having communication and knowing we’re on the same team [is important],” Watkins said. “We want to take care of the patient, but I do know that it’s hard to weed everybody out because not everybody has the patient’s interests at hand, not everybody has the resources to care for this high-touch, high-need patient base.”

In addition to maintaining relationships with other members of the care team, Chowdhry added that building relationships with patients is important. 

One way pharmacists can work with patients is by addressing financial barriers, which Moormansaid can be especially challenging in the specialty pharmacy space.

“The financial portion is definitely a huge barrier to patients because these products are so expensive and they have a difficult time being able to afford them without the help of copay assistance programs and what extras [they] provide,” Moorman said. “We help them overcome them [by] giving them all the information that they need to sign up for those programs.”

Finally, Watkins said educational programs, especially for infusion-based treatments, are essential for patients. Many patients may struggle with pain management, so there are programs to help with this and to normalize quality of life, Watkins said. Some programs can be particularly impactful for pediatric patients who may struggle to balance their treatments in school orother environments.“

We have the 504 [Individualized Educational Plan] to let them know the options they have at schools, but we also do fun things like photography and sewing and singing,” Watkins said in the forum.

Watkins said these programs helped patients who were not connecting with other individuals with hemophilia A during the pandemic lockdown.

Articles

Pharmacists can coordinate education programs for patients to normalize quality of life and minimize infusion-related pain.

Panelists Discuss Effective Management and Considerations for Hemophilia A

OTC medication safety is especially important for patients 65 years and older. In fact, older adults account for 30% of OTC medication use in the United States.

 Approximately 25% of older adults take a combination of 10 or more OTC and prescription medications.

 This can result in problems including adverse drug reactions (ADRs) and drug interactions. Redesigning pharmacies with specific OTC senior sections for older patients can improve medication safety. Pharmacists can play a critical role in this process to ensure that older patients are educated about appropriate OTC medication use and product selection.

Pharmacists can educate older patients about OTC medications that should be avoided or used cautiously because of the risk of ADRs and drug interactions. For example, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) should be avoided, especially long term.

 These medications can increase the risk of bleeding and stomach ulcers.

 Additionally, they can raise blood pressure and cause renal dysfunction. Patients taking anticoagulants such as apixaban (Eliquis) or warfarin (Coumadin) have a higher risk of bleeding, especially when taking them with NSAIDs.

In an interview, Michelle Chui, PharmD, PhD, professor and director of the Sonderegger Research Center for Improved Medication Outcomes at the University of Wisconsin-Madison School of Pharmacy, discussed her study regarding senior sections for OTC medications in pharmacies.

 The pilot study examined implementing senior sections in 4 Midwest pharmacies that included the following 4 medication classes: allergy, cold and cough, pain, and sleep.

 Certain high-risk products for older adults, such as aspirin when used for pain and diphenhydramine and cold and cough combination products, were excluded from the senior sections.

 The main OTC aisle also included signage identifying high risk medications and encouraging older individuals to visit the senior sections and ask pharmacists questions about products.

 The study found that the senior sections provided more effective, efficient, and frequent engagements between patients and pharmacy staff members (

“[Individuals] want the ability to select their own product on their own time; to support that, we need to design pharmacies to facilitate not only safety but also patient autonomy. We redesigned the OTC section of pharmacies with signage and tools to help patients make appropriate selections, in proximity to the pharmacy counter," Chui said.

"With pharmacists at close range, patients could easily reach out with questions, or pharmacists could come over and see [whether] they needed help choosing the safest OTC option for them. Our redesign provided an effective, sustainable long-term soluiton in that it builds a system that draws [individuals] to do the right thing," Chui said. "Importantly, it improved medication safety without increasing pharmacist or technician workload."

1. Stone JA, Lester CA, Aboneh EA, Phelan CH, Welch LL, Chui MA. A preliminary examination of over-the-counter medication misuse rates in older adults. 

. 2017;13(1):187-192. doi:10.1016/j.sapharm.2016.01.004

2. Tip sheet: ten medications older adults should avoid or use with caution. HealthinAging.org. Updated January 2019. Accessed July 28, 2022.

https://www.healthinaging.org/tools-and-tips/tip-sheet-ten-medications-older-adults-should-avoid-or-use-caution

3. Chui M. Improving medication safety for older adults. Agency for Healthcare Research and Quality. Updated March 2022. Accessed August 14, 2022. 

https://www.ahrq.gov/funding/grantee-profiles/grtprofile-chui.html

4. Gilson AM, Xiong KZ, Stone JA, et al. Improving patient-pharmacist encounters with over-the-counter medications: a mixed-methods pilot study. 

. 2020;11(1):10.24926/iip.v11i1.2295. doi:10.24926/iip.v11i1.2295

 is a drug information pharmacist and Pharmacy Times® contributor who lives in South Florida.

Redesigning stores with special OTC areas for older patients can enhance communication, education.

Medication Therapy Management Today®: Senior Sections in Pharmacies Can Improve Drug Safety

This is an advertisement paid for by Eisai Inc.

This brief tool provides information to help pharmacists prepare for counseling sessions with patients prescribed DAYVIGO

(lemborexant), a dual orexin receptor antagonist that is indicated for the treatment of adult patients with insomnia, characterized by difficulties with sleep onset and/or sleep maintenance.

 Pharmacists have an opportunity to counsel patients and help them get started with DAYVIGO at every prescription pickup. 

As a part of the counseling session, consider the following steps:

Emphasize the importance of sleep hygiene.

For patients seeking additional support or information, a savings program is available for eligible patients as well as patient education and support tools.

SELECTED SAFETY INFORMATION
CONTRAINDICATIONS


•DAYVIGO is contraindicated in patients with narcolepsy

Please see additional selected safety information below and full 

DAYVIGO is supplied as 5 mg and 10 mg tablets. The recommended starting dose of DAYVIGO is 5 mg.

The dose may be increased to the maximum recommended dose of 10 mg based on clinical response and tolerability.

There is no need for dose adjustment based on age, sex, BMI, and renal impairment.

Patients aged 65 years or older should use caution when taking DAYVIGO 10 mg.

Patients with severe renal impairment may experience an increased risk of somnolence.

For patients with moderate hepatic impairment, the maximum recommended dose is 5 mg once per night.

DAYVIGO is not recommended for patients with severe hepatic impairment.

Patients with mild hepatic impaiment may experience an increased risk of somnolence.

Advise patients to avoid concomitant use of DAYVIGO with strong or moderate CYP3A inhibitors and inducers.

The maximum recommended dose of DAYVIGO is 5 mg no more than once per night when coadministered with weak CYP3A inhibitors.

Provide patients with these key administration instructions for DAYVIGO:

Take DAYVIGO immediately before getting into bed and only if they can stay in bed for a full night (≥ 7 hours) before the planned time of awakening.

The effect of DAYVIGO may be delayed if taken with or soon after a meal.

DAYVIGO should not be taken more than once per night.

Remind patients to read the FDA-approved patient labeling (Medication Guide) that comes with their DAYVIGO prescription.

Review the Patient Counseling Information in Section 17 of the DAYVIGO Prescribing Information to advise patients of potential side effects.

As it may take a few days to assess patient response, the prescribing physician may have recommended a 

trial period of 7 to 10 days of DAYVIGO (lemborexant) treatment.

Remind patients that it is important to give DAYVIGO a trial of at least a week and see how it’s working.

Inform your patients that they may feel differently when they fall asleep and stay asleep while taking DAYVIGO than their previous experience or expectations.

Advise patients to follow up with their provider after 7 to 10 days—their doctor will determine if insomnia persists and will reassess for comorbid conditions.

In addition to treatment, patients may benefit from 

—habits that can help them optimize sleep. During counseling, ask your patients about their sleep patterns, such as:

Do you take any medications before bedtime?

Are you currently taking or have you tried taking any medications to help you sleep?

How much time elapses between consuming your last meal and drink of the day and going to bed?

Do you have trouble falling asleep, staying asleep, or both?

How long have you been experiencing insomnia symptoms?

Counsel your patients on examples of good sleep hygiene.

Ensure adequate exposure to natural light.

Have a regular bedtime routine and stick to a sleep schedule with the same bedtime and wake-up time (even on weekends).

Establish a pleasant sleep environment, create a relaxing ritual, and prepare their bedroom (eg, turn off lights, remove their phone or laptop, and keep their bedroom cool [between 60° and 70°F]).

Avoid stimulants (eg, caffeine and nicotine) in the evening close to bedtime.

Avoid alcohol use on days they plan on taking DAYVIGO.

Avoid late evening meals, as DAYVIGO also may take longer to work if they take it with or soon after a meal.

information on the programs available to support access to DAYVIGO.

 Additionally, pharmacists can show patients these helpful tools and downloadable resources to learn more.

 in multiple languages (English, Spanish, Chinese, Korean, and Russian) that patients can download and print to learn more about insomnia and how DAYVIGO may help.

Patients can start tracking their sleep before bed and when they wake to understand how DAYVIGO may be working. This can be a useful tool to help optimize therapy.Patients can start tracking by:

Eligible commercially insured patients may pay as little as 

$30 on out-of-pocket expenses on their prescriptions*

 for DAYVIGO with the DAYVIGO Instant Savings Card. Inform patients that they can download or activate a card at 

For assistance activating or processing the Instant Savings Card, pharmacists and patients can call 

. Instructions are available on the back of the card.

*DAYVIGO Instant Savings Card Terms and Conditions: 

Good toward the purchase of DAYVIGO prescriptions. Most commercially insured patients will pay as little as $30 of out-of-pocket expenses. Instant Savings Card benefit is limited to twelve uses annually. Patients could have additional financial responsibility for any amounts over Eisai’s maximum liability. No substitutions permitted. Save the Instant Savings Card to reuse with each prescription. 

Not available to patients enrolled in federal or state healthcare programs, including Medicare, Medicaid, Medigap, VA, DoD, or TRICARE.

 Patients must have commercial insurance. Cash paying patients are excluded. Not valid for DAYVIGO prescription reimbursed in full by any third party payer. May not be combined with any other discount or offer. Federal law prohibits the selling, purchasing, trading, or counterfeiting of this card. Void outside the USA and where prohibited by law. Eisai Inc. reserves the right to rescind, revoke, or amend this offer without notice at any time. You must be 18 years or older to use the card. Patients and pharmacies are responsible for disclosing to insurance carriers the redemption and value of the Instant Savings Card and complying with any other conditions imposed by insurance carriers, third party payers, and applicable law on the redemption. The value of the Instant Savings Card is not contingent on any prior or  uture purchases. This card may not be accepted at all pharmacies. This card is not an insurance program. No membership fees.This offer will expire 8/31/2023.

A support program for patients with insomnia, living with the challenges that accompany poor sleep. Patients can get access to tools and educational resources to help them navigate their personal insomnia challenges by visiting 

This program provides DAYVIGO at no cost to patients who meet program eligibility criteria. For more information, patients can call 

 (hours of operation are Monday to Friday 8 am to 8 pm ET) or go to 

Eligible patients with a valid prescription may obtain a free 10-day trial of DAYVIGO 5 mg when their Rx is accompanied by a voucher that the patient downloaded online or a physical voucher provided by the prescriber (one voucher redemption per patient).

 for downloadable resources for pharmacists with information on storage, dosing, clinical data, and patient assistance programs for DAYVIGO.

 for additional information on patient support, commercial coverage, billing, coding, and applicable forms.

For more information about DAYVIGO, see full 

Price disclosure information for prescribers available here:

https://us.eisai.com/RequiredPriceDisclosures

Central Nervous System (CNS) Depressant Effects and Daytime Impairment:


DAYVIGO can impair daytime wakefulness. CNS depressant effects may persist in some patients up to several days after discontinuing DAYVIGO. Prescribers should advise patients about the potential for next-day somnolence.
Driving ability was impaired in some subjects taking DAYVIGO 10 mg. Risk of daytime impairment is increased if DAYVIGO is taken with less than a full night of sleep remaining or at a higher than recommended dose. If taken in these circumstances, patients should not drive or engage in activities requiring mental alertness.
Use with other classes of CNS depressants (e.g., benzodiazepines, opioids, tricyclic antidepressants, alcohol) increases the risk of CNS depression, which can cause daytime impairment. Dosage adjustments of DAYVIGO and concomitant CNS depressants may be necessary when administered together. Use of DAYVIGO with other insomnia drugs is not recommended. Patients should be advised not to consume alcohol in combination with DAYVIGO.
Because DAYVIGO can cause drowsiness, patients, particularly the elderly, are at a higher risk of falls.
•

Sleep Paralysis, Hypnagogic/Hypnopompic Hallucinations, and Cataplexy-Like Symptoms:


Sleep paralysis, an inability to move or speak for up to several minutes during sleep-wake transitions, hypnagogic/hypnopompic hallucinations, including vivid and disturbing perceptions can occur with DAYVIGO. Prescribers should explain these events to patients.
Symptoms similar to mild cataplexy can occur with DAYVIGO and can include periods of leg weakness lasting from seconds to a few minutes, can occur either at night or during the day, and may not be associated with identified triggering event (e.g., laughter or surprise).
•


Complex sleep behaviors, including sleep-walking, sleep-driving, and engaging in other activities while not fully awake (e.g., preparing and eating food, making phone calls, having sex), have been reported to occur with the use of hypnotics such as DAYVIGO. Events can occur in hypnotic-naïve and hypnotic-experienced persons. Patients usually do not remember these events. Complex sleep behaviors may occur following the first or any subsequent use of DAYVIGO, with or without the concomitant use of alcohol and other CNS depressants. Discontinue DAYVIGO immediately if a patient experiences a complex sleep behavior.
•

Patients with Compromised Respiratory Function:


The effect of DAYVIGO on respiratory function should be considered for patients with compromised respiratory function. DAYVIGO has not been studied in patients with moderate to severe obstructive sleep apnea (OSA) or chronic obstructive pulmonary disease (COPD).
•

Worsening of Depression/Suicidal Ideation:


Incidence of suicidal ideation or suicidal behavior, as assessed by questionnaire, was higher in patients receiving DAYVIGO than placebo (0.3% for DAYVIGO 10 mg, 0.4% for DAYVIGO 5 mg, and 0.2% for placebo). In primarily depressed patients treated with hypnotics, worsening of depression and suicidal thoughts and actions (including completed suicides) have been reported. Suicidal tendencies may be present in such patients and protective measures may be required. Intentional overdose is more common in this group of patients; therefore, the lowest number of tablets that is feasible should be prescribed at any one time. The emergence of any new behavioral sign or symptom of concern requires careful and immediate evaluation.
•


Treatment of insomnia should be initiated only after careful evaluation of the patient. Re-evaluate for comorbid conditions if insomnia persists or worsens after 7 to 10 days of treatment. Worsening of insomnia or the emergence of new cognitive or behavioral abnormalities may be the result of an unrecognized underlying psychiatric or medical disorder and can emerge during the course of treatment with sleep-promoting drugs such as DAYVIGO.


•The most common adverse reaction (reported in 5% of patients treated with DAYVIGO and at least twice the rate of placebo) with DAYVIGO was somnolence (10% for DAYVIGO 10 mg, 7% for DAYVIGO 5 mg, 1% for placebo).

 The maximum recommended dose of DAYVIGO is 5 mg no more than once per night when co-administered with weak CYP3A inhibitors. Avoid concomitant use of DAYVIGO with strong or moderate CYP3A inhibitors.
•

 Avoid concomitant use of DAYVIGO with moderate or strong CYP3A inducers.

 There is a pregnancy exposure registry that monitors pregnancy outcomes in women who are exposed to DAYVIGO during pregnancy. Healthcare providers are encouraged to register patients in the DAYVIGO pregnancy registry by calling 1-888-274-2378. There are no available data on DAYVIGO use in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes.
There are no data on the presence of lemborexant in human milk, the effects on the breastfed infant, or the effects on milk production. Infants exposed to DAYVIGO through breastmilk should be monitored for excess sedation.
•

 Exercise caution when using doses higher than 5 mg in patients ≥65 years old.
•

 Patients with severe renal impairment may experience an increased risk of somnolence.
•

 The maximum recommended dose of DAYVIGO is 5 mg in patients with moderate hepatic impairment. DAYVIGO is not recommended in patients with severe hepatic impairment. Patients with mild hepatic impairment may experience an increased risk of somnolence.


•DAYVIGO is a Schedule IV-controlled substance.
•Because individuals with a history of abuse or addiction to alcohol or other drugs may be at increased risk for abuse and addiction to DAYVIGO, follow such patients carefully.

Dayvigo. Prescribing Information. Esai; 2021. Accessed July 20, 2021. https://www.dayvigohcp.com/-/media/Files/DAYVIGOHCP/PDF/prescribing-information.pdf

Sleep hygiene. National Sleep Foundation website. Accessed July 20, 2021.
www.sleepfoundation.org/articles/sleep-hygiene

 is a registered trademark used by Eisai Inc. under license from Eisai R&D Management Co., Ltd.

Getting Patients Started With DAYVIGO® (lemborexant) CIV

Cladosporium, Penicillium, Alternaria, and Aspergillus are the most common molds found in almost all environments.

 These are just a few of the hundreds of thousands of species of fungi. Molds grow in damp, warm areas and are spread by spores both indoors and outdoors. People are typically exposed to mold by contact, ingestion, or inhalation. The most common places to find mold indoors are bathrooms, kitchens, and basements. (And don’t forget that loaf of bread that has been sitting on the counter for too many days.) Outside, mold may reside in compost piles of hay, leaves, or vegetation or in damp, shady areas. Keep in mind that the higher the humidity, the more conducive the environment is to mold, and stirring up mold can send the spores into the air.

In 2004, the Institute of Medicine (IOM) found evidence linking mold exposure to coughing, upper respiratory tract symptoms, and wheezing in healthy people, with asthma symptoms in individuals with

asthma and hypersensitivity pneumonitis in those with weakened immune systems.

 Some people are sensitive to mold exposure and can exhibit symptoms, such as itchy or red eyes, skin irritation, and a stuffy nose.

 Further, those with chronic respiratory disease may experience difficulty breathing. Results of a study by National Institute of Environmental Health Sciences (NIEHS)—funded scientists showed that mold exposure in the first year of life may increase the risk of childhood asthma.

 Inhaling mold spores may cause allergic reactions, most commonly from July to early fall, but because mold grows both indoors and out, allergic reactions can occur year-round.

 Symptoms may include coughing, shortness of breath, and wheezing. For patients with allergies, clinicians can perform skin tests or allergen-specific immunoglobulin E blood tests to identify a mold allergy. Antihistamines and nasal steroids are available over the counter to help reduce nasal itching and other symptoms. For patients with allergic asthma, clinicians may consider allergy shots and/or an inhaler. Importantly, however, remember that reducing exposure is really the key.

The type of mold that seems to generate the most attention is Stachybotrys chartarum, also known as black mold. How common is black mold, the toxic mold that everyone fears?

Results of some studies have suggested that exposure to water-damaged building materials with S chartarum may be associated with idiopathic pulmonary hemorrhage (IPH) in infants, sick building syndrome, and toxic inflammatory effects in workers.

 Few toxicologic data were available, and the need for studies evaluating potential toxicity from long-term exposure was indicated.

After many toxicologic studies, the CDC concluded that evidence does not support a causative relationship between exposure to S chartarum and IPH in infants, intensification of asthma, or sick building syndrome, and the IOM committee drew the same conclusion.

Given that almost everyone is exposed to mold every day and everywhere, is it necessary to run testing to determine the type of mold found in the environment? The CDC does not recommend general or routine sampling for molds to identify the species, as allergies are the conditions most often associated with mold.

 Patients must be aware of measures to reduce exposure. This, in turn, will help reduce symptoms.

The CDC offers these specific recommendations

Clean bathrooms with mold-killing products.

Ensure adequate ventilation, including exhaust fans, in the bathroom and the kitchen.

Keep indoor humidity levels low, at less than 50% all day.

Use an air conditioner or a dehumidifier during humid months.

Use mold inhibitors, which can be added to paints.

Flooding, hurricanes, and tropical storms have drawn national attention to ensuring the safety of workers volunteering to help with the cleanup of damp, flooded areas and buildings.

are encouraged to use personal protective equipment to minimize exposure, reducing health problems such as allergies, dermatitis, and respiratory symptoms. The NIEHS Worker Training Program has provided safety training to workers in disaster and emergency response for more than 15 years, including resources and tools aimed at protecting their health and safety.

 Importantly, all response and recovery workers must be familiar with these recommendations to ensure their personal safety.

Exposure to mold is inevitable in almost all environments. Individuals with an allergy or sensitivity to mold may incur symptoms that can include a cough. The solution is to avoid unnecessary exposure and use the resources and tools provided by organizations such as the CDC and the NIEHS to promote safety and proper cleanup.

 is a nurse practitioner at Walmart Care Clinic in Cooper City, Florida.

Molds in the environment. CDC website. cdc.gov/mold/faqs.htm. Updated December 20, 2017. Accessed July 9, 2019.

Facts about mold and dampness. CDC website. cdc.gov/mold/dampness_facts.htm. Updated September 17, 2017. Accessed July 9, 2019.

Mold. National Institute of Environmental Health Sciences website. niehs.nih.gov/health/topics/agents/mold/index.cfm. Updated December 28, 2018. Accessed July 9, 2019.

Johanning E, Auger P, Morey PR, Yang CS, Olmsted E. Review of health hazards and prevention measures for response and recovery workers and volunteers after natural disasters, flooding, and water damage: mold and dampness. Environ Health Prev Med. 2014;19(2):93-99. doi: 10.1007/s12199-013-0368-0.

Mold allergy. Asthma and Allergy Foundation of America website. aafa.org/mold-allergy/. Updated October 2015. Accessed July 9, 2019.

Stachybotrys chartarum (or S. atra or S. alternans) [CAS No. 67892-26-6]: review of toxicological literature. National Toxicology Program website. ntp.niehs.nih.gov/ ntp/htdocs/chem_background/exsumpdf/stachybotrys_508.pdf. Published June 2004. Accessed July 9, 2019.

All-hazards resources. National Institute of Environmental Health Sciences website. tools.niehs.nih.gov/wetp/index.cfm?id=2569. Accessed July 9, 2019.

Cladosporium, Penicillium, Alternaria, and Aspergillus are the most common molds found in almost all environments.1 These are just a few of the hundreds of thousands of species of fungi.

Mold Can Cause a Persistent Cough

Glucometers play an important role in helping patients with diabetes manage the disease, as these devices track blood glucose fluctuations. There are a variety of glucometers available, with basic to advanced features.

 Pharmacists can educate patients about glucometers, providing instructions on appropriate use, for instance.

For the first time, the American Diabetes Association added a special section on diabetes technology to its updated guidelines.

 The guidelines emphasize that diabetes technology is continually expanding and includes devices that both deliver insulin and monitor blood glucose. Self-monitoring of blood glucose (SMBG) is extremely important, especially for patients using intensive insulin therapy (figure).

 Intensive insulin regimens are defined as multiple daily injections or insulin pump therapy.

The guidelines discuss a lack of evidence regarding how often SMBG is needed for patients who are not using intensive insulin regimens or who receive oral therapies.

 Patients using basal insulin should check their fasting glucose with SMBG to help achieve targets. Studies have questioned the routine use of SMBG in patients using oral medications.

 However, SMBG can provide useful information on the effects of diet and exercise on target goals and assess for hypoglycemia. The following are glycemic goals for patients with diabetes: glycated hemoglobin, <7%; fasting blood glucose, 80-130 mg/dL; and postpran- dial blood glucose, <180 mg/dL.

A recent study assessed the accuracy of 18 glucometers marketed in the United States, with the assessment comprising about 90% of all available devices from 2013 to 2015 that were cleared by the FDA.

The study included 1035 participants tested at 3 study sites, and the passing standard was considered within 15% or 15 mg/dL of the laboratory value. Participants were 18 years and older with no instances of diabetes, prediabetes, type 1 diabetes, or type 2 diabetes. The study found that just 6 of the 18 glucometers passed: Accu-Chek Aviva Plus, Accu-Chek SmartView, Contour Next, CVS Health Advanced, FreeStyle Lite, and Walmart ReliOn Confirm (Micro).

 Furthermore, this study can play a key role in counseling patients on the selection of a glucometer.

®, Andrea Levin, PharmD, BCACP, assistant professor in the Department of Pharmacy Practice at Nova Southeastern University College of Pharmacy in Davie, Florida, discussed important counseling points for glucometers. She emphasized the importance of checking strips to ensure that they have not expired and that patients should program the correct times into the glucometer. Also, individuals taking medications, such as insulin, that can cause hypoglycemia should have their glucometers with them at all times. Levin added that patients should not leave glucometers in a car because extreme heat can affect their efficacy. She also recommended using control solution periodically to ensure that a glucometer is working properly.

Patients should check with their insurance providers to determine coverage details for glucometers. Cost can vary, and some insurers limit coverage to specific models or place limits on the total number of test strips allowed.

 The Diabetes Forecast Consumer Guide provides information about most of the glucometers on the market.5 The guide includes details on the blood drop size needed, cost, manufacturer contact information, and technology features.

Glucometers also have special features, which may be helpful depending on the patient’s needs. These may include easy-to-handle and large test strips, as well as illuminated screens and audio, useful for individuals with impaired vision.

 Pharmacists should advise patients to not purchase or resell used test strips, which can give inaccurate results.

Patients should be counseled about the signs and symptoms of hypoglycemia, which include confusion, nervousness, shakiness, sleepiness, and sweating. Patients experiencing these symptoms should check their blood glucose levels immediately. Hypoglycemia is considered blood glucose <70 mg/dL and should be treated with 15 g of carbohydrates (eg, glucose tablets, juice).

Individuals should check their blood glucose again after 15 minutes of treatment, and if it is still <70 mg/dL, they should have another 15-g serving of carbohydrates. 

, is a drug information pharmacist and Pharmacy Times contributor who resides in south Florida.

Blood glucose meter: how to choose. Mayo Clinic website. mayoclinic.org/ diseases-conditions/diabetes/in-depth/blood-glucose-meter/art-20046335. Published December 17, 2016. Accessed January 20, 2019.

American Diabetes Association. 7. Diabetes technology: Standards of Medical Care in Diabetes-2019. 

. 2019;42(suppl 1):S71-S80. doi: 10.2337/dc19-S007.

American Diabetes Association. 6. Glycemic targets: Standards of Medical Care in Diabetes-2019. 

. 2019;42(suppl 1):S61-S70. doi: 10.2337/dc19-S006.

Klonoff DC, Parkes JL, Kovatchev BP, et al. Investigation of the accuracy of 18 marketed blood glucose monitors. 

. 2018;41(8):1681-1688. doi: 10.2337/dc17-1960.

American Diabetes Association. Blood glucose meters. Diabetes Forecast website. main.diabetes.org/dforg/pdfs/2018/2018-cg-blood-glucose-meters.pdf. Accessed January 20, 2019.

Pharmacists can offer important counseling points on the appropriate use of the devices to monitor blood glucose levels at home. 
 

Glucometers Help Patients Manage Diabetes

Diarrhea, which is defined as 3 or more loose watery stools a day, is common and can be classified as acute, persistent, or chronic. Acute diarrhea, the most common type, generally lasts 1 to 2 days and resolves on its own.

It is estimated that about 179 million cases of acute diarrhea occur in the United States annually.

Persistent diarrhea lasts 2 to 4 weeks, and chronic diarrhea continues for at least 4 weeks.

Pharmacists can play an important role in helping patients and counseling on prevention strategies.

A variety of conditions and diseases can cause diarrhea (

). Blood and stool tests and a colonoscopy can determine the cause. However, many cases resolve on their own without testing. Patients should be educated about the signs and symptoms of dehydration, a serious adverse effect of diarrhea, in adults and children, as the condition can be life-threatening if untreated (

Educated Patient