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.

Articles

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 (

). Patients with diarrhea accompanied by bloody stools, fever, or severe abdominal pain should be seen by a health care provider immediately, as this may be a sign of a serious infection.

Diarrhea usually resolves on its own without treatment. However, it is important to prevent dehydration. Oral rehydration solutions, such as Pedialyte for infants and children and Gatorade for adults, should be used to replenish electrolytes lost through mild to moderate diarrhea. OTC loperamide may be given to healthy adults with acute watery diarrhea, but it should be avoided in patients with bloody stools or fever

Individuals with severe dehydration may need to be hospitalized and given intravenous fluids, such as lactated Ringer’s and normal saline. Once patients are adequately hydrated, they can resume a normal diet. Breast milk or formula should be continued throughout the diarrhea episode.

Empiric antibiotic therapy should be started while waiting for stool test results for children with bloody diarrhea who have abdominal pain or fever, recently traveled internationally, or are younger than 3 months.

Adults should receive azithromycin or ciprofloxacin, and children should be administered a third-generation azithromycin or cephalosporin. Antibiotics should be avoided in patients with Shiga toxin-producing 

as there can be an increased risk of developing a type of kidney failure known as hemolytic uremic syndrome.

Pharmacists can educate patients on strategies to prevent diarrhea. Individuals should wash their hands with soap and water for at least 20 seconds, and hand sanitizer that contains at least 60% alcohol should be used when soap and water are not available. Advise patients to practice swim health to prevent diarrhea caused by 

Adults and children should not swim while sick with diarrhea. Swim diapers are important for children who are not toilet trained, and pool water should not be swallowed. 

Probiotics (eg, Culturelle) may prevent diarrhea that results from taking antibiotics,

so tell patients to wait at least 2 hours after taking an antibiotic to use a probiotic. While traveling abroad, individuals should only eat food that is cooked and served hot,

and avise patients to drink only beverages from factory-sealed containers and avoid ice. The CDC’s travel health notices can be consulted for up-to-date information on food safety.

Patients should be counseled on the risks of long-term proton pump inhibitor (PPI) use, which include 

infections and diarrhea. Monitor patients taking PPIs, and recommend tapering the dose for individuals who have completed a 4-week course of treatment with resolved symptoms.

Tell parents to ensure that their children are vaccinated to protect against rotavirus, which can cause severe watery diarrhea. Two vaccines, Rotarix and RotaTeq, are available, and the first dose is most effective if it is given before a child is 15 weeks of age.

Jennifer Gershman, PharmD, CPh, is a drug information pharmacist and Pharmacy Times

contributor who resides in South Florida. 

Diarrhea. National Institute of Diabetes and Digestive and Kidney Diseases website. 

niddk.nih.gov/health-information/digestive-diseases/diarrhea

Mayo Clinic staff. Diarrhea. Mayo Clinic website. 

mayoclinic.org/diseases-conditions/diarrhea/symptoms-causes/syc-20352241

McDonald EG, Milligan J, Frenette C, Lee TC. Continuous proton pump inhibitor therapy and the associated risk of recurrent Clostridium difficile infection. 

. 2015;175(5):784-791. doi: 10.1001/jamainternmed.2015.42.

Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. 

. 2017;65(12):e45-e80. doi: 10.1093/cid/cix669. 

Hlavsa MC, Cikesh BL, Roberts VA, et al. Outbreaks associated with treated recreational water-United States, 2000-2014. 

2018;67(19):547-551. doi: 10.15585/mmwr.mm6719a3.

Travelers’ diarrhea. CDC website. wwwnc.cdc.gov/travel/page/travelers-diarrhea. Updated October 23, 2017. Accessed May 29, 2018. 

Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: evidence-based clinical practice guideline. 

. Updated April 23, 2018. Accessed May 29, 2018.

Diarrhea: Causes, Management, and Prevention Strategies

Some women begin to feel anxious and depressed within a few days of giving birth. Many also experience crying spells for no clear reason, have trouble making decisions and sleeping, lose their appetite, and become angry at their newborn, other children, or significant other. These feelings, often referred to as the baby blues, typically last a few days to 2 weeks.

Affecting up to 80% of mothers, the baby blues are usually not severe enough to require treatment.

On the other hand, postpartum depression involves intense feelings of anxiety, hopelessness, or sadness that last much longer, affecting the mother’s day-to-day life. Women who have postpartum depression develop symptoms an average of 1 to 3 weeks after childbirth, but the onset can be anytime during the first year after childbirth.

 Postpartum, or postnatal, depression is estimated to affect 10% of women in wealthier countries, and an even higher percentage in countries that are less wealthy.

Some women are at a higher risk of developing postpartum depression. Women who experience depression during pregnancy tend to be at a greater risk of depression after giving birth. About 50% of women with postpartum depression experienced depression before or during pregnancy.

 Other mental disorders during pregnancy, such as anxiety or obsessive-compulsive disorder, are associated with a higher risk of postpartum depression. Risk factors include a lack of emotional support; medical complications during childbirth, such as premature delivery; and mixed feelings about the pregnancy.

Although the cause of postpartum depression is not known, it is believed that hormonal changes may play a role. Connected to this is that researchers suspect that changes in 2 genes may play a role in increasing the risk of developing postpartum depression. This belief is supported by findings from a small 2013 study. These genes are thought to be involved in the activity of the hippocampus and appear to respond to estrogen.5 Estrogen comes into play because, during pregnancy, estrogen and progesterone levels increase, only to rapidly return to normal within 24 hours of childbirth. It is this rapid change in hormone levels that is thought to be related to postpartum depression.

Netsi et al looked at the long-term effects of persistent, severe postpartum depression and its effects on children. To evaluate the impact, the researchers used data from the British Avon Longitudinal Study of Parents and Children.

 For details of the study, see the table.

Evidence suggests that both persistent and severe postpartum depression increase the risk of adverse outcomes in children.

 Research has listed an association between postpartum depression and delayed cognitive and language development, disorganized or insecure attachment, higher rates of behavioral problems, and lower grades. In addition, there is a documented link between postpartum depression and higher rates of depression in children during the latter teen years (16 to 18 years old).

Women who met the criteria for moderate and severe postpartum depression at 2 months and at 8 months post delivery made up the most vulnerable group and were found to be more likely to experience depression 11 years later.

Educated Patient