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.

Articles

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.

Myrna M. Weissman, PhD, analyzed the study, conducted by Netsi et al, and concluded that children born to women in the most vulnerable group have a 2-fold increased risk of having lower math scores at 16 years, a 4-fold greater risk of having behavioral problems between ages 3 and 4 years, and a 7-fold higher risk of depression at 18 years.

 She said that these findings suggest extending the universal screening for depression in all pregnant women to screening beyond pregnancy, possibly up to a year after delivery and during baby wellness visits.

This study was not free of limitations. One was the high rate of attrition, which may have led to an underestimation of the proportion of women who experience persistent and severe postpartum depression.

 Another was that the study could not determine the effects of treating postpartum depression using antidepressants or psychological treatment in the women and whether that reduced postpartum depression and improved child outcomes.

Shen et al found that though maternal and paternal depression can negatively affect child development, the paternal effect is less compared with the maternal effect.

 Another study found that reducing the symptoms of depression in a parent to remission can reduce adverse effects on the child.

Sage Therapeutics said that brexanolone (formerly SAGE-547) achieved primary end points in 2 phase 3 clinical trials in moderate (Study 202C) and severe (Study 202B) postpartum depression. The primary end point was a mean reduction from baseline in the Hamilton Rating Scale for Depression total score at 60 hours.

Brexanolone is listed as an allosteric modulator of both synaptic and extrasynaptic GABAA receptors and is a proprietary formulation of allopregnanolone, a naturally occurring molecule that is known to modulate GABA receptor activity.

 Its mechanism of action leads to varying degrees of desired activity versus complete receptor activation or inhibition.

 Available in an intravenous formulation, brexanolone has been granted breakthrough therapy status by the FDA.

 Sage is planning to file a new drug application with the FDA later this year for brexanolone and is seeking approval for its use in treating postpartum depression. Its plan is to bring brexanolone to the market in early 2019.

Anyssa Garza, PharmD, BCMAS, received her doctor of pharmacy degree from The University of Texas at Austin. She is the vice president of Content and Patient Education Programs at Digital Pharmacist and an adjunct assistant professor at The University of Texas at Austin College of Pharmacy.

American College of Obstetricians and Gynecologists. Postpartum depression. ACOG website. acog.org/Patients/FAQs/Postpartum-Depression. Published December 2013. Accessed April 21, 2018.

Office on Women’s Health. Depression during and after pregnancy. Office on Women’s Health website. womenshealth.gov/publications/our-publications/fact-sheet/ depression-pregnancy.html. Updated June 12, 2017. Accessed April 21, 2018.

National Institute of Mental Health. Postpartum depression facts. NIMH website. nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml. Accessed April 21, 2018.

Netsi E, Pearson RM, Murray L, Cooper P, Craske MG, Stein A. Association of persistent and severe postnatal depression with child outcomes. 

 2018;75(3):247-253. doi: 10.1001/jamapsychiatry.2017.4363.

Postpartum depression. In: Longe JL, ed. The Gale Encyclopedia of Psychology. 3rd ed. Farmington Hills, MI: Gale; 2016:902-905.

Weissman MM. Postpartum depression and its long-term impact on children. many new questions. 

 2018;75(3):227-228. doi: 10.1001/jamapsychiatry.2017.4265.

Sage Therapeutics announces brexanolone achieves primary endpoints in both phase 3 clinical trials in postpartum depression [news release]. Cambridge, MA: November 9, 2017. investor.sagerx.com/news-releases/news-release-details/sage-therapeutics-announces-brexanolone-achieves-primary. Accessed April 22, 2018.

Sage Therapeutics. Our programs. Sage website. sagerx.com/programs.php. Accessed April 22, 2018.

Keown A. Sage Therapeutics looks to file NDA for postpartum depression treatment later this year. BioSpace website. biospace.com/article/exclusive-sage- therapeutics-looks-to-file-nda-for-postpartum-depression-treatment-later-this-year/. Published January 12, 2018. Accessed April 22, 2018.

Postpartum Depression and Its Long-Term Effects on Children

, they typically think of a fatty, plaque-building substance that comes from the foods we eat. But the truth is that cholesterol is a naturally occurring substance in the body that is essential to health. Of course, like many things in excess, too much cholesterol in our blood can be bad and increase the risk of heart disease and stroke.

Here are 4 common misconceptions related to both cholesterol in general and common treatments for high cholesterol levels.

Misconception #1: All types of cholesterol are the same.

Cholesterol can be divided into 2 broad categories: dietary cholesterol, which is found in the food we eat; and serum cholesterol, which is a naturally occurring substance made in the body. Within our bodies, there are 2 main types of cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL). LDL, often referred to as the “bad cholesterol,” makes up most of the body’s cholesterol, and when levels are high, it can lead to plaque buildups in the arteries, resulting in heart disease and stroke.

On the other hand, HDL, or the “good cholesterol,” absorbs cholesterol in the body and carries it back to the liver, where it is removed from the body. Higher levels of HDL have been shown to reduce the risk for heart disease and stroke.

 Ideal cholesterol levels for most adults are less than 200 mg/dL total cholesterol, less than 100 mg/dL LDL, and above 60 mg/dL HDL.

Misconception #2: Eating foods high in cholesterol will significantly increase cholesterol levels in the body.

For many years, nutritionists warned that eating a diet high in cholesterol would increase cholesterol levels in the body and elevate the risk of heart disease. Although this is still a slight area of controversy among health experts, evidence suggests that this may not be the case. Instead, research shows that our genetic makeup, rather than diet, tends to be the driving force of cholesterol levels in the body. About 85% of the cholesterol in the body is produced in the liver, rather than from the cholesterol we consume.

 Additionally, it is believed that when dietary cholesterol is increased, the body compensates, and the liver starts to produce less cholesterol.

In the 2015-2020 US Dietary Guidelines, the previous recommendation of limiting dietary cholesterol to 300 mg per day was removed. For most people, a healthy diet can certainly consist of foods containing cholesterol, such as meats and eggs, along with fruits, vegetables, whole grains, and caloric moderation. Of course, eating massive amounts of food that contain high amounts of cholesterol may not be recommended, either, as foods high in cholesterol tend to be more calorie dense.

Regarding saturated fat, several studies published in the past few years concluded that there was no association between saturated fat intake and heart disease. Despite this, the US Dietary Guidelines recommend that people consume less than 10% of calories per day from saturated fats.

One area that most experts will agree on is that foods high in trans fats should be limited because of their LDL-raising effects. A number of studies have observed an association between increased trans fat intake and an increased risk of cardiovascular disease.

Misconception #3: People who are thin don’t have to worry about having high cholesterol levels.

It is true that people who are overweight or obese are more likely to have high cholesterol and that a combination of exercise and diet can lower elevated cholesterol levels. However, it is also true that people who are thin can have elevated levels. Remember, because our cholesterol levels are mostly the result of our genetic makeup, a person’s weight may not be an immediate cause. People who have very sedentary lifestyles may also be at a higher risk. Finally, there are certain genetic disorders (eg, familial hypercholesterolemia) that can predispose people to have higher cholesterol levels, regardless of their weight.

It is also important to keep in mind that as people get older, cholesterol levels tend to rise. This is why the American Heart Association recommends that starting at age 20, everyone should get tested for cholesterol and other risk factors about every 4 to 6 years.

Misconception #4: Everyone who takes a statin for high cholesterol treatment experiences muscle pain.

I often hear people talking about not wanting to take a statin to treat their high cholesterol levels out of fear of experiencing muscle pain or cramping as possible adverse effects. Additionally, these are often reasons for patients who have already been prescribed a statin to stop taking it.

It is true that some people who take a statin may experience muscle pain but certainly not everyone. Real-world studies suggest that up to 10% to 15% of people taking statins experience some degree of muscle pain or cramping, but fortunately there are ways to mitigate these effects.

 Doctors may recommend a brief drug holiday to see whether symptoms resolve when patients are not taking the medication or may change the dose or interval of the medication. Finally, there is some evidence that people who exercise regularly before taking statins are less likely to suffer from muscle pain and cramping.

Timothy O’Shea, PharmD, is a clinical pharmacist at Horizon Blue Cross Blue Shield of New Jersey.

HDL (good), LDL (bad) cholesterol and triglycerides. American Heart Association website. heart.org/HEARTORG/Conditions/Cholesterol/HDLLDLTriglycerides/HDL-Good-LDL-Bad-Cholesterol-and-Triglycerides_UCM_305561_Article.jsp. Updated April 2017. Accessed November 8, 2017.

Common misconceptions about cholesterol. American Heart Association website. 

heart.org/HEARTORG/Conditions/Cholesterol/AboutCholesterol/Common-Misconceptions-about-Cholesterol_UCM_305638_Article.jsp

. Updated April 2017. Accessed November 2, 2017.

Why you should no longer worry about cholesterol in food. Cleveland Clinic website. health.clevelandclinic.org/2015/02/why-you-should-no-longer-worry-about-cholesterol-in-food/. Published February 19, 2015. Accessed November 2, 2017.

US Department of Health and Human Services and US Department of Agriculture. Dietary guidelines for Americans 2015-2020. Eighth edition. health.gov/dietaryguidelines/2015/guidelines/. Published December 2015. Accessed November 2, 2017.

Bitzur R, Cohen H, Kamari Y, Harats D. Intolerance to statins: mechanisms and management. 

. 2013;36(suppl 2):S325-S330. doi: 10.2337/dcS13-2038.

When people hear the word cholesterol, they typically think of a fatty, plaque-building substance that comes from the foods we eat.

Four Common Cholesterol Misconceptions

One of the biggest struggles that patients face is ensuring that they have the proper medications on hand and are taking their medications correctly (figure 1). Historically, patients have been given new prescriptions and asked to manage multiple, complex therapies on their own. This can result in delays in starting therapy, duplicate therapies, and gaps in care due to numerous issues. For most patients, it can be incredibly confusing to navigate the world of health care, pharmacy, prior authorizations, and drug interactions. Studies have shown retail adherence averaging 30% to 50% when patients are asked to manage their therapies on their own, and up to half of all new prescriptions may never get filled. Patients are making 5 to 6 trips to the pharmacy every month but still not getting the most benefit from their medications.

Thrifty White’s RxMedSync model makes correctly filling prescriptions much easier. The internal system identifies all eligible patients who are on 2 or more maintenance medications, and the store team reaches out to discuss the benefits of the program with each patient. The model has more than 73,000 enrolled patients who have opted in to the program. Upon individuals’ enrollment, the pharmacy team performs an initial medication review to ensure that each patient is taking the correct medications at the correct times and isn’t missing any therapy. Once the team knows that the medications are correct, it aligns them to all fill on the same date each month and proactively schedules the patient’s pickup appointment. This allows patients to each make one trip to the pharmacy every month and know that they are getting the proper medications.

Each subsequent month, the patient care team reaches out 10 days prior to the upcoming medication exhaust date to review any therapy changes, doctor visit outcomes, and adverse effects. Once the team confirms that the patient medication list is correct, it fills the patient’s medication pack and sends it to the local store for pickup on the agreed-upon date. The team manages any prior authorization or prescription renewals upstream so that there are no delays in getting the medications to each patient. Simplifying this process has resulted in adherence scores of higher than 95% and patients’ averaging 354 days on therapy each year (figure 2). Thrifty White has even created programs to sync up 30-day and 90-day fills, allowing patients to customize their schedules and still receive the full benefits.

As Thrifty White has continued to see the success of this model, it has looked for ways to further engage patients and drive better outcomes. The first step is always making sure that they are on the right medications and have medication on hand. From there, Thrifty White looks for ways to simplify its process, such as providing tools free of charge to help patients take their medications correctly each day. For patients who just need a simple reminder, Thrifty White provides RxTimercaps, which provide a countdown since the vial was last opened. Another solution is the HealthyPackRx Blister packaging program, which simplifies complex regimens by creating blister packs for each dose time, then including the proper medications. For patients who have trouble remembering when to take certain doses, they simply pull the next packet out of the box, double-check the label, and take those medications. This is a great way to ensure that patients are taking the proper medications every time.

Pharmacies continue to play a large role in the health care system, and finding ways to simplify and drive adherence opens the door to opportunities to expand pharmacy practice. In Thrifty White’s model, having a scheduled pickup appointment each month allows the pharmacy to layer on additional clinical services to each fill. In addition to picking up medications, a patient may also have an annual Comprehensive Medication Review, receive a 

, and have an injectable medication administered in the store. In the future, Thrifty White could layer on additional clinical surveys, such as therapy effectiveness assessments, glycated hemoglobin (A1C) checks, lab draws, and preventive cancer screenings, all possible because of a robust medication synchronization program that allows the team to know when patients are coming in and build the practice around them. By creating a robust patient management plan, Thrifty White is able to lower overall health care costs and drive better patient outcomes. In a one-year pilot program, the model saved one health plan more than $2400 per patient in total health care costs.

Pharmacists have long been considered the most accessible health care practitioners, as well as some of the most trusted. It is time that pharmacists leverage their physical footprint to provide clinical services above and beyond the transactional “putting pills in a bottle.” As pharmacists move toward this future, a well-functioning medication sync program is a great foundation on which to build a clinical practice.

Jeremy Faulks, PharmD, is the Director of specialty pharmacy, Thrifty White Pharmacy.

One of the biggest struggles that patients face is ensuring that they have the proper medications on hand and are taking their medications correctly.

Driving Patient Adherence and Outcomes Through Appointment-Based Refill Programs

Many of us take in too much sodium, which can put us at an increased risk for health problems. Your body needs only a very small amount of sodium—an essential nutrient required to maintain a balance of bodily fluids and proper muscle and nerve function.

Do you know how much sodium you take in or need each day? Sodium is both found in salt and occurs naturally in many foods, even those that don’t taste salty. You don’t have to sprinkle table salt, also called sodium chloride, on your food to get too much sodium. In fact, most of the sodium we eat each day sneaks up on us in prepared and processed foods, which has prompted the FDA to take steps to lower the amount of sodium added to the foods we buy. In July of this year, the FDA released guidance for manufacturers and restaurants on reducing the amount of sodium they add.

Your kidneys filter your blood and remove excess fluid, using osmosis to draw the extra water out and move it into a collecting channel that leads to your bladder, where it becomes urine. This process involves a delicate balance of sodium and potassium. If your sodium intake is too high, this raises the amount of sodium in your bloodstream, which pulls water into your blood vessels and disrupts this delicate balancing act. The increased volume of blood inside your blood vessels causes blood pressure (BP) to rise. High BP (also called hypertension) strains your kidneys and can cause diseased kidneys to worsen. Excess sodium in the body also forces the heart to work harder, which can increase the risk for heart disease and stroke.

High BP affects an estimated 1 in 3 Americans, according to the CDC. In African Americans, high BP affects almost 1 in 2 individuals. The effects of salt and sodium on BP tend to be greater in African Americans, individuals older than 50 years, and individuals with high BP, diabetes, or kidney disease.

Ninety percent of Americans, including children and adolescents, consume more sodium than recommended, according to the CDC. Today, the average American takes in a whopping 3400 mg of sodium per day. That’s almost 50% more than what is generally recommended when you consider that the sodium intake goal for adults and older teens is 2300 mg per day. And those who have been diag- nosed with high BP or who have prehypertension may have even lower sodium intake goals.

The recommended upper limits of sodium per day for children are as follows:

Many prepared and processed foods contain high amounts of sodium. These foods include breads, natural and processed cheeses, deli meats, sand- wiches (including hamburgers and hot dogs), snacks (popcorn, chips, pretzels, and crackers), pizza, pasta dishes, salad dressings, and soups. It is important to remember that just because you don’t taste the salt, that doesn’t mean the food is not high in sodium. Even sweet desserts or sugary cereals can contain lots of sodium. You have to keep your daily totals in mind. Even if a single food doesn’t contain too much sodium, eating that food several times a day can put you at risk of getting too much salt.

• Speak with a dietician or your health care pro- vider about your nutritional goals. A dietician can create an eating plan that will help balance your sodium intake and reduce your risk for high BP.

• Keep a food diary to track the amount of sodium you are consuming. The goal is to reduce your sodium intake, not to keep an exact tally.

• Check the nutrition facts label for sodium content because not all foods high in sodium taste salty. Also, check for nutrient claims on food and beverage packages (Table).

• Prepare your own food when possible, and limit your intake of fast foods and convenience foods. About 75% of dietary sodium comes from eating packaged and restaurant foods.

• Flavor your foods with fresh herbs and spices instead of salt. If you are taking certain medications to treat high BP, salt substitutes are not recommended. If you have any questions about what kind of seasoning you can use, be sure to ask your health care provider or pharmacist.

As you reduce the amount of sodium you consume, it’s likely that your taste for sodium will slowly decrease. Before you know it, you probably won’t even miss it.

Beth Bolt is a freelance health and science writer based in Northern California. She’s on Twitter: @beth_bolt.

Many of us take in too much sodium, which can put us at an increased risk for health problems. 

You Are Probably Getting Too Much Sodium

Flu season is under way, and, along with it, lots of confusion and unreliable information. Maybe you’re not sure you want to get vaccinated this year. Let’s separate these 7 common flu shot facts from fiction.

 It is not possible to get the flu from the influenza vaccine. 

Most people don’t have any adverse effects (AEs) from the influenza vaccine, and when AEs do occur, they are usually very mild. Although soreness, redness, tenderness, or swelling is common where the flu shot is given, the flu shot cannot cause you to get the flu. This is because influenza vaccines are made with viruses that are inactivated or attenuated (weakened); recombinant flu vaccines have no virus at all.

Some vaccine reactions have been reported after the nasal spray vaccine is given; these AEs include runny nose, nasal congestion, cough, chills, tiredness/weakness, sore throat, and headache. Although these AEs sound similar to flu symptoms, they are mild and short-lasting.

When individuals report getting the flu after getting vaccinated, it’s likely that they were already sick or were exposed to the flu virus during the 2-week period it takes for immunity to set in. Another explanation is that some rhinoviruses, which are associated with the common cold, cause symptoms similar to the flu and can be mistaken for the flu.

 It’s okay to skip the flu shot if you’ve gotten vaccinated in previous years.

Unlike the polio and chickenpox vaccines, protection from flu vaccination declines over time, so an annual vaccination is needed to get the “optimal” or best protection against the flu. Although you may have some protection if you got the flu vaccine last year, there is no way to know how much.

The flu vaccine protects against several strains of flu that scientists predict will be the dominant strains most likely to circulate this year. Trivalent vaccines protect against 3 strains of the flu, for instance, while quadrivalent vaccines protect against 4 strains. However, these dominant strains mutate, or change, from year to year.

Therefore, the viruses that you were immunized against last year are now different. A new flu shot will give you protection against the types of flu that are likely to cause an outbreak this year. The CDC is not recommending the nasal spray vaccine for use during the 2016-2017 season because of concerns about its effectiveness.

Flu season is under way, and, along with it, lots of confusion and unreliable information.

Educated Patient