, students from the Daniel K. Inouye College of Pharmacy at the University of Hawaii at Hilo discussed their unique experiences as students in Hawaii. The state has a distinct culture and different patient populations from the mainland United States, and the students said that has led them to have unique perspectives on culturally competent care and pharmacists’ roles in the community.

Andrew Schuler, fourth-year pharmacy student: 

At the Daniel K. Inouye College of Pharmacy, every student took a class called Communication and Culture, a class that educated us on the importance of understanding the challenges of a language barrier, as well as how religious beliefs may also be a challenge when it comes to treating a patient's disease. The most important thing you must do is listen to the patient, understand their concerns, and by doing that, you will gain their trust to be able to treat them appropriately.

Taylor Elola, second-year pharmacy student: 

One of our courses during the first year was actually called Communication and Culture. And this class focused on learning to communicate vital drug information effectively to patients, a lot of motivational interviewing to promote patient adherence and compliance; and most of all, like in depth, education about different familial, cultural, spiritual, and even religious practices, and customs that may affect a patient's outlook on medications, vaccines and health care overall. From this class, we learned more about these customs and practices as well as our role as health care providers to be empathetic, respectful, be active listeners and enthusiastic educators. 

Analeslie Martinez, fourth-year pharmacy student: 

So as mentioned, doing these rural health certificates, I learned about the really unique care that rural health communities require or have. I've also been involved in several organizations at our school that promote specific care to rural populations of Hawaii. For example, I'm in this organization that was called Ho'omalu Ola, which actually translates to "guardians of health." And we provided free health screenings to a rural fishing village called Miloli'i. We also did patient education on chronic illnesses, and even provide them with food bags to promote healthy eating, and kind of promoted some education through there as well. I'm also involved in a organization called Pacific Islander Mobile Screening Clinic. And we also provided free health screenings to everyone in the community on behalf of higher emphasis on Pacific Islanders, since they are an underserved population. And what's so unique about this specific organization was that prior to COVID-19, this organization partnered up with the medical school in a Oahu JABSOM, and they would come over here we'd have this really big event on the Big Island, a bunch of community members would come out and we promote health. So it was a great way to connect everyone together. Also, what has been really special about being here is that, um, the opportunities that I've been able to get through my pharmacy rotations, like the IPPE/APPE, is there's so many different locations that we are able to go to so there's rotation sites all over the state of Hawaii, which is really able to tailor the students interests to their passions. For me, for example, I decided to stay on the Big Island for three rotations. I'm going to be going to New Mexico right after, I'm going to be in the Navajo reservation, and also in Gala. And then my last rotation I will be in Saipem. Yeah, so our school has really helped realize my goals of learning through experience where I'm able to really have different types of pharmacy experience in rural locations across Hawaii, the mainland and abroad.

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The most important thing you must do is listen to the patient, understand their concerns, and by doing that, you will gain their trust to be able to treat them appropriately.

Unique Offerings, Curriculum to Prepare for Cultural Differences

Head pain is responsible for fewer than 5% of acute medical care, however, migraines affect more than 1 billion people worldwide. 

 typically involve recurring episodes of pulsing or throbbing pain on either side of the head, along with nausea, vomiting, and/or sensitivity to light and sound.

If left untreated or unsuccessfully treated, migraine pain can last from hours to days and can be moderate to severe, often becoming debilitating.Migraines can cause 1.3 years of a patient’s life to be lost to debilitating discomfort.The condition is frequently multifactorial and patient-specific, causing accessible patient care and treatments to be limited and ignored.

Patients with chronic headaches have a 2.49-fold greater risk of suicidal ideation and are 3 times more likely to experience depression. The negative health outcomes associated with migraines provide an opportunity for pharmacists in the inpatient and outpatient settings to support patients experiencing migraines.

Migraines have a genetic component, as 4 of 5 patients with migraines have a family member who experiences them as well. If a parent has migraines, their offspring has a 50% chance of having them, which increases to 75% if both parents experience migraines.

Other medical conditions have been found to increase the risk of developing migraines, such as anxiety, bipolar disorder, depression, epilepsy, and sleep disorders. Although there is no cure for migraines, treatments focus on relieving symptoms and preventing additional attacks. Nonmedical relief of symptoms include drinking fluids; using a cool compress or ice pack on the back of the neck, forehead, or top of head; and resting with the eyes closed in a cool, dark, quiet area.

In the outpatient setting, misuse of OTC headache agents, such as Excedrin, is frequent and can lead to chronic headache pain due to overuse. If patients are taking OTC pain relievers more than 2 days a week, they should be directed to see a physician, who may prescribe a product to better manage the migraines.

Because each individual’s migraines are different, it stands to reason that not every available medication works in every case. Pharmacists can help patients determine which medications might work for them and educate them about how the medications work and their possible adverse effects.

Migraines are multifactorial and patient-specific, causing accessible care and treatments to be limited and ignored.

Pharmacist Insights: Migraine Medications

 optimally? Well, we can lookat the guidelines. The Infectious Diseases Society of America—Society of Healthcare Epidemiologists of America guidelines were updated in 2021. Bincy, can you walk us through what the recommendations were for treatment of a first episode of 

 infection, it’s recommended to use fidaxomicin instead of vancomycin. They say this with moderate certainty based on the data, but that’s assuming we have the resources to be able to use fidaxomicin, because sometimes it’s not available. It’s not on formulary in the hospital, or unavailable, or too expensive for the patient to get from their insurance, so they do say that vancomycin is an acceptable alternative.

 Excellent. Does metronidazole really enter the picture any longer? Bincy, you had mentioned earlier that in the IBD [inflammatory bowel disease] population, the answer is no. I can say generally the answer is largely no. The recommendation was to use metronidazole if nothing else is available, if the white cell count is less than 15,000 and the creatine is less than 1.5 mg/dL. Metronidazole has been largely phased out of the treatment algorithm. Teena, can you walk us through what the recommendations were for a second episode or first recurrence?

Sure. If vancomycin was used initially for the first episode, there is a strong recommendation to use fidaxomicin for the first recurrence. If fidaxomicin was used in the first episode, then either you can use pulsed or tapered vancomycin. That is one of the recommendations for a recurrence.

Excellent. Tom, what about third episode and beyond, or second recurrence and beyond?

 Paul, fidaxomicin again. Looking at those recurrent episodes, it’s a conditional recommendation with low certainty of evidence, but I’ve found data rather compelling for the recommendation of fidaxomicin, as Teena mentioned, as either standard or extended pulse regimen. You look across all its randomized trials. The absolute difference in sustained response at 30 days was significantly different. Again, it was a small subset, but directionally, we saw that in 90 days as well. Anytime I look at these absolute differences, Paul, I always convert them to a number needed to treat. For every 10 patients you treat with fidaxomicin, with these third episodes and beyond, you’re going to gain one more cure. We think about the long-term consequences; the emotional, physical, and mental well-being or tolls that 

 puts on these patients. To me, it’s worth it. We look at these economic studies that look at quality-adjusted life shares and the cost of a year gain; they’re all considered reasonable therapies. Also, they do state within the guidelines, vancomycin also predictably results in a successful initial cure, even [in] patients with recurrent infections. They still provide some opportunities, vancomycin in patients, for some of the reasons that Bincy mentioned, [as] if there’s insurance concerns. But I would argue patients should get the best drug. The cost of recurrence is $25,000, the complications is $50,000. Again, think about those numbers needed to treat use of fidaxomicin; avoiding all those downstream consequences, I think, provides a lot of value for our patients.

 I tend to agree. I think there’s several important points here. First is that the IDSA—SHEA guidelines used a PICO (population, intervention, comparison, outcome) analysis. This was really a largely statistical analysis. Tom, you did a nice job of boiling it down to the reality, which is number needed to treat. There are a couple of concepts here. One, fidaxomicin is in; two, metronidazole is largely out; and three, bezlotoxumab. What is bezlotoxumab? It is a fully humanized monoclonal antibody that is given in addition to a standard-of-care antimicrobial. It’s a one-time infusion, and it has really compelling data behind it between 2 clinical trials, the MODIFY I (NCT01241552) and MODIFY II (NCT01513239) studies. Across those clinical trials, the number needed to treat was 10 to reduce 1 recurrence overall, but importantly, in that age over 65 population, that population that we see the most 

 in, across the clinical trials in an a priori set analysis, the number needed to treat was 6. That’s compelling data to say: “Hey, you know what, bezlotoxumab should be thought of for patients at high risk for recurrence.” Within the guidelines, they recommended it for patients at high risk for recurrence, with a first recurrence or second recurrence and beyond if they haven’t received it once already. Now it does have an extended half-life, with a half-life of 19 days, so it stays within patient systems for about 90 days in appreciable quantities. Well, that 90 days is usually the time that we spend in follow-up assessing patients for future recurrence. 

Experts review treatment options for first, second and recurring episodes of Clostridioides difficile infection.

Treatment Options for C. difficile Infection (CDI)

, we need to think about what changes happened to the microbiota. What changes do happen to the microbiota with 

? I usually like to go back to the original study that looked into this by Ching and colleagues from Michigan State University about 15 years ago. They looked at a group of individuals who had no infection. They looked at individuals who had an initial episode of 

, and then they looked at individuals with a first recurrence. They compared the constituency of the microbiota, as well as the diversity of the microbiota. What they found was that when they compared no infection with initial infection, there were no statistically significant differences. There was a slight trend for decrease in the diversity of the microbiota, but it didn't achieve statistical significance. Once they compared initial infection with recurrent infection, that was the circumstance where there was a statistically significant depletion of the diversity with the loss of two main fila, the Bacteroidetes and the Firmicutes. The Bacteroidetes and the Firmicutes are the most essential pieces of the microbiota that help us prevent 

. Now you say, “Well, how does this all correlate back to the infection?” The way that this correlates back to the infection is that antimicrobials treat that vegetative phase, treat that phase that releases the toxins that stimulate the diarrhea syndrome most associated with 

. But don't forget about that spore phase. That spore phase is spread but also results in recurrence. The way that we eradicate the spore phase of 

 is through a healthy microbiota. Now it's important to understand that at the end of antimicrobial treatment, our microbiota has been depleted because of the dysbiosis that led us to get 

, but also the antimicrobials that we use to treat 

 further deplete that microbiota. It's important to realize that following antimicrobial therapy, without further intervention, it's up to our microbiota to regrow and refortify itself. Unfortunately, sometimes that doesn't work quite as well as we'd like. In fact, 25% to 30% of the time with an initial infection that doesn't work well, and patients recur. With a first recurrence, 40% to 50% will go on to recur after that, and up to 60% as patients get caught in this cycle of recurrence after recurrence after recurrence; a massive burden on the patient population and also a massive burden on the health care system. Treating 

 optimally really needs to be prioritized.

A gastroenterologist reviews the long-term impact of dysbiosis and Clostridioides difficile infection.

Long-Term Impact of C. difficile Infection (CDI) and Infection Recurrence

We spoke with Carina Dolan PharmD, Editor in Chief of the Pharmacy Market Outlook, about the highlights and the big picture moving forward for hospitals and health systems.

I really wanted to talk to you about this pharmacy market outlook that you helped to write. And I wanted to just ask you first, what were the key findings in this pharmacy market outlook report that should be highlighted, such as anything related to remdesivir, or at a minimum?

Yeah, so the pharmacy market outlook report is really an aggregation of our Vizient Pharmacy Program participant member spend, we look at the top 85% of our members drugs. And so our findings from the pharmacy market outlook find that of our top 10 rankings, adalimumab actually ranks as our number one drug by Vizient members spend, and then second was remdesivir. We have seen a couple changes over the last couple of iterations, which is mostly related to the ongoing pandemic. So remdesivir is used in the supportive care of COVID. And so we will see the total spend and remdesivir go up and down as the pandemic waxes and wanes. And so for the July edition, adalimumab was again put as the number one ranked drug by Vizient pharmacy spend.

And going off of that and what you just said. So I know that right now, as a lot of people know, we're going through global inflation, this is affecting many people. But in this report, it was highlighted that drug price inflation could be lower than overall inflation. Why do you think that is?

That's a great question. And I received that question quite a bit since the Pharmacy Market Outlook is focused on the forecasting of pharmaceutical spend. So the drug price inflation that we're estimating for the calendar year 2023 is at 3.26%. Currently, or at the time of writing, the national inflation was I believe it was 8.3%. And so that is lower than our overall national inflation rate. But one thing that we are finding is that the inflation that we're seeing with drug prices that pharmaceutical companies can take price increases at any time, and we regularly track that which is what goes into the Pharmacy Market Outlook. So it doesn't entirely match up with our national inflation rate, because of the fact that pharmaceutical companies can take price increases and usually do year over year irrespective of the global inflation rate.

 And going off of more cost-effective things. I know that the report also says that the use of more cost-effective biosimilar insulin has increased in recent years. How do you think this will impact the hospital and health system industry?

 So biosimilars, overall, whether it's insulin or biosimilar, oncology agents, or biosimilar, supportive care agents; overall, biosimilars help decrease the costs in purchasing the products and also is decreasing the cost that patients may have. So to the health systems, it's really a cost savings, opportunity, anything that is brought to the market that is a competition, we see as cost savings opportunities for our health systems, which leads into savings for our savings for patients across the board.

 And overall, what does the picture look like going forward for drug prices in hospitals and health systems such as high-cost medications or lower cost generics biosimilars, in that aspect?

 That is a great question. That's really the heart and soul of what the pharmacy market outlook is. So it's looking at our Vizient member spend, and it is trying to estimate how we see prices and drug utilization moving in the future. So our estimated price inflation rate is really a moderate price increase, and we're seeing this moderate price increase because we are seeing more utilization and more drugs overall in that high cost drugs space. So more expensive drugs, but we're also seeing that being offset by generic opportunities coming to the market as well as biosimilar opportunities coming to the market. So we're seeing a bit of a balance there.

 So in the Pharmacy Market Outlook Report, are you seeing a change in where medications are used?

 Yes, Jill, we have we have seen over trending of our Vizient Pharmacy program participants spend. We have seen some movements from medications that have been historically moved on the inpatient acute care side moving to the ambulatory or the non-acute sector of the market, and we've even seen further movement out into Physician Clinics as well as home infusion. With the ongoing COVID-19 pandemic, we really learned that institutions and members were trying to make additional areas for the administration of medications. And we've seen this be a large impact on our members, the ability to move medications from the acute care space to the ambulatory space, and possibly even to home infusion. And in some regards, we've even seen some payer mandated movement as well. So that is something that we are tracking and are monitoring for our members.

Pharmacy Times spoke with Carina Dolan, PharmD, Editor in Chief of the Pharmacy Market Outlook, about the highlights and the big picture moving forward for hospitals and health systems.

The Big Picture Moving Forward as a Hospital, Health System

There are unique cultural differences, mostly in the sense that there is a highly diverse population here, that may not be seen on the mainland. I believe that real connections are important when considering pharmacy care in the state of Hawaii. It's a really small world here, you know, when you live on an island or a couple of islands, so the relationships that we build with our patients and our health care team is really important. There's been so many times where I'm out in the community event and I see patients or other health care providers that I've worked with who recognize me or I recognize them. And that's very special about being a student and working here, seeing those common faces and showing the patients that you, too, are part of the community. And I really feel like it enhances our relationships with them.

Well, Hawaii has one of the highest homeless populations in which they do not have the necessary access to health care. This causes a problem since preventable diseases and other major health concerns in this population are not being treated in a timely manner, until it becomes so severe that that person ends up in the emergency room, which ends up increasing hospital costs. Affordability is another challenge in Hawaii. Living on an island causes the price of goods to be quite high compared to the rest of the United States. I mean, gas, food, costs of living, making it harder for most of the population to also be able to afford their medication. I mean, it is our responsibility as pharmacists to overcome this barrier. And to really think to ourselves, are the patients being fully adherent to their medications? Are they skipping doses to try and save money? I mean, unfortunately, for most, the answer is yes. Various solutions that pharmacists may come up with are finding cheaper alternative medications, or coupons that will help cover some of the medication cost, or directing patients to an assistive program that help cover the medication cost. I mean, at the end of the day, controlling the patient's blood pressure, glucose levels in a diabetic patient, or preventing someone's asthma attack are the goals that must be met in order to improve the quality of life for the patients in our community.

Being a part of the community with cultural differences is great to see in our community. But that also means that English is not always the first language for everyone living in Hawaii, which may make it difficult for patients to communicate with health care providers or make it difficult to read the instructions on a prescription label. A lot of these patients may end up seeking treatment advice and recommendations from family members or other non-medical experts, which can lead to dangerous outcomes. Again, as health care providers, we need to look out for such barriers. I mean, one example is by using telephone-based services that will help with interpretation. We must make sure that the patient is aware that we are here for them, and we are always going to look out for their best interest.

In such a diverse community like Hawaii, it may be difficult to provide the same care to all cultural, ethnic and socioeconomic backgrounds. It becomes a challenge to pharmacists and other health care professionals to provide culturally competent health care that is open minded and all inclusive. Personally, I find that Hawaii forms a tight knit community despite these diversities, which helps with health compliance and adherence through familial support. When all members of the community are looking out for each other, it makes our job as health care providers easier because that is our main goal to look out for that for others.

Hawaii has a distinct culture, and the students said that has led them to have unique perspectives on culturally competent care.

Pharmacy Students in Hawaii Get Experience With Unique Patient Populations 

About 1 in 8 women in the United States will develop breast cancer in their lifetime. Overall mortality for breast cancer has decreased over the years with the addition of complex treatment, such as PARP inhibitors. The webcast discusses this class of medications and see how they fit into the treatment paradigm for breast cancer.

Use of PARP Inhibitors in Breast Cancer: Implications for Pharmacy Practice

 We’re going to shift gears a little bit and talk about overall treatment of 

. It’s important to remember that 2 things must happen for an individual to get 

: You have to be exposed, and you have to have a state called dysbiosis. We’ve thrown the dysbiosis term around a bit, but Tom, can you walk us through what the microbiota is, what it’s made of, and what dysbiosis means?

 Sure, Paul. The question is, where do I start? The gut microbiome, I think, is the thing that really describes it best; it really is the forgotten organ. We think about it like it’s this complex ecosystem, comprising not millions, or billions, but over a hundred trillion organisms and their genetic content. The diverse organism within the micro ecosystem is called the microbiota. It includes bacteria, viruses, phages, fungi, and other single-cell organisms. Most research today has involved bacterial microbiota, given their predominance relative to other microbes. It’s estimated [that] there’s over a thousand different bacteria residing within a healthy gut. Most of them are in the lumen of the large intestine. When we think about the different bacteria, we look at the fila, we have Firmicutes, Bacteroidetes, Actinobacteria, and Proteobacteria. These 4 comprise 99% of the intestinal microbiota in healthy adult individuals. We think about the 2 most predominant ones when we talk about a healthy gut: We’re talking about Firmicutes and Bacteroidetes. In a setting of healthy homeostasis or eubiosis, the gut has an array of functions, aids in digestion, metabolism, and immune modulation, among other factors. I kind of think about its two primary functions. It offers both protective effect and metabolic function. It presents colonization resistance from 

 infection and other resistant pathogens, and ensures immune modulation of both the innate and adaptive immunity, so that balance of pro- and anti-inflammatory mediators ensures good gut integrity. We think about metabolic functions, bio acid homeostasis—we have learned a lot about that in recent years, in how the gut plays a major role in ensuring that. Short-chain fatty acid production as well as vitamin synthesis, the B vitamins as well as vitamin K. Really the opposite of that, when you have this disruption of the hemostatic state, it’s called dysbiosis. At dysbiosis we have an alteration in the composition in order functions of the microbiome. Everybody’s microbiome is different; it’s almost like a fingerprint. What we typically see is change in the abundance of healthy bacteria relative to the less healthy microbe. In a setting of dysbiosis, we have an increased abundance of 

 Klebsiella, the proteus bacteria relative to Firmicutes and Bacteroidetes. When we think about precipitating factors, genetic defects, all the risk factors that I discussed before, stress diets, it all goes back to diet, alcohol consumption, infection, and clearly [the] use of antibiotics. When we think about dysbiosis, why it’s so concerning, is that I think we take our forgotten organ, the microbiome, for granted.¼With dysbiosis, we have infections like 

, but the consequences of dysbiosis really extend beyond infection. You have immune-mediated autoimmune disease. It’s being linked to Type 1 diabetes, metabolic cardiovascular disorder Type 2 diabetes, obesity, colorectal cancer, certain neuropsychiatric conditions like Parkinson disease, infection conditions like I mentioned, and there’s even some suggestion there’s a link to kidney disease. When it’s working well, it is the forgotten organ. It’s only in that setting at dysbiosis that we really get concerned about it.

 I think you did a really nice job kind of covering the microbiome, which is the genetic complement; the microbiota, which are the various living species; dysbiosis, which is an alteration from normal; and then that ever-important piece that you alluded to also, which is the metabolome. We care what’s in the microbiota, but we care more metabolically what the microbiota is producing. That’s again another piece of this area that we’re just starting to dig deeper into and we’re starting to understand.

Dr. Tom Lodise provides an overview of gut microbiota and the consequences of dysbiosis.

Gut Microbiota and Consequences of Gut Microbiota Disruption

: Now, you mentioned earlier a little bit about colonization. Bincy, can you walk us through what colonization is, in general? Then, when do you test for C. [Clostridioides] difficile in a patient with inflammatory bowel disease, and do you have a test of choice?

 Colonization, interestingly, in our IBD patients can vary. I've seen it significantly more so in our patients that have had recurrent C. diff, refractory C. diff infections, along with patients that have still moderate to more severe inflammatory bowel disease. We think it's related to the alterations of microbiome, where the patients with the active disease are unable to get their normal flora back and to stay in place, essentially. The C. diff continues to recur or starts to become activated from the spore to active form. Those cases can be very challenging to treat, in part, and I'm sure we'll talk about this in the future, about getting the C. diff under control (it) involves getting their inflammatory bowel disease under control to prevent those recurrences and get rid of that colonization, if possible, for these patients. Now, as far as testing an IBD patient for C. difficile infection, it can be challenging. The main challenge is because patients with IBD, if they end up getting C. diff, it's hard to differentiate if it's really C. diff infection, or is it really an IBD flare? In our general population, if patients end up getting diarrhea or pain, it's easy because you know something is different for them. They need to be evaluated and tested. The IBD patient, when they're getting diarrhea, you can't really say it's necessarily from C. diff infection. It could be an exacerbation of their inflammatory bowel disease. In my general practice, whenever a patient that has IBD starts telling me that they are having a flare, I often check for C. difficile infection along with their assessment of their IBD. I think it varies. Knowing that the burden of disease is high, we know that there's an increased risk of C. diff infection in the IBD patient population, I truly believe it's very important to test when there's a true clinical suspicion for them. This is especially true when your patients have been in remission of their IBD then all of a sudden develop acute onset of symptoms, sometimes could be similar to their IBD flare, but oftentimes, patients will also tell us that this flare seems a little bit different to their typical Crohn's disease flare or their ulcerative colitis flare, and that's when my radar goes up to think, "Could this be something different?" It's a C. diff infection or another type of bacterial infection, which our patients with IBD are also at increased risk for as well. That can include E. coli and salmonella, and other things, not just C. difficile. Again, going back to when to test, whenever there's a clinical suspicion when their disease symptoms have changed, when they go from remission to an actual flare, which is when we typically test for a C. diff infection. It's important because the sooner we test them the sooner we can get them treated. It's always better for their disease process because our IBD patients can deteriorate quite quickly and end up being hospitalized during worsened severity of their overall gut health itself.

: Excellent. Well, I think you covered really the general idea, multiple pearls came out of that little piece, but really, any time a patient presents with a potential inflammatory bowel disease flare, we can think about testing them for C. difficile. Also thinking about generating that differential diagnosis that we spoke about before. As we shift gears, and we're going to talk in much greater detail about treatment of C. difficile, can you walk us through what your treatment algorithm is for a patient with inflammatory bowel disease that is diagnosed definitively with C. difficile?

 Key steps to take include having a strong clinical suspicion early on, test them early on, and then treat them early on, along with assessing their disease activity for inflammation. What you want to do is, once you have confirmed the diagnosis, I'm always testing for the toxin because again these patients could have been colonized, they've had disease previously, or a C. diff infection previously. I always want to check for the toxin to see if that's what's activating their symptoms. So, if they're toxin positive, then I go ahead and start treating them aggressively. Our guidelines have switched, we no longer even mention metronidazole in our IBD patient population, we've been switching over to initiating therapy with at minimum vancomycin, and now with newer guidelines, it's just starting them with fidaxomicin. Typically, either of those is what we start with, and in our IBD patients, which should be your initial treatment. We know that those medications provide better efficacy of treatment and reduce the risk of recurrence as well. The other main aspect of treating C. diff infection in IBD patients, you can just go by treating the C. diff infection alone. Very often, their IBD is also in a flare, and you need to be aggressive in treating their inflammatory bowel disease. What often happens is that physicians or hospitalists may, especially these patients in the hospital with the severe infection, is often our IBD patients are on immunosuppressive therapy, they think, "Well, there's an infection going on, we've got to stop or hold their biologics or small molecules," and that's actually the incorrect way to treat them. You must be aggressive on both fronts, treating the C. diff and treating their IBD. Often, we're starting new biologics, or increasing their dosing or frequency to get their IBD under control because if we don't get their IBD under control, you can treat their C. diff initially, but most often they will recur, or it will take much longer to get rid of the C. difficile infection in those patients. That's a very key point, in managing C. diff infection in IBD patients: You have to treat both aspects aggressively, and early on.

: Excellent, and going with the flow on these patients of course, also. If you're treating the C. difficile, and you're keeping their other treatments stable, and they're not getting better, that might be a circumstance to intensify some of the other medications. Really thinking our way through this and assessing in real time because these patients with inflammatory bowel disease, and C. diff, are frankly, complicated, and we need to best understand what you just listed for all of us.

Dr. Abraham discusses importance of differential diagnosis of C. difficile infection (CDI) in patients with IBD and how both IBD and CDI should be managed.

Diagnosis and Management of C. difficile Infection (CDI) in Patients with Inflammatory Bowel Disease

, Deeb Eid, PharmD, regulatory affairs advisor at CVS Health, discussed how pharmacists and technicians are working to advance pharmacy practice. The COVID-19 pandemic accelerated many changes in the pharmacy field, but maintaining that momentum and working together will be essential for the future growth of pharmacy.

. I'm here with Deeb Eid, regulatory affairs advisor at CVS health, to discuss advancing pharmacy practice for both pharmacists and technicians. So, the entire pharmacy field has changed a lot and advanced a lot in the last 2 years or so. How does this really necessitate advanced pharmacy practice for pharmacists and technicians?

Thank you so much for the introduction, I appreciate it and I’m really looking forward to chatting with you today. And thanks for the first question. You know, just to get it out of the way, obviously, you know, anything that I talk about today is going to be things from my opinions and things that I have either come across or researched.

And so, to answer your first question about the field of pharmacy changing in the past 2 years, you're absolutely correct. In the last couple of years, pharmacy has had an opportunity, really, to step up and showcase their value and importance in health care as a whole. And we've been shown generally speaking to the public, but also to other agencies out there, like the FDA and others, that we are a critical piece as the medication experts, and also beyond just the dispensing process. So, I think, as we have an aging population, we have changes in societal expectations, we're moving towards maybe more efficiency, cost effectiveness, and even some automation in the future pharmacy. And I think some of the other personnel that are involved in the pharmacy are really in a position to provide care or are in a position to provide service and communication. And really, I think, continue to work through the interesting environment that we're going to see in probably the next 10 to 20 years.

Absolutely. Gaining provider status has really been a centerpiece of all of these efforts, so what efforts are being made in this direction and why is this essential?

Yeah, provider status is an interesting topic. And definitely, like you said, a real centerpiece in terms of pharmacy practice. I think it's super critical to ensure that we as a profession are recognized as providers and obviously to be paid for services, but the services that we are capable of, and also that bring patients value. I think that's a key piece to remember, is that patients do need to have the value in the services that we are providing. And as pharmacy and the profession move forward, I believe we are moving into those areas.

I think one of the things that I want to say is that it is a bit interesting. Now, this topic has been around for probably 10 to 15 years, you know, we've been talking about provider status, and it's probably been around for even longer than that. But it's a little bit ridiculous, in my opinion, that we're a doctorate level health care professional and we're not recognized as providers. In my opinion, it's a little bit challenging for us to move forward in some of the things that we're trying to get into, in terms of services and things that bring patients value. Unfortunately, we have a lot of politics involved in the process. There's some turf wars that are getting in the way. There are some states out there, I know, that have been working towards passing legislation or adapting some of their rules, and some of those states have been successful. So, that is obviously, you know, we're moving towards the right direction.

And one misconception that I do want to address, that I think a lot of people believe, is that gaining provider status possibly from the federal and even state level is going to be kind of like this resolution to all pharmacy issues. But I don't think that it is. I think it's part of a complicated puzzle, and it's one piece to the puzzle that needs to be resolved. But I don't think it's, you know, kind of a magic pill or a one-size-fits-all that's just going to magically solve everything that's going on in pharmacy. From the federal level, there's been a standstill and provider status. I think some of it has been due to challenges with lobbying. I've heard that scoring of the bills on the federal level has also been a challenge. I think that my best takeaway on this topic is we as a profession, we need to step up our game. We're being outspent by other professions by millions of dollars in the lobbying area and so that is a huge challenge for us. And we can't keep fighting the same topic for the next 20 years. It's already been about 10 or 15 years that we've been working on this. So, we really need to step up, we need to unite, and we need to put money and efforts into this topic to move it forward on the federal and even the state level.

Definitely. And, of course, advancing technicians is really essential in order for pharmacists to be able to step up and do these other responsibilities. So how are our technicians really stepping forward and taking on those responsibilities?

That's an awesome question and I'm glad you asked this actually, it’s one of my favorite topics to talk about. So, I'll try to keep it brief on this one. So, you know, technicians have been stepping up taking on more responsibility and we've seen this across the board. The first thing that comes to mind is immunizations, administration of immunizations, and medications. Of course, if we look back to 2018, 2016, kind of, you know, the very beginning, and in the state of Idaho, where this originated from a state level, we went from about 3 states who had passed some sort of laws or rules and in 2018, to now over 20-plus states who have passed either laws or rules or continue to work on this. And then, the other piece that was very important during the pandemic, that has been important during this pandemic, is the federal PREP Act with, you know, the HHS Federal PREP Act, which has allowed for essentially all 50 states and DC for technicians to administer various types of vaccines and immunizations. And that has really moved the profession forward in terms of allowing another individual on the team to help out with, you know, the increasing challenges that we're having, and really to protect patients. So, immunizations is one piece.

Another piece I'm seeing out there is technician product verification. So having technicians be involved in the final product verification, within the dispensing process. A lot of people are a little iffy on the topic, you know, it makes some people nervous, but I can tell you that there's over 40 years of either evidence or published literature, over 25-plus pieces of published literature and posters on the topic that showcases with various amounts of training, with various amounts of sectors of pharmacy, that technicians are capable of doing this in a safe and effective way. That's very comparable to that of a pharmacist. And so that's another area where we've seen a few states out there and advancements. And of course, there's training programs and a lot of models of how to set that up.

Another area would be expansion of remote work or work from home allowances. So, you know, allowing technicians the flexibility to be able to help take off some of the workload that's happening in a lot of our in-person pharmacies. And so that's also been another advancing area to help with distribution of work.

And then the last piece is point of care testing, point of care, test-and-treat programs. So, it's crucial to have technicians being a part of this as we advance. Of course, we've seen this with COVID-19 and, again, the Federal PREP Act allowances, but really just having technicians be on the testing side of things. And then the pharmacist obviously is then able to treat in some states and in some states even prescribe off those test results.

Wonderful. Well, speaking of prescribing, can you discuss the Paxlovid authorization for pharmacists and how that could be a step in the direction that we're talking about?

Great question. So, the Paxlovid authorization is a very positive step moving forward by the FDA. They revised their Emergency Use Authorization for Paxlovid, and it essentially allows the state licensed pharmacists to prescribe Paxlovid to eligible patients. And it has a positive impact on those patients because as we know, patients are out there, and they need these medications, or they might be looking for some relief if they've gotten COVID-19 or have contracted the disease. And so, it is a positive impact and another person on the team that can help patients in terms of their health.

Now, it is super important that the FDA from the federal level is recognizing pharmacists as a prescriber. This is definitely a huge step forward from where we've been. It does beg the question, though, of why not more? You know, if pharmacists are able to prescribe for a medication that was just released within the last couple of years for a fairly new disease, why can't they prescribe for other disease states that have been around for ages that we have data on, that we've been involved with treating for multiple years and multiple patients and we have a lot of studies. And so, I think that that's kind of the takeaway for me, is it's exciting to see that the FDA is recognizing pharmacists as prescribers. And I hope that with some lobbying efforts, and us stepping up and uniting as a profession, we can continue to move forward in other areas. And there's some states out there that have, like Idaho, for example, Utah, Colorado, they've moved into pharmacist independent prescribing, and I think that that's really the next big step for us.

Absolutely. And how is technology really being used and leveraged to advance pharmacy practice?

Yeah, technology is super important in terms of advancing practice and not just advancing practice, but really make sure that we have models in place that are efficient, safe, and also bring something to the patient that's going to be keeping up with societal expectations, right? So, that's one thing that I like to think about as well. So, automation is in place to ensure that we can have a safer dispensing process, so when you have robots who are able to dispense medications, no matter what type of facility you're in, you're almost guaranteed that it's going to be as safe of a process as possible, as long as everything is set up and maintained correctly by those who are working on setting up the robots and keeping them up to date. Tele-pharmacy and telehealth is another area within automation that is, you know, allowing for more or additional people maybe out there who wouldn't typically be able to be seen, maybe be able to be seen from the comfort of their own home, who maybe need something urgent or need to see a pharmacist or need to see a health care professional, and maybe pharmacy’s tied into that. So, that's another piece where we're bringing health care into the patient's home and making it a little bit more accessible.

Of course, we have central fill and central processing, which allow for fulfillment of our products and processing of our orders, removing some of the work from the actual pharmacies. Obviously, you know, there's a lot of people who are going to pharmacies these days, and a lot of individuals out there who are struggling with the increasing workload. So that's another type of automation, where again, we're trying to kind of distribute the work in different ways. And then you have kind of a more personal level. Think of, you know, your personal device or your phone, you have apps, they're helping people where they're able to go in and refill their medications, they're able to request an appointment. We have kiosks that are being placed in certain states that a patient can go in, and maybe they need their antibiotic that they just saw the prescriber for and they're able to pick up. We have locker systems that are also coming out there, where again, you can have your prescription filled, and maybe you can't make it until after hours. So, that's the exciting piece of pharmacy, I believe, right now. And it's definitely helping with advancements, but also just I think safety and efficiency.

Definitely. And as we've kind of discussed, the COVID-19 pandemic accelerated a lot of these changes that, maybe they were coming down the road, but it really pushed it to the forefront. But now that we're kind of entering a new normal, we're kind of living with COVID-19 now, so how can pharmacists and technicians maintain the momentum that they've had over the last couple of years?

Yeah, really great question. So, I think one of the big takeaways we've seen from COVID-19 and the entire pandemic and what has happened is that there are states out there who started using executive orders, there are states out there who started passing legislation, changing their rules, issuing emergency authorizations to allow for pharmacy to serve patients, right? And that's I think the big takeaway that people should have from this is that, really, what was in the way was the laws and the rules of the state. It's not that pharmacy isn't capable of doing more or isn't capable of advancing. I think that COVID-19 showed us that in times of need, we could and we were capable, it was just some of those pieces that were blocking us. And so, moving forward, how do we enter the new normal? How do we maintain that moving forward?

Well, I think number one, we have to embrace that pharmacy has been able to do more for quite some time now. But we have to realize that there is a lot. Once you keep adding to the plate, there's a lot to do, and that's where it becomes overwhelming. And that's where you may not have enough people to be doing these different things. And so that's where we need to continue to work on. How do we use automation to help us in those processes? How do we use things like remote work, work from home, central fill, central processing, some of these things that I just talked about with technology? How do we better use those to expand, you know, some of the increased editions that we're looking at? And how do we then utilize that to spread the workload out so that we are able to continue to keep up because it gets to a point where there's just too much on your plate, right? And no matter how many people you have, no matter how much help you have, etc., like there's just too much to do. And so, we have to make sure we're using those automations and technologies and processes to be more efficient. And to be able to keep up the momentum and not overwork ourselves.

Is there anything you'd like to add anything that I didn't think to ask about?

The one thing I think I would mention is I think we're at a point right now in pharmacy where there's a lot of unknowns. Like we talked about today, we have increases in demands, we have potential decreases in the available people who want to either be in pharmacy or who wants to continue to work in pharmacy because of those high demands. I hear a lot of people talking about that topic that you just mentioned, you know, the workload and the burnout, and just things that are continuing to evolve. And I encourage people out there to talk about the topic, but let's talk about the solutions. How do we work creatively and together towards the solution? So, I think a lot of the times when I see the topic brought up, it's not necessarily being talked about in terms of solutions. It's more of there is the problem, which we have to recognize that obviously, there is a problem. But I think moving forward, we need to work together to figure out what are the solutions and realize that the solutions may be things that are not necessarily things that would be the first thing that comes to mind. When you think of the topic like we talked about today, automation can be a huge deal in terms of helping, being able to delegate, being able to work remotely, doing some of these things. You know, as we talked about in terms of advancements, those are the types of things that as we continue to move forward, we need to make sure we're taking care of our profession, taking care of our people, and we need to make sure that we're using our resources properly so that it's not just relying on the backs of everybody, right? You know, a lot of a lot of professions out there have moved towards automation and that's on purpose, not to take away jobs from people but to help with the efficiency and help to relieve some of the challenges that we're having in terms of a workload and conditions and that sort of thing.

The COVID-19 pandemic accelerated many changes in the pharmacy field, but maintaining that momentum and working together will be essential for the future growth of pharmacy.