Plexus and Ethics

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Lately, I have been a little bit bothered by what I am seeing by other pharmacists regarding the MLM company Plexus. I posted a more professional spin on my thoughts in Pharmacy Times, but I wanted to go deeper into the issues.

Updated: Read this link: https://www.truthinadvertising.org/what-you-should-know-about-plexus/

Plexus claims on their website many different benefits of their products, all with an asterick leading the reader to the bottom of the website,

"Disclaimer: These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease"

The problem is that their own ambassadors make claims that are not backed up by any study. First let's list out all the things I have personally seen posted on social media in regards to this product:

  • Plexus Slim helped a patient with Crohn's discontinue the need for Remicade and other pharmaceuticals. At the end of the paragraph is the same statement " This one person's experience. Plexus does not claim to prevent, treat, or cure any disease." But you just did. You just claimed it is treating Crohn's and then place a disclaimer at the end of the claim. Putting the disclaimer in doesn't cancel out what was just claimed.

  • Plexus Slim treats ADHD in children. Here, here and here.

  • Plexus Slim treats anxiety and depression and other mental health illnesses. Here, here and here.

  • Plexus Slim lowers cholesterol and weight.

  • Plexus Slim isn't about weight loss (why Slim in the name? because initially it was about weight loss, then they figured out how to market it from women professionals (nurses, pharmacists, etc... for gut health and inflammation) but it's about GUT HEALTH,  INFLAMMATION and BLOOD SUGAR.

  • Plexus Slim cures the common cold.

  • Plexus Slim cures PTSD.

  • Plexus Sli treats arthritis.

What does Plexus Slim (the pink drink) contain?

Plexus Slim is a weight loss supplement manufactured by the network marketing company Plexus Worldwide, Inc. According to Plexus Worldwide’s website (accessed on August 13, 2015), each serving (1 “Slim Pack”) of Plexus Slim contains the following ingredients.

1. 200 mcg chromium (as chromium polynicotinate)

2. 530 mg of a proprietary blend of:

  • Green coffee bean extract (containing an unknown, unlisted amount of chlorogenic acid and less than 2% natural caffeine)
  • Garcinia cambogia fruit extract
  • Alpha lipoic acid

3. Other ingredients: polydextrose, citric acid, natural flavors, beet extract (for color), stevia leaf (Stevia Rebaudiana) extract, luo han guo fruit extract, guar gum, silicone dioxide.

They discuss their findings from the angle of natural health and cite natural health websites; however even people deeply rooted in natural health and wellness cite the claims of Plexus Slim.

According to a news website:

The FDA issued a warning letter to Plexus Worldwide stating three of its products were "not generally recognized as safe and effective for the above referenced uses." The letter went on to say "these drugs are misbranded. You should take prompt action to correct the violations."

That's exactly what the company did.

"We don't want to make claims that are not there, etc. So we take it very seriously," Clark said. "We adjusted the website language and made those changes. And now we're in compliance with the FDA's guidelines and everything is good."

Clark has been with Plexus since 2011, and in that time the company has grown at lightning speed.

"In 2010, we did about $1 million in sales. 2014, we were north of $300 million," Clark said.

He admits the company would not be where it is without its ambassadors.

No, Plexus would not be where it is today without its ambassadors making the outright claims about what Plexus can do without a single study or evidence to back them up. They use money and awards to gray the ethics of medical professionals who desperately want out of their 9 to 5 jobs and will say anything to sell their products. #doyoutrustme?

No, I do not trust you. I trust double-blind placebo studies and medical evidence of proof. I trust that if Plexus Slim was really capable of treating so many things, we would do away with most medications and give Plexus Slim as treatment in the hospital and community.

Don't be swayed by a drink that claims it can do so many things. Trust the evidence. And believe me, if Plexus Slim was able to do all the things it can do, the company would take the time to set up these studies rather than removing the language and allowing the ambassadors to do all the misleading.

The Pharmacist's Manifesto

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See original at Pharmacy Times.

Pharmacists do not become pharmacists to just dispense medications.

They do not do it just to make a lot of money.

They do not go through 6-8 years of study to feel important or to walk around being patted on the back.

They do it (at least I hope they do it) because they want to help a person, a patient, who needs help.

I remember the day the Pharmacist’s Oath was read aloud to my newly graduated pharmacy class. The feeling of accomplishment filled my being, and I felt proud and nervous to begin the career I had spent the last many years preparing and studying.

This is the updated version in 2009 by the American Pharmacists Association:

"I promise to devote myself to a lifetime of service to others through the profession of pharmacy. In fulfilling this vow:

• I will consider the welfare of humanity and relief of suffering my primary concerns.

• I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.

• I will respect and protect all personal and health information entrusted to me.

• I will accept the lifelong obligation to improve my professional knowledge and competence.

• I will hold myself and my colleagues to the highest principles of our profession’s moral, ethical and legal conduct.

• I will embrace and advocate changes that improve patient care.

• I will utilize my knowledge, skills, experiences, and values to prepare the next generation of pharmacists.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.”

These points should be important to all pharmacists, and many of them embrace the reasoning we chose pharmacy in the first place. We care, continue to learn, respect, remain ethical and work toward change and preparation for the future of our profession.

These points sound well and good. It wraps up neatly the ideas and beliefs we should hold dear; however, is it applicable in the day-to-day grind of pharmacy work and life?

The retail pharmacist that dispenses with minimal staff has something to add to the conversation.

The pharmacist overseeing warehouse fulfillment operation on a reduced staffing budget would probably worry about the optimal outcomes for patients.

The hospital pharmacist held tightly under a metric goal of so many orders per hour would probably worry as well.

There is a balance between profit margins and production regardless of what field discussed. Physicians and nurses are under tight restrictions as well and at the end of the day, the patient is the one who may suffer.

What does it mean to consider the welfare of humanity and relief of suffering to be our primary concern? It could mean that when a nurse phones down for an immediate dose of a pain medication for a patient, we should do all we can to make the time from phone call to patient receiving the medication as small of a time as we can. It could mean that when someone is out of medication refills in a retail setting, we attempt to help if we can. It could mean that we do all we can to make sure in the warehouse setting that medications are checked and double checked for accuracy and advocate for standards of certification for technicians. The examples go on.

Go above and beyond for the patient. If a pharmacist keeps the ultimate customer in mind, the patient, how could it be argued? Providing care for the patient should be the pharmacist’s manifesto.

Oncology Support

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BCPS Oncology Support

 

Antiemetics

Acute onset: occurs within 24hr of chemotherapy, peaks 5-6hr, resolves within 24hr

Delayed onset: >24hr after chemo [cisplatin, carboplatin, cyclophosphamide, doxorubicin]

Anticipatory: conditioned response triggered by sights, smells; more likely to occur with delayed N/V is not controlled

Breakthrough: despite prophylaxis treatment and requires additional rescue meds

Refractory: occurs during treatment cycles when ppx and/or rescue has failed in previous cycles

 

Risk Factors: <50 yo, female, motion sickness, N/V pregnancy, N/V previous chemo [alcoholism decreases risk]

General Principles for Managing Chemo/Radiation N/V

1. PPx meds before moderate or high emetogenic agents

2. antiemetics should be scheduled for delayed N/V

3. most common: High- serotonin antag + dex (steroid increases efficacy by 10-20%)

4. may also add aprepitant to above regimen.  [metoclopramide + dex used to be the most common]

 

High (>90%): [doxorubicin/epirubicin + cyclophos], carmustine, cisplatin>50mg/m2, cyclophosphamide>1500mg/m2

Minimal (<10%): most ‘mabs, Vins, interferon alpha<5million/m2, methotrexate <50mg/m2

 

Treatment: Use ppx for all chemo high-low (not routine for minimal)

1. 5-HT3: all similar efficacy (except palonosetron)   AEs- HA, constipation

2. corticosteriods: dex more studied than methylpred   AEs- infrequent with short duration (insomnia, fluid retention)

3. neurokinin-1 antag: aprepitant (PO) fosaprepitant (IV)   DDI- CYP3A4(warfarin-decrease INR, oral dex- decrease dose 40%, OCs- another form)   AEs- asthenia, dizziness, hiccups

4. benzamide analogs (metoclopramide): AEs- mild sedation, EPS

5. phenothiazines (prochlorperazine, promethazine): AEs- EPS, drowsiness, HoTN

6. butyrophenones (haloperidol, droperidol): AEs- EPS, sedation, less HoTN than above

7. benzodiazepines (lorazepam): only in combo, can help manage EPS   AEs- amnesia (can be good with anticip)

8. Others: cannabinoids (dronabinol, nabilone); H2 blockers/PPI

 

Pain Management

General Principles for Cancer Pain Management

1.  oral route preferred- scheduled basis, not as needed (as needed for breakthrough pain); >2 doses may need modify

2. maximize one drug dose and schedule before adding another drug

3. provide medications for AEs: constipation, sedation

4. assess pain often- most important step!

 

Treatment

1. mild-mod (1-3): nonopiod- NSAIDs, ASA, APAP (platelets, SCr)

2. mod-severe (4-6): + weak opiod- codeine, hydrocodone (watch for APAP OD with combos)

3. persistent severe (7-10): change weak to strong opiod- morphine, oxycodone (constipation- stimulant laxatives, urinary retention, sedation- dextramphe, methylphen, N/V- meclizine, phenothiazines)

4. Bisphosphonates: Pamidronate or zoledronic acid for skeletal pain (spinal cord compression, fracture, bone mets) in breast CA and myeloma [SCr,elec]

5. Adjuvant: antidepressants, anticonvulsants, transdermal lidocaine, corticosteroids, benzos (spasms), strontium-89

 

Febrile Neutropenia: ANC<500, nadir usually day 10-14 [No chemo if WBC<3000, ANC<1500, or Plate<100]

Febrile= one temp 101 or 100.4 >1hr

Reassess all pts in 3-5 days after abx

CSFs may be given: similar in efficacy, should be initated in 24-72hr post-chemo, cont until post nadir ANC>10,000

 

Thrombocyotpenia (plate<100, no increased risk of bleeding until <20, transfuse plate when symptoms)

Oprelvekin (interleukin-11)- ppx, cont until post-nadir >50   AEs- edema, SOB, tachycardia, conjunctival redness

Anemia/Fatigue: epoetin/darbipoetin alfa

Chemoprotectants

1. Dexrazoxane: anthracyclines- cardiotox. May use in pts doxorubicin >300mg/m2 and may benefit from cont. use

2. Amifostine: cisplatin- nephrotox and head/neck radiation- xerostomia. AEs- HoTN, metallic taste, flush

3. Mesna: ifosfamide/cyclophosphamide- hemorrhagic cystitis (metabolite acrolein)

 

Oncology Emergency

1. hypercalcemia: thiazide and hormonal therapy can exacerbate

                Treat (cCa> 14):NS 3-4L in 24hr, loop (to prevent fluid overload), bisphosphonates, calcitonin, steroids

2. spinal cord compression- dexamethasone and radiation or surgery

3. tumor lysis syndrome (uric acid, K, P): hydration and allopurinol, rasburicase with uric acid> 10

 

Misc Pharmacotherapy

1. leucovorin rescue- MTX > 100mg/m2 [Also used in combo with 5-FU to enhance activity, NOT rescue]

2. Extravasation (vesicants): ACs (topical dimethyl sulfoxide, dexrazoxane, cold), Vins (hyaluronidase, heat),mechlorethamine (Na thiosulfate) oxaliplatin, paclitaxel

3. Diarrhea- loperamide (higher than usual doses)

4. Renal dose: MTX, carboplatin, cisplatin, etoposide, bleomycin, topotecan, lenalidomide

5. Hepatic dose: doxorubi, daunorubi, vincrist, vinblast, docetaxel, paclitaxel, sorafenib, pazopanib

6. Never administer Viscristine intrathecally

Safety Culture in Pharmacy

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From Pharmacy Times: Safety Culture in Pharmacy

I have never met a pharmacist who intentionally set out to make an error. Most pharmacists are detail-oriented individuals who take their roles seriously.
 
After all, pharmacists are the umpires of the health care game. They enter, verify, and triple check prescriptions, orders, and final products until they are satisfied.
 
Pharmacists make sure that the correct medication is going to the correct patient. I signed up for this when I applied to pharmacy school in 1993.
 
At the time, I didn’t know what I was signing up for except a nice salary. I had no idea about the culture of safety in many medical jobs, or that a career in pharmacy required perfectionism.

Fate would have it that I married a man in safety, as well. While he reduces on-the-job accidents along with the Occupational Safety and Health Administration (OSHA) and other safety organizations, I work in a hospital where helping patients become well is the goal.
 
Nevertheless, the Journal of Patient Safety estimates that more than 400,000 people die each year due to harm in the hospital, making it the fourth leading cause of death in the United States. If this were any other industry, the organization would be shut down until the cause of harm was fixed, but hospitals simultaneously save lives, and so they stay open.

Hospitals have cultures that blame people rather than processes. Blaming people reduces error reporting, which shuts down improvement in processes.
 
Health care needs to view all errors as opportunities to improve systems and processes to catch mistakes caused by human error. Keep in mind that humans build processes, as well.
 
But will blaming people instead of processes ever change?

I asked a pharmacist once why he didn’t report errors. He told me that he only reports the errors that matter.
 
Don’t they all matter, though? Choosing and picking which error to report is looking through a punitive lens rather than a process lens.

I try to make it my practice to report all errors, even my own, because it is the only way to shed light on things that need to be adjusted in the system. If there are duplications missed regularly and a trend develops, the system analysts can figure out how to adjust the alerts to be better.
 
Changing how pharmacists check for errors could help, but if we don’t report, then they don’t know. In the meantime, we shouldn’t pick and choose what we report.

In the automotive industry, safety falls under human resources. Many times, an employee safety group is developed to look at the issues affecting the company.
 
Hospitals should employ the same type of safety group that not only encompasses risk management, information technology, and nursing, but also includes actual clinicians who work with the systems and interact with patients and their orders.
 
There should be multiple pathways provided for employees to bring suggestions and concerns to the group to look at the system and make it better, rather than just reporting errors with no follow-up and breaking down the processes that lead to a particular mishap.

We have processes and rules in place to make hospitals safer, but the culture can be so tainted that no one follows the protocols that are in place. It is true that when you start looking at safety through the lens of culture, you see how challenging it is to change.
 
Safety culture starts at the highest level of an organization and trickles down. If management does not have safety as a priority, then I guarantee you that no one else will.

One of the most damaging messages a pharmacist can receive is leadership mishandling a medical error. If our leaders do not take the time to investigate the systems involved with the error and how the error happened, and instead rush to punitive action toward the clinician, then staff members will become more jaded and less involved.
 
Medical errors are almost always the result of systematic flaws, rather than a person’s incompetence. Rushing to judgment rarely improves safety culture in a hospital and turns clinicians into something worse.

Here’s what a culture of safety in the pharmacy would look like:

Order entry and verification would not be in an area where distractions are abundant. There would be a telephone, but mainly for outbound calls. Order entry/verification would be in a quieter environment separate from where phones are ringing. Why host tasks that require perfection in an area that isn’t conducive to patient safety? If the room isn’t separate, then there will be constant interruptions. Every interruption, while pharmacists are in the middle of doing their job, is a recipe for disaster, just as it is for a nurse on the floor.


There would be continuity of care with work assignments. If pharmacists or nurses are changing hospitals every day, then they never really learn their patients. Processes could also vary from one hospital to another, which can lead to confusion for the clinician. If a pharmacist regularly works in the same environment, then he or she can see what processes need to change to ensure patient safety. Relationships between nursing and physicians would improve due to continuity of care. 


Nurses and pharmacists would report every single error, no matter how small. Only situations where there was blatant disregard of policy or unsafe acts would be punitive. If there is a near miss, then praise, where the error was discovered prior to the patient receiving the wrong care, would be given. The system should be designed to catch errors at different levels, rather than to rely on one step of the process. 
A safety focus group would be set up where issues and processes are analyzed on a routine basis, and changes are evaluated based on these analyzes. This focus group in the pharmacy could report to a larger group in the hospital with each department represented if a particular issue affects other departments.

More: Hospitals Mess Up Medications in Surgery A Lot - Bloomberg Business October 2015

Osteoporosis: Topic of the Day

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osteoporosis

The National Osteoporosis Foundation released an update to its Clinician's Guide to the Prevention and Treatment of Osteoporosis last year (April 2014). 

The current version (2014) was released April 1, 2014. The 2014 version of the Clinician’s Guide stresses the importance of screening vertebral imaging to diagnose asymptomatic vertebral fractures; provides updated information on calcium, vitamin D and osteoporosis medications; addresses duration of treatment; and includes an expanded discussion on the utility of biochemical markers of bone turnover and an evaluation of secondary causes of osteoporosis.

Osteoporosis Guidelines

Postmenopausal women and men age 50 and older

National Osteoporosis Foundation (2014) U.S. Preventative Services Task Force among other organizations

Postmenopausal women

 American Association of Clinical Endocrinologists (2010) – North American Menopause Society (2010)

Men

Endocrine Society (2012)

Review of the 2014 NOF Clinician's Guide

  • Approach to the diagnosis and management of osteoporosis
  • Universal Recommendations 
  • Pharmacotherapy (Who) and FDA indications
  • Sequential and combination therapy
  • Duration of treatment

Dual‐energy Absorptiometry (DXA) Bone Density Testing: Indications

  • NOF guideline
    • Women > 65 years old and men > 70 years old
    • Younger postmenopausal women, women in the menopausal transition, and men age 50‐69 years old with clinical risk factors for fracture • e.g., current smoker, low body weight, history of osteoporosis, low trauma fracture in a first‐degree relative
    • Adults who have a fracture after age 50 years
    • Adults with specific conditions or medications associated with bone loss
  • Other – Women 50‐ 64 years old with FRAX overall fracture risk > 9.3% (USPSTF) – 

WHO Definition of Osteoporosis Based on Bone Mineral Density testing results:

  • Normal 
    • BMD within 1 SD of the mean level for a young-adult reference population
    • T-score at -1.0 and above
  • Lone Bone Mass (Osteopenia)
    • BMD between 1.0 and 2.5 SD below that of the mean level for a young-adult reference population
    • T-score between -1.0 and -2.5
  • Osteoporosis
    • BMD 2.5 SD or more below that of the mean level for a young adult reference population
    • T-score at or below -2.5
  • Severe or Established Osteoporosis
    • BMD 2.5 SD or more below that of the mean level for a young adult reference population
    • T-score at or below -2.5 with one or more fractures

Imaging Recommendations

  • Vertebral Imaging recommended for women age 70 and older and all men age 80 and older if BMD T-score at the spine, total hip or femoral neck is </= -1.0
  • Women age 65-69 and men age 70-79 if BMD T-score at the spine, total hip or femoral neck is </= -1.5
  • Postmenopausal women and men age 50 and older with specific risk factors: low trauma fracture during adulthood (age 50), historical height loss of 1.5 inches or more (4 cm), prospective height loss of 0.8 inches or more (2 cm), or recent or ongoing long-term glucocorticoid treatment.

FRAX was developed to calculate a 10-year probability of a hip fracture and the 10-year probability of a major osteoporotic fracture (defined as clinical vertebral, hip, forearm or proximal humerus fracture). FRAX algorithm available at www.nof.org as well as at www.shef.ac.uk/FRAX.

FRAX is for postmenopausal women and men age 50 and older. In patients being pharmacologically treated for osteoporosis, clinical judgment must be use in interpreting results. No treatment in 2 years could be interpreted as untreated. Femoral neck BMD is preferred in calculating FRAX.

Diagnosis of Osteoporosis (WHO Criteria) (Postmenopausal women and men >/= 50 years of age)

  • T‐score at ‐1.0 or above  (SD) Normal
  • T‐score between ‐1.0  and ‐2.5 (SD) - Low bone mass (Osteopenia)
  • T‐score at or below ‐2.5 (SD) - Osteoporosis
  • T‐score at or below ‐2.5 (SD) with one or more fractures - Severe or established osteoporosis SD = standard deviation

Diagnosis of Osteoporosis (International Society for Clinical Densitometry 2007 Guidelines)*

  • Z‐score above ‐2.0 (SD) “Within the expected range for age”
  • Z‐score at or below ‐2.0 (SD) “Low bone mineral density for chronological age” or “Below the expected range for age” SD = standard deviation Premenopausal Women, Men < 50 Years of Age, and Children * These criteria are never used alone to diagnose osteoporosis in these populations

RECOMMENDATIONS IN ALL PATIENTS:

Several interventions to preserve bone strength can be recommended to the general population. These include an adequate intake of calcium and vitamin D, lifelong participation in regular weight-bearing and muscle-strengthening exercise, cessation of tobacco use, identification and treatment of alcoholism, and treatment of risk factors for falling. 

Bone‐Healthy Lifestyle:

  • Calcium - Recommended elemental calcium intake should be obtained ideally through dietary sources + supplements
  • Age Group Recommended Daily Intake Maximum Daily Intake
    • 19-50 years 1000 mg
    • 50-70 years 2000 mg Men = 1000 mg Women = 1200 mg
    • ≥ 71 years 1200 mg

According to the updated 2014 National Osteoporosis Foundation guideline, intakes of calcium in excess of 1200 to 1500 mg per day could place a patient at increased risk for kidney stones, cardiovascular disease (CVD), and stroke. (J Bone Metab 2014;29:531‐3; J Bone Metab 2014;21:21‐8; Am J Clin Nutr 2011;94:270‐277)

Vitamin D: This is the amount needed to maintain the majority of healthy patients within the sufficient range

  • Age Group Recommended Daily Intake
    • National Osteoporosis Foundation (2014)
      • <50 years 400-800 units (4000 units max daily intake) 
      • ≥ 50 years 800-1000 units (4000 units max daily intake)
  • Institute of Medicine (2010)
    • ≥ 71 years 800 units (4000 units max daily intake)
    • 51-70 years 600 units (4000 units max daily intake)
    • 19-50 years 600 units (4000 units max daily intake)

When to Consider Drug Treatment

  • History of (low trauma) hip or vertebral fracture
  • T‐score - ‐2.5 at femoral neck, hip, or spine by central DXA
  • Postmenopausal women and men 50 years of age if T‐score between –1 and –2.5 and 10‐year hip fracture probability of 3% or a 10‐year all major osteoporosis‐related fracture probability of 20%

Bisphosphonates:  inhibit osteoclastic bone resorption and reduce osteoclast activity and beneficial effect on osteoblasts.

  • Drug holidays are being considered for bisphosphonates to prevent which serious long‐term adverse effects 
  • Show residual effects after discontuation
  • Evidence for efficacy beyond 5 years is limited, whereas rare safety concerns become more common beyond 5 years. 
  • Reasonable to discontinue after 3-5 years in patients who have a modest risk of fracture after the initial treatment period, but in high risk, continued treatment or alternative treatment should be considered.

Non-Bisphosphonates: produce temporary effects that wane with discontinuation.

Duration of Treatment and Drug Holiday

  • Alendronate: Duration of treatment 5 years. Assessment for reinitiation: 1-2 years
  • Risedronate: Duration of treatment 5 years. Assessment for reinitiation: 1 year
  • Zoledronic acid: Duration of treatment 3 years. Assessment for reinitiation: 2-3 years

Denosumab Role in Therapy

  • FDA osteoporosis indications
    • Postmenopausal women and men with high fracture risk (Osteoporosis fracture, multiple risk factors, can’t use other meds)
    • Androgen deprivation therapy for nonmetastatic prostate cancer
    • Adjuvant aromatase inhibitor for breast cancer
  • AACE guideline – first line
  • Increases BMD for at least 8 years
  • Vertebral, hip, & nonvertebral fracture prevention
  • Quicker reversal with medication discontinuation
  • Adverse effects: Common adverse reactions (> 5% and diff placebo)
    • Back, shoulder, leg, and musculoskeletal pain – Increased cholesterol – Cystitis
    • Cases of MRONJ and atypical fractures

Raloxifene Role in Therapy

  • FDA indications
    • Osteoporosis prevention and treatment
    • Postmenopausal women with osteoporosis and/or at high risk for invasive breast cancer
  • AACE guideline –Second‐ and third‐line therapy
  • Dose ‐ 60 mg daily
  • Contraindications ‐ active or past history venous thromboembolism
  • Precaution – risk for stroke
  • Adverse effects – Vasomotor symptoms (hot flushes) – Leg cramps – Breast tenderness – Spotting – Venous thromboembolism – Box warning – fatal stroke

Teriparatide Role in Therapy

  • FDA indications
    • Postmenopausal women at high risk for fracture
    • Men with primary or hypogonadal osteoporosis at high risk for fracture
    • Glucocorticoid‐induced osteoporosis
    • High fracture risk
      • Previous fracture
      • Extremely low BMD (T‐score < ‐3.5)
      • Multiple risk factors for fracture
    • Teriparatide Dose, Selection, and Common Adverse Effects
      • 20 mcg subcutaneously daily for 24 months
      • Once weekly injection in trials – ? Start antiresorptive agent before end of therapy
      • Contraindications – Skeletal muscle radiation, bone cancer, hypercalcemia, Paget’s disease
      • Common adverse effects
        • Orthostasis – first doses
        • Nausea, arthralgia, leg cramps
        • Hypercalcemia (check calcium at baseline)
        • Box warning ‐ osteosarcoma (animal data)

Calcitonin: Role in Therapy, Efficacy, Dose, and Adverse Effects

  • FDA indication – osteoporosis treatment for women   5 years post menopause with low bone mass
  • AACE guideline – fourth‐line therapy
  • Only vertebral fracture prevention
  • Dosing –Intranasal ‐ 200 units daily alternating nares
  • Adverse effects –Nasal – rhinitis, epistaxis, irritation –Subcutaneous – pain, redness –Other – nausea, allergic response, backache, headache –FDA post‐marketing analysis for cancer risk
References:
  • National Osteoporosis Foundation (2014)
  • U.S. Preventive Services Task Force – calcium vitamin D (2013)
  • Ann Intern Med 2013;158:691‐696
  • U.S. Preventive Services Task Force – screening (2011) – www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm
  • International Society for Clinical Densitometry (2013) – www.iscd.org/documents/2013/07/2013‐iscd‐official‐ positions‐adult.pdf
  • American Association of Clinical Endocrinologists(2010)
  • Endocr Pract 2010;16(Suppl 3):1‐37
  • North American Menopause Society (2010) – www.menopause.org/docs/default‐document‐ library/psosteo10.pdf?sfvrsn=2
  • Endocrine Society (2012) – J Clin Endocrinol Metab 2012;97:1802‐1822

 

 

 

 

Could a Robot Do Your Job?

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Could Artificial Intelligence Replace Pharmacists?

The question that pharmacists need to ask themselves is, “Could my job function be replaced by artificial intelligence?” Many would respond confidently with a no. According to Geoff Colvin of Fortune magazine, author of Talent is Overrated and Humans are Underrated, if your job does not have human behavior in its function, you would be quite surprised to hear you are replaceable. Computers and robots cannot show empathy, compassion, sympathy or collaboration. Artificial intelligence (AI) can check drug-drug interactions, drug-disease state interactions and make recommendations and much more.  AI can check medication compounding and final product with better accuracy than human accuracy. To survive long-term, pharmacists need to provide more than just a final verification with order entry and final product.

Pharmacists’ jobs are a big target for more automation especially since medication errors are a big issue in public health safety. According to the Institute of Medicine, an estimated 7,000 deaths in the U.S. each year are due to preventable medication errors. Medication errors also cost about $16.4 billion annually. Pharmacists are slowly being replaced at the University of California San Francisco Medical Center and are responsible for receiving prescriptions, packaging, and dispensing.

Pharmacists need to collaborate with other healthcare professionals

Pharmacists need working relationships with physicians and other healthcare professionals in the hospital or in the ambulatory care setting. We need to be a valid member of the healthcare team offering real-time advice and recommendations on patients during rounds. We also need improved communication. If we merely sit in a seat in the same room of a hospital entering orders and checking the final product, we could easily be replaced by artificial intelligence.

It becomes even more vital for the Pharmacist Provider Status bill to pass simply to help add billable functions to our role instead of just billing for product. I have no doubt with the right system and hospitals willing to pay for the technology, pharmacists could lose their role in order entry and checking. We make mistakes because we are human and checking is not a complicated process. We already have the potential to allow computer systems to do the allergy checking and drug interaction checking for us without much of a thought. We now have prescribers entering orders directly into the computer. It is not unfathomable for a computer to check what the prescriber entered with much more accuracy than a pharmacist for less money.

Pharmacists need to be involved with direct patient care.

Medication reconciliation is a place where pharmacists could have patient contact and ensure that medications are entered correctly into the electronic medical record. Pharmacists could be more involved in warfarin and diabetic education collaborating with other professionals. Pharmacists could also be involved with educating patients about their medications before they leave the hospital. All of these things do cost money for the hospital since they are mostly not billable, but the pharmacist would be able to do more than what a computer could do alone.

A computer is unable to replace human interaction. Pharmacists need to bring more value to the healthcare table than functions that can be done by artificial intelligence.