Nebraska May/June 2019 | Volume 82, Number 3 MORTAR & PESTLE Official Publication of theNebraska Pharmacists Association
Remote Dispensing | Pg 4
Annual Convention | Pg 5 For NPA Members Probiotics | Pg 14 Rabies | Pg 22 Sunscreens | Pg 32 Head Lice | Pg 33 Rx and the Law | Pg 43 Nebraska MORTAR & PESTLE We Hear That! • NPA member, Jeff Kildow, Bayard, PharmD, graduate • NPA member, Eugene Heath, Lincoln, passed away April of the University of Nebraska Medical Center College of 20, 2019, in Elk City, Oklahoma. He graduated in 1965 from Pharmacy, was named the UNMC College of Pharmacy the University of Missouri. Most of his professional life was Community Preceptor of the Year. Congratulations, Jeff! centered around pharmaceutical research and working with the FDA. Condolences to the Heath family! • The University of Nebraska Medical Center College of Pharmacy was one of the recipients of the National • NPA member, Mark Swenson, Norfolk, passed away May Association of Chain Drug Stores (NACDS) Foundation 11, 2019. Mark was a graduate of the University of Nebraska 2019 Scholarships for Advance Patient Care. UNMC Medical Center College of Pharmacy. He was an inspiration students will address rural health disparities in Nebraska to doctors, nurses, teachers and pharmacy customers. by screening 500 rural patients for Hepatitis C under the Condolences to the Swenson family! supervision of faculty and pharmacists preceptors. Congrats to UNMC!
Please send "We Hear That" news and photos to [email protected]. You may think your news isn't important, but M&P subscribers enjoy reading about their pharmacy friends from across the state.
NPA Staff Joni Cover, JD Marcia Mueting, PharmD Diane Webb Chief Executive Officer Nebraska DUR Director Finance & Marketing
Pharmacy Technician Board of Directors Publisher Second class postage paid at Lincoln, Christina Gerard The Nebraska Mortar & Pestle (M&P) Immediate Past President, Nebraska, and at additional mailing offices. (ISSN 0028-1891) is owned and published Jennifer Tilleman Postmaster: send address changes to by the Nebraska Pharmacists Association Students Nebraska Mortar & Pestle, 6221 S 58th St, President, to provide continuing pharmacy education, Alexander Brown, CU Suite A, Lincoln, NE 68516-3687 or email Ally Dering-Anderson drug information, news, and trends in Cory Durbin, UNMC [email protected]. President-Elect, Pam Miller the profession of pharmacy. Opinions expressed by the contributors, whether Treasurer, Jeffrey Steffensmeier Nebraska Pharmacists Association Network Chairs signed or otherwise, do not necessarily Chief Executive Officer, 6221 S 58th St, Suite A Academia/Specialty Practice, reflect the attitudes of the publisher nor are Joni Cover Lincoln, NE 68516 Nicole White they responsible for them. p: 402.420.1500 | f: 402.420.1406 Hospital/Health-System, District Members The M&P is published six times a year e: [email protected] | w: npharm.org District 1, Ken Kester Jerome Wohleb - February, April, June, August, October District 1, Jeffrey Steffensmeier Independent, Trevor Bertsch and December. The subscription rate for non-members is $30 per year. The District 2, Jeanie Shipman Industry, Ryan Flugge Long-Term Care, managing editor is Joni Cover. The office District 2, Eric Sundsboe of publication is 6221 S 58th St, Suite A, Mackenzie Farr District 3, Beth Boals-Shively Lincoln, NE 68516-3687. District 3, Kelly Hamilton New Practitioner, Jacelyn Watt
2 May/June 2019 Nebraska MORTAR & PESTLE
Disaster Preparedness With the recent flooding in Nebraska, it is a good time to make sure that In Case You Missed It your disaster plan is up-to-date and all employees know what to do in the event Your NPA member benefits include a daily email with important drug and of a disaster. health information, as well as answers to member questions. Below is a According to Title 175 of the We Hear That! Nebraska Administrative Code, partial list of some of the most recent Daily News Dose items and other 8-006.07, The pharmacy must establish important pharmacy news that you may have missed. and implement disaster preparedness plans and procedures to protect the potency, efficacy, safety, and security Welcome Cory Durbin! USP 800 Deadline December 1 of the drugs, devices, or biologicals in The NPA welcomes Cory Durbin, The purpose of USP General Chapter the pharmacy in instances of natural University of Nebraska Medical <800> Hazardous Drugs - Handling (tornado, flood, etc.) or other disasters, Center College of Pharmacy, PharmD in Healthcare Settings is to describe disease outbreaks, interruption of utility Candidate, Omaha, to the NPA Board of practice and quality standards for services, or other similar situations. Directors as the UNMC Student Board handling hazardous drugs in healthcare Such plans and procedures must Representative. settings and help promote patient address and delineate: safety, worker safety, and environmental 1. How the pharmacy will provide Medicaid Lowers Total Daily protection. for the storage of drugs, devices, and biologicals at the proper MME Limit Effective June 1 The chapter defines processes intended to minimize the exposure to temperature; Nebraska Medicaid will implement total hazardous drugs in healthcare settings. 2. How the pharmacy will provide daily dose limits of opioids. These limits All hospitals and pharmacies are for the disposal of drugs, devices, are intended to enhance the safe use of expected to meet the requirements and biologicals if the pharmacy opioids. of USP Chapter <800> by December 1, determines their potency, efficacy, or An initial daily limit of 300 Morphine 2019. safety has been adversely affected; Milligram Equivalents (MME) was put in If your facility has not yet begun 3. How the pharmacy will secure the place in December 2018 with the new preparation, start by reviewing the drugs, devices, and biologicals from lower limit of 250 MME implemented Chapter information. Go to https://www. the public; and next month for Nebraska Medicaid usp.org/usp-chapter-800-download to 4. How the pharmacy will maintain patients with pain, unless being treated download a copy of the USP General patient records and inventory for active cancer, enrolled in hospice, Chapter <800>. records. or receiving end of life care. Claims for total daily doses of more than 250 MME will reject on June 1, 2019 unless an Pharmacists for Healthier Lives Medical Marijuana Survey Based on the responses to a March approved prior authorization is on file. The NPA has joined Pharmacists for Healthier Lives – a coalition of national member survey, the NPA Board of and state pharmacy organizations Directors voted to support a version of DEA Take Back Day Results LB 110, a medical marijuana initiative in The April 27th Take Back Day collected coming together in a coordinated effort to raise the collective profile of the Nebraska, that would allow pharmacists and destroyed close to 469 tons involvement in providing and educating of potentially dangerous unwanted pharmacy profession. The campaign works to enhance public perception and patients about medical marijuana. Here drugs. There were 47 sites in Nebraska are the results: accepting unwanted medications and awareness regarding the value of the pharmacy profession and its role on the • Should pharmacies be allowed to collected 5,661 pounds. Congratulations sell OTC cannabidiol products? healthcare team. to the law enforcement agencies and Yes 64.8%, No 35.2% their partners for another successful • Should pharmacists be part of event. Pharmacists Wear White Coats and the process of providing medical Remind your patients that Every Many Hats - Here to listen, to inform, marijuana to patients? Day is Take-Back Day in Nebraska. and to help you live your healthiest Yes 75.3%, No 24.7% To find a participating location, go to life. We are #pharmacists. Accessible. • Should pharmacists be allowed leftovermeds.com or type "drug disposal Knowledgeable. #Indispensable. to own medical marijuana dispensaries? near me" in the Google Maps search bar. https://pharmacistsforhealthierlives.org/ Yes 71.1%, No 28.9% Thank you for responding to the survey and for the additional feedback.
www.npharm.org 3 Nebraska MORTAR & PESTLE July 19 & 20, 2019 The Cornhusker Marriott Hotel Remote Lincoln, Nebraska Dispensing
Curtis Discount Pharmacy
In September 2018, Dan Kreis, PharmD, owner of Gothenburg Discount Pharmacy in Gothenburg, Nebraska, opened the remote dispensing pharmacy - Curtis Discount Pharmacy - in Curtis, Nebraska with Pictured left to right: Dan Kreis, PharmD; Kendra Pate, Pharmacy Technician; and Adam Lee, PharmD. fellow pharmacist, Adam Lee. Curtis had been without pharmacy services for about ten years and is located nearly 40 miles from the closest pharmacy. Dr. Kreis Dan said that the remote dispensing pharmacy had been contacted by several people in the Curtis verification and patient counseling demands have not community asking him to open a pharmacy in town. interrupted work flow at the supervising pharmacy. JOIN US! Dan’s State Senator, Matt Williams, had sponsored If a patient is waiting for a prescription in Curtis, the Ally Dering-Anderson, PharmD, RP the 2018 Legislative Bill 731 which allowed remote pharmacy in Gothenburg is notified with a buzzer President pharmacy dispensing. Planning for the pharmacy system. There is a dedicated computer in Gothenburg Please join us at this year's NPA Annual Convention, Nebraska Pharmacists Association began with the City of Curtis prior to the passing for the remote dispensing site. Patients in Curtis have July 19 & 20, 2019 at the Lincoln Marriott Cornhusker of LB 731. access to a large screen to view the pharmacist in Hotel in Lincoln, Nebraska. The remote dispensing pharmacy has been well Gothenburg who is performing the counseling. The received by the patients and providers in Curtis. The pharmacies are connected by Telepharm software and store has a robust front-end with over-the-counter use McKesson’s Pharmaserv software for prescription The convention is a great time to exchange information, medications. Three certified pharmacy technicians processing. network, and learn the most current information that have staffed the remote dispensing location at any The greatest challenge for opening the remote can impact you and your practice. We are excited about one time. One lives in Curtis; the others travel from dispensing pharmacy was the additional paperwork for the line up of wonderful speakers and excellent topics, Gothenburg. Because of the success of the location ordering controlled substances from the wholesaler and the increased workload in opening a new and third-party contracts for the remote site. but most importantly, we look forward to connecting pharmacy, a pharmacist had been on-site three or four Curtis Discount Pharmacy is one of four remote with you! days each week. When a pharmacist is on-site at the dispensing pharmacies in Nebraska. The other remote remote dispensing location, flu shots are administered dispensing pharmacies include: and prescriptions from other pharmacies can be transferred. The remote dispensing pharmacy is open • Overton Community Pharmacy, Community Monday through Friday from 9:00 am to 5:00 pm. The Pharmacy Services, Gretna number of prescriptions filled at the remote dispensing • Pierce Pharmacy, Steffen Drug, Hartington location has exceeded Dan and Adam’s projections. • Emerson Apothecary, The Apothecary Shop, Pender
Joni Cover, JD Chief Executive O cer Nebraska Pharmacists Association 4 May/June 2019 Nebraska MORTAR & PESTLE July 19 & 20, 2019 The Cornhusker Marriott Hotel Lincoln, Nebraska
JOIN US! Ally Dering-Anderson, PharmD, RP President Please join us at this year's NPA Annual Convention, Nebraska Pharmacists Association July 19 & 20, 2019 at the Lincoln Marriott Cornhusker Hotel in Lincoln, Nebraska.
The convention is a great time to exchange information, network, and learn the most current information that can impact you and your practice. We are excited about the line up of wonderful speakers and excellent topics, but most importantly, we look forward to connecting with you!
Joni Cover, JD Chief Executive O cer Nebraska Pharmacists Association www.npharm.org 5 Nebraska MORTAR & PESTLE SCHEDULE FRIDAY, JULY 19
6:30 am – 3:30 pm R
T D V T P E 6:45 am – S S E I 7:45 am P N A F Robert Percell, MD, FACC, Electrophysiologist, Bryan Heart Industry sponsored breakfast. Registration is required.
7:50 am – W 8:00Annual am NPA President, Ally Dering-Anderson,Convention PharmD CPE S 1 I L Rear Admiral Scott F. Giberson, Deputy Director, Centers for Medicare & Medicaid Services KEYNOTE ACPE UAN 0128-0000-19-028-L04-P/T SPEAKER 1.5 hrs | 0.15 CEUs - Knowledge-based CPE Activity 8:00 am – Learning Objectives: 1. Discuss the foundational principles of an infectious leader, regardless of Rear Admiral 9:30 am the leadership style utilized. Scott F. Giberson 2. Enumerate three ways to develop trust as a leader and provide examples. Deputy Director, Centers for 3. Analyze some of the common challenges of 21st century leadership and Medicare & Medicaid Services be able to articulate ways to overcome them. 4. List and explain the implementation of the four key determinants of infectious leadership. I L 5. Di erentiate between motivation and inspiration and assess how to Friday at 8:00 am apply this as a leader.
9:30 am – 9:45 am B
CPE S 2 E T : T 10 N D Creighton University School of Pharmacy & Health Professions PharmD Candidates: Ti any Bihis; Ryan Kano; Mackenzie Moritz; Kateri Petto; and Laura Yacinthe; and 9:45 am – University of Nebraska College of Pharmacy PharmD 10:30 am Candidates: Melissa Borsh; Anthony Donovan; Kelsey Haywood; Natasha Konfrst; and Xiaoxiao Qi ACPE UAN 0128-0000-19-029-L01-P/T 1.5 hrs | 0.15 CEUs - Knowledge-based CPE Activity Learning Objectives: 1. Identify the top ten new drugs. 2. Describe each drug’s role in therapy.
10:30 am – 10:45 am B 6 May/June 2019 Nebraska MORTAR & PESTLE SCHEDULE FRIDAY, JULY 19
10:45 am – CPE S 2 EXHIBITORS* 11:30 am E T : T 10 N D AbbVie
10:45 am – I N M Allergan 11:15 am Ryan Flugge, Network Chair Amarin Pharmaceutical 11:30 am – AnnualL E ConventionAstraZeneca Pharmaceuticals 1:00 pm Athenex Pharmaceuticals W’ H P 1:00 pm – • Meet the Pharmacy School Deans BTG Pharmaceuticals 2:00 pm • Membership Meeting/Report • Awards Creighton University School of Pharmacy & Health Professions 2:00 pm – 2:15 pm B Dakota Drug
CPE S 3 Great Plains Quality Innovation C G -A P Network Jean Amoura, MD, MSc, Associate Professor, Department Independent Pharmacy of Obstetrics & Gynecology, University of Nebraska Medical Cooperative (IPC) Center College of Medicine; and Jay Irwin, PhD, Associate Professor of Sociology & Janssen Pharmaceuticals 2:15 pm – Anthropology, Faculty Member, University of Nebraska at McKesson 3:15 pm Omaha ACPE UAN 0128-0000-19-030-L04-P/T Nebraska MEDS Drug Disposal 1.0 hr | 0.10 CEU - Knowledge-based CPE Activity Learning Objectives: Nebraska Total Care 1. Defi ne transgender/gender non-binary patient terminology. 2. Review common health care barriers and best practice guidelines for Novo Nordisk - Biopharm, working with transgender/gender non-binary patients. 3. Identify medical interventions for transgender/gender non-binary patients. Diabetes and Obesity Pfi zer - Internal Medicine and 3:15 pm – Vaccines 3:30 pm B Pharmacists Mutual CPE S 4 P L R Seattle Genetics Joni Cover, Chief Executive O cer, Nebraska Pharmacists SpartanNash Buying Group Association; and 3:30 pm – Marcia Mueting, PharmD, Nebraska Pharmacists Sunovion Pharmaceuticals 5:00 pm Association, Lincoln, NE Tabula Rasa Healthcare ACPE UAN 0128-0000-19-031-L03-P/T 1.5 hrs | 0.15 CEUs - Knowledge-based CPE Activity Learning Objectives: Walgreens 1. Describe how recent revisions in statutes and regulations impact the practice of pharmacy. WellCare of Nebraska 2. Identify changes in Federal and State law. *At time of printing 5:00 pm E
www.npharm.org 7 Nebraska MORTAR & PESTLE SCHEDULE SCHEDULE SATURDAY, JULY 20 SATURDAY, JULY 20
CPE S 3 6:30 am – CONVENTION 1:00 pm R O P : SPONSORS N-O T O P C O D Amarin Pharmaceutical Krysta Baack, PharmD, BCPS, Emergency Medicine Clinical 6:45 am – Steven Krueger, MD, Cardiology, Nebraska Heart Institute Coordinator, Nebraska Medicine Creighton University School of 7:45 am Breakfast sponsored by Amarin Pharmaceutical. Learning Objectives: Pharmacy & Health Professions 1. Examine the di erent types of pain syndromes. Registration is required. 2. Identify non-opioid options for treating di erent pain syndromes. Independent Pharmacy 10:30 am – Cooperative (IPC) 11:30 am 7:50 am – W D D : H S I W 8:00 am NPA President, Ally Dering-Anderson, PharmD McKesson T D A I Annual ConventionNational Association of Chain Nic Bonney, Investigator, Nebraska State Patrol CPE S 1 Drug Stores (NACDS) Learning Objectives: A W W -B 1. Identify methods of drug diversion by employees and patients. R B L -T C Pharmacists Mutual 2. Defi ne the legal steps to be taken in cases of drug diversion.
Anna Legreid Dopp, PharmD, Director, Clinical Guidelines ACPE UAN 0128-0000-19-032-L04-P/T and Quality Improvement Center on Medication Safety and 1.0 hr | 0.10 CEU - Knowledge-based CPE Activity Quality, American Society of Health-System Pharmacists 8:00 am – ACPE UAN 0128-0000-19-035-L04-P/T DONATIONS N C & B L 9:00 am 1.0 hr | 0.10 CEUs - Knowledge-based CPE Activity Learning Objectives: Pharmacists Mutual Academia/Specialty – Nicole White, Network Chair 1. Defi ne burnout, well-being, and resilience. 11:30 am – Hospital/Health-System – Jerome Wohleb, Network Chair 2. Explain why clinician burnout is a patient care and healthcare workforce Rx Systems Independent – Trevor Bertsch, Network Chair problem. 1:00 pm 3. Describe the work led by the National Academy of Medicine (NAM) and Long-Term Care – Mackenzie Farr, Network Chair by the American Society of Health-System Pharmacists (ASHP). New Practitioner – Jacelyn Watt, Network Chair 4. Identify strategies for advancing pharmacy workforce Pharmacy Technicians – Christina Gerrard, Board Member well-being and resilience. CPE S 4 9:00 am – 9:15 am B P S & M E N : T P CPE S 2 Edward M. DeSimone, II, RP, PhD, FAPhA, Nebraska T A D C Coalition for Patient Safety, Board of Directors; Professor of Pharmacy Sciences, Creighton University School of Christine L. Chasek, LIMHP, LADC, LPC, Associate Professor, Pharmacy & Health Professions; and Department of Counseling and School Psychology; Director 1:00 pm – Daniel Rosenquist, MD, Nebraska Coalition for Patient of BHECN at UNK; President-Elect International Association 2:00 pm Safety, Vice President; Columbus Family Practice 9:15 am – of Addiction and O ender Counseling, University of Associates; Consultant, COPIC, Patient Safety & Risk 10:15 am Nebraska at Kearney Management ACPE UAN 0128-0000-19-036-L04-P/T ACPE UAN 0128-0000-19-033-L05-P/T 1.0 hr | 0.10 CEU - Knowledge-based CPE Activity 1.0 hr | 0.10 CEU - Knowledge-based CPE Activity Learning Objectives: Learning Objectives: 1. Identify the barriers to having productive clinical conversations. 1. Describe the role and activities of the Nebraska Coalition 2. Describe the Five Principles of Motivational Interviewing (MI). for Patient Safety. 3. Illustrate the principles of MI to clinical practice by experiencing a role 2. Identify at least three major causes of medication errors. play scenario. 3. Compare and contrast Root Cause Analysis with Risk Management.
10:15 am – 10:30 am B
8 May/June 2019 Nebraska MORTAR & PESTLE SCHEDULE SATURDAY, JULY 20
CPE S 3 O P : N-O T O P Krysta Baack, PharmD, BCPS, Emergency Medicine Clinical Coordinator, Nebraska Medicine Learning Objectives: 1. Examine the di erent types of pain syndromes. 2. Identify non-opioid options for treating di erent pain syndromes. 10:30 am – 11:30 am D D : H S I W T D A I AnnualNic Bonney, Investigator, Convention Nebraska State Patrol Learning Objectives: 1. Identify methods of drug diversion by employees and patients. 2. Defi ne the legal steps to be taken in cases of drug diversion.
ACPE UAN 0128-0000-19-032-L04-P/T 1.0 hr | 0.10 CEU - Knowledge-based CPE Activity
N C & B L Academia/Specialty – Nicole White, Network Chair 11:30 am – Hospital/Health-System – Jerome Wohleb, Network Chair 1:00 pm Independent – Trevor Bertsch, Network Chair Long-Term Care – Mackenzie Farr, Network Chair New Practitioner – Jacelyn Watt, Network Chair Pharmacy Technicians – Christina Gerrard, Board Member
CPE S 4 P S & M E N : T P Edward M. DeSimone, II, RP, PhD, FAPhA, Nebraska Coalition for Patient Safety, Board of Directors; Professor of Pharmacy Sciences, Creighton University School of Pharmacy & Health Professions; and 1:00 pm – Daniel Rosenquist, MD, Nebraska Coalition for Patient 2:00 pm Safety, Vice President; Columbus Family Practice Associates; Consultant, COPIC, Patient Safety & Risk Management ACPE UAN 0128-0000-19-033-L05-P/T 1.0 hr | 0.10 CEU - Knowledge-based CPE Activity Learning Objectives: 1. Describe the role and activities of the Nebraska Coalition for Patient Safety. 2. Identify at least three major causes of medication errors. 3. Compare and contrast Root Cause Analysis with Risk Management.
www.npharm.org 9 Nebraska MORTAR & PESTLE SCHEDULE CONVENTION SATURDAY, JULY 20 DETAILS
2:00 pm – LOCATION & ACCOMMODATIONS 2:15 pm B CONTINUING PHARMACIST & TECHNICIAN The host hotel for the NPA’s 2019 Annual Convention EDUCATION REGISTRATION is The Marriott Cornhusker Hotel at 333 South 13th CPE S 5 Street in Lincoln, Nebraska. For reservations, call 402- T P ’ R T C The 2019 NPA FULL REGISTRATION 474-7474. Room block expires July 4, 2019. Ask for the Karsen Duncan, PharmD, Clinical Pharmacist, Bryan Health Annual Convention FRIDAY & SATURDAY Nebraska Pharmacists group rate. ACPE UAN 0128-0000-19-037-L04-P/T is sponsored by Includes up to 11.5 hours of continuing pharmacy 2:15 pm – 1.0 hr | 0.10 CEU - Knowledge-based CPE Activity education for pharmacists and pharmacy technicians; Learning Objectives: the Nebraska Council for BREAKFAST 3:15 pm 1. Describe the former transition of care process between hospital and Continuing Pharmacy Education access to handouts; breakfasts; morning and Breakfasts are free to all convention attendees and are long-term care. afternoon refreshment breaks; and lunch with 2. Identify Bryan Medical Center’s process for transitions of care (primarily (NCCPE). NCCPE is accredited the only breakfast options provided by the NPA. CPE is hospital to skilled nursing facility/community). by the Accreditation Council for exhibitors. not available. Registration is required. Annual3. Evaluate barriers to implementing Convention a pharmacist-led transition service. 4. Defi ne the need for collaboration between pharmacists in all areas of Pharmacy Education (ACPE) as a care to ensure medication compliance. provider of continuing pharmacy FRIDAY ONLY REGISTRATION Includes up to 5.5 hours of continuing pharmacy TICKETED EVENTS education. Event Registration Only 3:15 pm – education for pharmacists and pharmacy technicians; Registration for Friday’s Lunch with Exhibitors, 3:30 pm B access to handouts; breakfast; morning and afternoon On Friday, July 19 and Saturday, and Saturday’s boxed lunch may be purchased refreshment breaks; and lunch with exhibitors. 20, 2019, pharmacists and CPE S 6 as stand alone items. They do not include access pharmacy technicians may earn SATURDAY ONLY REGISTRATION to any continuing education sessions, breakfasts, W’ N ? A C -B A up to 11.5 contact hours (1.15 Includes up to 6.0 hours of continuing pharmacy refreshment breaks, or program materials. D M CEUs) of continuing pharmacy education for pharmacists and pharmacy technicians; Ryan Flugge, PharmD, BCPS, Medical Liaison, Medical education credits (CPE) for access to handouts; breakfast; morning and afternoon CANCELLATION & REFUND POLICY 3:30 pm – Markets, Novo Nordisk attendance of the entire CPE 4:30 pm refreshment breaks; and lunch. We understand that circumstances may arise that ACPE UAN 0128-0000-19-034-L01-P/T activity and the completion of 1.0 hr | 0.10 CEU - Application-based CPE Activity require you to cancel. Cancelled registrations must be Learning Objectives: an activity evaluation. If activity in writing. Cancellations received on or before July 12, 1. Interpret the ADA Standards of Care in diabetes management. evaluations are not completed 2. Di erentiate between patient populations and appropriate agents STUDENT REGISTRATION 2019, will receive a refund in the amount paid less a 25% based on evidence. by August 15, 2019, CPE credits administrative fee. No refunds will be made after July 13, 3. Devise a plan for patients to achieve maximum outcomes. will not be awarded. Credits will FULL REGISTRATION 2019. Please notify the NPA of any changes prior to the be refl ected in the NABP CPE FRIDAY & SATURDAY event to help facilitate the check-in process. Monitor System no later than 45 Includes access to all continuing pharmacy education days after the convention. For sessions; access to handouts; breakfasts; morning HANDOUTS questions, call (402) 420-1500. and afternoon refreshment breaks; and lunch with Speaker materials will be posted at www.npharm.org and exhibitors. will be available from the NPA convention app. Materials may be viewed or printed before and after the convention. FRIDAY ONLY REGISTRATION Includes access to Friday’s continuing pharmacy TARGET AUDIENCE education sessions; access to handouts, breakfast; Programming has been designed for pharmacists, morning and afternoon refreshment breaks; and lunch pharmacy technicians, and student pharmacists with exhibitors. in all practice settings who take part in the overall healthcare of patients and Nebraska residents. SATURDAY ONLY REGISTRATION Includes access to Saturday’s continuing education sessions; access to handouts; breakfast; morning and afternoon refreshment breaks; and lunch. 10 May/June 2019 Nebraska MORTAR & PESTLE CONVENTION DETAILS
PHARMACIST & TECHNICIAN LOCATION & ACCOMMODATIONS The host hotel for the NPA’s 2019 Annual Convention REGISTRATION is The Marriott Cornhusker Hotel at 333 South 13th Street in Lincoln, Nebraska. For reservations, call 402- FULL REGISTRATION 474-7474. Room block expires July 4, 2019. Ask for the FRIDAY & SATURDAY Nebraska Pharmacists group rate. Includes up to 11.5 hours of continuing pharmacy education for pharmacists and pharmacy technicians; BREAKFAST access to handouts; breakfasts; morning and Breakfasts are free to all convention attendees and are afternoon refreshment breaks; and lunch with the only breakfast options provided by the NPA. CPE is exhibitors.Annual Conventionnot available. Registration is required. FRIDAY ONLY REGISTRATION Includes up to 5.5 hours of continuing pharmacy TICKETED EVENTS Event Registration Only education for pharmacists and pharmacy technicians; Registration for Friday’s Lunch with Exhibitors, access to handouts; breakfast; morning and afternoon and Saturday’s boxed lunch may be purchased refreshment breaks; and lunch with exhibitors. as stand alone items. They do not include access SATURDAY ONLY REGISTRATION to any continuing education sessions, breakfasts, Includes up to 6.0 hours of continuing pharmacy refreshment breaks, or program materials. education for pharmacists and pharmacy technicians; access to handouts; breakfast; morning and afternoon CANCELLATION & REFUND POLICY refreshment breaks; and lunch. We understand that circumstances may arise that require you to cancel. Cancelled registrations must be in writing. Cancellations received on or before July 12, STUDENT REGISTRATION 2019, will receive a refund in the amount paid less a 25% administrative fee. No refunds will be made after July 13, FULL REGISTRATION 2019. Please notify the NPA of any changes prior to the FRIDAY & SATURDAY event to help facilitate the check-in process. Includes access to all continuing pharmacy education sessions; access to handouts; breakfasts; morning HANDOUTS and afternoon refreshment breaks; and lunch with Speaker materials will be posted at www.npharm.org and exhibitors. will be available from the NPA convention app. Materials may be viewed or printed before and after the convention. FRIDAY ONLY REGISTRATION Includes access to Friday’s continuing pharmacy TARGET AUDIENCE education sessions; access to handouts, breakfast; Programming has been designed for pharmacists, morning and afternoon refreshment breaks; and lunch pharmacy technicians, and student pharmacists with exhibitors. in all practice settings who take part in the overall healthcare of patients and Nebraska residents. SATURDAY ONLY REGISTRATION Includes access to Saturday’s continuing education sessions; access to handouts; breakfast; morning and afternoon refreshment breaks; and lunch. www.npharm.org 11 Nebraska MORTAR & PESTLE CONVENTION ANNUAL REGISTRATION CONVENTION
Name Phone
Badge Name Email
Mailing Address NABP e-Profi le ID # City/ZipAnnual Convention Date of Birth (MM/DD) Call 402-420-1500 or email [email protected] for guest pricing and registration information.
Early Bird On or Before On or After 06/30/2019 07/01/2019 Full Registration (Friday & Saturday) PAYMENT Pharmacist $230 $270 $______Check (Payable to the NPA) NonMember Pharmacist $330 $370 $______Technician/Student $130 $170 $______Check Number NonMember Technician/Student $180 $220 $______
Friday Only Registration Credit Card Pharmacist $160 $200 $______NonMember Pharmacist $260 $300 $______Card Number Technician/Student $100 $140 $______NonMember Technician/Student $150 $190 $______Exp. Date Sec. Code Saturday Only Registration Pharmacist $140 $180 $______Signature NonMember Pharmacist $240 $280 $______Technician/Student $100 $140 $______NonMember Technician/Student $150 $190 $______Mail Nebraska Pharmacists Lunch Registration Only Association Friday Lunch & Exhibits $45 $55 $______6221 S. 58th St., Suite A Lincoln, NE 68516 Saturday Lunch $35 $45 $______Mobile R T $______www.npharm.org [email protected]
I plan to attend breakfast on: Friday Saturday Fax Free for registered attendees. 402-420-1406
HAVE A QUESTION? npharm.org/2019AnnualConvention | [email protected] | 402-420-1500 12 May/June 2019 Nebraska MORTAR & PESTLE
Nebraska Pharmacists Association Mental Health First Aid Training
Originally designed in Australia, this THURSDAY, July 18, 2019 8-hour course teaches you a five-step 7:30 am - 7:50 am Members Only Registration – Limited to the first action plan to help someone who may 50 registered members. Registration is $60.00 and includes program materials and lunch. be experiencing a mental health or Login and register at www.npharm.org. substance use challenge. Similar to 7:50 am - 8:00 am Welcome, NPA CEO, Joni Cover traditional physical First Aid and CPR, 8:00 am - Noon Mental Health First Aid Mental Health First Aid is help provided Anthony Pudlo, PharmD, MBA, BCACP, Vice President, to a person developing a mental health Iowa Pharmacy Association problem or experiencing a crisis until Pharmacist UAN 0207-9999-18-019-L04-P Pharmacy Technician UAN 0207-9999-18-019-L04-T professional treatment is obtained or the 8.0 contact hours (0.8 CEUs) crisis resolves. Learning Objectives Upon completion of this activity, participants will be able to: The training helps you to (1) assess a 1. Discuss the prevalence and impact of mental health situation, (2) offer initial help and support, problem in the United States. and (3) connect someone to appropriate 2. Discuss the barriers to treatment of mental health care if an individual is experiencing a disorders. 3. Describe the spectrum of mental health interventions, mental health or substance use problem. treatments and support. With a focus on learning risk factors, 4. Discuss the core components of recover for people warning signs, and resources for mental experiencing mental health or substance abuse illness and substance use disorders, problems. 5. Describe how the Mental Health First Aid Action attendees will be provided with the skills Plan fits within the array of interventions available to to display calmness, non-judgmental address mental health problems. attitude, empathy, and support in order 6. Give an overview of the signs, symptoms, and possible risk factors and warning signs of depression and anxiety. to be a reassuring and encouraging 7. Give an overview of the signs, symptoms, and possible professional in your area of practice. risk factors and warning signs of people who are experiencing a panic attack and may be in crisis. 8. Give an overview of the signs, symptoms, and possible risk factors and warning signs of people who are Disclosures: experiencing a traumatic event and may be in crisis. The speaker declares no conflicts of interest 9. Give an overview of the risk factors and warning signs or financial interest in any product or service of psychotic disorders. mentioned in this program, including grants, employment, gifts, stock holdings, and 10. Give an overview of the risk factors and warning signs honoraria. of substance use disorders. NCPA’s education staff declares no conflicts of interest or 11. Demonstrate the Mental Health First Aid Action Plan financial interest in any product or service mentioned in this for someone who may be in a crisis such as a suicide program, including grants, employment, gifts, stock holdings, or self-injury. and honoraria. 12. Discuss how to respond to someone who is not in crisis. NCPA is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. 13. Provide helpful resources and support groups for This program is accredited by NCPA for 8.0 contact hours people experiencing mental health disorders. (0.8 CEUs) of continuing education credit. ACPE UAN: 0207-9999-18-019-L04-P and 0207-9999-18-019-L04-T. Activity type: Application-Based. Noon - 1:00 pm Lunch Program sponsored by Janssen 1:00 pm - 5:00 pm Mental Health First Aid (continued)
www.npharm.org 13 Nebraska MORTAR & PESTLE
Continuing Pharmacy Education | Lesson #7 Probiotics: What Does the Evidence Say?
Written by Nichole Boggs This continuing pharmacy education lesson was written by Nichole Boggs, PharmD Candidate, University of Nebraska Medical Center College of Pharmacy who does not have any conflicts of interest, nor does she have any financial relationships with a commercial interest related to this continuing pharmacy education activity.
Objectives probiotics, by definition, “are Studies show conflicting At the conclusion of this lesson, live microorganism that, when data when it comes to analyzing pharmacists and pharmacy administered in adequate amounts, the effectiveness of probiotics technicians should be able to: confer a health benefit on the across several different uses. 1. Explain the mechanism of action host”.1 Probiotics have long been One of the main conflicts is the of probiotics. studied to determine their role in lack of standardization amongst 2. Identify disease states that treatment, prevention, and side probiotic strains due to their probiotics may be utilized. effect mediation. There are several unique makeup of bacteria. 3. Describe choices of various possible mechanisms by which Dosing is another complicating probiotics and yogurt. probiotics may exhibit their effects. factor in the effectiveness for 4. Explain the potential efficacy The overall concept is that the probiotics. Each study used their found. “good” bacteria from probiotics own unique regimens for giving 5. List potential risks associated interact with the microbiota of the the probiotic such as type of with probiotic use. gut and influence the patient’s antibiotic, timing of initiation of response and defense to “bad” probiotic, and the type and dose of Background bacteria.2 There are receptors in bacteria present in the probiotic.4 According to the Food and the host’s gut that the probiotic Agriculture Organization of the may interact with specifically. Probiotics come in doses that United Nations (UN) and World Probiotics have also been are colony-forming units (CFU) and Health Organization (WHO), shown to produce or secrete typically vary in doses between certain factors in a host’s gut.3 107 to 1010 CFUs depending the
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genera used.5 CFUs only refer to different clinical features of their Probiotic vs. Yogurt the live bacteria that are present, intestinal microbiome ecosystem The National Yogurt Association but does not consider the dead making a uniform approach of (NYA) determines whether brands bacteria, thus leading to potentially treatment difficult. Primarily, the are considered to have active, live higher doses than realized.6 studies of probiotics in the use of cultures. NYA is not a regulatory IBS focus on the complications organization and brands are not Disease States for Potential of IBS diarrhea (IBS-D) than required to be evaluated by the Probiotic Use IBS constipation (IBS-C).3 NYA to report their bacteria. The Clostridium difficile infection lack of regulatory organization may (CDI) is an adverse effect of Choosing Between Probiotics lead to discrepancy. To get a seal antibiotic therapy or a hospital- There are several different strains of approval from NYA, products acquired infection that results of bacteria that are made into must have at least 100 million in severe diarrhea and can lead probiotics. Some formulations cultures per gram for refrigerated to life-threatening inflammation contain a single strain while products and 10 million cultures of the colon. Probiotics may be some contain multiple strains in per gram for frozen products.12 considered as CDI prevention each dosage form. This makes it because of their potential to difficult to compare results and The challenge of using yogurt prevent a patient losing their analyses from previous studies as a supplement is the dosing or intestinal microbiome to antibiotic as almost all studies use different amount, the choice of yogurt used, therapy. Recurrence is a common probiotics without defining the and its efficacy versus the probiotic manifestation of CDI. The exact microbiota in the probiotic. supplements. A meta-analysis prevention of this recurrence studied probiotic dairy products could dramatically increase the There are certain strains that regarding their efficacy in AAD. quality of life for patients.7 have shown promise in various Although the dairy probiotics did treatment regimens. Lactobacillus reduce the overall incident of AAD, Antibiotic-associated diarrhea rhamnosus (L. rhamnosus) and the results were not statistically (AAD) is a common adverse effect Saccharomyces boulardii (S. significant (95% CI 0.95-1.07). of some antibiotic treatments boulardii) have been studied Actimel, by Danone®, is a probiotic affecting as many as 30% of extensively and have shown to drink that was shown to have a patients.8 The factors that make a have potential benefits particularly decrease in AAD which contains patient more susceptible to include in AAD. Various patient populations Lactobacillus casei.11 Actimel is the antibiotic used and unique may require different strains not readily available in the United characteristics of the patient. to have the most benefits. For States, but yogurts such as Fage®, AAD is a result of the disruption example, S. boulardii appears to Chobani®, and Dannon® all contain of normal microbiome of the be more effective in the pediatric L. casei as a live bacterium13. GI tract caused by antibiotics.9 population as compared to Penicillins, more so broad- elderly when it comes to AAD.11 A 2014 systematic review identified spectrum, cephalosporins, and randomized controlled trials clindamycin are among some of (RCTs) that evaluate the use of the antibiotics that have shown to 10 have increased incidence of AAD. Table 1 | What is Available at the Drugstore?20
Irritable bowel syndrome (IBS) is Brand Name Probiotic Strain a chronic gastrointestinal disorder Align® Bifidobacterium longum that results in microbial imbalance of the GI flora. IBS can be a Culturelle® Lactobacillus rhamnosus GG difficult disorder to treat due to the Florastor® Saccharomyces boulardii high variability of symptoms and patient reports. All patients have VSL #3® Capsules multistrain
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yogurt consumption and the in 11 patients. Only eight of the to placebo. These results were reduction of AAD. Only two studies 927 patients receiving antibiotic shown to be statistically significant met the criteria, but were both alone acquired CDI. No statistically (95% CI 0.64-0.67).11 ESPGHAN, the “low in methodological quality”. significant benefit was found by Europeans Society for Paediatric Compared to no intervention, adding a probiotic to antibiotic Gastroenterology, Hepatology, yogurt consumption resulted in therapy in the prevention of CDI.15 and Nutrition recommends L. statistically significant reduction rhamnosus or S. boulardii for in AAD (95% CI 0.31-1.00).14 For treatment of CDI, probiotics the prevention of AAD that is may be added to traditional supported by moderate evidence.17 A 2015 study was completed guideline recommended therapy regarding the use of yogurt in AAD as an alternative role of use. L. rhamnosus GG is the in children. The children received A study primarily analyzed the identified strain in Culturelle® 200 grams per day of yogurt that duration of diarrhea as well as the Kids. S. boulardii is the strain contained Lactobacillus rhamnosus recurrence of CDI. The duration present in Florastor® Kids. It is GG (LGG), Lactobacillus acidophilus was found to be, on average, one important to note that due to their (La-5), or Bifidobacterium, or day shorter in the probiotic group lack of regulations as a drug, the a pasteurized yogurt for the (p=0.039). The rate of recurrence microorganism can change while placebo group. The placebo was not significantly less. The marketing it as the same brand group experienced more adverse study also found that patients on name.6 It is important to read the events that included abdominal probiotics had fewer total days of packaging in order to make an pain and loss of appetite. For diarrhea with a decreased rate of appropriate recommendation. efficacy, the probiotic group had diarrhea occurrence. There was a decrease in stool frequency, no increase in adverse events A 2012 systematic review duration, and delay of onset that when comparing probiotic versus analyzed 82 RCTs that included were all statistically significant.5 placebo.16 Therefore, according to over 11,000 patients. Overall, the Although there are no brands in the the 2018 CDI guidelines, probiotic study concluded that patients United States that have this exact use is not recommended in either given a probiotic had a statistically formulation, Stonyfield® and Kite prevention or treatment of CDI.7 significant reduction in AAD Hill® are two brands that have two when primarily compared to of the three ingredients available. Antibiotic-Associated placebo (P<0.001). Trials utilized Several yogurts such as Chobani®, Diarrhea (AAD) Lactobacillus, Bifidobacterium, Dannon®, Siggi®, Yoplait®, and Meta-analyses studies have Saccharomyces, Streptococcus, Fage® contain L. acidophilus along shown consistent evidence Enterococcus, and/or Bacillus with other strains of live bacteria.13 that probiotics are beneficial either as single agents or in in the prevention of antibiotic- combination. When analyzed Efficacy associated diarrhea, particularly as a breakdown of subgroups CDI in children. Strains S. boulardii or for each genus analyzed, no For prevention of CDI, a study was L. rhamnosus GG have shown the statistical difference was found performed at Scripps Memorial most promise in the prevention of amongst the genera utilized.8 Hospital in 2016. There were 1,576 antibiotic-associated diarrhea.11 patients treated with IV antibiotics IBS-D Efficacy and 649 of these patients received A meta-analysis included 32 A trial conducted in 2008 the same probiotic. There were studies testing a probiotic versus demonstrated that when a multiple antibiotics that were a placebo. The study focused on multistrain probiotic was utilized, it used, and whether to start antibiotics that are considered high was able to improve IBS symptoms probiotic or not was entirely up risk for AAD including amoxicillin, by stabilizing the gut microbiome. to the discretion of the physician. beta-lactams, cephalosporins, and Recently, a RCT showed that Of the 649 patients receiving clindamycin. Collectively, there Lactobacillus paracasei (L. concomitant antibiotic plus was a lower occurrence of AAD paracasei) only partially improved probiotic therapy, CDI occurred with probiotic usage as compared IBS symptoms. Results of this study
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also found a decrease in pro- disease may be at an increased systematic review found “the inflammatory markers. It is possible risk of probiotic exposure resulting overwhelming existing evidence that L. paracasei alters the function in Lactobacillus endocarditis. This suggests that probiotics are safe” by reducing immune activation. particular invasive infection has in the general population.19 Other studies showed a decrease high intrinsic resistances to several in abdominal cramping and pain in antibiotics including vancomycin In case reports published from IBS patients while taking probiotics. and meropenem. This infection has 1976 to 2018, 93 patients found Probiotic treatment appears to been recorded with both probiotic to have developed infectious depend on the individual gut supplements as well as high complications related to probiotic microbiome ecosystem in order amounts of yogurt intake. Although ingestion, but this is not all- to allow a predictive response.3 Lactobacillus is considered encompassing due to the large relatively safe, translocation amount of case reports that were Limitations and systemic exposure to the not published. Probiotics are The overarching issue seems to organisms may result in invasive regulated as a dietary supplement, be lack of standardization when infections in susceptible patients.4 therefore, exempting the products comparing studies. When each from safety and efficacy claims. study is completed using entirely If Lactobacillus is found in There have been studies that were different strains of bacteria, it blood, it should not be immediately not only able to identify the strain becomes difficult to interpret all considered a contaminant but of bacteria found in the patient’s of these results as a large cohort rather the patient’s diet and blood, but also were able to match of data and extrapolate the data probiotic consumption should be the DNA of the bacteria to that across multiple scenarios. analyzed. Immunosuppressed of the probiotic strain utilized.18 patients, recipients of solid organ Age of the patient should transplant, or patients with a Conclusion be considered when choosing history of HIV infection may be Probiotic studies lack conclusive appropriate probiotics. Studies considered high risk due to the evidence for the effectiveness of show that different ages susceptibility of a dangerous probiotics in most disease states. respond better to different infection if translocation of the One study may show a significant strains of probiotics. When age bacteria were to occur.4 Patients decrease in CDI while another and disease state are both with inflammatory bowel disease study may show no difference considered, it has been shown (IBD), due to its immunogenicity found. The lack of standardization that pediatric patients appear to in nature, may also be at risk. of which probiotics were used, respond better to S. boulardii Probiotics, if translocated to as well as their manufacturing than adults and significantly blood in IBD patients, have been and regulations as a dietary better than elderly patients.11 linked to increase inflammation supplement, will continue to markers and increase relapse and be a deterrent in the studies. Genetic variability in the hospitalizations for these patients.6 bacteria of the probiotic is For probiotics to become a another important factor. Although Lactobacillus infection standard of care in the treatment given identical strains, there is appeared in patients that were of CDI, AAD, and IBS, it would be still variance within the strains at the extremes in ages from less beneficial if probiotics become due to their unique genetic than one year old to greater than regulated as drugs. Regulation makeup. This is especially true 60 years old. Newborns were would allow consistency in these in dairy products due to the especially susceptible to infection studies, creating the opportunity mechanisms of fermentation.11 complications from Bifidobacterium to determine the effects probiotics compared to any other group of could play in various disease states. Risks patients. In nearly all the newborns L. rhamnosus is a bacterium that that contracted the infection, is typically colonized in the GI external feeding and central venous flora. Patients with structural heart access were also utilized.18 A 2014
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References 1. Health and Nutrition Properties of 11. Agamennone V, Krupp C, Rijkers G, Kort R. A Practical Guide for Probiotics in Food Including Powder Policies for the Nebraska Mortar & Milk with Live Lactic Acid Bacteria. Probiotics Applied to the Case of Pestle (M&P) continuing pharmacy Rome: World Health Organization and Antibiotic-Associated Diarrhea in The education lessons and quizzes: Food and Agriculture Organization of Netherlands. BMC Gastroenterology. 1. M&P Quizzes are valid only for the the United Nations, 2001. 2018;18:103. 12. Goldman R, Butler N. Yogurt with membership year in which they are 2. Bienenstock J, Gibson G, Klaenhammer published. Quizzes for the 2019 Lactobacillus Acidophilus. Healthline. R, et al. New Insights Into Probiotic Membership Year must be received Mechanisms: A Harvest From Functional 2015. by December 12, 2019. Quizzes and Metagenomic Studies. Landed 13. Plowe K. Yogurt Brands Containing cannot be carried over to another Bioscience. 2013;4:2,94-100. Probiotics. Livestrong. 2018. membership year. 14. Patro-Golab B, Shamir R, Szajewska 2. If more than three questions are 3. Barbara G, Cremon C, Azpiroz F. missed, the quiz will be returned. Probiotics in Irritable Bowel Syndrome: H. Yogurt for Treating Antibiotic- The quiz can be resubmitted. Where Are We? Neurogastroenterology Associated Diarrhea: Systematic Review 3. CPE transcripts can be printed from and Motility. 2018. and Meta-Analysis. Elsevier: Nutrition. NABP e-Profiles at www.nabp.net. 4. CPE credits are submitted to 4. Naqvi S, Nagendra V, Hofmeyr A. 2015;31:796-800. 15. Box M, Ortwine K, Goicoechea M. NABP by the 15th of each month. Probiotic Related Lactobacillus For example, M&P CPE quizzes No Impact of Probiotics to Reduce rhamnosus Endocarditis in a Patient completed in the month of June with Liver Cirrhosis. IDCases. Clostridium difficile Infection in 2019 will be sent to NABP e-Profiles 2018;13:e00439. Hospitalized Patients: A Real-world before July 15, 2019. 5. Fox M, Ahuja K, Robertson I, et al. Can Experience. Open Forum Infectious The Nebraska Council Probiotic Yogurt Prevent Diarrhoea in Diseases. 2018. 16. Barker A, Duster M, Valentine S, et for Continuing Pharmacy Children on Antibiotics? A Double-Blind, Education (NCCPE) Randomised, Placebo-Controlled Study. al. A Randomized Controlled Trial is accredited by the BMJ Open. 2015;5:c006474. of Probiotics for Clostridium difficile Accreditation Council 6. Simone C. The Unregulated Probiotic Infection in Adults (PICO). Journal for Pharmacy Education Market. Clinical Gastroenterology and of Antimicrobial Chemotherapy. (ACPE) as a provider of continuing pharmacy education (CPE). This CPE Hepatology. 2018. 2017;72:3177-3180. 17. Szajewska H, Canani RB, Guarino A, home study activity has been accredited 7. McDonald LC, Gerding D, Johnson for 1.0 contact hour or 0.10 CEU. UAN S, et al. Clinical Practice Guidelines et al. Probiotics for the Prevention 0128-0000-19-026-H01-P for pharmacists for Clostridium difficile Infection in of Antibiotic-Associated Diarrhea and UAN 0128-0000-19-026-H01-T Adults and Children: 2017 Update in Children. Journal of Pediatric for pharmacy technicians. This is by the Infectious Diseases Society Gastroenterology and Nutrition. 2016; a knowledge-based CPE activity 62:3. targeted to pharmacists and pharmacy of America (IDSA) and Society for technicians. Healthcare Epidemiology of America 18. Costa RL, Moreira J, Lorenzo A, Lamas (SHEA). Clinical Infectious Diseases. C. Infectious Complications Following 2018;66(7):e1-e48. Probiotic Ingestion: A Potentially The Nebraska Pharmacists Association 8. Hempel S, Newberry S, Maher A, et Underestimated Problem? A systematic disclaims any liability to you or your patients resulting from reliance solely al. Probiotics for the Prevention and Review of Reports and Case Series. upon the information contained herein. Treatment of Antibiotic-Associated BMC Complementary and Alternative Diarrhea: A Systematic Review and Medicine. 2018;18:329. Meta-Analysis. Journal of the American 19. Didari T, Solki S, Mozaffari S, et al. A Medical Association. 2012;307(18):1959- Systematic Review of the Safety of Quiz Answers may be submitted: 1969. Probiotics. Expert Opinion on Drug 9. Barbut F, Meynard JL. Managing Safety. 2014;13:227-239. Online: www.npharm.org Antibiotic Associated Diarrhoea. BMJ. 20. Sniffen J, McFarland L, Evans C, Fax: 402-420-1406 Email: [email protected] 2002;324:1345. Goldstein E. Choosing an Appropriate Probiotic Product for your Patient: An Mail: Nebraska Mortar & Pestle 10. Haran J, Hayward G, et al. Factors 6221 S 58th St, Ste A Influencing the Development of Evidence-Based Practical Guide. PLoS Lincoln, NE 68516 Antibiotic Associated Diarrhea in ED ONE. 2018;13(12):e0209205. Patients Discharged Home: Risk of Administering IV Antibiotics. American Journal of Emergency Medicine. 2014;32(10):1195-1199.
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Probiotics - What Does the Evidence Say? Quiz #7, May/June 2019, ACPE 0128-0000-19-026-H01-P/T
1. What difficulties arise with the use of probiotics? 6. What does the 2018 Clostridium Difficile Infection a. Lack of standardization Guidelines recommend regarding the use of b. Variation of doses probiotics for prevention? c. Various probiotic strains a. Do not recommend d. All of the above b. Recommend use for adults greater than 65 years old 2. What is a typical dose for a probiotic? c. Recommend use for everyone a. 108 mg d. Recommend use for kids less than 5 years old b. 103 CFUs c. 108 CFUs 7. What is the identified strain present in Culturelle d. 1015 CFUs Kids®? a. B. longum c. L. rhamnosus GG 3. Antibiotic-associated diarrhea can affect as many b. L. casei d. S. boulardii as ____ of patients? a. 10% 8. What patient population is at an increased risk of b. 20% infection if translocation of Lactobacillus occurs? c. 30% a. HIV patients d. 40% b. Immunosuppressed patients c. Recipient of solid organ transplant 4. Most studies to date have focused on which d. All of the above component of IBS? a. IBS-C 9. Newborns are most susceptible to infection b. IBS-D complications from which probiotic strain? c. Mixed IBS a. Bifidobacterium d. Immunogenicity b. Lactobacillus c. Saccharomyces 5. For the seal of approval from the National Yogurt d. Streptococcus Association, how many live cultures must be in refrigerated yogurt products per gram? 10. Probiotics are primarily regulated as ______? a. 1 million a. Drugs b. 10 million b. Food c. 100 million c. Supplement d. 1 billion d. All of the Above
Keep the TOP portion for your records. Return the BOTTOM portion to the NPA office. Or, take this quiz online at www.npharm.org
Name ______2019 Quiz #7 - Probiotics - What Does the Evidence Say? ACPE #0128-0000-19-026-H01-P for pharmacists Mailing Address______ACPE #0128-0000-19-026-H01-T for technicians City/State/Zip______1.0 Contact Hour - Knowledge Based CPE Activity
The deadline for this quiz is December 12, 2019. Circle one (1) Answer: CPE Home Study Evaluation 1. a b c d 6. a b c d 1. Rate this lesson: (Excellent) 5 4 3 2 1 (Poor) 2. a b c d 7. a b c d 2. Did this lesson meet each of its objectives? ___ Yes ___ No 3. Was the content without commercial bias? ___ Yes ___ No 3. a b c d 8. a b c d If not, please explain______4. a b c d 9. a b c d 4. Did the lesson meet your educational/practice needs? __ Yes __ No 5. a b c d 10. a b c d 5. Comments/future topics are welcome. ______
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SCHOOL OF PHARMACY AND HEALTH PROFESSIONS Congratulations Class of 2019 The Creighton University School of Pharmacy and Health Professions Class of 2019 included 124 Doctor of Pharmacy graduates. A Hooding Ceremony was celebrated the evening of Friday, May 17, at the Ryan Athletic Center and D.J. Sokol Arena. The following day, graduates participated in the Creighton University Commencement exercises at CHI Health Center Omaha.
Lauren Aase Kyu Won Choi Whitney Hessel * Erin Kozlow Chaska, Minnesota Omaha, Nebraska Kansas City, Missouri Geneva, Illinois Rabie Abasi Yajing Chu * Xavier Hill Kelsey Krause * Ojai, California Issaquah, Washington Natchez, Mississippi Coon Rapids, Minnesota Halima Adam * John Colorado Zachary Hiraki Pablo Larios * Orlando, Florida Wellman, Iowa Honolulu, Hawaii Austin, Texas Madison Ahlstrom * Daniel Dabbs * Viet Ho Nga Le * Manteca, California Scooba, Mississippi North Sioux City, Fort Worth, Texas South Dakota Erhovwo Akpati * Amy Eiden * Madeline Leiter * Sparks, Nevada Forest City, Iowa Domini Hood * Lincoln, Nebraska Bixby, Oklahoma Ambreen Amir * Sarah Ermer Connie Liang Chandler, Arizona Sioux Falls, South Dakota Zachary Houfek Honolulu, Hawaii Omaha, Nebraska Kelli Anderson * Brianne Fife Samuel Llona Dorchester, Nebraska Scottsdale, Arizona Kalee Huddleston Portland, Oregon Innsbrook, Missouri Brianna Argubright Mary Franklin Lauren Lockhart * La Salle, Illinois Lino Lakes, Minnesota Eric Hugenberg Omaha, Nebraska Omaha, Nebraska Heather Atkinson * Leah Frye * Lyudmyla Lyashenko * Sparks, Nevada Chadron, Nebraska Clarissa Hunzeker Camanche, Iowa Waukee, Iowa Arielle Bautista Michon Fuchigami Maryam Manesh Waipahu, Hawaii Honolulu, Hawaii Pauline Huynh League City, Texas Portland, Oregon Kelly Baxter * Kaeley Gerstle William Mansur Omaha, Nebraska Coldspring, Texas Annabel Jacobs St. Paul, Minnesota Waconia, Minnesota Alexandra Bedore Matthew Gotfryd Joseph Manzione * Spencer, Iowa Oak Lawn, Illinois Bo Jansa Sicklerville, New Jersey Wahoo, Nebraska Kristine Belanger * Sara Greenberg * Mary McNeely Wisconsin Rapids, Wisconsin Far Rockaway, New York Edyta Judge * Forest Lake, Minnesota Des Moines, Iowa Samuel Blakeslee * Sean Grubish Rhianna Mehrer Casper, Wyoming Owatonna, Minnesota Kathryn Kalipinde Alexandria, South Dakota Waconia, Minnesota Daniel Bundrick Levent Guldal * Zisi Monheit * Kannapolis, North Carolina Ann Arbor, Michigan Trista Kaltenbach Brooklyn, New York Beresford, South Dakota David Cao Carmen Gust * Diana Ndunda Thousand Oaks, California Worcester, Massachusetts Samantha Katzman Nairobi, Kenya Chisago City, Minnesota Siyi Chen Hallie Hartman * John Nguyen Wuhan FC, China Gibbon, Nebraska Peter Khong Brooklyn Park, Minnesota Omaha, Nebraska Tiffany Cheng Brandon Hataye Linh Nguyen Bloomington, Minnesota Kaneohe, Hawaii Jacqueline Kinnear * Lincoln, Nebraska Omaha, Nebraska Alvin Cheung Kayla Haverkamp Ngoc Nguyen * Honolulu, Hawaii Springville, Iowa Amy Kolari San Diego, California Virginia, Minnesota
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Baleigh Ohrt David Ross * Henry Tarnue Westboro, Missouri Loveland, Colorado Minneapolis, Minnesota Kellye Oishi * Kasey Rubin Colton Taylor Honolulu, Hawaii San Diego, California Olathe, Kansas Nicholas Olund Taylor Sakai Matthew Thomas * St. Paul, Minnesota Honolulu, Hawaii Tigard, Oregon Miriam Opara * Jennifer Salagaj * Johnny Tran Lima, New York Woodland Park, Colorado Stockton, California Jami Wade * Olathe, Kansas Brent Oswald Stacy Sandage * Minh Tran Madison, Nebraska Pontiac, Illinois Omaha, Nebraska Brittany Webster * Roanoke, Virginia Rohini Patel-Shah * Megan Schafer Caressa Trueman San Antonio, Texas Burbank, California Lancaster, New York Devorah Weinstock * Lakewood, New Jersey Hoang-Oanh Pham Kristen Schmidt Rachel Tyler Lincoln, Nebraska Carol Stream, Illinois Omaha, Nebraska Travis Welchert Springfield, Nebraska Tuan Phan * McKenzie Sesker Stephanie Ung Seattle, Washington Cannon Falls, Minnesota Honolulu, Hawaii Anthony Wilcox Amarillo, Texas Mary Powell * Cassondra Solesbee * Nicholas Van Peursem Watertown, Wisconsin Gainesville, Texas Sioux Falls, South Dakota Claire Willman Overland Park, Kansas Kasey Reeves * Megan Spragg * Trent Van Tress Delafield, Wisconsin Tucson, Arizona Henderson, Nevada Taylor Wojcik Grand Island, Nebraska Angela Reimers * Sheena Starkel * Matthew Vang Sioux Valley, Minnesota Spokane, Washington Glenwood, Iowa Kayla Yonamine Wailuku, Hawaii Gregory Reynolds * Morgan Sturm * Karan Verma Grand Junction, Colorado Golden, Colorado Hicksville, New York Novelle Yu Honolulu, Hawaii Sharla Rivera Christian Sukola * Peter Vigil * Ewa Beach, Hawaii Tacoma, Washington Springville, California * Distance Pathway students
Kelly Baxter Residency at the Omaha VA Medical Center “The distance program has allowed me the flexibility to complete my degree wherever the military sent us (my husband is a U.S. Air Force pilot) and for that I am beyond grateful. Creighton is more than just a school, it’s a community. You will learn more in the next four years than you can imagine—not just about pharmacy, but about yourself, your values, your goals and your passions.”
Linh Nguyen Residency at the Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas “The Creighton family has made a positive and meaningful impact on me, and I hope one day I will be able to serve as role model and give back to my Creighton community. I look forward to working with veterans in inpatient and outpatient settings with other residents while exploring Houston. Being bilingual, I also hope to moonlight at an independent Vietnamese pharmacy in the Bellaire area.”
Minh Tran Regulatory Pharmaceutical Fellowship at Purdue University “Omaha will always be home to me and I want to always contribute to the network of successful young adults who come from the Midwest. After graduation, I will be in a post-doctoral fellowship, partnering with IU Health, Janssen Pharmaceuticals and the Food and Drug Administration, which will expose me to various drug information roles in academia, industry, and government.”
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Continuing Pharmacy Education | Lesson #8 RABIES Disease, Counseling, and Treatment
Objectives At the conclusion of this lesson, pharmacists and pharmacy technicians should be able to: 1. Identify common carriers of rabies. 2. Review ways to avoid rabies exposure. 3. Discuss the prophylactic use of rabies vaccine. 4. Cite the post-exposure regimen for treating known or suspected rabies exposure.
Introduction According to the World Health Organization more than 59,000 people world-wide will die from rabies this year. It is unlikely that any will be in the United States, but it is possible, as illustrated by a 6-year old who died in the United States in January 2018 because he was scratched by a bat but did not receive treatment to prevent a rabies infection. With quick and proper treatment rabies is 100% preventable. The goals for this lesson are to familiarize pharmacists and pharmacy technicians with the disease and the appropriate counseling, prophylaxis, and post- exposure treatment of rabies.1,2
Rabies Disease Rabies is a zoonotic (transmitted from animals to Written by humans), progressive encephalomyelitic disease caused Ally Dering-Anderson by two lyssaviruses: the rabies virus and the Australian bat lyssavirus. Lyssaviruses are RNA viruses in the family of Rhabdoviridae. Rhabdoviridae viruses are naturally and Jolyn Merry hosted by humans, mammals and vertebrates. Most This continuing pharmacy education lesson was written by rhabdoviridae viruses have selected hosts and limited Ally Dering-Anderson, PharmD, and Jolyn Merry, PharmD, geographic distribution. The rabies virus, however, neither of whom have any conflicts of interest, nor does they have is found throughout most of the world, absent only any financial relationships with a commercial interest related to in Antarctica and on certain islands. Both the term this continuing pharmacy education activity. “rabies” and the genus lyssavirus take their names from
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ancient words that are descriptive of patient is grim, with fewer than 20 1960 the majority of rabid animals were this disease: Latin rabies meaning reports of people who have recovered domestic. Mongooses continue to be “madness” and Greek lyssa meaning from symptomatic disease. Rabies a reservoir for rabies in Puerto Rico. “violent”.3,4,5,6 deaths are not always well reported Even though human rabies is rare in in poor and developing countries. the United States, it is estimated that Rabies is transmitted primarily Children are the most common victims nearly 40,000 people are vaccinated through saliva from an infected animal. of the disease and many will die at in the United States every year as post- The infectious saliva is introduced home without any medical intervention exposure precautionary therapy. As through a bite, a scratch, or saliva and with no public health reporting. of July 5, 2017, the CDC reported that coming into contact with mucous Often, people diagnosed with rabies Hawaii remains rabies-free.2,13,14 membranes of the eyes, nose, or are unable to identify the causative mouth. Human-to-human transmission event.2,11 Worldwide is extremely rare having been Around the world, the most common documented only as the result of tissue Sources of Exposure source of human exposure is dogs. transplant from a deceased, diseased Nebraska Pharmacists with travel clinics or simply patient into another person.2,7,8 In Nebraska in 2018, the most common being asked about travel vaccines, source of potential human exposure should consider prophylactic rabies Initial viral infection infects muscle was bats. In 2017, bats were also the vaccine for travelers to areas of the cells at the location of the bite or most common source of exposure, world with high rates of rabies. India, scratch. The virus quickly travels but skunks also contributed a number China, and the Democratic Republic of through the body to infect the central of exposures, as well. Most of these the Congo had the most human cases nervous system, then the peripheral animals were not captured; therefore, in 2015. Haiti also has a high mortality and autonomic nervous systems. the animal’s rabies status was never rate from rabies. Antarctica is the only Finally, the lyssaviruses multiply in determined. While bats are the continent without rabies. There are a the salivary glands. Infection with leading source of potential exposures few islands where there is no rabies lyssaviruses results in inflammation in Nebraska, most bats in Nebraska disease. It is occasionally thought of the brain and nervous tissue in are not infected with rabies. Some that Australia has no rabies. While it is humans and other mammals. Common researchers estimate that less than technically true that there has been no symptoms of rabies infection include 1% of the bat population carry rabies. identification of the lyssavirus known varying degrees of paralysis, anxiety, Domestic animals are uncommon as rabies in Australia, the Australian insomnia, confusion, agitation, sources of exposure with an average bat lyssavirus also causes rabies paranoia, terror, and delirium. of one exposure from cats annually. which is reported to have a 100% Hydrophobia is also common, which The last potential exposure from a fatality rate if symptoms of disease are aids in the transmission of the virus canine was documented 2015, and the exhibited.3,6,8,15,16 to a new host. Since the virus grows report indicated that the canine was in the salivary glands, if the infected not a domesticated dog or pet.12,13 Rabies Control animal could drink and swallow, there In the United States, Europe, Australia, would be less virus to be transmitted United States and Japan, animal control laws via a bite.8,9,10,11 In the United States, bats are also requiring the vaccination of domestic Unlike other viral diseases, the the most common source of human animals have dramatically reduced the asymptomatic phase of rabies can vary exposure. Rabid bats have been spread of rabies. Conversely, rabies greatly from a few days to greater than documented in 49 of the 50 United cases are increasing in India since the a year. Infection from severe wounds States. Fewer than 5% of United States passage of a law in 2001 that forbids on the face or neck progress more exposures can be attributed to dogs. the killing of dogs. Great Britain, by quickly than single bites or non-bite From 2000 – 2004 more cats than virtue of being an island with very exposures on the extremities. Patients dogs were found to be rabid in the restrictive animal importation laws, must receive treatment before the United States. The CDC reports that and very strict quarantine procedures, onset of symptoms. After symptoms greater than 90% of all animal cases has a rabies rates nearing zero. Even have started, the prognosis for a now occur in wildlife, while prior to though Great Britain has very low
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While vaccination of domestic Table 1 | At A Glance: MMR Vaccine Controversy17 animals is a hallmark of rabies control in the United States, the prevention In 1998, respected medical journal The Lancet carried the results of a small-scale study of human rabies also includes public (12 children) that claimed a link between the Measles Mumps Rubella (MMR) combined vaccine and autism and colitis in children. education to avoid animals that are clearly ill, avoiding contact with wild The leader of the research team, Andrew Wakefield promoted mass media coverage of animals, and seeking immediate the study. MMR became the biggest science story of 2002 and the public’s confidence medical care for any suspected in the vaccine was seriously shaken and vaccination rates fell. exposure. Training children not to Concerned over MMR safety, organisations such as the NHS, the US Centers for provoke animals is also essential Disease Control and Prevention and the Cochrane Library carried out large-scale to the control of rabies exposures. epidemiological studies. These highlighted some adverse vaccine effects, such as Provocation may be as simple as rashes and joint pain, but could not replicate the findings of the original study. attempting to pet or feed an unfamiliar animal or as barbaric as intentional In 2004, Sunday Times journalist Brian Deer revealed that, two years prior to the animal incitement. Avoidance of research, Wakefield had been hired by lawyers from the UK’s legal aid fund, who were hoping to prove that the vaccine damaged children. This undeclared conflict of interest unfamiliar animals is a difficult warning led to The Lancet partially retracting publication of the study. for children to understand, especially near baby animals and animals that The study was fully retracted in 2010, after allegations that the study data had been are other’s pets. Adult supervision falsified. At the same time, the General Medical Council found Wakefield guilty of of children around animals and serious professional misconduct, unnecessarily invasive tests on children and multiple, undeclared conflicts of interest. He was struck off the medical register. reinforcement of this message is The scientific consensus is that there is no causal link between the MMR vaccine and important. The vast majority of fatal autism. rabies cases worldwide occur in children.2,3,19 Credit to Alastair Choy; The Telegraph; United Kingdom; 25 April 2018; with permission.
Table 2 describes the CDC rabies exposures, in the spring of 2018 lowest rates in those countries where recommendations for the disposition falling animal vaccination rates led rabies is considered enzootic.3,13,16,17 of a potentially infectious animal, the British Veterinary Association to and the recommendations for post- undertake a public service campaign Nebraska has a state law requiring exposure prophylaxis. Non-domestic with announcements that “Dogs the vaccination of domestic animals. or exotic warm-blooded animals known cannot get ‘autism.’” Similar concerns Neb. Rev. Stat. Sec. 71-4402(1) reads: or suspected to have been exposed about falling vaccination rates have Every domestic animal in the State to rabies should be euthanized been expressed by veterinarians in of Nebraska shall be vaccinated immediately, if they can be safely the United States (see Table 1 for a against rabies with a licensed captured. Euthanasia techniques brief discussion of the genesis of this vaccine and revaccinated at should attempt to preserve brain controversy, as prepared by Alastair intervals specified by rules tissue. Euthanizing non-domestic or Choy for the Telegraph). and regulations adopted and exotic warm-blooded animals is also promulgated by the department. recommended when they have caused Experts estimate that over 70% Young domestic animals shall a human exposure. Unfortunately, of the population of domestic animals be initially vaccinated at the it is uncommon that a wild animal in any area must maintain vaccine age specified in such rules will be captured following an human coverage against rabies to decrease and regulations. Unvaccinated exposure. With non-domestic, exotic transmission between domestic domestic animals acquired or or wild species all recommendations animals and humans. The higher moved into the State of Nebraska for disposition include euthanasia, the coverage, the less likely that a shall be vaccinated within thirty there are no recommendations for domestic animal (dog, cat, ferret) will days after purchase or arrival quarantine or observation for these be a rabies carrier. Worldwide canine unless under the age for initial animals. It is unlikely that wild rodents vaccination rates are <20% with the vaccination.18 (mice, rats, etc) would survive an attack
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a live, attenuated vaccine that was Table 2 | Guidelines to Animal Disposition administered into the abdomen in and Post-exposure Vaccination2 dosing regimens consisting of 14 to 23 injections. This vaccine and Evaluation and Disposition Post-exposure Vaccination the subsequent vaccine developed Animal Type of Animal Recommendation by David Semple which is also a Domestic • Healthy, available for 10- • Do not begin vaccination live, attenuated vaccine, resulted in Dog, Cat, Ferret day observation unless animal becomes significant neurologic side effects. • Rabid or suspected rabid symptomatic • Unknown (escaped) • Immediately vaccinate Stories of the pain of the injections, • Consult with public the unusual site of administration health officials (abdomen) and the severe side effects Raccoon, Skunk, Fox, • Regard as rabid unless • Consider immediate were used to discourage inappropriate Coyote, most other animal is proven negative vaccination animal encounters. The Pasteur-Roux carnivores; Bats by laboratory test vaccine is no longer produced. The Livestock, Horses, Rodents, • Consider each exposure • Consult with public Semple vaccine is still utilized in a Rabbits and Hares, other individually health officials few countries, but is not used in the mammals United States or Europe. There was Note: The bites of also a short-lived adsorbed rabies squirrels, hamsters, guinea vaccine, formulated using Rhesus pigs, gerbils, chipmunks, rats, mice, other small monkey lung tissue cultures that is rodents, rabbits, and hares no longer available on the American almost never require rabies market.21,22,23,24 post-exposure prophylaxis.
Based on CDC Recommendations United States Vaccines The current inactive United States from a rabid animal; therefore, it is In some cases, there will be law rabies vaccines offer significant unlikely that wild rodents are significant expressly directing the actions to be improvements in the route of risks for rabies transmission. It should taken for these animals. In animals administration, number of doses, and be noted that while bats may resemble that are current on rabies vaccine, side effects. There are currently two rodents, they are completely different another dose of vaccine should be rabies vaccines available in the United mammals.2,14,15,20 administered immediately, and the States. Both are inactive vaccines animal should be observed for 45 with primary side effects of redness Domestic animals (dogs, cats, days. In many communities the owner at the injection site and sore arms (or ferrets) with known or suspected may observe the animal, in others thighs depending upon patient age). rabies exposures, and those that have a quarantine for observation will be The two American rabies vaccines are exposed or potentially exposed a required. Domestic rodents (mice, rats, created differently. Imovax®, by Sanofi human, may be euthanized. In those gerbils, etc.) are very rarely infected Pasteur, is produced in human diploid situations where the owner is unwilling with rabies. In the case of an exposure cell cultures. Imovax® is sometimes to sacrifice the animal, quarantine from a wild animal, or known rabid abbreviated HDCV (human diploid cell precautions should be undertaken. domestic animals, the domestic rodent vaccine). RabAvert®, by Novartis, is Quarantine for unvaccinated animals should be euthanized.2 produced in chick embryo cell culture requires strict isolation for 6 months, and is sometimes abbreviated PCECV preventing direct contact with Rabies Vaccine (purified chick embryo cell vaccine). humans or other animals. Animals History [Note: Health care providers are that have a history of rabies vaccine, Louis Pasteur and Emile Roux reminded that using abbreviations but are overdue for a booster should developed the original rabies vaccine for vaccines is discouraged because be euthanized or quarantined for in 1885. The vaccine was derived quality related events have been observation at the discretion of from the nerve tissue of purposefully reported due to the misinterpretation the local rabies epidemiologist. infected rabbits. The vaccine was of abbreviations.]
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These vaccines are considered rabies vaccine. Imogam®, rabies administered in three doses: to be equipotent, equiprotective, immunoglobulin, by Sanofi Pasteur, is Dose 1 Day 1 and interchangeable. Switching available as 150IU/ml and is supplied Dose 2 Day 8 (7 days following dose 1) between brands in a single regimen in 2ml and 10ml vials. HyperRab®, Dose 3 Days 22-29 (21 to 28 days should be avoided when possible, rabies immunoglobulin, by Talecris is following dose 1) as long as it does not cause delay also available as 150IU/ml in both 2ml in the administration of the full and 10ml vials. Rabies immunoglobulin For people with repeated exposure regimen.25,26,27,28 should NEVER be mixed in the same through work, rabies immunity testing syringe as rabies vaccine. Because is recommended biannually, with single The inactive rabies vaccines used immunoglobulin is derived from human booster doses being administered in the United States are appropriate for plasma there is a chance for allergic to maintain the defined titer of >1:5. all ages, including infants and pregnant reactions. Rabies immunoglobulin Immunity testing is not routinely patients. In adults, these vaccines are should not be administered without recommended for travelers.1,2,26,27,31 administered intramuscularly in the ready access to epinephrine. deltoid. For small children and infants, Patients requiring live attenuated Post-exposure Treatment administration should be into the vaccines (measles, mumps, rubella, Patients who have a known or anterolateral thigh. Gluteal injections varicella, rotavirus, yellow fever) suspected exposure are broken into are to be avoided because the vaccine should be advised to wait 3 months two groups: those with a known bite does not have proven efficacy when following the administration of rabies versus all other types of exposures, deposited into fat cells.1,25,28 immunoglobulin before receiving such as minor or unnoticed injuries, these live attenuated vaccines. Given exposure of mucous membranes Rabies Immunoglobulin that 40,000+ patients annually are or existing wounds to potentially Following vaccination, the treated with rabies immunoglobulin, infectious material including saliva, development of rabies antibodies pharmacists need to be careful about brain or nervous tissue. This to rabies takes about 7 days. screening for recent immunoglobulin differentiation is useful in making Administering rabies immunoglobulin administration prior to administering decisions regarding the timing of can confer passive immunity. Rabies any live vaccine.2,28,29,30 treatment initiation or treatment versus immunoglobulin is dosed 20IU/kg, non-treatment. Once the decision to given once. The Immunoglobulin Preventative Rabies treat has been made, the treatment should be given at the same time Vaccine is the same for both groups. Contact as the first dose of rabies vaccine Rabies vaccine is unique amongst with other materials, blood, urine, or or within 7 days of the first rabies vaccines in that it is not only used feces of a known or suspected rabid vaccine. After that time, host antibodies prophylactically pre-exposure, but also animal or petting such an animal is not should have developed and the for post-exposure treatment. Rabies considered an exposure. Likewise an immunoglobulin will not provide any vaccine, used prophylactically, is inadvertent exposure to the modified benefit. If there is a bite or visible recommended for people who are at live vaccine used for domestic wound, as much immunoglobulin high risk of exposure: veterinarians, animals should not be considered an as possible should be infiltrated animal handlers, people who exposure.2,3,32,33 around the area, with any remaining work in rabies laboratories or who immunoglobulin administered deep handle rabies biologic products, Any unattended child, mentally IM, using a separate needle, at a site and spelunkers. The vaccine is also disabled, or chemically impaired distant from the site of the rabies appropriate for people who are person found in a room with a bat vaccine. Care must be taken not to likely to come into contact with rabid is an indication for post-exposure administer intravenously.29,30 animals through work or travel. This treatment. Competent adults are may include nature photographers, often able to describe any exposures Human rabies immunoglobulin is travelers to areas of the world and the decision to treat should be prepared by cold alcohol fractionation where rabies is common or others based on each individual incident. All from pooled venous plasma from with a definable risk. Pre-exposure, people awakening with a bat in the people hyper-immunized with the or prophylactic, rabies vaccine is room should consider post-exposure
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treatment because bat bites are not always painful and do not always leave Table 3 | Post-exposure Dosing1,2 an obvious mark on the skin. The low Patient Rabies Vaccine Human rate of bat rabies as well as the near Characteristics Dosing Days Immunoglobutin 100% fatality rate if symptoms develop before treatment are issues to consider No previous vaccination 1, 3, 7, 14 20 IU/kg Immuno-competent when deciding whether or not to receive post-exposure treatment.2,14 No previous vaccination 1, 3, 7, 14, 28 20 IU/kg Immuno-compromised Dead animals, especially those with significant injuries, such as animals Previous vaccination 1,3 None killed on roadways, should be treated as having the potential to cause an exposure via nervous or brain matter. immediately and the second to be animal hosts and the widespread While laboratory confirmation of rabies given on day 3. Patients who have nature of the virus, eradication is can be obtained when the animal brain previously received rabies vaccine not a realistic goal. That does not is available for testing, post-exposure are not given rabies immunoglobulin mean, however, that the prevention therapy should not be delayed for following an exposure.2,28 of human death cannot be improved. laboratory testing. If laboratory testing Post-exposure therapies, starting with produces a negative rabies result, any For patients who have not been appropriate wound care, vaccination, remaining post-exposure therapy may vaccinated against rabies, post- and immunoglobulin, can prevent 8 be discontinued. exposure therapy includes both rabies a rabies infection. Recognition of vaccine and rabies immunoglobulin. the value of vaccination in domestic Immediately following a known or The rabies immunoglobulin and the animals and the prevention of suspected exposure patients should first rabies vaccine are administered animal-to-human exposure is vital to wash the area thoroughly with soap as quickly as possible. Three preventing human death. and water. If available, a virucidal additional doses of rabies vaccine are agent, such as povidone-iodine, should administered on days 3, 7, and 14. The While bats are the most common be used to irrigate any skin wounds. guidelines for post-exposure care for source of rabies exposure in the United Irrigation with povidone-iodine is not immunosuppressed patients include a States, world-wide attempts have appropriate for exposures in the eye 5th dose of rabies vaccine on day 28. been made to control rabies in wild or mouth. If the exposure is a puncture For the immunocompromised patient, animals, including dosing foxes in the wound, including a bite, tetanus the immunoglobulin is to be given at Swiss Alps with chicken heads treated prophylaxis should be considered, in the same dose as instructed for non- with live attenuated rabies vaccines, addition to the rabies post-exposure immunosuppressed patients. but dogs remain the leading cause protocols listed below. Patients who of human exposure. Finding ways to are unable to quickly find a record of When patients have an create a stable and affordable canine tetanus immunization should be given international exposure, treatment may vaccine will help to decrease human the appropriate tetanus and diphtheria be initiated upon return to the United exposure and the resulting human 2,28 vaccine. States. Every attempt should be made fatalities. To reach the 70% coverage to determine the care provided abroad, goal necessary to protect humans, 1 Following a known or suspected but rabies vaccine and immunoglobulin in every 2 unvaccinated dogs would rabies exposure patients should seek should be strongly recommended for need to be vaccinated, in addition immediate medical attention. See Table these patients. to maintaining vaccination status in 3 for post-exposure dosing of both the the 20% current on rabies vaccines. rabies vaccine and immunoglobulin. Conclusion September 28th has been declared For patients who have received the Rabies is a caused by two viruses, World Rabies Day in hopes of bringing prophylactic vaccine series, post- that together, cover most of the globe. attention to this international health exposure therapy includes 2 doses of Because there are so many possible problem.3,31,34 rabies vaccine. The first dose given
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References Policies for the Nebraska Mortar & 18. https://nebraskalegislature.gov/laws/statutes. 1. World Health Organization, Rabies Vaccine; Pestle (M&P) continuing pharmacy https://www.who.int/ith/vaccines/rabies/en/; php?statute=71-4402; accessed 5 Feb 2019. education lessons and quizzes: accessed 18 Feb 2019. 19. CDC Rabies What Type of Exposure 2. CDC Rabies; https://www.cdc.gov/rabies; Occurred?; https://www.cdc.gov/rabies/ 1. M&P Quizzes are valid only for the accessed 6 Feb 2019. exposure/type.html; accessed 13 Mar 2019. membership year in which they are 3. Rupprecht C, Kuzmin I, Meslin F; Lyssaviruses 20. FHSU prof: Bats facing killoffs from wind published. Quizzes for the 2019 and rabies: current conundrums, concerns, turbines, disease; Janney C; Hays Post; Membership Year must be received contradictions and controversies; F1000 6 Feb 2019; https://www.wind-watch.org/ by December 12, 2019. Quizzes Research; 23 Feb 2017,6:184. news/2019/02/06/bats-facing-killoffs-from- cannot be carried over to another 4. Cassell’s Latin Dictionary; London; Cassell; wind-turbines-disease/; accessed 22 Feb membership year. p 883. 2019. 2. If more than three questions are 5. Rotivel Y; Introduction to the Federation of 21. Giesen A, Gniel D, Malerczyk C, 30 Years of missed, the quiz will be returned. American Scientists; 26 April 2009-archived. Rabies Vaccination with Rabipur: A Summary The quiz can be resubmitted. 6. World Health Organization Rabies Maps; of Clinical Date and Global Experience; 3. CPE transcripts can be printed from http://www.who.int/rabies/rabies_maps/en/ Expert Review of Vaccines; 14 (3): 351-367. NABP e-Profiles at www.nabp.net. index.html; accessed 19 Feb 2019 22. Burgoyne GH, Kajiya KD, Brown DW, 4. CPE credits are submitted to 7. Compendium of animal rabies prevention Mitchell JR. Rhesus diploid rabies vaccine NABP by the 15th of each month. For example, M&P CPE quizzes and control, 2011. National Association of (adsorbed): a new rabies vaccine using RFhL- completed in the month of June State Public Health Veterinarians, Inc. MMWR 2 cells. J Infect Dis 1985;152:204-10. 2019 will be sent to NABP e-Profiles Recomm Rep, 2011 Nov 4;60(RR-6):1-17. 23. Rabies Vaccine Pasteur https://www. before July 15, 2019. 8. Rabies Fact Sheet No99; http://www.who.int/ historyofvaccines.org/timeline#EVT_100876; accessed 20 Feb 2019. mediacentre/factsheets/fs099/en/ accessed The Nebraska Council 24. Rabies Vaccine Semple https://www. 24 Feb 2019. for Continuing Pharmacy historyofvaccines.org/content/rabies-vaccine- 9. Giesen A, Gniel D, Malerczyk C, 30 Years of Education (NCCPE) Rabies Vaccination with Rabipur: A Summary human-semple-type; accessed 20 Feb 2019. is accredited by the of Clinical Date and Global Experience; 25. Rabies Vaccine: Vaccine Information Accreditation Council Expert Review of Vaccines, 14 (3): 351-367. Statement, US Department of Health and for Pharmacy Education 10. Rabies; AnimalsWeCare.com Sep 2013; http:// Human Services, CDC, 6 Oct 2009. (ACPE) as a provider of continuing www.animalswecare.com/home_section/ 26. Imovax; Package Insert; SanofiPasteur; Apr pharmacy education (CPE). This CPE rabies/; accessed 24 Feb 2019. 2013. home study activity has been accredited 11. CDC, what type of exposure occurred? 27. RabAvert; Package Insert; GSK Vaccines; for 1.0 contact hour or 0.10 CEU. UAN https://www.cdc.gov/rabies/exposure/type. 2018. 0128-0000-19-038-H01-P for pharmacists html; accessed 26 Feb 2019. 28. Recommendations of the Advisory and UAN 0128-0000-19-038-H01-T 12. http://dhhs.ne.gov/publichealth/Pages/epi_ Committee on Immunization Practices; for pharmacy technicians. This is epirabie.aspx; accessed 7 Feb 2019. MMWR 2008;57 [No. RR-3]. a application-based CPE activity 13. Birhane MG, Cleaton JM, et.al., Rabies 29. Imogam; Package Insert; SanofiPasteur; Nov targeted to pharmacists and pharmacy Surveillance in the United States during 2018 technicians. 2015; Journal of the American Veterinary 30. HyperRab; Package Insert; Grifols Medical Association, 15 May 201; Vol 250, No Therapeutics; Sep 2012. The Nebraska Pharmacists Association 10, p 1117-1130. 31. Hicks DJ, Fooks AR, Johnson N. disclaims any liability to you or your 14. Klug BJ, Turmelle AS, Ellison JA, et al, Rabies Developments in rabies vaccines. Clin Exp patients resulting from reliance solely upon the information contained herein. Pevalence in Migratory Tree-Bats in Alberta Immunol. 2012;169(3):199-204 and the Influence of Roosting Ecology and 32. Cantor C, A Bat in the House, A Rabies Sampling Method on Reported Prevalence of Scare; Rutgers Today; 29 Feb 2012. Rabies in Bats; J Wildl Dis, 2011 47:64-77. 33. Rabies & Australian bat lyssavirus information Quiz Answers may be submitted: 15. https://rabiesalliance.org/world-rabies-day; sheet; http://www.health.vic.gov.au/ideas/ Online: www.npharm.org accessed 25 Feb 2019. bluebook/rabies_info. Fax: 402-420-1406 16. https://aphaih.org/2018/09/28/world-rabies- 34. Grambo RL; The World of the Fox. Email: [email protected] Vancouver: Greystone Books, 94-95. day-rabies-prevention-around-the-world/; Mail: Nebraska Mortar & Pestle accessed 12 Feb 2019. 6221 S 58th St, Ste A 17. Dogs Cannot Get Autism according to Lincoln, NE 68516 British Veterinary Association; https:// www.telegraph.co.uk/news/2018/04/25/ dogs-cannot-get-autism-british-veterinary- association-warns/; accessed 14 Feb 2019.
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Rabies: Disease, Counseling, and Treatment Quiz #8, May/June 2019, ACPE 0128-0000-19-038-H01-P/T 1. Rabies is a zoonotic disease. What does zoonotic mean? 6. What is the most common source of a known or suspected a. A disease causing a zombie-like state. human rabies exposure world-wide? b. A disease present on all but one continent. a. Bats c. Dogs c. A disease transmitted from animals to humans. b. Cats d. Mongooses d. Bat-borne disease. 7. Taylor has been exposed to a potential rabies infection 2. You are staffing a travel clinic. Christian is going on aocky R through a wild-animal bite. She weighs 205 pounds, is 26 Mountain cave exploration encounter and wants to know years old, has no known drug allergies, and has never been if rabies vaccine is appropriate. She is current on all age- vaccinated against rabies. In addition to administering a appropriate vaccines but has never been vaccinated against rabies vaccine, you want to give rabies immunoglobulin. rabies. Which is the best answer? What dose of immunoglobulin is appropriate for Taylor? a. 3 doses of purified chick embryo vaccine are appropriate. a. 1860 IU c. 1860 mg b. 5 doses of Pasteur-Roux vaccine are appropriate. b. 4100 IU d. 4100 mg c. Rabies immunoglobulin should be given to Christian d. Rabies vaccine is only appropriate for foreign travel. 8. Mrs. Frantik is planning a trip to Paris. She read, on a social media site, that there are rabid dogs in rural France. She 3. Brooklyn works for animal control and has just been bitten is now in a panic and asking for your help. Which of the by a stray dog. Brooklyn has never been vaccinated against following is good advice for her? rabies. Which is the best therapy for her? a. Don’t approach or provoke any dogs during your trip. a. Give 4 doses of rabies vaccine. b. We can dispense rabies immunoglobulin for you to take b. Give rabies immunoglobulin 20 IU/kg and with you, in case you are exposed. 4 doses of rabies vaccine. c. We can schedule rabies vaccine for you, if you have c. Give rabies vaccine and 4 doses of 5 weeks or more before your trip. immunoglobulin 20 IU/kg. d. We will give you doxycycline to take with you. Don’t take d. Wait until the necropsy on the dog is completed it unless you are bitten. to decide. 9. Which of the following public health initiatives has resulted 4. Jacob works with Brooklyn, from the previous question. He in the greatest reduction of human exposure to rabies in was also exposed when the dog’s saliva contaminated both the United States? of his eyes. Jacob received prophylactic, post-exposure a. Improvement in rabies vaccine treatment for rabies 6 years ago. Which is the best therapy b. Improvements in the sanitation system for him? c. Mass vaccination of school aged children a. Give 2 doses of rabies vaccine. d. Required vaccination of domestic animals b. Give rabies immunoglobulin 20 IU/kg and 4 doses of rabies vaccine. 10. Which of the following patients should be given post- c. Give rabies vaccine and 4 doses of immunoglobulin exposure treatment for rabies? 20 IU/kg. a. A child who awakens to find a bat in her room. d. Wait until the necropsy on the dog is completed to decide. b. A hunter who has been exposed to deer blood. c. An environmental services person who cleans up 5. What is the most common source of a known or suspected dog urine. human rabies exposure in Nebraska? d. A and D should each be treated. a. Bats c. Dogs b. Cats d. Squirrels
Name ______2019 Quiz #8 - Rabies: Disease, Counseling, and Treatment ACPE #0128-0000-19-038-H01-P for pharmacists Mailing Address______ACPE #0128-0000-19-038-H01-T for technicians City/State/Zip______1.0 Contact Hour - Application Based CPE Activity The deadline for this quiz is December 12, 2019.
Circle one (1) Answer: CPE Home Study Evaluation 1. a b c d 6. a b c d 1. Rate this lesson: (Excellent) 5 4 3 2 1 (Poor) 2. Did this lesson meet each of its objectives? ___ Yes ___ No 2. a b c d 7. a b c d 3. Was the content without commercial bias? ___ Yes ___ No 3. a b c d 8. a b c d If not, please explain______4. a b c d 9. a b c d 4. Did the lesson meet your educational/practice needs? __ Yes __ No 5. a b c d 10. a b c d 5. Comments/future topics are welcome. ______
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Spring 2019 Honors Convocation and Commencement
The Joslyn Art Museum was the venue for the 2019 Scholastic Honors Convocation on May 3. Fifty-nine seniors were vested with their doctoral hoods and took the Pharmacist’s Oath. Senior recognition awards and the 2019 Preceptor, Faculty Preceptor and Site of the Year Awards were also presented at the Convocation. Spring Commencement was held at the Baxter Arena May 4. The 2019 graduates and senior award recipients are presented below and on the following page.
2019 Doctor of Pharmacy Degree Recipients
Kyle Baumgart, Columbus Brian Haskell, Lincoln Spencer Moore, Hebron with high distinction Lindsay Heimann, Omaha Catherine Nguyen, Omaha Nichole Boggs, Ponca Brandon Heuermann, Grand Island with distinction Brittney Boterman, Tea, SD with high distinction Lien Nguyen, Can Tho City, Vietnam Delores Anita Brown, Stanton Lauren Hoeft, Holdrege Ngoc Nguyen, Saigon, Vietnam Colin Brunick, Sioux Falls, SD with distinction Mackenzie Patterson, Bellevue Qing Cao, Zhengzhou, China Miranda Hopper, Grand Island with high distinction with high distinction Tanner Johnson, Elkhorn Corey Paz, McCook Adam Cheloha, Lincoln with high distinction Jessica Prucha, Omaha Kelsey Christensen, Seward Kokou Kanley, Omaha with distinction Brendan Cope, Omaha with distinction Weilin Qian, Shanghai, China Kevin Creal, Lincoln Abraham Karimi-ASL, Omaha Margaret Renner, Fairbury Jacob Duncan, Aurora, CO Stefanie Kellogg, Ashland Travis Scheuler, Grand Island Dane Ewald, Omaha Byron Korf, Yuma, CO Hunter Severin, Bellevue Morgan Flannigan, Lawrence, KS with distinction Jacob Siel, Franklin Megan Fleury, Omaha Matthew Laetsch, Atkinson with highest distinction Erik Furst, Omaha with distinction Logan Smolla, Giltner Yangyang Gao, Wenzhou, China Michaela Leddy, Omaha Nathan Suck, Aurora Krissa Glaubius, Gering, NE Jazmin Lee, Bloomfield Carlos Torres, Abilene, TX with distinction with high distinction Amy Venteicher, Pierce Ashleigh Grammar, Wildwood, MO Shanna Leise, Hartington Darin Williams, Maxwell with distinction Kent Marburger, Humboldt Lauren Wilson, Alva, WY Jordan Gran, Soldier, IA Nicholas Miesbach, Waverly with distinction Allison Graner, Omaha Molly Miller, Kennard Christine Zentner, Cedar Rapids Molly Haley, Red Oak, IA with highest distinction Fan Zhang, Beijing, China Alex Hamilton, Fremont
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The College of Pharmacy Class of 2019 named Jeffery Kildow, Popular rotation Pharm.D., Preceptor of the Year. Faculty Preceptor of the Year site, Grand Island was presented to Jennifer Foster, Pharm.D., Clinical Assistant VA, hosted twenty Professor. Site of the Year award was presented to Grand P4s this year. Island Veterans Administration and accepted by Drs. Brent Their reputation Bollwitt, Lourdes Heuermann, Paula Carlson, and Lisa Bilslend. has been earned through the Dr. Kildow’s practice site is Regional challenging and West Hospital in Scottsbluff, NE. diverse patient population students work with but more importantly the quality Students praised Dr. Kildow’s of preceptors at this site. The preceptors are excellent at excellence at balancing both the facilitating learning opportunities through relevant and management and the clinical side of interesting mini lectures and projects. The most rewarding part pharmacy. He allowed flexibility and of this rotation is the trust that the preceptors show in the encouraged rotation students to gain students. They encouraged independent clinical problem- experience in many patient care solving, allow students to do full patient work-up, and expect settings including overnight shifts. He students to make appropriate recommendations to their care. spent significant time reviewing Students finish the four weeks feeling very confident in their important topics and provided excellent feedback throughout abilities as pharmacists. the rotation. Gary Stroy, a 1967 graduate, was Dr. Foster was awarded the Faculty presented with the Distinguished Preceptor of the Year award. Dr. Foster Alumnus Award. Mr. Story co- practices at OneWorld Community Health founded a company called LifeScan, Center where the focus is on ambulatory which pioneered the concept of care. personal blood glucose monitoring for managing diabetes. He was an initial Dr. Foster is one of the most vibrant and investor in ChemTrack, which was a passionate healthcare professionals you’ll firm that developed the first home ever have the opportunity to work with. cholesterol test. He is a co-inventor on From day one, you can feel her true passion several patents, and he is recognized for the profession. She is extremely worldwide for his pioneering contributions in the area of knowledgeable and beyond willing to teach and to share her immunoassay technology for therapeutic drug monitoring and knowledge in any way she can. She is a true role model for our diabetes management. profession, and I think the field of pharmacy would benefit greatly if we all strived to practice like she does. Congratulations to Drs. Kildow and Foster, Grand Island VA, and Distinguished Alumnus, Gary Stroy.
Senior Award Recipients
Rho Chi Achievement Award Bradley G. Wulf Memorial Award Varro and Virginia Tyler Award Krissa Glaubius Spencer Moore Jazmin Lee
Phi Lambda Sigma Award Clinical Services Award US Public Health Service Excellence in Delores Anita Brown Kokou Kanley Public Health Pharmacy Practice Award Delores Anita Brown Kappa Psi Key Cunningham Memorial Award Jacob Siel in Pharmacodynamics Patient Care Champion Award Matthew Laetsch Logan Smolla Merck Index Award Nathan Suck Qing Cao Joseph B. Burt Memorial Award Mackenzie Patterson Tanner Johnson Facts and Comparisons Award of Excellence in Clinical Communication Mylan Pharmaceuticals Award Phyllis Rhodes Award Jacob Duncan Brandon Heuermann Molly Miller Excellence in Advanced Practice Barbara Osborne Manchester Award Academy of Students of Pharmacy Experiences Recognition Award Lindsay Heimann Certificate of Recognition Award Michaela Leddy Amy Venteicher Stephen A. Scholtz Memorial Award Kyle Baumgart
www.npharm.org 31 Nebraska MORTAR & PESTLE Sunscreen Products Written by Shana Castillo, PharmD
As summer approaches, it’s time Sunscreens may provide labeling that gels, lotions, oils, ointments, sprays, and to start thinking about sunscreens. The indicates they are “water resistant” sticks. The FDA is requesting additional American Academy of Dermatology (AAD) (40 minutes) or “very water resistant” data on powders but proposes that estimates that 20% of people will develop (80 minutes).5 The AAD suggests that any other dosage forms be handled skin cancer in their lifetime.1 Of course, consumers purchase a product that is with new drug applications. Finally, the best way to protect against this is to at least “water resistant”; however, it’s any combination product with both wear protective clothing or to stay out important to note that there is no such sunscreen and insect repellant will not of the sun altogether, but when this isn’t thing as a “waterproof” sunscreen.1,4 be considered GRASE.2 possible, sunscreen provides an effective Only broad spectrum sunscreens with alternative. New proposed regulations by and SPF ≥15 are allowed to include Tips for Consumers the U.S. Food and Drug Administration labeling that states they “decrease the The new FDA proposed ruling will allow (FDA) aim to ensure that sunscreen risk of skin cancer and early skin aging consumers to feel confident in knowing products are safe and effective and caused by the sun”. Others may only that the sunscreen they choose is safe make it easier for consumers to identify state that they “help prevent sunburn”.3 and effective. Remind patients to always important information on the product The FDA now proposes in its new ruling use products according to their labeling labeling itself.2 that the front label advise consumers and apply 15 minutes before intended to read the skin cancer and skin aging exposure.7 The AAD suggests that most Sun Protection Factor (SPF) alert on sunscreens that do not prevent adults need to apply about 1 ounce – or A common misconception is that SPF these.2 the size of a shot glass – to the body.1 relates directly to the amount of time A good method of distribution is ½ spent in the sun. For example, “If I burn Generally Recognized as Safe and teaspoonful to the face and neck area after one hour, a sunscreen with an SPF Effective (GRASE) Products (avoiding the eyes), ½ teaspoonful to of 30 will allow me to stay in the sun Some nonprescription products in the the arms and shoulders, ½ teaspoonful without burning for 30 times that.” This U.S. are allowed to be marketed without each to the front and back of the torso, is simply not true. SPF is a measure of an approved new drug application and 1 teaspoonful to each leg and top solar energy exposure which is affected because they are generally recognized of foot.7 Sunscreen should be reapplied by factors in addition to time, such as as safe and effective (GRASE). Under according to label instructions but solar intensity and skin type.3 The AAD the new proposed ruling, the FDA every 2 hours for products that are not recommends that consumers use a considers only zinc oxide and titanium water-resistant. The expiration date on sunscreen with an SPF of at least 30.1 A dioxide, both physical sunscreens, to be the sunscreen label should be checked previous FDA proposed ruling suggested GRASE. Aminobenzoic acid (PABA) and before use and the product should be that products should be labeled with a trolamine salicylate are not considered stored out of direct sunlight to retain maximum SPF of 50+, citing a lack of GRASE and the FDA proposes that potency and effectiveness.7 evidence showing increased protection there is insufficient evidence to make 1. American Academy of Dermatology, Sunscreen FAQs. https://www.aad. 3 beyond this; however, the new a determination regarding the other org/media/stats/prevention-and-care/sunscreen-faqs. Accessed April 14, 2019. proposed ruling increases that value to twelve chemical sunscreens at the 2. U.S. Food and Drug Administration, FDA advances new proposed 2 2 regulation to make sure that sunscreens are safe and effective. 60+. SPF is only indicative of protection present time. A recent exploratory February 21, 2019. https://www.fda.gov/NewsEvents/Newsroom/ PressAnnouncements/ucm631736.htm. Accessed April 1, 2019. against UVB radiation which is why it is study further demonstrated the need 3. U.S. Food and Drug Administration, Questions and answers: FDA announces new requirements for over-the-counter (OTC) sunscreen important to select a product labeled as for more research on these products products marketed in the US. June 23, 2011. https://www.fda.gov/ Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/ “broad spectrum” to ensure coverage when it showed the magnitude of UnderstandingOver-the-CounterMedicines/ucm258468.htm. Accessed against UVA radiation as well.4 The systemic exposure to four commercially April 23, 2019. 4. U.S. Food and Drug Administration, Sunscreen: how to help new proposed ruling would require all available sunscreen ingredients after protect your skin from the sun, July 14, 2017. https://www.fda.gov/ Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/ sunscreens with an SPF ≥15 to provide application to 75% of the body surface UnderstandingOver-the-CounterMedicines/ucm239463.htm. Accessed April 23, 2019. broad spectrum coverage as well, area every four hours. The resulting 5. U.S. Food and Drug Administration, CFR – Code of Federal Regulations Title 21. April 18, 2018. https://www.accessdata.fda.gov/scripts/cdrh/ making it easier for consumers to select plasma concentrations were above 0.5 cfdocs/cfcfr/CFRSearch.cfm?fr=352.76. Accessed April 23, 2019. 6. Matta MK, Zusterzeel R, Pilli NR, et al. Effect of sunscreen application an appropriate product. This key product ng/mL for all four ingredients, a level at under maximal use conditions on plasma concentration of sunscreen 6 active ingredients: a randomized controlled trial. JAMA. 2019. doi: 10.1001/ information will also be presented in a which the clinical effects are unknown. jama.2019.5586. [Epub ahead of print]. new, easier to read format.2 Dosage formulations of sunscreen 7. Krinsky DL, Ferreri SP, Hemstreet BA, Hume AL, Newton GD, Rollins CJ, Tietze KJ. Handbook of Nonprescription Drugs: An Interactive Approach Other Key Labeling Requirements considered GRASE are butters, creams, to Self-Care, 19th Ed. Washington, D.C.: the American Pharmacists Association, 2018.
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Continuing Pharmacy Education | Lesson #9
Debugging the Mysteries of Head Lice
Written by: Eric Hoie, PharmD, RPh (corresponding author); Kimberley Begley, PharmD, RPh; Jenny Tilleman, PharmD, RPh; and Karen K. O’Brien, BS Pharm, PharmD, RPh; Associate Professors of Pharmacy Practice at Creighton University School of Pharmacy & Health Professions. None of these authors have any relevant financial relationships that would be considered a conflict of interest for the purposes of this continuing pharmacy education activity. This article will include a discussion of non-FDA approved (off-label) medication use.
Objectives Alternative treatments are available, lice are transmitted through head-to- At the conclusion of this lesson, although most lack solid scientific head contact, so outbreaks typically pharmacists and pharmacy technicians evidence of efficacy. Misinformation occur in day-care centers and should be able to: about head lice is rampant, often elementary schools where children 1. Describe the transmission and leading to misdiagnoses and improper directly interact with one another. diagnosis of head lice. treatment. Many schools still have Household members and caretakers “no-nit” policies that prevent children may also become infested.1 Head 2. Identify available prescription and from returning to school until they are lice are problematic, but they are not over the counter treatments for lice. nit free. The National Association of known to transmit any disease and 3. Discuss ways to educate patients School Nurses (NASN), the American are not considered a health hazard.2 and communities about head lice. Academy of Pediatrics (AAP), and Secondary bacterial infections may the Centers for Disease Control and develop when patients scratch itchy Introduction Prevention (CDC) have declared areas on the scalp causing open 1 Head lice infestations are common “no-nit” policies that are based on lesions. in the United States and affect all misinformation, not scientific facts, Head lice infestation (pediculosis) socioeconomic classes. Outbreaks disrupt student learning, and stigmatize is not due to poor hygiene or typically occur in preschool or and shame children. Pharmacists can cleanliness of the environment and all elementary school settings where assist their communities by arming socioeconomic groups can be affected. children have direct head-to-head themselves with evidence-based Nevertheless, having lice carries contact. Their household members and facts to help dispel fallacies related to a stigma and infested children are caregivers may also become infested. effective management of head lice. often excluded from events with their Traditional treatment strategies include schoolmates and friends. Although application of topical products to kill Background sound data are lacking, it is estimated that six to twelve million cases of lice and/or nits (eggs), followed by Head lice (Pediculus humanus capitis) pediculosis occur annually in children manual removal of lice and nits from infestation is a common occurrence three to eleven years old in the United the hair using fine-tooth nit combs. and affects people worldwide. Head
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1 States. Treatments for head lice are Figure 1: Life Cycle of the Louse Transmission generally safe and effective when used Head lice cannot fly or hop, they can correctly. Misinformation about head only crawl. The primary manner in lice abounds and this article aims to which lice are transmitted from an provide evidence-based information infested person to another individual to help readers distinguish facts from is via close head-to-head contact. Pets fallacies. See Table 1 for facts and do not carry head lice from person to fallacies. Pharmacists can play a key person.4 role in dispelling incorrect perceptions Rarely, head lice may be about head lice and educating patients transmitted to a human host from about effective management of this inanimate objects such as articles common problem. of clothing, stuffed animals, towels, bed linens, contact with upholstered Etiology furniture or carpet, helmets, combs or The life cycle of the head louse has three 1,6 The head louse is a parasitic insect stages: egg (nit), nymph and adult. Stages of brushes. that requires a human host for its the lifecycle: survival. The life cycle of the head 1. Egg (nit) is laid on the hair shaft. Diagnosis louse involves three stages: egg, also 2. Nymph emerges from eggs laid on day 0. Seeing a live nymph or louse in the 3. Nymph moults for the first time. known as a nit, nymph and adult (see hair or on the scalp establishes a 3 4. Second moult. Figure 1). The adult female louse lays diagnosis of pediculosis.1 However, 5. Third moult. single eggs on the hair shaft of the head lice move rapidly, avoid light, and 6. Adult male and female lice mate. host approximately ¼” from the scalp. can be difficult to spot if only a few are 7. Female lays first eggs two days after Females lay eight to ten eggs daily and present. The presence of nits does produce between 80 and 100 eggs mating and can lay four to eight eggs per day for the next 16 days. not necessarily confirm an infestation. in their lifetime. The eggs are “glued” 8. Louse dies. Nits located more than ¼ inch from to the hair shaft with a substance the scalp are likely nonviable or are produced by the louse and resemble Used with permission: The Pharmaceutical Journal 7 SEP 2016 empty egg casings. Pediculosis is likely small oval specks (about the size of when nits are attached to the hair shaft a knot in thread) that are yellow to 4 and within ¼ inch of the scalp. Use of white in color. The eggs will hatch into and eyelashes. Lice stay close to a magnifying glass in good lighting nymphs in six to nine days and leave the scalp of humans and use their may help determine if the egg casing the egg casings. When the nymph piercing mouthparts to dig into the is empty or if a nymph is present in hatches, it resembles an adult head skin and feed on blood multiple times the egg. Eggs may be easier to locate louse but is much smaller, about the per day. Without a host, lice will die in the hair behind the ears or at the size of a pinhead. Nymphs may appear within one to two days because they nape of the neck. Misdiagnoses occur reddish in color due to ingested blood no longer have warmth and a food commonly when dandruff or other or grayish in color after the blood has source and eggs will die within a week hair debris, droplets of hair products, been digested. Nymphs pass through because they are not incubated at an 5 nonviable nits, or even other insects three molting cycles and become appropriate temperature. are mistaken for lice or viable nits.7 mature adults roughly ten days after Pruritis, caused by an allergic hatching. An adult louse is the size of a Figure 2: Louse Size reaction to louse saliva, is the most strawberry seed or sesame seed (see common symptom associated with Figure 2) and may live on a person’s pediculosis. Scratching may lead to head for up to 30 days.4 sores on the scalp. Other potential The louse prefers environments symptoms include a tickling sensation that are dark and warm to maintain of movement in the hair and nighttime its body temperature. Adult head lice restlessness or trouble sleeping have six clawed legs which facilitate because head lice are most active in gripping the hair shaft and they are the dark.4,6 commonly found behind the ears, If evidence of an active infestation near the temples, at the nape of the is found, all household members and neck or under a ponytail. Occasionally, Source: Centers for Disease Control and Prevention close contacts should be carefully they may be located on eyebrows checked. Treatment is indicated only
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Table 1 | Head Lice: Fact versus Fallacy*
Fallacy Fact Head lice infect people with poor hygiene Personal hygiene or cleanliness in the home or school has nothing to do with getting habits or those who reside in unclean head lice. environments. Head lice infestations should be avoided Head lice should not be considered a medical or public health hazard. Head lice are because lice spread infection. not known to spread disease. People’s pets can spread lice. Head lice are specific to humans. Dogs, cats and other pets do not play a role in the spread of head lice. Lice are mobile and can hop and fly from Head lice move by crawling. Lice cannot hop, fly, or swim. Most transmission is only by person to person. direct head-to-head contact. You cannot see head lice because they are Head lice are the size of sesame seeds. They can be tan, brown, or gray in color. They microscopic. might be a bit difficult to see with the naked eye, so it is helpful to look for them in natural light with a magnifying glass. Lice can hide and live in beds, clothing or Head lice need warmth and a host to survive. They live close to the human scalp and brushes for days. feed on human blood several times a day. Adult head lice can live 1–2 days off the human head. Lice can be easily spread by sharing The most common way head lice are spread is through direct contact with the hair of earphones or sports helmets. an infested person. Spread by contact with inanimate objects rarely occurs. Head lice legs are adapted to hold onto human hair. They would have difficulty attaching firmly to smooth or slippery surfaces like plastic or metal. If an egg falls out of the hair, it may hatch and Eggs are glued to the hair shaft by a “cement-like” substance made by lice and are infest another person. very hard to remove. When a nymph (baby louse) is hatched, it cannot survive without the warmth and food source of a human head. Lice misdiagnosis is uncommon. Identification of eggs, nymphs, or adult lice establishes the diagnosis. This can be difficult sometimes because lice avoid light and can crawl quickly. Dandruff, hair casts, hairspray or hair gel residues, dirt, scabs, or other insects (e.g., aphids caught in the hair) have led to misdiagnosis of lice infestation. In all cases of head lice infestation, people If this is a person’s first infestation or if the infestation is light, the patient may be will have incessant itching. asymptomatic, Itching is the most common symptom and is caused by an allergic reaction to louse bites. For first time infestations, it may take 4–6 weeks for itching to appear. Other symptoms experienced are a feeling that something is moving in the hair, irritability or sleeplessness, or sores on the head caused by scratching. Cutting your child’s hair so that it is very short Lice infestation is not significantly influenced by hair length, so this will not impact the prevents the spread of head lice. risk of getting head lice. Children with head lice should stay home The American Academy of Pediatrics’ guidelines recommend letting the parent of the from school until they are nit-free. child know about the lice diagnosis but refraining from sending the child home that day or restricting them from attending school. “No-nit” policies have been associated with increased risk of incorrect diagnosis of head lice, increased number of days children are out of school and negative social stigma. *Adapted from: Centers for Disease Control and Prevention hhttps://www.cdc.gov/parasites/lice/head/index.html. Pontius DJ. Demystifying Pediculosis: School Nurses Taking the Lead. Continuing Nursing Education. 2014;40(5):226- 235.
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if live nymphs, adult lice or viable pediculicidal (kills lice) and some are lotion to hair and scalp area beginning eggs are present. All infested family both pediculicidal and ovicidal (kills behind ears and the back of the neck members should be treated on the eggs). Oral prescription drugs are also and then cover all the hair. Leave the same day to prevent reinfestations in an option. Non-pharmacologic options lotion on hair and scalp for ten minutes the household. include nit combs, desiccation devices after applying. Use a timer or clock to and alternative topical products. track the time. Rinse hair and scalp Prevention with warm water in a sink. To keep the lotion off the rest of the body do Common concerns that arise when Pharmacologic Treatments not rinse off in a shower or bathtub. an individual has lice are how to Topical Products (Table 2) Dry hair with a towel and comb out prevent the transmission of lice to Dimethicone gel is a silicon polymer tangles. Wash hands carefully after the other household members and how approved for individuals two years application and rinsing steps. If live to avert re-infection via contact with of age and older. When applied, lice are seen seven days or more after items in the house. It is helpful to bear dimethicone occludes the respiratory treatment, repeat this entire process.15 in mind that lice will survive only one system of lice and inhibits water Pyrethrins with piperonyl butoxide to two days once removed from the excretion leading to death. In a study shampoo is approved for use in host.6 Thus, items that have been of 58 children, 98.30% were free of individuals two years of age and older. in contact with an infected person live lice and 55.20% were free of Like permethrin, pyrethrins hyper- within 24-48 hours prior to treatment viable eggs one day after treatment. stimulate the nervous system leading must be disinfected. Combs, brushes Fourteen days after treatment 96.50% to paralysis and death. The shampoo and hair accessories can be soaked were still free of live lice and 80.70% does not leave a residue, so a second in hot water (at least 130°F) for five were free of viable eggs. Forty-three application is necessary. Pyrethrins to ten minutes and allowed to air children received one treatment, 10 are derived from chrysanthemum dry. Clothing, bedding, and other children received two treatments and 5 plants and there have been rare machine washable articles should be received three treatments.11 reports of allergic reactions and washed in hot water (at least 130°F) Directions for use: Cover face asthma exacerbations in individuals and dried at high heat. Upholstered and eyes with a towel and keep eyes with ragweed allergies.14 Resistance furniture, car seats and floors should be closed during treatment. Apply behind has been reported but varies vacuumed.5,8,9 Insecticide sprays are not the ears and back of neck. Apply to dry geographically.14,16 recommended due to the self-limiting hair and massage until thoroughly wet. nature of lice and potential toxicity if Wait ten minutes. While hair and scalp Directions for use: Shake the inhaled or absorbed through the skin.5 are wet with gel, comb out lice, eggs shampoo well. Cover face and eyes Recommendations to seal all items that and nymphs with a lice comb. After with a towel and keep eyes closed cannot be washed in a plastic bag for combing the entire head, wash hair during treatment. Apply pyrethrin with fourteen days are still advanced by thoroughly with shampoo and warm piperonyl butoxide shampoo to dry some organizations,4,6 while others no water.12 hair and scalp beginning behind ears 10 and the back of the neck. Keep the longer endorse this measure. Permethrin lotion, 1%, is approved shampoo on for ten minutes, but no Preventing passage of head lice for use in individuals two months of longer. Use a timer or clock to track from one person to another is fairly age and older. Hyper-stimulation of the time. After ten minutes, use a small simple. Hairbrushes/combs, hair the nervous system leads to paralysis amount of warm water to form a lather accessories, hats, scarves, or other and death. Permethrin is a synthetic and shampoo as usual. Rinse hair and clothing items should not be shared. pyrethrin and leaves a residue on the scalp thoroughly with warm water. Dry Avoid head-to-head contact with hair which allows for continued killing hair with a towel and comb out tangles. infected people and do not lie on of newly hatched nymphs so a second Repeat this entire process in seven to beds, pillows or carpets with which treatment may not be necessary, 13,14 ten days to kill the lice that hatch from they may have had contact in the however, resistance is widespread. 17 4,8 eggs. past 24-48 hours. Directions for use: Keep eyes Benzyl alcohol lotion, 5%, is closed during treatment. Wash hair approved for individuals six months of with shampoo and rinse with water. Do Treatment age and older. It is occlusive and kills not use a conditioner or a shampoo Many treatment options are available lice by suffocation. It is not ovicidal, so that contains a conditioner because for head lice including pharmacologic a second application is necessary. In this decreases effectiveness. Dry and non-pharmacologic. Over-the- clinical trials 75% of patients were lice- hair with a towel until damp. Shake counter (OTC) and prescription topical free two weeks after two treatments permethrin lotion well. Cover face and products include creams, lotions, applied one week apart.13,18 shampoos and gels, some of which are eyes with a towel. Keep eyes closed during treatment. Apply permethrin
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Table 2 | Topical Drugs for Head Lice*
FDA- Approved Lower Age or Drug OTC/Rx Ovicidal Resistance Weight Limit Dosage and Administration Dimethicone gel – generic OTC Yes No 2 years Apply to dry hair for 10 minutes comb hair LiceMD with provided comb then shampoo hair. (Quantum Pharmaceuticals) Permethrin 1% cream rinse – OTC No Yes 2 months Apply to shampooed, towel- dried hair for generic 10 minutes then rinse; repeat 7 days later. Nix (Insight) Pyrethrins w/piperonyl OTC No Yes 2 years Apply to dry hair for 10 minutes then butoxide shampoo – generic shampoo; repeat 7-10 days later. Rid (Bayer) Benzyl alcohol 5% lotion – Rx No No 6 months Apply to dry hair for 10 minutes then Ulesfia rinse; repeat 7 days later.1 (Lachlan) Ivermectin 0.5% lotion – Rx No No 6 months Apply to dry hair and scalp for 10 minutes Sklice then rinse.2 (Arbor) Malathion 0.5% lotion – Rx Yes Not in US 6 years13 Apply to dry hair for 8-12 hours then generic shampoo; repeat 7-9 days later if Ovide (Taro) necessary.5,6 Spinosad 0.9% suspension – Rx Yes No 6 months Apply to dry hair for 10 minutes then Natroba (ParaPro) rinse; repeat 7 days later if necessary.6
*Adapted with permission by The Medical Letter®, Volume 58, November 21, 2016. 1. The amount of benzyl alcohol 5% lotion recommended per application depends on hair length: 0-2 inches (4-6 oz), 2-4 inches (6-8 oz), 4-8 inches (8-12 oz), 8-16 inches (12-24 oz), 16-22 inches (24-32 oz), >22 inches (32-48 oz). 2. The manufacturer recommends using up to one single-use, 4-oz tube of topical ivermectin lotion per application. 3. The safety and effectiveness of malathion lotion have not been established in children <6 years old; it is contraindicated in children <24 months old. 4. In clinical trials, patients used a maximum of 2 fl oz of malathion lotion per application. 5. One or two 20-minute applications have also been effective (TL Meinking et al. Pediatr Dermatol 2004; 21:670). 6. The manufacturer recommends using up to one 4-oz (120 mL) bottle of spinosad 0.9% suspension per application.
Directions for use: Cover face rinsing steps. May shampoo hair after lotion to cover the entire scalp area and eyes with a towel and keep eyes rinsing the lotion from scalp and hair. and hair thoroughly. Use up to one closed during treatment. Apply benzyl Repeat this entire process in one week entire 117 gram tube. Leave the lotion alcohol lotion to dry hair and scalp to kill the lice that hatch from eggs.19 on hair and scalp for ten minutes after area. Apply the lotion in the scalp Ivermectin lotion, 0.5%, is the hair and scalp are completely areas behind the ears and at the back approved for individuals six months covered. Use a timer or clock to track of the neck. Use enough lotion to of age and older. Ivermectin causes the time. After ten minutes have cover the entire scalp area and all the paralysis and death and while not passed, rinse hair and scalp only with hair. Keep the lotion on for ten minutes ovicidal, lice that hatch after treatment water. Wash hands thoroughly after the after applying. Use a timer or clock to normally die within 48 hours.20 application and rinsing steps. Discard track the time. After ten minutes, rinse Directions for use: Keep eyes any unused portion of the tube once the lotion from the scalp and hair with closed during treatment. Apply you finish this treatment. Wait 24 hours 21 water in a sink. To keep the lotion off ivermectin lotion to dry hair and dry before shampooing hair. the rest of the body do not rinse off scalp area starting at the scalp and Malathion lotion, 0.5%, is in a shower or bathtub. Wash hands then working outwards towards the approved for individuals six years carefully after the application and ends of the hair. Be sure to use enough of age and older. Malathion hyper-
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stimulates the nervous system which area first and then apply outwards after treatment began 79.5%, 83% prevents feeding, leading to death.12 towards the ends of the hair. Keep the and 95% of patients were lice free in One application of malathion is usually suspension on for ten minutes after Groups 1, 2 and 3 respectively. Four sufficient, and resistance has not applying. Use a timer or clock to track weeks after treatment began 72%, 78% been reported in the United States.13 the time. After ten minutes, rinse the and 92.5% of patients were lice free in Malathion is contraindicated in children suspension from scalp and hair with Groups 1, 2 and 3 respectively.26 under two years of age and has not warm water in a sink. To keep the been studied in children under the age lotion off the rest of the body do not Non-Pharmacologic Treatment of six years.13 rinse off in a shower or bathtub. Wash Nit Combs hands thoroughly after the application Directions for use: Keep eyes Proper use of a nit comb is an effective and rinsing steps. May shampoo hair closed during treatment. Apply non-pharmacologic treatment strategy after rinsing the suspension from scalp malathion lotion to dry hair and scalp for head lice removal. Combing may be and hair. If live lice are seen one week area being sure to cover area behind used as an alternative to pediculicide after treatment, repeat this entire ears and at the back of neck. Use treatment or may be performed after process.24 enough lotion to cover the entire scalp treatment with a pediculicide to area and hair thoroughly. Allow hair Lindane shampoo is available remove dead lice and nits. A variety of to air dry and to remain uncovered. in the United State but is not nit combs are commercially available Malathion lotion is flammable. The recommended by the American at most pharmacies. Prior to using a lotion and wet hair should not be Academy of Pediatrics (AAP) due 13 nit comb, apply conditioner to facilitate exposed to open flames or electric to potential neurotoxicity . For that moving the comb through the hair. heat sources including hair dryers or reason, directions for use are not Tangles should be removed with a curlers. Leave the lotion on your hair provided in this article. standard comb first, then use a nit and scalp for eight to twelve hours. comb. Working with small sections of After eight to twelve hours, shampoo Oral Products (Table 3) hair at a time, comb from the scalp hair and scalp with warm water in a Ivermectin is an antihelmintic agent to the end of the hair strands. It may sink. To keep the lotion off the rest of that is used for parasitic infections be helpful to move from one side of the body do not rinse off in a shower or in humans and animals. It is not FDA the head to the other, utilizing clips or bathtub. Wash your hands thoroughly approved for the treatment of head lice bands to separate the combed hair after the application and rinsing steps. but has been shown to be effective in from the uncombed hair. If any nits If live lice are seen seven to nine days studies. A single dose of ivermectin, or lice are removed when combing, after treatment, repeat this entire 22 400 mcg/kg, was given to 398 patients dip the comb in soapy water and process. on day one. Study personnel applied wipe with a tissue before returning Spinosad suspension, 0.9%, is malathion to 414 patients on days one to combing the hair.9 Combing once approved for individuals six months of and eight. On day fifteen, 95.2% of does not guarantee that all lice and age and older. Spinosad also contains the patients treated with ivermectin nits are removed. Repeat the combing 10% benzyl alcohol and is thought to were lice free compared to 85% in the procedure every two to four days be ovicidal so a second application is malathion group, p < 0.001.25 for a minimum of two to three weeks 15 usually not required. In two studies Trimethoprim/Sulfamethoxazole to ensure all the lice and nits are comparing spinosad to permethrin, (TMP/SMX) is not FDA approved removed.8 84.6% and 86.7% of spinosad treated for head lice but like ivermectin has Electronic lice combs are also patients were lice free fourteen been shown to be effective in treating commercially available. These combs days after the last treatment while infestations in a clinical study. One have oscillating teeth that claim 44.9% and 42.9% of permethrin hundred and fifteen children were to remove live lice better than the treated patients were lice free. More divided into three groups. Group 1 was standard lice combs, but there are permethrin treated patients required a 23 treated with 1% permethrin which was no studies confirming these claims. second treatment. repeated in seven days if lice were Electronic combs are substantially Directions for use: Shake the still present. Group 2 was treated with more expensive than a standard nit suspension well right before use. TMP/SMX 10 mg/kg/day divided twice comb and manufacturers warn against Use a towel to cover face and eyes daily based on the TMP component use in people with seizure disorders or and keep eyes closed during this for 10 days. Group 3 was treated with pacemakers.6 treatment. Apply spinosad suspension a combination of permethrin and TMP/ to dry hair and scalp area. Use enough SMX using the same treatment and suspension to cover the entire scalp dose as Groups 1 and 2. Two weeks
38 May/June 2019 Nebraska MORTAR & PESTLE
Table 3 | Oral Products for Head Lice
FDA-Approved Lower Age or Drug Resistance Weight Limit Dosage and Administration
Ivermectin tablets1 – Stromectol No 15 kg2 200-400 mcg/kg PO once; repeat 7-10 days later (Merck & Co)
Trimethoprim/Sulfamethoxazole1 No 2 months 10 mg/kg/day of TMP divided BID for 10 days
1Not FDA-approved for treatment of head lice. 2The safety and effectiveness of oral ivermectin have not been established in children weighing <15 kg.
Alternative Treatments require special training for effective the policies vary greatly from “no- An alternative to standard use. Models intended for consumer nit” policies to the more up-to-date pharmacologic agents may be an use at home are available through recommendations from NASN, AAP, attractive option to some, especially various retail sources. A regular hair and CDC.30,31,32,33,34,35,36 Contact your if treatment “failed” with one of the dryer cannot be substituted for this local school system to find their current pediculicides. Besides manual removal purpose because it produces hotter air policy. of nits with a nit comb, alternative that may burn the scalp.8 treatments include natural products, Overall, alternative treatments Conclusion such as essential oils; occlusive agents; may have some benefit, but there Head lice infestations are common in and desiccation. are no studies to evaluate efficacy or the United States affecting 6-12 million safety. In addition, the lack of standard Essential oils are gaining in individuals per year. Many treatment doses/strengths for the essential popularity. Some essential oils with options are available including OTC oils make product comparisons and purported effects on lice include tea products, prescription drugs, and recommendations for use arbitrary. tree oil, anise oil, ylang ylang oil and alternative therapies. There are many nerolidol, an alcohol found in many fallacies about lice and lice treatments 6 essential oils. There are very few School Policies that are widely available for public studies involving these oils, but one In the past, many schools had a “no- consumption including personal study that looked at in vitro activity of nit” policy that prohibited students hygiene, how lice are transmitted and tea tree oil and nerolidol demonstrated from returning to school until they were “no-nit” policies for school districts. a potential role for these oils in nit free. Several organizations have Pharmacists must become familiar with treatment.21 The potential adverse issued position statements calling for evidence-based information about effects are unknown and essential oils elimination of “no-nit” policies. The lice and lice treatments so they can may elicit allergic reactions in some National Association of School Nurses provide sound advice to their patients. individuals.28 (NASN), the AAP and the Centers Occlusive or smothering agents for Disease Control and Prevention ostensibly suffocate head lice when (CDC)4,6,10 have all emphasized applied to the hair and scalp. These that a “no-nit” policy is based on include mayonnaise, olive oil, butter misinformation not scientific facts, and petroleum jelly. Little evidence unnecessarily stigmatizes and shames demonstrating effectiveness of these children and disrupts the learning 8 products is available. process. The NASN recommends Desiccation or dehydration therapy allowing a child to remain in school if involves the application of hot air an infestation is observed, notifying followed by combing. The mechanism the child’s parents/caregiver at the of action is to kill lice or viable eggs end of the school day and providing through dehydration. Commercial information about evidence-based machines, such as those used in lice treatment options.29 In a review of removal clinics, are expensive and several Nebraska school districts,
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References 21. MedlinePlus. Ivermectin Topical. Available at: https://medlineplus.gov/druginfo/meds/a613011. 1. Centers for Disease Control and Prevention Policies for the Nebraska Mortar & html. (CDC). Parasites: Lice: Head Lice: Epidemiology Pestle (M&P) continuing pharmacy 22. MedlinePlus. Malathion Topical. Available at: & Risk Factors. Available at: https://www.cdc. https://medlineplus.gov/druginfo/meds/a611010. education lessons and quizzes: gov/parasites/lice/head/epi.html. Accessed April html. 12, 2019. 23. Stough D, Shellabarger S, Quiring J, Gabrielsen 1. M&P Quizzes are valid only for the 2. Centers for Disease Control and Prevention AA Jr. Efficacy and safety of spinosad and membership year in which they are (CDC). Parasites: Lice: Head Lice: Disease. permethrin creme rinses for pediculosis capitis published. Quizzes for the 2019 Available at: https://www.cdc.gov/parasites/lice/ (head lice). Pediatrics. 2009;124(3):e389-e395 Membership Year must be received head/disease.html. Accessed April 12, 2019. 24. MedlinePlus. Spinosad Topical. Available at: by December 12, 2019. Quizzes 3. Buegess IF. Head lice: resistance and treatment https://medlineplus.gov/druginfo/meds/a611012. cannot be carried over to another options. The Pharmaceutical Journal. 7 SEP html. membership year. 2016. 25. Chosidow O, Giraudeau B, Cottrell J, Arezki Izri, 4. Centers for Disease Control and Prevention 2. If more than three questions are Hofmann R, Mann SG, Burgess I. Oral Ivermectin (CDC). Parasites: Lice: Head Lice: General missed, the quiz will be returned. versus Malathion Lotion for Difficult-to-Treat Information: Frequently Asked Questions The quiz can be resubmitted. Head Lice. N Engl J Med. 2010;362:896-905. (FAQs). Available at: https://www.cdc.gov/ 3. CPE transcripts can be printed from 26. Hipolito RB, Mallorca FG, Zuniga-Macaraig ZO, parasites/lice/head/gen_info/faqs.html. NABP e-Profiles at www.nabp.net. Apolinario PC, Wheeler-Sherman J. Head Lice Accessed April 12, 2019. 4. CPE credits are submitted to Infestation: Single Drug Versus Combination 5. Centers for Disease Control and Prevention Therapy with One Percent Permethrin and NABP by the 15th of each month. (CDC). Parasites: Lice: Head Lice: Prevention Trimethoprim/Sulfamethoxazole. Pediatrics. For example, M&P CPE quizzes & Control. Available at: https://www.cdc.gov/ 2001 Mar;107(3):E30. completed in the month of June parasites/lice/head/prevent.html. Accessed April 27. Di Campli E, Di Bartolomeo S, Delli Pizzi P, 2019 will be sent to NABP e-Profiles 12, 2019. Di Giulio M, Grande R, Nostro A, Cellini L. before July 15, 2019. 6. Devore CD, Schutze GE. Head Lice. Pediatrics. Activity of tea tree oil and nerolidol alone or in 2015;135(5):e1355-65 combination against Pediculus capitis (head The Nebraska Council 7. Centers for Disease Control and Prevention lice) and its eggs. Parasitol Res. 2012 Nov; 111(5): for Continuing Pharmacy (CDC). Parasites: Lice: Head Lice: Diagnosis. 1985–1992. Education (NCCPE) Available at: https://www.cdc.gov/parasites/lice/ 28. www.headlice.org http://www.headlice.org/faq/ head/diagnosis.html. is accredited by the treatments/alternatives.htm. 8. Mayo clinic Headlice: Diagnosis and Treatment. Accreditation Council 29. National Association of School Nurses. (2016). Available at: https://www.mayoclinic.org/ for Pharmacy Education Head lice management in the school setting diseases-conditions/head-lice/diagnosis- (ACPE) as a provider of continuing (Position Statement). Silver Spring, MD: Author. treatment/drc-20356186. Accessed April 12, pharmacy education (CPE). This CPE Smith S, Bobo N, Strasser KM, Haynie KM. 2019. home study activity has been accredited 30. Omaha Public Schools (2019). Policies and 9. University of Nebraska Lincoln Extension. Regulations of Douglas County School District for 1.0 contact hour or 0.10 CEUs. UAN Available at: https://lincoln.ne.gov/city/health/ No. 0001. Available at: https://district.ops.org/ 0128-0000-19-039-H01-P for pharmacists environ/CEH/pdf/018MLice.pdf. Accessed April boardofeducation/policyandregulations.aspx. and UAN 0128-0000-19-039-H01-T 12, 2019. Accessed April 15, 2019. for pharmacy technicians. This is 10. Pontius D. Demystifying Pediculosis: School 31 Lincoln Public Schools (2013). Health Services a knowledge-based CPE activity Nurses Taking the Lead. Pediatric Nursing. Practice Guideline: Head Lice. Available at: targeted to pharmacists and pharmacy September-October 2015;40(5):226-235. https://home.lps.org/healthservices/general- technicians. 11. Ihde ES, Boscamp JR, Loh JM and Rosen L. health-services-information/. Accessed April 15, Safety and efficacy of a 100 % dimethicone 2019. The Nebraska Pharmacists Association pediculocide in school-age children MC. 32 Millard School District. Head Lice Guidelines. Pediatrics. 2015;15:70. disclaims any liability to you or your Available at: http://www.millard.k12.ut.us/ 12. Horizons for the Blind. Parasite Infestation patients resulting from reliance solely images/Docs/Forms/SchoolNurse/Millard%20 Treatments: LiceMD Lice & Egg Removal upon the information contained herein. School%20District%20Head%20Lice%20 Kit Pesticide Free. Available at: http://www. Guidelines%20Procedures.pdf. Accessed April directionsforme.org/item/1916984 15, 2019. 13. Albrecht S. The Prevention and Treatment of Quiz Answers may be submitted: Head Lice in Children. US Pharm. 2012;37(3):32- 33 Norfolk Public Schools (2019). Norfolk Public School District: Student Services: Health 36. Online: www.npharm.org Services: Policies. Available at: https://www. 14. Lebwohl M, Clark L, Levitt J. Therapy for Head Fax: 402-420-1406 Lice Based on Life Cycle, Resistance, and Safety norfolkpublicschools.org/district/student- services/health-services/policies.html. Email: [email protected] Considerations. Pediatrics. 2007;119:965-974 Mail: Nebraska Mortar & Pestle 15. MedlinePlus. Permethrin Topical. Available Accessed April 15, 2019. 6221 S 58th St, Ste A at: https://medlineplus.gov/druginfo/meds/ 34 Nebraska City Public Schools. Central Offices: Lincoln, NE 68516 a698037.html. Parent Resources: School Health. Available 16. Frankowski BL, Bocchini JA Jr; Council on at: http://www.nebcityps.org/home/resources/ School Health and Committee on Infectious school-health/head-lice. Accessed April 15, Diseases. Head Lice. Pediatrics. 2010 2019. Aug;126(2):392-403. 35 North Platte Public Schools (2015). 17. MedlinePlus. Pyrethrin and Piperonyl Butoxide Employees Handbook. Available at: https:// Topical. Available at: https://medlineplus.gov/ www.nppsd.org/vimages/shared/vnews/ druginfo/meds/a601105.html. stories/586499ce143ff/2018-2019%20 18. Benzyl alcohol lotion for head lice. Med Lett Employees%20Handbook.pdf. Accessed April Drugs Ther. 2009;51:57 15, 2019. 19. MedlinePlus. Benzyl Alcohol Topical. Available 36 Scottsbluff Public Schools. Procedure for at: https://medlineplus.gov/druginfo/meds/ Head Lice Detection and Management at a611011.html. School. Available at: https://www.sbps.net/ 20. The Medical Letter® on Drugs and Therapeutics. cms/lib011/NE01912194/Centricity/Domain/442/ Volume 58 November 21, 2016. SBPSHeadLiceAdministrativeProcedure.pdf. Accessed April 15, 2019.
40 May/June 2019 Nebraska MORTAR & PESTLE
Debugging the Mysteries of Head Lice Quiz #9, May/June 2019, ACPE 0128-0000-19-039-H01-P/T
1. Select the true statement regarding head lice. 6. Which product is available over the counter? a. Contracting head lice is a sign of poor hygiene. a. Benzyl alcohol b. Head lice are a vector for disease. b. Malathion c. Head lice are winged and can crawl, hop, and fly. c. Permethrin d. Head lice need a warm environment and a human d. Spinosad host for survival. 7. What product has both pediculicidal and ovicidal activity? 2. Select the true statement regarding head lice. a. Benzyl alcohol a. Cats and dogs play a role in the spread of head lice. b. Ivermectin b. If head lice are detected in the home, insecticide c. Pyrethrins and piperonyl butoxide sprays are recommended for use on furniture and d. Spinosad bedding. c. Lice eggs will die within one week if not incubated at 8. Which product should be used with caution in a patient an appropriate temperature. with chrysanthemum or ragweed allergies? d. National organizations such as the American a. Dimethicone Academy of Pediatrics support “no-nit” policies b. Malathion in schools. c. Permethrin d. Pyrethrins with piperonyl butoxide 3. Head lice are commonly spread ______. a. by airborne transmission 9. Which product use to treat head lice is applied to damp b. by direct contact hair? c. by sharing combs, brushes or hats a. Benzyl alcohol d. via waterborne transmission b. Dimethicone c. Ivermectin 4. A diagnosis of pediculosis is established by______. d. Permethrin a. observing the child of lice-infested family members itching his scalp. 10. Which medication used to treat head lice comes in b. visualization of a live nymph or louse on the scalp. both a topical and oral formulation? c. visualization of egg casings on a hair shaft. a. Ivermectin d. visualization of eggs on a hair shaft one inch away b. Malathion from the scalp. c. Permethrin d. Spinosad 5. What is the definition of an ovicide? a. An agent that kills a head louse. b. An agent that kills a nymph. c. An agent that kills the eggs of a head louse. d. An agent that paralyzes but does not kill a head louse.
Keep the TOP portion for your records. Return the BOTTOM portion to the NPA office. Or, take this quiz online at www.npharm.org
Name ______2019 Quiz #9 - Debugging the Mysteries of Head Lice ACPE #0128-0000-19-039-H01-P for pharmacists Mailing Address______ACPE #0128-0000-19-039-H01-T for technicians City/State/Zip______1.0 Contact Hour - Knowledge Based CPE Activity
The deadline for this quiz is December 12, 2019. Circle one (1) Answer: CPE Home Study Evaluation 1. a b c d 6. a b c d 1. Rate this lesson: (Excellent) 5 4 3 2 1 (Poor) 2. Did this lesson meet each of its objectives? ___ Yes ___ No 2. a b c d 7. a b c d 3. Was the content without commercial bias? ___ Yes ___ No 3. a b c d 8. a b c d If not, please explain______4. a b c d 9. a b c d 4. Did the lesson meet your educational/practice needs? __ Yes __ No 5. a b c d 10. a b c d 5. Comments/future topics are welcome. ______
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AND THE LAW Written by Don R. McGuire, Jr, RPh, JD
DEA regulations to allow the patient or contractual requirements could result in Partial fills the prescriber to request the partial fill. an audit and recoupment of third party Partial filling of prescriptions has been For non-controlled substances, payments. It is especially important to going on for a long time in pharmacies. what is the legal status of partial follow the contractual requirements in So long in fact that most pharmacists filling in those states whose laws and cases of partial filling when the patient don’t think about the legalities of regulations are silent on the issue? The fails to pick up the remainder of the doing so. When you search for laws answer depends on your view of how prescription. Failure to adjust billings in or regulations about partial filling, the law works. Some would say that those cases could end up as cases of you get few results addressing partial there is nothing prohibiting it, so I can unjust enrichment or fraud. filling for non-controlled substances. proceed to partially fill the prescription. At first glance, the issue of partially One of the few that is found is in West The other view would say that there filling a prescription seems pretty Virginia.1 This code section allows the is nothing permitting it, so I can’t do benign. However, it does present some partial filling of any prescription if the it. Given the history of partial filling, I pitfalls for the unwary. The legal and/ pharmacy is unable to supply the entire would agree with the former view. It or contractual requirements may be amount or if the patient requests a is such an ingrained part of pharmacy contradictory to what is seen as good lesser amount. Many states just don’t practice, with little apparent risk to the patient care. For example, the patient address partial filling for non-controlled public, that regulators haven’t felt the presents with a new prescription for substances in their laws or regulations. need to address it. an expensive medication. It may make Almost all states have a regulation However, there are risks when sense to dispense a few days’ supply to regarding the partial filling of controlled partial filling a prescription. There make sure that the patient can tolerate substances, particularly Schedule II. have been claims reported when the the new treatment. But this can be Many of them are worded similarly to remaining portion of the prescription problematic if regulations or contractual the DEA regulation on this subject.2 has been filled incorrectly. Partial filling requirements do not allow partial fills. What is different about the DEA is a deviation from the normal workflow, Unfortunately, the world is not always regulation is that it only allows partial so there is an increased chance of error rational or logical. Because of these filling in situations where the pharmacy in that situation. Errors occur most often complexities, partial filling should be is unable to supply the entire amount with look-alike, sound-alike pairs. There addressed in your pharmacy’s policy of the prescription. It doesn’t permit can also be interruptions in therapy and procedure manual. the patient to request a partial fill if the remainder is overlooked or of a Schedule II substance. One misplaced. There is also a risk that the 1. West Virginia Code Section 30-5-27. 2. Title 21 CFR Sections 1306.13. Section 1306.23 of the unforeseen results of these patient will not come back to finish the for Schedules III, IV, and V does not contain regulations has been its potential course of their treatment. It is important that limitation. contribution to the opioid crisis. In to make sure that there is accurate 3. Public Law 114-198 response to the crisis, Congress documentation of what was dispensed passed the Comprehensive Addiction and when. 3 and Recovery Act of 2016 (CARA). On top of the treatment risks, This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and the Nebraska Pharmacists One of the many provisions of the law there are also contractual issues. Association through Pharmacy Marketing Group, Inc., a company allows the patient or the prescriber to Partial filling may be addressed in dedicated to providing quality products and services to the pharmacy community. request a partial fill of a prescription your contracts with third-party payers. ©Don R. McGuire Jr, RPh, JD, is General Counsel, Senior Vice for Schedule II controlled substances. These provisions may address when President, Risk Management & Compliance at Pharmacists Mutual Although the DEA hasn’t rewritten its partial filling may occur, how it is to be Insurance Company. This article discusses general principles of law and risk management. It is not intended as legal advice. regulations, the interpretation of the law documented, and how to charge for Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar has been that CARA supersedes the the prescription. Failure to follow the with policies and procedures of their employers and insurance companies, and act accordingly.
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