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Clinical Pearls: Pulmonary Hypertension

August 16, 2022
By Jessica Sheard

This article is part of a series appearing in Interactions, our biweekly newsletter, written and researched by CSHP's students. We've created this series as a valuable learning activity for pharmacy students undertaking rotations at CSHP. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the students to select hot topics that are of interest and utility to both the students and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca.

Background

Pulmonary hypertension (PH) is an uncommon, yet serious disease that significantly impacts those who are diagnosed. Once an individual is diagnosed with pulmonary hypertension, their mortality rate increases seven-fold, regardless of the classification or severity of PH at diagnosis1. The prevalence of PH globally is 1% but increases to 10% in those over the age of 651. The Pulmonary Hypertension Association estimates that there are between 5,000 and 10,000 patients, of all ages, genders, and backgrounds, living with PH in Canada2. Although there has been significant progress to the diagnosis and management of PH in Canada, the prognosis in these patients remains poor, and patients affected still face significant morbidity and mortality1. Pharmacists can play a key role in pulmonary hypertension management by ensuring medication safety, patient adherence, patient and provider education, side effect management, and transitions of care support3.

There are five classes of PH that are recognized by the World Health Organization (WHO), the Canadian Cardiovascular Society, and the Canadian Thoracic Society1.
 


It is important for pharmacists in acute care centres to be aware of the differences between the classifications of pulmonary hypertension, as they will guide both chronic medication management in acute pulmonary hypertension, as well as the treatment of acute pulmonary hypertension itself. 

Available Targeted Therapies in Canada

There are 10 Health Canada approved targeted therapies for use in pulmonary arterial hypertension. These medications target three mechanisms that are known to cause PAH and its symptoms. Patients diagnosed with PAH often have deficient levels of prostacyclin1. Prostacyclin pathway agents are used in PAH to open blood vessels and improve symptoms of PAH, such as chest pain and shortness of breath4. Pulmonary arterial hypertension is also associated with elevations in endothelin-1, a potent vasoconstrictor1. Endothelin receptor antagonists will reverse the effects of endothelin-1 and help to prevent blood vessels from narrowing1,4. PAH patients will also be deficient in endogenous nitric oxide (NO)1. Two families of medications are used as nitric oxide pathway agents, phosphodiesterase type 5 inhibitors (PDE-5i) and soluble guanylate-cyclase stimulators (sGCs)1.

 

Acute Management

Patients hospitalized with acute pulmonary hypertension often experience concomitant right ventricular (RV) failure. RV failure in PH patients can lead to rapid decompensation and cardiogenic shock, that may be irreversible and lead to death5. Patients may present to hospital with either acute onset of chronic PAH, or acute PAH6. Patients with pre-existing PAH are vulnerable to serious illness and death from acute onset PAH6. These patients may have predisposing factors such as COPD, sleep disordered breathing, portopulmonary hypertension, and right heart failure that will exacerbate to acute PAH6. Acute PAH may also occur in patients without prior PAH, due to massive pulmonary embolism (PE), sepsis, or acute lung injury (ALI)6. 

Acute management of pulmonary hypertension is first focused on treating triggering factors such as presence of infection, anemia, arrhythmia, PE, or other comorbidities, and administering supportive therapy5,7. Right ventricular dysfunction or failure must be prioritized in PH management through fluid status, managing RV afterload, and by optimizing cardiac output5,6,7. Most cases of RV failure are associated with fluid overload7,8. In these patients, fluid overload should be treated using IV diuretics5,7. However, in some cases hypovolemic patients may require fluid administration7. Reducing RV afterload is one of the most important interventions to reverse RV failure in PH patients7. Therapies used to reduce RV afterload in the acute setting include prostacyclins and other PAH-targeted therapies, as well as inhaled nitric oxide5,7. Epoprostenol, a prostacyclin, is often the drug of choice in PAH with RV failure5. This agent is used initially due to its rapid onset, shorter half-life, titratability, and pronounced reduction in afterload and mortality8. Treprostinil may also be used in place of epoprostenol, however, it is less often used due to its longer half-life5. Once the patient has been stabilized, there may be addition of oral endothelin receptor antagonists or PDE-5 inhibitors with or without withdrawal of the prostacyclin, depending if the patient is experiencing acute PAH or acute on chronic PAH7. Sildenafil’s short half-life and minimal side effects make it useful in critically ill PAH patients5. Nonspecific vasodilators such as calcium channel blockers should not be used in these patients due to profound systemic hypotension7. PAH patients who are critically ill with RV failure must also have cardiac output and systemic blood pressure optimized, while reducing pulmonary vascular resistance. Patients with low cardiac output and hypotension may need treatment with inotropes such as the β1-agonist dobutamine5,7. Vasopressors such as norepinephrine (NE) and vasopressin can be used to optimize systemic blood pressure and perfusion5,7.

Hypoxemia is common in critically ill patients with pulmonary hypertension. Hypoxemia in these patients may lead to added pulmonary vasoconstriction, and treatment with supplemental oxygen should be initiated with an oxygen saturation of over 90% recommended5. Due to the complex nature of pulmonary hypertension, it is highly recommended to contact a centre of expertise as soon as possible, and to obtain a referral to a pulmonary hypertension centre if possible5,7.

Medication Considerations

Initiation of new PAH medications in critically ill patients is complex and should be managed with the help of an experienced PH team, including pharmacists5. It is important not to initiate medications indicated for Group 1 PH, in patients diagnosed with Groups 2-5 PH, as they may worsen symptoms, including precipitation of pulmonary edema in Group 2 PH patients5. However, in most patients admitted to hospital with pre-existing pulmonary hypertension, home treatment should be continued5. Abrupt discontinuation or dose reductions of PAH therapies may result in rapid decompensation and death in hospitalized patients5. PAH medications are considered high-risk and are prone to potentially fatal medication errors9. There are important clinical considerations for when patients are hospitalized while receiving PAH targeted therapy.

Transitions of Care

Pharmacists can play a key role the transitions of care for critically ill PH patients, including at hospital discharge. A recent report explored the role of critical care and ambulatory care pharmacists within a multidisciplinary team to improve the transitions of care for pulmonary hypertension patients10. In this program, the critical care pharmacist collected a PAH medication history, information on their home medication specialty pharmacy, and initiated medication access steps for new medications in hospital10. When the patient’s care was transferred to the ambulatory care pharmacist prior to discharge, the ambulatory care pharmacist provided adherence and medication counselling, adverse effect management, contacted the patient’s specialty pharmacy to ensure medication is continued, followed up on medication coverage, and followed up with the patient within 14 days after their discharge to ensure adherence and provide education when needed10.

Summary

While the complex and progressive nature of pulmonary hypertension results in significant morbidity and mortality for patients, pharmacists can play an important role in ensuring safe medication management while patients are in hospital. Pharmacists can aid in continuity of care for important PAH targeted therapy medications in hospitalized PAH patients and help to manage medications in both acute PAH and acute on chronic PAH. Pharmacists can also ensure that PAH target therapies are not used in inappropriate patient populations such as Group 2 and 3 PH, where the underlying heart or lung disease should be the focus of management. Finally, pharmacists can provide important education and ensure medication coverage to improve the transitions of care for their PH patients from their hospital admission to their discharge. 

References

  1. Hirani, N., Brunner, N. W., Kapasi, A., Chandy, G., Rudski, L., Paterson, I., Langleben, D., Mehta, S., & Mielniczuk, L. (2020). Canadian Cardiovascular Society/Canadian Thoracic Society Position Statement on pulmonary hypertension. Canadian Journal of Cardiology, 36(7), 977–992. https://doi.org/10.1016/j.cjca.2019.11.041 
  2. About Pulmonary Hypertension. Pulmonary Hypertension Association. 2021. Retrieved June 23, 2022, from https://phassociation.org/AboutPHA/ 
  3. Macaulay, T. E., Covell, M. B., & Pogue, K. T. 2015. An update on the management of Pulmonary Arterial Hypertension and the pharmacist’s role. Journal of Pharmacy Practice, 29(1), 67–76. https://doi.org/10.1177/0897190015615902
  4. Treatment Options. Pulmonary Hypertension Association of Canada. 2021. Retrieved June 23, 2022, from https://phacanada.ca/For-Physicians/Treatment-Options 
  5. Barnett, C. F., O’Brien, C., & De Marco, T. 2022. Critical Care Management of the patient with pulmonary hypertension. European Heart Journal. Acute Cardiovascular Care, 11(1), 77–83. https://doi.org/10.1093/ehjacc/zuab113 
  6. Hui-li, G. 2011. The Management of Acute Pulmonary Arterial Hypertension. Cardiovascular Therapeutics, 29: 153-175. https://doi-org.cyber.usask.ca/10.1111/j.1755-5922.2009.00095.x
  7. Hoeper, M. M., & Granton, J. 2011. Intensive Care Unit management of patients with severe pulmonary hypertension and right heart failure. American Journal of Respiratory and Critical Care Medicine, 184(10), 1114–1124. https://doi.org/10.1164/rccm.201104-0662ci 
  8. Tilea, I., Varga, A., Georgescu, A.-M., & Grigorescu, B.-L. 2021. Critical Care Management of decompensated right heart failure in Pulmonary Arterial Hypertension Patients – an ongoing approach. The Journal of Critical Care Medicine, 7(3), 170–183. https://doi.org/10.2478/jccm-2021-0020
  9. Barlow, A., Barlow, B., Koyfman, A., Long, B., & Bissell, B. 2021. Pulmonary arterial hypertension in the emergency department: A focus on medication management. The American Journal of Emergency Medicine, 47, 101–108. https://doi.org/10.1016/j.ajem.2021.03.072
  10. Martirosov, A. L., Smith, Z. R., Hencken, L., MacDonald, N. C., Griebe, K., Fantuz, P., Grafton, G., Hegab, S., Ismail, R., Jackson, B., Kelly, B., Miller, M., & Awdish, R. 2020. Improving transitions of care for critically ill adult patients on pulmonary arterial hypertension medications. American Journal of Health-System Pharmacy, 77(12), 958–965. https://doi.org/10.1093/ajhp/zxaa079
 
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August 16, 2022
Clinical Pearls: Pulmonary Hypertension
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Call for Appraisers for the National Awards Program 2022

August 15, 2022

 

CSHP is seeking award appraisers for the 2022 National Awards Program. Award appraisers are critical to the success of CSHP’s National Awards Program -- Your contribution to this process enhances the visibility of excellence in hospital pharmacy practice. To help select this year’s award-winning projects and to help celebrate hospital pharmacy excellence, please consider submitting your name as an appraiser for the National Awards Program.

We are seeking appraisers with knowledge in the following areas:

  •  Administration/Management
  • Cardiology
  • Computers/Technology
  • Critical Care
  • HIV/AIDS
  • Infectious Diseases
  • Nephrology
  • Oncology
  • Palliative Care
  • Pediatrics
  • Psychiatry
  • None of the above (general appraiser)

As an appraiser you must hold a professional degree in pharmacy and your CSHP membership dues must be paid for the current year. However, no prior review or research experience is required.

Where possible, submissions are distributed to those knowledgeable in the subject area and appraisers are asked to judge the projects based on contribution to patient care. Please note that appraisers are still able to submit to the National Awards Program. In this instance, you will be asked to review projects submitted to categories to which you have not applied.

Projects will be assigned to appraisers in mid-October. You will be asked to review up to three projects during the appraisal period. Award appraisers are asked to volunteer approximately one hour of their time per submission reviewed. This year’s appraisal period will run from October 10-31, 2022.

For more information, please refer to the Frequently Asked Questions page .

If you would like to serve as an appraiser, please notify Robyn Rockwell, Membership & Awards Administrator, by September 30, 2022. Please indicate the areas in which you can review and whether you are able to review French submissions.

August 15, 2022
Call for Appraisers for the National Awards Program 2022
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CSHP awards 2022: Call for nominations

August 15, 2022

The CSHP Awards Committee invites applications and nominations for the 2022-2023 National Awards Program. The goal of the awards program is to improve patient outcomes by promoting excellence in pharmacy practice throughout hospitals and other collaborative healthcare settings. Awards are presented annually to Pharmacists and Pharmacy Graduates, Pharmacy Technicians, Individual Supporters, and Students in recognition of outstanding commitment and dedication to the patient and profession. The Hospital Pharmacy Student Award is presented to a Student Pharmacist.

The following awards will be offered this term:

  • Distinguished Service Award
  • Excellence in Pharmacy Practice – Interprofessional Collaboration
  • Excellence in Pharmacy Practice – Leadership
  • Excellence in Pharmacy Practice – Patient Care
  • Hospital Pharmacy Student Award

This year, the Awards Committee welcomes submissions to the Excellence Awards with a focus on environmental sustainability. Show us how you’re making climate change a priority in your practice. 



You can nominate an individual or team for an award. Nominations are due by September 30, 2022. Award recipients will be announced in January via email, CSHP’s website, and social media platforms. Awards will be presented in-person at the Together 2023 conference in Banff, Alberta. Learn more about the awards program here .

Although several national awards have been retired, including the Isabel E. Stauffer Meritorious Service Award, in many cases, equivalent awards are being offered by certain CSHP branches. Check your branch website for available awards and submission deadlines.

Did you know you can apply to both branch and national award programs? The Awards Committee encourages submissions to both programs in the same year. Even if you have already applied for a branch award, consider nominating yourself, your colleague, or your project for national recognition.

To read about last year's award winners, click here.

For more information, please contact:
Robyn Rockwell
Membership and Awards Administrator
Canadian Society of Hospital Pharmacists
(877) 340-2756 ext. 222
(613) 909-9964
rrockwell@cshp.ca

 
August 15, 2022
CSHP awards 2022: Call for nominations
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Resource spotlight: Pulmonary Hypertension

August 12, 2022

 

Written by Jessica Sheard

This article was written and researched by a CSHP student member for Interactions, our biweekly newsletter. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the student to select topics that are of interest and utility to both the student and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca

Background


Pulmonary hypertension (PH) is an uncommon, yet serious and progressive disease that results in significant morbidity and mortality in all patients diagnosed1. This “Resource Spotlight” will provide pharmacists with resources that will help them learn more about pulmonary hypertension, its classifications, and its treatments, and highlights clinical guidelines and information regarding acute management in hospitalized patients. 

Pulmonary Hypertension Association of Canada

The Pulmonary Hypertension Association of Canada is a federally registered charitable organization that was created by patients, caregivers, and healthcare providers. The organization provides useful resources and community support for patients with PH and their caregivers, as well as educational resources for healthcare providers. Pharmacists can find a brief overview of available treatments for pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension in Canada 2, and overview of risk factors associated with pulmonary hypertension and signs of symptoms to watch out for in these patients3. When encountering patients with pulmonary hypertension in the hospital, pharmacists may need to provide education and recommendations on their medications, including over the counter (OTC) products. A brief overview of common OTC products that should be avoided in patients with pulmonary hypertension can be found in this resource4.

Canadian Cardiovascular Society and Canadian Thoracic Society Guidelines

The Canadian Cardiovascular Society (CCS) and Canadian Thoracic Society (CTS) released an updated position statement on pulmonary hypertension in 20205. This new position statement was created due to the rapid changes in the management of PH since their previous position statement in 2005. In this document, pharmacists can find guidelines on supportive management, targeted therapies for pulmonary arterial hypertension (PAH) available in Canada, treatment strategies, and information on medication access in Canada. The position statement also contains a map of current pulmonary hypertension treatment facilities for reference. 
The Canadian Cardiovascular Society has developed a webinar6 for healthcare providers to learn about updates in pulmonary hypertension, based on the aforementioned combined position statement from the CCS and CTS. The webinar discusses classification of PH, patient case examples, and management of PH, including general medications, PAH-targeted therapies, and acute management. 

Current Literature

Patients with pulmonary arterial hypertension will often be on one or more targeted therapies to improve their symptoms. An article by Barlow et al, 7 provides an overview of the available targeted therapies that are used chronically in PAH patients, with important clinical considerations of these therapies for when patients are presenting to the emergency department.

Critical care management of the patient with pulmonary hypertension8, published recently in The European Heart Journal provides a great overview of pulmonary hypertension epidemiology, pathophysiology, and a concise overview of patient management in critical care, including PH medication, fluid, and hemodynamic management. 

A concise clinical review 9 by Hoeper and Granton includes important information on the management of patients with severe pulmonary hypertension and right heart failure. In this article, pharmacists can find information on the pathophysiology and classification of PH, triggering factors of PH and RV failure, as well as important management and monitoring considerations for patients admitted to the ICU. Although published in 2011, this article still contains useful clinical guidance in the Canadian context.

References

1. Hirani, N., Brunner, N. W., Kapasi, A., Chandy, G., Rudski, L., Paterson, I., Langleben, D., Mehta, S., & Mielniczuk, L. (2020). Canadian Cardiovascular Society/Canadian Thoracic Society Position Statement on pulmonary hypertension. Canadian Journal of Cardiology, 36(7), 977–992. https://doi.org/10.1016/j.cjca.2019.11.041

2. Treatment Options. Pulmonary Hypertension Association of Canada. 2021. Retrieved June 23, 2022, from https://phacanada.ca/For-Physicians/Treatment-Options 

3. Sometimes It’s PH. Pulmonary Hypertension Association of Canada. 2021. Retrieved June 23, 2022, from https://phacanada.ca/For-Physicians/Sometimes-It-s-PH

4. Managing medications. Resources - Pulmonary Hypertension Association of Canada. Retrieved June 23, 2022, from https://phacanada.ca/Living-with-PH/Resources/Living-with-PH/Managing-medications. 

5. Hirani, N., Brunner, N. W., Kapasi, A., Chandy, G., Rudski, L., Paterson, I., Langleben, D., Mehta, S., & Mielniczuk, L. (2020). Canadian Cardiovascular Society/Canadian Thoracic Society Position Statement on pulmonary hypertension. Canadian Journal of Cardiology, 36(7), 977–992. https://doi.org/10.1016/j.cjca.2019.11.041 

6. Pulmonary hypertension webinar series. Canadian Cardiovascular Society. https://ccs.ca/pulmonary-hypertension-webinar-series/. Published August 27, 2021. Accessed June 23, 2022.

7. Barlow, A., Barlow, B., Koyfman, A., Long, B., & Bissell, B. 2021. Pulmonary arterial hypertension in the emergency department: A focus on medication management. The American Journal of Emergency Medicine, 47, 101–108. https://doi.org/10.1016/j.ajem.2021.03.072

8. Barnett, C. F., O’Brien, C., & De Marco, T. 2022. Critical Care Management of the patient with pulmonary hypertension. European Heart Journal. Acute Cardiovascular Care, 11(1), 77–83. https://doi.org/10.1093/ehjacc/zuab113 

9. Hoeper, M. M., & Granton, J. 2011. Intensive Care Unit management of patients with severe pulmonary hypertension and right heart failure. American Journal of Respiratory and Critical Care Medicine, 184(10), 1114–1124. https://doi.org/10.1164/rccm.201104-0662ci 
 
August 12, 2022
Resource spotlight: Pulmonary Hypertension
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Resource spotlight: Clinical resources and creating safe spaces for 2SLGBTQ+ patients

July 27, 2022

 

Written by Jessica Sheard

This article was written and researched by a CSHP student member for Interactions, our biweekly newsletter. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the student to select topics that are of interest and utility to both the student and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca

Background

It is estimated that there are at least 1 million 2SLGBTQ+ people over the age of 15 living in Canada as of 20181, with 1 in 300 people over 15 identifying as either transgender or non-binary2. Although there has been progress for 2SLGBTQ+ inclusivity, patients in this community still face significant healthcare disparities due to societal rejection, stigma, prejudice, and discrimination3. Many 2SLGBTQ+ patients report having negative experiences with the healthcare system and with healthcare providers. Some patients report inappropriate questions or lack of knowledge from their healthcare providers, while other patients report outright refusal of care and discrimination4,5. Negative or discriminatory experiences can result in long-lasting affects for 2SLGBTQ+ patients. Small, honest mistakes can be triggering for patients who have had previous negative experiences, and can lead to emotional responses, or delaying and avoiding receiving future care. In this “Resource Spotlight” pharmacists can learn more about the 2SLGBTQ+ community, how to integrate inclusive strategies into their practice to create safe and welcoming spaces for 2SLGBTQ+ patients, and access clinical guidelines important for transgender patient care. 

Cultural Competency, Inclusivity, and Safe Space Guidelines

Health Professionals Advancing LGBTQ Equality (previously known as the Gay & Lesbian Medical Association (GLMA) is the world's largest and oldest association of lesbian, gay, bisexual, transgender, and queer (LGBTQ) healthcare professionals. GLMA was founded in 1981, as the American Association of Physicians for Human Rights, with the mission of ensuring equality in healthcare for 2SLGBTQ+ individuals and healthcare professionals. GLMA has created a three-part webinar series titled “Quality Healthcare for Lesbian, Gay, Bisexual & Transgender People” (GLMA - Cultural Competence) free for anyone to access. The webinar series covers topics to understand healthcare needs of 2SLGBTQ+ people, creating a welcoming and safe environment, and clinical skills for the care of transgender patients. 

Rainbow Health Ontario (RHO) has created a new online learning platform for healthcare providers called LGBT2SQ Health Connect.  On this platform pharmacists can access the LGBT2SQ Foundations Course, to heighten comfort and competency when providing high quality and inclusive, affirming, welcoming, culturally sensitive care. The course is available for free for healthcare professionals in Ontario, and $50 for those outside of Ontario. Many other courses are available through LGBT2SQ Health Connect, including another useful course called Removing the Barriers: Making your Organization LGBT2SQ friendly, which is offered at scheduled intervals bimonthly. This course explores various strategies for programs and services, policies, and inclusive language, intake forms and signage. The LGBT2SQ Foundations course is a prerequisite for this course, and all others on LGBT2SQ Connect. Course descriptions can be found here (Education & Training | Rainbow Health Ontario). Pharmacists can sign up for an account to access these courses here (Rainbow Health Ontario).

The University of Toronto Faculty of Medicine has created this (LGBT Infographic Page 1 – Aug 9, 2016 (utoronto.ca)) condensed infographic for healthcare providers. The infographic, through useful information, tips, and creative drawing, is a tool for healthcare professionals to learn about 2SLGBTQ+ terminology and providing inclusive healthcare. 

This article (LGBTQ cultural competence for pharmacists (pharmacytoday.org)) published by Pharmacy Today and developed by American Pharmacists Association (APhA) as a continuing education home-study, aims to increase 2SLGBTQ+ cultural competence for pharmacists. The activity contains a brief pre-assessment questionnaire, learning material, and 20 question assessment following the readings. Learners will cover topics including foundational concepts about the 2SLGBTQ+ community, 2SLGBTQ+ health disparities relating to physical and mental health, the pharmacist’s role in 2SLGBTQ+ patient care, and creating a welcoming pharmacy environment.

Mount Sinai Hospital has developed this gender identity policy (General Manual Master Form - Microsoft Word (rainbowhealthontario.ca)) to provide guidelines for the care of trans, intersex, and Two Spirit individuals in the hospital. This policy covers the rights of members of the hospital community, including patients and staff, responsibilities of members of the hospital community, and guidance on policies for managers and employees. Policies surrounding education, bed assignments, washroom access, and intake forms can be found in this document. Although specific to one hospital, this policy manual can be used as an example for hospitals and departments in creating and implementing policy to protect patients of various gender identities. 

Trans Care BC Resources

Trans Care BC provides free educational courses on gender diversity for healthcare providers that introduce key terms and concepts as well as basic strategies for creating welcoming and gender-affirming services in both a basic, 30-minute course, and expanded 60-minute course for professionals regularly interacting with gender-diverse individuals. The basic course can be accessed here (Intro to Gender Diversity - LearningHub (phsa.ca)) and expanded course here (Intro to Gender Diversity - Expanded - LearningHub (phsa.ca)), and learners can receive a certificate of completion after signing up for a free account. To bypass the account sign up and complete the courses without receiving a completion certificate, access the basic course here (Intro to Gender Diversity - Overview | Rise 360 (articulate.com)) and expanded course here (Intro to Gender Diversity - Expanded - Overview | Rise 360 (articulate.com)).

Trans Care BC has very useful practice tools that can be used by pharmacists and pharmacy departments to assess their current practices and implement strategies to improve patient care for gender-diverse patients. This short reference (Gender-Affirming_Patient_Care_In_a_Hospital_Setting.pdf (phsa.ca)) provides tips for healthcare workers in hospitals to ensure they are providing gender-affirming care to their patients. The reference provides guidance on pronouns, referring to patients, and name verification with example scripts, and guidance on transferring care, washroom access for patients, and times of greater vulnerability for this population. Pharmacists can reflect on their knowledge, approach to gender diverse patients, personal comfort, and patient engagement using this personal reflection tool (Service_Provider_Reflection_Tool.pdf (phsa.ca)). Pharmacists can also use this tool to reflect on their approach to advocacy and allyship for their gender-diverse patients, their organizational supports, and to create time-based goals to improve their patient care. 

This tool (20_Care_Strategies.pdf (phsa.ca)) can be used by pharmacists and pharmacy departments to find strategies that will increase and improve access to care for gender-diverse patients. The practice tool includes 20 strategies, 10 which are organizational and program specific, and 10 that are service provider and staff specific. Strategies can be marked based on relevance to the organization, a level can be given based on current practices, and targeted goals can be created to meet the strategy guidelines. This organizational assessment tool (Organizational_Assessment_Tool.pdf (phsa.ca)) can also be used by pharmacy departments and hospitals to help develop an approach to offering more inclusive and gender-affirming care. It can be used on its own, or in combination with the Service Provider Reflection Tool. Sections for assessment include education, visibility and outreach materials, programming, forms and charts, waiting rooms, referral services, rooming, and hospital policies for providing gender-affirming care and protecting gender-diverse patients from discrimination. 

Clinical Guidelines

Sherbourne Health and Rainbow Health Ontario developed clinical guidelines for gender-affirming primary care for trans and non-binary patients. This Canadian guideline (Guidelines for Gender-Affirming Primary Care with Trans and Non-Binary Patients (rainbowhealthontario.ca)) provides a brief framework for providing gender-affirming care to trans and non-binary patients, a useful list of other transgender health guidelines, and clinical guidance surrounding hormone therapies in transgender patients. Within the clinical guidelines for hormone therapies, pharmacists can find convenient tables for formulations and dosing, and monitoring parameters, including bloodwork and time to onset of expected effects from hormone therapy. Pharmacists can also find tables outlining precautions for both feminizing and masculinizing medications, with guidance to minimize associated risks. 

This Standards of Care (SOC) clinical guideline (SOC V7_English.pdf (wpath.org)) was created by the World Association for Transgender Health (WPATH). This organization has been creating Standards of Care for transgender and gender diverse patients since 1979. The SOC document is intended to provide clinical guidance for healthcare professionals to maximize the overall health, psychological well-being, and self-fulfillment of transgender and gender diverse patients. Guidelines on primary care, gynecologic and urologic care, reproductive options such as sperm and oocyte preservation, voice and communication therapy, mental health services, and hormonal and surgical treatments can be found within the SOC. It is important to note that most of the research that has guided this document comes from a North American and Western European perspective. 

Research Surrounding Hormone Therapy in Transgender Patients

Many transgender patients will choose to initiate hormone therapy to achieve characteristics of their gender, which may result in clinical considerations for healthcare providers while they are in hospital. This meta-analysis and meta-regression study (Frontiers | Risk of Venous Thromboembolism in Transgender People Undergoing Hormone Feminizing Therapy: A Prevalence Meta-Analysis and Meta-Regression Study | Endocrinology (frontiersin.org)) identifies the prevalence of VTE in transgender patients on feminizing hormone therapy. This review (Perioperative Transgender Hormone Management: Avoiding Venou... : Plastic and Reconstructive Surgery (lww.com)) discusses the evidence and recommendations surrounding the management of feminizing hormones for patients in the perioperative period. 

Two Spirit Resources

The National Collaborating Centre for Indigenous Health is an organization established by the Government of Canada, funded by the Public Health Agency of Canada (PHAC), and hosted by the University of Northern BC. The organization was established to support Indigenous health equity. This webinar (NCCIH - National Collaborating Centre for Indigenous Health > Home > NCCIH PUBLICATIONS) is an introduction to Two-Spirit people and their health. An accompanying document, and suggested pre-reading for the webinar, on Two-Spirit health can be accessed here: An Introduction to the Health of Two-Spirit People: Historical, contemporary and emergent issues (ccnsa-nccah.ca).

This (Indigenous gender diversity: creating culturally relevant and gender-affirming services - LearningHub (phsa.ca)) free, three-hour course was created by Trans Care BC in collaboration with gender diverse Indigenous and Two-Spirit community members. It is intended to increase awareness, knowledge, and skills for people working in healthcare settings to ensure culturally relevant and gender-affirming services for gender diverse Indigenous people. 

There is an Inclusive Healthcare Community (QID - Community Page)) that can be found on QID. This community contains resources for pharmacists and can be used as a space to ask questions or share resources surrounding care for 2SLGBTQ+ patients and other marginalized patients. 
 
References 
  1. A statistical portrait of Canada’s LGBTQ2+ communities. Statistics Canada; 2021 June 15 [cited 2022 June 2] Available from: https://www150.statcan.gc.ca/n1/en/daily-quotidien/210615/dq210615a-eng.pdf?st=LSJc4Y2w
  2. Canada is the first country to provide census data on transgender and non-binary people. Statistics Canada; 2022 Apr 27 [cited 2022 June 2] Available from: https://www150.statcan.gc.ca/n1/en/daily-quotidien/220427/dq220427b-eng.pdf?st=CgjeOryJ
  3. LGBTQ2 Health in Canada: Study brief for the Standing Committee on Health [Internet]. Rainbow Health Ontario. 2019. Available from: https://www.ourcommons.ca/Content/Committee/421/HESA/Brief/BR10445304/br-external/RainbowHealthOntario-revised-e.pdf
  4. Transgender-Affirming Hospital Policies [Internet]. Human Rights Campaign Foundation. 2016. Available from: https://assets2.hrc.org/files/assets/resources/TransAffirming-HospitalPolicies-2016.pdf?_ga=2.13740471.1667924262.1652800445-840857854.1652800445
  5. Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. Annals of Emergency Medicine. 2014;63(6):713-720.  https://doi.org/10.1016/j.annemergmed.2013.09.027.
July 27, 2022
Resource spotlight: Clinical resources and creating safe spaces for 2SLGBTQ+ patients
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