News

Resource spotlight: Perioperative Management of Parkinson’s Disease

Written by Bhawani Jain

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

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Managing Parkinson’s Disease (PD) in the hospital can be a complex process that involves a variety of factors including drug interactions, timing of PD therapy, communication issues, and seeking alternative medications during surgery. This week’s “Resource Spotlight” shows resources to help pharmacists understand PD from a clinician and patient perspective, including management of PD drug therapy.  
 

Parkinson Canada  
Parkinson Canada is the Canadian national organization for Parkinson’s Disease. This website contains a variety of resources, especially for patients to learn about PD and how to manage their symptoms. There are plenty of handouts and fact sheets for patients and clinicians about topics pertaining to PD such as “Young-Onset Parkinson's Disease: Advice for Physicians From Individuals Living With YOPD ”. One important resource is “Managing My Parkinson’s Disease in Healthcare Settings ”. Though this resource is intended for patients, clinicians and pharmacists can understand the perspective of patients with PD and can remind patients about things they should mention or bring before arriving to the hospital for elective surgery. This resource also helps pharmacists understand the roles that other health professionals have in caring for a patient with PD. This resource also has a list of some of the medications that patients should avoid taking, which is also helpful for hospital pharmacists. 

 

Canadian Guideline for Parkinson Disease  
The Canadian Guideline for Parkinson Disease, published by the Canadian Medical Association Journal, is a resource for physicians, pharmacists, and other healthcare professionals to receive updated information about PD treatment in Canada. It highlights a summary of communication recommendations, diagnosis and progression of PD, various medication and procedure treatments, and ways to manage non-motor symptoms. This guideline contains a summary of key recommendations backed by empirical evidence in all areas of PD diagnosis, management, and treatment. This resource also contains a flowchart of PD diagnosis and progression and what clinicians can do at certain stages of the patient’s progression of PD.  

 

American Parkinson Disease Association  
The American Parkinson Disease Association (APDA) is the United States national organization for PD. Like the Canadian website, there are a variety of resources for patients and clinicians. There is also information about educational webinars and current clinical trials in PD treatment. A useful resource published by the APDA is a list of “Medications To Be Avoided Or Used With Caution in Parkinson’s Disease ”. This is not an exhaustive list and only provides information for patients taking selegiline, rasagiline, or safinamide. However, it is a useful two-page resource that hospital pharmacists can quickly refer to for patients taking one of these medications so that drug interactions can be avoided.  

 

Key Information for Hospital Pharmacists - Parkinson's UK
The Parkinson’s Disease Society of the United Kingdom has published a resource specifically for hospital pharmacists. It contains information about medication considerations, managing side effects with medications while avoiding drug interactions, how to manage swallowing issues for affected patients, drugs to avoid, ensuring that patients receive their medications on time, preparation of medications before the patient is admitted to hospital, and supporting the patient to take control of their medications post-discharge. It is a helpful and comprehensive resource that hospital pharmacists can consult to know more about how to best care for a patient with PD. The Parkinson’s UK website  also contains a separate set of resources specifically for healthcare professionals such as guidelines, clinical tools, assessments, and resources that can be provided to patients.  

 

Research Articles for Perioperative Care 
There are some research articles that can be helpful for hospital pharmacists. “Managing Parkinson's disease during surgery ” is an article that focuses on preventing complications from missing dopaminergic medication during surgery for patients with PD. The article focuses on advance planning, appropriate prescribing, and specialist advice. There are also some examples of alternative enteric and non-enteric medications that can be administered to patients during surgery to prevent progression and worsening of PD while in the hospital. The American Journal of Medicine has also published a journal titled “Perioperative Management of Patients with Parkinson’s Disease ” which contains a comprehensive list of recommendations, complications that can arise, and ways they can be prevented and managed. There is also information about how post-operative pain and psychiatric issues can be treated, while avoiding medications that can worsen PD.  

 

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References 

Clinical pearls: Perioperative Management of Parkinson’s Disease

By Bhawani Jain

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.

 
Parkinson’s Disease (PD) is a progressive neurodegenerative disease that leads to a variety of motor and non-motor symptoms such as tremors, slowing in movement (i.e. bradykinesia), muscle rigidity, dementia, and progressive autonomic dysfunction, among many other clinical features.^1,2 It is the second-most common disease worldwide, after Alzheimer’s disease.³ The prevalence of PD increases with age and predominantly affects adults above 60 years of age.^1,4 In Canada, the average age of onset of PD is 64.4 years with a diagnosis at 66.2 years. In 2013-2014, about 84000 Canadians over 40 years of age were living with PD with a 1.5-fold greater prevalence in males compared to females.⁴  

People over the age of 65 with PD are about 1.45 times more likely to have an unplanned admission to hospital than those over 65 without PD and have longer hospital stays and readmission rates.⁵ There are multiple reasons for hospitalizations among patients with PD, and these include motor complications due to PD (i.e. falls, fractures), co-morbid complications (pneumonia, cardiac issues, genitourinary infections, cancer, stroke), elective surgery, and other reasons.⁶  

 
Patients with PD use antiparkinsonian medications to manage their symptoms and prevent worsening of their condition. It is important for these patients to take their antiparkinsonian medications as prescribed and on time because delays in timing and abrupt withdrawal of medication can lead to a worsening of motor symptoms that do not recover.⁷ This can significantly impact patient safety, treatment, quality of life, and duration of stay in the hospital. It is important for hospital pharmacists to ensure that a thorough medication review is completed when a patient with PD is admitted to hospital for elective surgery. These patients should continue taking their medications up to the time of surgery and immediately after surgery to prevent complications of PD and worsening of symptoms.⁸ If a patient with PD is having elective surgery, it is important that a best possible medication history (BPMH) is completed, (with an emphasis on timing of their antiparkinsonian medications) prior to surgery to ensure the same medications can be ordered promptly for continuity of care. Some patients with PD may have difficulty swallowing, so they may require liquid forms of medications or other dosage forms.⁸ Knowing this beforehand is important because unique dosage forms of certain medications may not be readily available beforehand and may need to be ordered in advance to prevent delays in receiving PD therapy in hospital.  

Patients with PD undergoing surgery are at risk of complications such as aspiration pneumonia, post-operative respiratory failure, and neuroleptic malignant syndrome.⁹ Since muscle rigidity is a common symptoms in those with PD, the orofacial muscles can be affected as well. This causes oropharyngeal dysphagia, or difficulty swallowing. Due to this, patients with PD become at risk of aspiration pneumonia which causes up to 70% of deaths among deaths due to complications of PD.^10,11 Furthermore, abrupt discontinuation or delayed continuation of antiparkinsonian medications can precipitate neuroleptic malignant syndrome which is a potentially lethal neurological emergency characterized by hyperthermia, altered consciousness, changes in mental status, and further autonomic dysfunction.^12,13 As such, it is important to reduce the risks of complications. It is generally recommended that the PD therapy the patient receives in the hospital resembles the patient’s usual treatment regimen as closely as possible.⁹ Patients who take the oral combination of carbidopa and levodopa and are having a long surgery can be given the same medication via a nasogastric tube during surgery so that the patient doesn’t experience delays in the timing of PD therapy.¹⁴ In patients with PD who are expected to experience delayed gastric emptying, post-operative ileus, or other conditions that make enteral medication inappropriate, switching the patient’s medications to a parenteral medication may be required, and this may be a different medication entirely.⁹ Knowing the possible alternatives to PD medications available in the hospital will be beneficial for the patient’s recovery in hospital, especially if the patient is admitted to the hospital due to an emergency or urgent surgery in which case communicating with the patient before admission was not possible.  

 
Since patients with PD are typically of advanced age, it is common for these patients to have co-morbid conditions and require medication for these conditions. As such, it is important for hospital pharmacists to be aware of drug interactions between antiparkinsonian medications and other medications to ensure that the patient’s therapy for PD is not being hindered.  

Table 1: A Non-exhaustive List of Drug Interactions for Common Antiparkinsonian Medications and their Mechanism for Interaction.^2,15,16,17 



After surgery, many patients require new medications. Patients may also require antibiotics post-surgery or due to acquiring nosocomial infections in the hospital. Furthermore, many patients experience side effects due to their antiparkinsonian medications such as nausea, vomiting, orthostatic hypotension, dyskinesias, hallucinations, confusion, and other effects.² These patients may also require medication to manage these side effects. Due to these considerations, it is important to assess whether a new medication is appropriate for the patient while also not affecting the patient’s current therapy to manage PD.  

Table 2: A Non-Exhaustive List of Antiparkinsonian Medications, Dosage Forms, and Details Available in Canada^{2, 15, 17-23}

It is important to understand that patients with PD are all unique and there are a wide range of clinical presentations and symptoms of varying progression and disability. This makes it crucial to ensure that the hospital environment and therapy supports the patient and is unique to their needs. For instance, some patients with PD may experience difficulties with communication such as slurring of speech and a quiet voice.²⁴ In this case, it may be important for a patient to have their caregiver or loved one close by to assist with communication. Having a healthcare professional who is specialized in neurodegenerative disease and movement disorders (nurse, doctor, etc.) in the patient’s healthcare team would be very beneficial as well.²⁵
 

PEBC update

The Pharmacy Examining Board of Canada recently shared updates from its Annual Board Meeting on March 26, 2022, featuring statistics from 2021 and summaries of PEBC's recent projects.

2021 by the numbers

2551 candidates took the Pharmacist Qualifying Examination-Part I (MCQ) in 2021, compared with 2162 in 2020.

2513 candidates took the Pharmacist Qualifying Examination-Part II (OSCE), compared to 975 in 2020.

1935 individuals took the Pharmacist Evaluating Examination in 2021, compared to 1827 in 2020.

2412 applicants were ruled acceptable for admission into the Evaluating Examination, compared to 2464 in 2020.

733 names were added to the Pharmacy Technician Register by examination in 2021, compared to 461 in 2020, bringing the total to 12,257 since 2009.

1180 candidates took the Pharmacy Technician Qualifying Examination-Part I (MCQ) in 2021, compared to 716 in 2020.

1136 individuals took the Pharmacy Technician Qualifying Examination-Part II (OSPE in 2021, compared to 673 in 2020. 

PEBC projects

As a result of the pandemic, PEBC committed to exploring the possibility of conducting virtual performance examinations for the OSCE and OSPE. The Board is undertaking a pilot study to explore the feasibility of the virtual format, on its own and compared to in-person exams. 

The Board is also conducting a comprehensive review of PEBC's certification processes, to identify ways to enhance the process. Recommendations will be made by an advisory committee of pharmacists, pharmacy technicians, and a physician.

 

 

Call for nominations: Fellows Recognition Committee

 

The Fellows (FCSHP) Recognition Committee is now calling for nominations for one Committee Member position. Joining this committee is an exciting way to celebrate Canadian hospital pharmacy excellence. If you know an eligible CSHP member who would thrive in this role, please consider nominating them for this position! 

How long is the term?
Committee members are appointed for a three-year term and are eligible for reappointment for one additional three-year term. The term for this position begins August 2022.

Who is eligible?
Nominees must have achieved Fellow status and hold current membership in CSHP.

How can I nominate someone?
Provide a short biography or statement including information on how the nominee qualifies for the position. Nominations for the Committee must be made in writing, signed by the nominee and a nominator, and be submitted to the Chair of the Fellows Nominating Committee, using the nomination form. Nominators must also hold the FCSHP designation. Click here for details and to access the nomination form.

Deadline
All nominations must be received by May 31, 2022.

Call for applications: Members of the Education Grant Committee

 

The CSHP Foundation's Education Grant Committee is recruiting interested CSHP Members to join us! We are looking for broad geographical representation from our members. The Committee reviews submissions for CSHP Foundation education grants and provides recommendations to the Foundation Board.

The CSHP Foundation supports research and educational programs that advance pharmacy practice and patient care in hospitals and other collaborative healthcare settings.

Term of appointment for committee members:
2 years, option of 2 additional 2-year terms, 6 years maximum

Candidate criteria:
- Current CSHP member
- Experience and a keen interest in pharmacy-related educational activities.

Instructions for applicants:
Please submit the following documents by the deadline date:
- Copy of your curriculum vitae.
- One-page statement describing your past involvement with CSHP and your interest in volunteering for this position.

Submit the above noted documents to the CSHP office by e-mail to Rosemary Pantalone at rpantalone@cshp.ca

For more information on the role of  member of this Committee, please contact Miranda So (Chair, Education Grant Committee) at: Miranda.So@uhn.ca

Deadline date for applications: Tuesday, June 28, 2022

Resource spotlight: Endometriosis

Written by Erica Evangelista

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

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Endometriosis is an inflammatory disease that affects over 176 million people worldwide. It is characterized by lesions of endometrial-like tissue outside of the uterus, and is associated with pelvic pain and infertility.(1) There is currently no known cure for endometriosis, however symptom management can be targeted to relieve associated pain, prevent disease recurrence and treat infertility.(2,3) Management can be multifaceted and includes options such as medications, surgery, or both. 

Pharmacists can play a significant role in reducing the economic burden of endometriosis on the Canadian healthcare system, managing consequences of co-morbidities associated with endometriosis, and contributing to peri-and post-operative management. This week’s Resource spotlight aims to highlight resources and tools that provide helpful information to both healthcare providers and patients, respectively. To read more about endometriosis, check out CSHP’s recent Clinical pearls article on endometriosis.

 
Journal of Obstetrics and Gynaecology Canada (JOGC) Diagnosis and Management Guidelines for Endometriosis
 
This JOGC publication provides clinical practice guidelines pertaining to diagnosis and management of endometriosis. This publication includes 8 chapters with information on management of pain and infertility, medication options, surgery, and cancer risk. Each chapter is supported by emerging clinical and scientific evidence statements and grading of summary recommendations.
 
Endometriosis.org
 
This website is the global platform for news and information regarding endometriosis. It links all stakeholders in endometriosis by providing evidence-based information on medical treatment, surgical treatment, and coping and support options. 
 
Global Library of Women’s Medicine (GLOWM) - Endometriosis
 
The Global Library of Women’s Medicine is a free and publicly available resource that provides medical professionals with expert, peer reviewed guidance on best practices for women’s medicine.4 GLOWM published a thorough chapter on endometriosis with topics ranging from, but not limited to, definition, prevalence, epidemiology, clinical presentation, pathophysiology, pathology, detailed diagnosis, and treatment.  
 
World Endometriosis Society (WES)
World Endometriosis Society is a global organization whose mission is to improve quality of life for those affected by endometriosis through education, advocacy, clinical care, and collaboration with stakeholders. This organization also facilitates research on endometriosis and adenomyosis through evidence-based standards and innovations. 5 Furthermore, they contribute to the World Endometriosis Research Foundation (WERF), a global charity that conducts international research with the objective of improving knowledge of and treatments for endometriosis.
 

 
YourPeriod.ca
 
YourPeriod.ca is a website created by the Society of Obstetricians and Gynaecologists of Canada (SOGC) to provide up-to-date, expert information about menstruation. In the Resources tab, patients have access to a wide array of website resources, infographics, and videos specific to topics such as endometriosis, pelvic pain, sexual and reproductive health, pregnancy, and menopause. 
 
Of value to healthcare providers, a section within the same Resources tab is dedicated to guidelines for specific issues, such as menstrual suppression, endometriosis, abnormal uterine bleeding, uterine fibroids, and more.  

 
1 Johnson NP, Hummelshoj L, World Endometriosis Society Montpellier Consortium, Abrao MS, Adamson GD, Allaire C, Amelung V, Andersson E, Becker C, Birna Árdal KB, Bush D. Consensus on current management of endometriosis. Human reproduction. 2013 Jun 1;28(6):1552-68.
 
2 Gilliland GB. Endometriosis. Compendium of Pharmaceuticals and Specialties [Internet]. 2 March 2018 [22 March 2022]. Available from: https://www.myrxtx.ca
 
3 Kim, A, Adamson, G, Glob. libr. women's med., Endometriosis. July 2008. (ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10011
 
4 The Global Library of Women’s Medicine (GLOWM). Objectives of this site. [cited on 18 April 2022, Internet]. Available from: https://www.glowm.com/objectives 
  5 World Endometriosis Society. Endometriosis: Mission. [cited on 18 April 2022, Internet]. Available from: http://endometriosis.ca/about/mission/ 

 

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External Resources

Unless otherwise noted, the Canadian Society of Hospital Pharmacists (CSHP) does not endorse or imply endorsement of the resources provided here.

These resources are provided without warranty of any kind, either expressed or implied. It is the responsibility of the user of the resource to judge its suitability for his or her particular purpose within the context of his or her practice and the applicable legislative framework. In no event shall CSHP or any persons involved in providing the resource be liable for damages arising from its use.

Resources are free unless otherwise indicated. 

Tramadol amendments: CSHP advocacy at work

Survey: International Survey of Peripheral Vasopressor Infusions in Critical Care (INFUSE)

You have been invited to take part in an international survey, the International Survey of Peripheral Vasopressor Infusions in Critical Care (INFUSE), which aims to describe the current clinical practice regarding the administration of peripheral vasopressor infusions in critically ill patients. 

This is an electronic survey regarding your institutional peripheral vasopressor infusion guideline and clinical practice. It will take about 5 minutes to complete. If you agree to participate in this study, your completion of the survey will be implied consent. 

Please complete the INFUSE study survey via this link, where you may also download the Participant Information Sheet for further information about this study.   
 

If you would like more information, please feel free to contact the Principal Investigator, Mrs Arwa Abu Sardaneh to discuss further and answer any questions you may have.  

Arwa Abu Sardaneh, BPharm (Hons)
Clinical Pharmacist | Department of Pharmacy | Royal Prince Alfred Hospital 

50 Missenden Rd, Camperdown, NSW, 2050 

Ph: +612 9515 8261 | Fax: +612 9515 5678 

arwa.abusardaneh@health.nsw.gov.au  

 The conduct of this study at the Royal Prince Alfred Hospital has been authorised by the Sydney Local Health District. Any person with concerns or complaints about the conduct of this study may also contact the Research Governance Officer on +612 9515 7899 and quote protocol number X21-0420. 

 

We're hiring! Engagement Specialist - FT

Clinical pearls: Endometriosis

By Erica Evangelista

Background

Endometriosis affects over 176 million individuals worldwide. Pharmacists play a significant role both in reducing the economic costs of endometriosis & in managing consequences of co-morbidities associated with the disease, such as chronic pain. Pharmacists can also effectively consider factors regarding peri- & post-operative management.

Endometriosis is an inflammatory disease associated with pelvic pain & infertility, characterized by lesions of endometrial-like tissue outside of the uterus.¹ As a result of this chronic inflammatory reaction, scar tissue may form primarily in the pelvic peritoneum, ovaries, bladder, bowel, & in the diaphragm & lungs.^2,3

Clinical presentation

• Not pathognomonic symptoms include fatigue, pelvic pain, infertility, mittelschmerz, dyspareunia & dysfunctional uterine bleeding^4,5,6 painful bowel movements, constipation & low back pain.⁷
• Some patients diagnosed with endometriosis are asymptomatic.⁶

Diagnosis

• Challenging to diagnose: definitive diagnosis often takes 7 -12 years from symptom onset ⁹
• Clinical suspicion: physical examination & history of pelvic pain, dysmenorrhea & dyspareunia
• Confirmation of diagnosis: direct visualization via laparoscopy & biopsy if required ^4,6

Epidemiology

Endometriosis affects over 1 million people in Canada & over 176 million worldwide.^10,11 1 in 10 women & unmeasured numbers of transgender & gender diverse people are diagnosed.¹⁰

Risk factors ⁵

• Low body mass index (BMI)
• Tall height
• Family history of endometriosis
• Gynaecologic factors e.x. early age of menarche, short menstrual cycle & heavy menstrual flow

Pathogenesis

Mechanism

The underlying mechanism of endometriosis is not yet established. Plausible theories include:

• Histogenesis: transplantation, celomic metaplasia & induction ⁶
• Genetic predisposition (family history) ^12,13
• Aberrant endocrine signaling ¹⁴
• Imbalanced cell proliferation and apoptosis ¹⁴
• Altered immunity ¹⁴
• Retrograde menstrual flow ¹⁴

Management & treatment options

There is currently no known cure for endometriosis, but symptom management can successfully target associated pain, infertility & pelvic masses. ^4,6

In managing endometriosis, the goals of therapy include relieving pain, treating infertility & preventing recurrence.⁴ Management can be multifaceted & can include medications, surgery, or both. ^4,6 Surgery should be reserved for patients with endometriosis-associated pain for whom medication has failed.¹⁵ It is inadvisable to initiate medication alone or in combination with surgery if the patient’s only symptom is infertility, as this does not improve pregnancy rates.¹⁶ However, laparoscopic treatment of mild disease does improve pregnancy rates.¹⁵

Figure 1: Management of Endometriosis

Created by Erica Evangelista, adapted from The Compendium of Pharmaceuticals and Specialties (CPS) Algorithm on Endometriosis⁴  and Society of Obstetricians and Gynaecologists of Canada (SOGC) Management of Symptoms Associated with Suspected or Confirmed Endometriosis¹⁷

Table 1 (below) examines types of medications appropriately indicated for symptoms associated with endometriosis. Note: Most of these treatments are not suitable for long-term use due to side-effects.^2,18 Up to 50% of patients have a recurrence of symptoms within 5 years of medical management.

Table 1: Pharmacologic choices

Category	Class & examples	Symptom control	Mechanism of efficacy	Advantages	Disadvantages
Analgesics	NSAIDs e.x. Ibuprofen, Naproxen	1st line for mild menstrual pain with or without endometriosis diagnosis	Inhibit endometrial prostaglandins to prevent abnormal uterine contractions 4	Can be used as adjunct to hormonal therapies if needed	Do not always relieve endometriosis-related pain. Typically work better in combination with other treatment 19 Long-term use not recommended due to side effect profile 20 Not appropriate in patients with renal insufficiency
	Opioids  e.x.  Oxycodone, Hydromorphone, Codeine, Tramadol hydrochloride21	Pelvic pain	Effect on bowel motility may reduce pelvic pain4		Not recommended for endometriosis pain due to limited evidence & lack of established guidelines. 22,23 Opioid use before diagnosis significantly increases risk of prolonged opioid use after diagnosis.24
Hormonal therapies	Combined oral contraceptives e.x. Ethinyl estradiol (EE) /norethindrone (Brevicon ®)  EE/desogestrel (Marvelon ®)  EE/drospirenone (Yasmin ®)  EE/levonorgestrel (Min-Ovral ®, Seasonale ®, Alesse ®)	1st line for endometriosis pain & dysmenorrhea ideally administered continuously 15	Decidualization & atrophy of endometrial implants 6 Reduction of retrograde menstrual flow Ovulation suppression Prostaglandin generation reduction		Initial proliferative response can exacerbate  symptoms in months prior to improvement 6  Must use lowest effective estrogen dose to limit estrogen dependency of lesions Not appropriate in patients with liver disease & breast cancer
	Progestin-Only Contraceptives   e.x. Dienogest (Visanne ®) Norethindrone acetate (Norlutate ®) Medroxyprogesterone acetate (Provera ®, Depo-Provera ® Levonorgestrel intrauterine system (Mirena ®)	1st line for endometriosis pain	Decidualization & atrophy of endometrial tissue 6 Significant pain relief	Use if patient has contraindication to estrogen use	Potential BMD loss Not effective in improving infertility. Particularly, Depo-Provera has slow return to fertility upon discontinuation
	Androgen Agonists e.x. Danazol (Cyclomen ®)	2nd line for dysmenorrhea Treats moderate to severe disease	Hypoestrogenic vaginal changes, vasomotor symptoms, & endometrial atrophy 6	Highly effective for dysmenorrhea but less effective for chronic pelvic pain 25	Teratogenic Many side effects from androgenic properties (hair loss, weight gain, acne, hirsutism) 26
	Gonadotropin-Releasing Hormone Agonists +/- add-back hormone therapy   e.x. Buserelin acetate (Suprefact ®) Goserelin acetate (Zoladex ®) Leuprolide acetate  (Lupron Depot ®)  Nafarelin acetate (Synarel ®) Triptorelin pamoate (Trelstar ®)	2nd line for endometriosis associated pain 15 Reserved for patients with persistent symptoms after use of 1st-line therapy 20	Hypoestrogenic state to induce atrophy & regression of endometriotic implants 27 No significant differences in pain relief with 3 month vs. 6 month treatment duration 28   * GnRH agonist + add-back therapy is as effective as GnRH agonist monotherapy for relieving pelvic symptoms 29	If patient undergoes IVF, using GnRH agonist with HT add-back 3-6 months before IVF is associated with improved pregnancy rate 15	Gonadotropic flare & pain prior to long-term receptor down-regulation 14 Use add-back hormonal therapy when appropriate to mitigate BMD loss & flare up. Women should be encouraged to have adequate calcium intake & vitamin D supplementation while on therapy 4 Recurrence of symptoms over 5 yrs after completion of therapy ranges from 37% in mild disease to 74% in severe 30
	Gonadotropin-Releasing Hormone Antagonists   e.x. Elagolix (Orilissa ®)	Dysmenorrhea	Reduces dysmenorrhea, nonmenstrual pain and dyspareunia 4	Quick onset & avoids gonadotropin flare upon initiation	Hypoestrogenic side effects (hot flashes, increased lipid level & BMD loss)
Neuromodulators 16,32	TCA Amitriptyline   SNRI Duloxetine Venlafaxine   Anti-convulsants Gabapentin Pregabalin   Muscle relaxants Cyclobenzaprine	Pelvic pain   Treatment should come from an interdisciplinary approach according to the type of pain they experience 31   Muscle relaxants can help reduce overall muscle tone & spasms contributing to pelvic pain	Alters pain processing due to central sensitization 31,32	For TCAs and SNRIs, may benefit patients with concurrent mental health issues Association between endometriosis-associated pain & psychiatric conditions such as depression are highly prevalent. 24,33 Affordable & well tolerated 34 Could prevent unnecessary long-term hormone therapy & surgery that may compromise fertility 34	Lack of studies involving neuromodulators in endometriosis 31

 

Complimentary therapies

• Pelvic floor physiotherapy ⁶
• CBT ⁶
• Electrotherapy * ²⁰
• Acupuncture ²⁰
• Exercise ⁶
• Dietary products & vitamins B1. B6 and D * ^20,35,36
• Aromatase P450 inhibitors * ^4,6,14,20
• Selective progesterone receptor modulators * ^4,6,14,20

* Not well established & require further research

 

Special populations: Pregnancy & lactation

Women with endometriosis who are pregnant or breastfeeding may experience a temporary relief of endometriosis-associated symptoms.⁴ For patients desiring to conceive, excision is a preferable surgery option to ablation because spontaneous pregnancy rates are higher 9 - 12 months after surgery. ⁴

 

Pharmacists’ roles 

Information online often provides patients with misinformation on endometriosis.³⁸ Pharmacists play a pivotal role in directing patients to evidence-based resources to better understand their diagnosis. Patients suffering from endometriosis-associated chronic pain may also experience mental health issues; there is a highly prevalent association between endometriosis & psychiatric conditions such as depression, anxiety & self-directed violence.^24,33,39 Pharmacists can collaborate with the interdisciplinary team to manage chronic pain & find appropriate therapies for patients with multiple co-morbidities.

Perioperative management

Surgical management can be approached either conservatively or definitively. In conservative surgery, the goal of therapy is to restore normal anatomy & help relieve pain through procedures such as direct ablation or laparoscopic excision.⁹ This method is preferred in women of reproductive age. Ablation removes only the surface level of endometriosis via heat & is not an effective technique for treating endometriosis, as the endometrial-like cells can still grow & cause pain. Despite ablation resulting in poor outcomes, higher re-operation rates & increased pain, it remains the most common surgical approach for endometriosis.⁴⁰ On the other hand, definitive surgery may involve removal of all visible lesions of endometriosis. Definitive procedures include bilateral oophorectomy, hysterectomy, and/or salpingectomy, depending on the affected organ.⁹ Definitive surgery is reserved for patients in significant pain for whom conservative treatment failed & who do not intend to conceive in the future. Laparoscopic excision remains the most preferred surgical approach, regardless of severity of disease, as it provides greater visualization of lesions, quicker recovery & more rapid return to normal activity.^9,26

Upon admission, pharmacists gather & document accurate medication history of the patient. This provides pharmacists with the opportunity to identify & resolve drug therapy problems, for instance holding herbal dietary supplements 1-2 weeks prior to surgery due to increased bleeding risk with anesthetic agents.⁴¹ For women & transgender & gender diverse individuals on oral contraceptives or hormone replacement therapy, these agents should be discontinued 4-6 weeks prior to surgery, as they can further increase risk of venous thromboembolism.^42,43 For this reason, deep venous thrombosis prophylaxis such as low-molecular-weight heparin or unfractionated heparin should be initiated in moderate to high-risk patients. ⁴⁴ At baseline, 4 to 5 non-CHC (combined hormonal contraceptive) users are at risk of experiencing a VTE per 10,000 per year, whereas that of CHC users rises to 8-9 per 10,000 per year. ⁴⁵

To minimize the risk of perioperative infection complications, the team may initiate appropriate empiric prophylaxis therapy of an antibiotic. For example, the first-line choice of antibiotic for hysterectomy is a first-generation cephalosporin.^46,47 If patients are allergic to cephalosporin, alternatives include clindamycin, erythromycin, or metronidazole. ⁴⁶ 

Postoperative management

Surgeries carry a risk of postoperative nausea and vomiting (PONV). ⁴⁸ Pharmacists play a role in preventing & treating PONV through initiating antiemetic agents such as 5HT3 antagonists, antidopaminergics, corticosteroids, NK-1 receptor antagonists, & prokinetic agents. Pharmacists should help advocate for prevention of PONV, as preventing is more effective than treating PONV. ⁴⁹ Ondansetron, dexamethasone, & haloperidol are equally effective in preventing PONV. ⁴⁹ 

Although gynecologic surgeries do provide adequate pain control, patients are still at risk of experiencing postoperative chronic pain. In the outpatient setting, pharmacists contribute to pain management by collaborating within primary care practice such as family, ambulatory, and pain clinics. In the inpatient setting, hospital pharmacists are likely to collaborate with surgeons or anaesthesiologists to ensure adequate pain control.

Long-term health consequences 

The available data over recent years suggests that women with endometriosis may be at higher risk of developing chronic diseases such as cancer, autoimmune diseases, asthma or allergic manifestations & cardiovascular diseases, but further studies are required to confirm the associative relationship. ^50-53

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Click here for references.

Drug shortages: FAQ

 

Drug Shortages

Drug shortages are a global issue that can significantly affect patient outcomes. CSHP plays a key role in advocating for mitigation strategies to minimize the impact of drug shortages on Canadians. Keep reading to learn more about the impacts of drug shortages, and ways CSHP and other stakeholders work to protect Canada’s healthcare system.

 
What are the main reasons for drug shortages?

Causes of drug shortages are multifactorial and can include the following, either alone or in combination:

• Shortage of raw materials to make API (active pharmaceutical ingredient), excipients or packaging materials
• Manufacturing difficulties and disruption in supply chain
• Regulatory issues: policies, communication with stakeholders, implementation of safety and efficacy standards.
• Voluntary recalls
• Globalization, mergers, and acquisitions of drug companies
• Supply and demand issues
• Logistical issues: transportation, natural disasters, contamination, management incompetency

 
What are the impacts of drug shortages?

Drug shortages and resulting issues oblige members of the healthcare team to quickly use their problem-solving skills. When encountering a drug shortage, the pharmacy team may need to find appropriate therapeutic substitutes, determine different concentrations of the drug, and adjust strengths or dosage forms of the same medication. The team may also communicate with other healthcare professionals and source scarce drugs from other hospitals or suppliers. The table below highlights the economic and clinical consequences of drug shortages.

Impact of drug shortage	Potential consequences
Economic	Increased hospital expenses Increased budget for stakeholders Increased risk of drug shortages for alternative drugs Increased out-of-pocket expenses Importation of medication from other countries
Clinical	Increased medication safety incidents Compromised clinical patient outcomes Reduced clinical work with patients Strained professional relationships with healthcare professionals and patients Potential for patients to seek counterfeit medication

 
How does CSHP advocate to prevent and mitigate the impacts of drug shortages nationally?

One of CSHP’s fundamental values for pharmacy practice has been advocating for patient safety. Our objective is to minimize drug shortages and mitigate their effects by continuing to actively collaborate with governments, industry, distributors, wholesalers, major corporations, other healthcare providers, and stakeholders. CSHP’s efforts include the following examples:

Health Canada consultations

CSHP participates in calls with Health Canada and other stakeholders (including provinces and territories, manufacturers, other healthcare associations, and group purchasing organizations). CSHP’s roles are to:

• Help determine whether the current drug shortage should be considered critical
• Share this information with members
• Help the Canadian population understand the decision-making process behind these mitigation strategies.

Membership in the Alliance for Safe Online Pharmacies Canada

As a member of Alliance for Safe Online Pharmacies (ASOP) Canada, CSHP collaborates with other stakeholders to:

• Advocate to prevent American federal and state legislation proposals to import drugs from Canada.
• Prepare official submissions to federal legislatures concerning FDA’s Proposal on Importation of Prescription Drugs.

Membership in the Multi-Stakeholder Steering Committee on Drug Shortages (MSSC)

As an active member of the Multi-Stakeholder Steering Committee on Drug Shortages (MSSC), CSHP’s roles have been to:

• Actively participate in public reporting of drug shortages (since 2011)
• Collaborate with stakeholders to draft a letter requesting that Canada’s drug supply be protected against US importation proposals and legislation
• Help create reference documents regarding drug shortages (attached below in Question #6 under MSSC References).
• Participate in the International Summit on Medicines Shortages with both the International Pharmaceutical Federation and the Canadian Pharmacists Association

 

What other stakeholders are involved in mitigating drug shortages, and what are their respective roles?

Stakeholders	Roles
Hospital pharmacy managers and technicians	Finding appropriate therapeutic alternatives Substituting another medication in the same therapeutic class as the scarce drug  Substituting medication in a different therapeutic class from the scarce drug, but with a similar mechanism of action Determining different pack sizes or concentrations Determining different strengths or dosage forms of backordered medication Communicating with other healthcare professionals and suppliers to obtain medication Compounding medications if possible Determining prioritization of patient populations for distribution of scarce medication   Notifying other stakeholders of updates on drug shortages (including high-alert medication warnings) Educating patients
Group purchasing organizations	Serving as a link between hospitals and suppliers Promoting sharing of documents from hospitals such as guidance on drug shortages, mitigation strategies, and suggestions for therapeutic alternatives Ensuring a fair allocation of scarce medication to as many hospitals as possible Requesting protective allocations if a medication is at risk of being in shortage
Manufacturers	Reporting any foreseeable drug shortages to Health Canada Participating in multi-stakeholder calls Communicating with global partners to ensure additional medication for Canadian drug supply
Health Canada	Health Canada’s Drug Shortages Division (DSD) plays a key role in responding to drug shortages: Coordinating information sharing between impacted groups, implementing mitigation strategies, and assessing potential impact of shortages Expediting Establishment License Review, Submission Review, and Lot Release for medications Providing guidance on access to unauthorized drugs through the Special Access Programme In exceptional circumstances, releasing an interim order from Minister of Health to help safeguard Canadian drug supply

 

 

How can CSHP members receive updates about drug shortages? 

CSHP offers a free Pharmacy Specialty Network (PSN) for all CSHP members to stay updated on current drug shortages. This is a forum for pharmacy staff to seek support and suggestions from peers facing similar challenges with managing drug shortages in their institutions. Topics of discussion may include, but are not limited to: therapeutic alternatives, preservation strategies, obtaining SAP products, look-alike alerts, and drug shortage updates. 

To access to the CSHP Drug Shortages PSN, click here. Alternatively, please follow these steps: Member Centre > Pharmacy Specialty Networks > Create Account or Log-In to QID > Search Communities > Drug Shortages PSN

 

Where else can I seek up-to-date information on drug shortages?

Drug Shortages Canada / Pénuries de médicaments Canada

Drug Shortages in Canada (Government of Canada)

House of Commons report on Drug Supply in Canada: A Multistakeholder Responsibility 

Canadian Drug Shortage website

US Food and Drug Administration’s Report on Drug Shortages

MSSC resources:

Multi-Stakeholder Toolkit: A Toolkit for Improved Understanding and Transparency of Drug Shortage Response in Canada

Protocol for the Notification and Communication of Drug Shortages

Guidance Document to Mitigate Drug Shortages through Contracting and Procurement

Preventing Drug Shortages: Identifying Risks and Strategies to Address Manufacturing-Related Drug Shortages in Canada

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 References 

Adams C. Understanding Drug Shortages During a Pandemic. Hospital News [Internet]. 2020 [cited 14 March 2022]. Available from: https://hospitalnews.com/understanding-drug-shortages-during-a-pandemic-2/

Drug Shortages. Canadian Society of Hospital Pharmacists (CSHP) [Internet]. 2020 [cited 14 March 2022]. Available from: https://www.cshp.ca/site/adv/advocacy/drug-shortages?nav=advocacy

Shukar S, Zahoor F, Hayat K, Saeed A, Gillani AH, Omer S, Hu S, Babar ZU, Fang Y, Yang C. Drug Shortage: Causes, Impact, and Mitigation Strategies. Frontiers in pharmacology. 2021;12.

Drug Shortages Continue to Compromise Patient Care. Institute for Safe Medication Practices (ISMP) [Internet]. 11 January 2018. [cited 16 March 2022]. Available from: https://www.ismp.org/resources/drug-shortages-continue-compromise-patient-care

 

Call for Hospital News writers

CSHP is looking for 5-6 members (1 being a pharmacy resident) who are interested in contributing a brief article to CSHP's special section of Hospital News Magazine. By sharing your story, you'll help to raise awareness and appreciation among wider audiences for the varied work of pharmacy teams. Please share your expertise with us and help advocate for the pharmacy profession! To see last year's collection of articles, click here. 

Details

• Article length: 300 - 800 words 
• Theme: "Hospital pharmacy and the COVID-19 pandemic: Where do we go from here?"
• Topics could include (but are not limited to): Equity in pharmacy, learning as a pharmacy resident during the pandemic, new directions and developments in pharmacy, burnout and mental health in pharmacy professionals, and much more! 
• Style: Casual, magazine style for a general audience  (i.e. imagine you're explaining pharmacy issues to a neighbour or friend)
• No references or citations needed
• Editing provided by CSHP and Hospital News
• You'll be listed as the author, with a byline
• Due date for article completion: April 20, 2022

If you are interested in participating, please email CSHP's Content Writer Rachel Glassman at rglassman@cshp.ca by Friday, April 1, 2022 (deadline extended) with a topic of your choice and a sample of your previous written work. Any questions are welcome, so please don't hesitate to reach out. 

 

ICYMI: PAM 2022 highlights

Thanks to your efforts and enthusiasm, it's been a vibrant and fun-filled Pharmacy Appreciation Month! In case you missed it, keep reading for a round-up of some of our favourite moments of #PAM2022 so far. 

1. Listen to CSHP President Zack Dumont's interview with HealthPRO. Zack highlighted the valuable work of hospital pharmacy "unsung heroes," the challenges we face, and big practice changes on the horizon. Watch the conversation here.
2. Read a Victoria Hospitals Foundation interview with Sean Spina, CSHP President-Elect. Sean shared his perspective on hospital pharmacy's essential role in the Hospital at Home program, and the importance of evidence-based advocacy: "I have dedicated much of my career to using data to advocate for recognition in the healthcare system of the essential role that our teams play in care delivery." Read the interview here.
3. Check out a recent interview with CSHP's 1999 Distinguished Service Award winner Bonnie Salsman, who reflects on her legendary pharmacy career and the many changes she's witnessed in the profession. See the conversation here.
4. Read the inspiring story of two young patients, ages 6 and 7, whose debilitating drug-resistant epilepsy was treated with life-changing medications thanks to a pharmacy team at Hamilton Health Services. Read the story here.
5. Check out all the amazing stories and hospital pharmacy love on social media: Tributes to pharmacy teams from hospitals, kudos and special shoutouts, advocacy highlights, and your awesome lists of reasons you're proud to be a hospital pharmacy professional. 

Clinical pearls: Race-conscious and personalized medicine — What pharmacists can do to acknowledge race-based and genetic variations that affect drug therapy

Written by Bhawani Jain

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

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Introduction

We all have different genetics and backgrounds, so why should everyone receive identical medical treatment for a diagnosis or condition? Personalized medicine is on the rise, with medical treatments tailored to a patient’s unique characteristics, such as genetic differences and environmental conditions. Genetic testing for every patient may not always be necessary, and it can be difficult to achieve due to cost and a lack of resources. Nevertheless, for hospital pharmacists it is important to understand that drug treatments may not work universally for all patients. Quality patient care can sometimes require hospital pharmacists to consider genetic variations that may impact medication therapy. As such, this article examines three genetic variations that are prevalent among specific populations, and how these differences may influence the pharmacists’ choice of drug treatment.

Aldehyde Dehydrogenase 2 mutation (ALDH2*2) among East Asian individuals

Approximately 45% of people of East Asian descent (about 560 million people and 8% of the global population) have the genetic variation ALDH2*2.^1,2 The aldehyde dehydrogenase 2 (ALDH2) enzyme is important for metabolizing toxic and reactive aldehydes in the body to non-reactive carboxylic acids.¹  A loss-of-function point mutation in this enzyme (ALDH2*2) results in an inability to metabolize these toxic aldehydes, which then accumulate in the person’s body. For example, rather than being metabolized via the ALDH2 enzyme, alcohol is converted into acetaldehyde in the liver. Those with ALDH2*2 accumulate acetaldehyde in their body after consuming alcohol, causing facial flushing as well as nausea and tachycardia.³

Along with the metabolism of aldehydes, ALDH2 also metabolizes nitroglycerin to nitric oxide, a vasodilator used to prevent and treat angina and acute myocardial infarctions (heart attacks), among other uses.² The conversion to nitric oxide by ALDH2 is important for vasodilation. Compared to someone without the mutation, those with ALDH2*2 are 10 times less able to convert nitroglycerin to nitric oxide, and they require about 40% more nitroglycerin to achieve the same therapeutic response as someone without the mutation.⁴ Hospital pharmacists should be aware of the effect of ALDH2 on metabolism of nitroglycerin. This may impact decisions regarding the use and dosage of nitroglycerin in multiple settings, including cardiology, emergency medicine, and obstetrics (where nitroglycerin is used to relax the uterus). It is important for hospital pharmacists to gauge the efficacy of nitroglycerin for these patients. They may also consider dose increases or alternative medications, such as nitroprusside, that are not affected by ALDH2.⁴

Individuals with ALDH2*2 who consume alcohol also have an increased risk of diabetes, osteoporosis, reactive airway disease, lung cancer, and cardiovascular disease (including myocardial infarctions, coronary artery disease, and cardiac ischemia), among other health risks.⁴ Furthermore, those with ALDH2*2 who smoke and drink frequently have a 189-fold risk of developing esophageal cancer due to the accumulation of toxic aldehydes from these activities.⁴ As a result, it is important to speak to patients with ALDH2*2 about the increased health implications of frequent drinking and smoking.

Clinicians can initiate a conversation with patients to screen for ALDH2*2, asking if they are of East Asian descent, and if they experience facial flushing after consuming alcohol, especially within the first few years after they began drinking.³ If the patient is a child, the question can be directed to their parents to determine the likelihood of the child having the genetic variation.

 

Glucose-6-phosphate Dehydrogenase (G6PD) deficiency among Kurdish Jewish individuals

Glucose-6-phosphate dehydrogenase (G6PD) is an enzyme that protects red blood cells from being damaged by oxidizing agents. Red blood cells use hemoglobin to transport oxygen in the body. Reactions between hemoglobin and oxygen produce oxidizing agents such as superoxide anion (O^2-) and hydrogen peroxide.⁵ These chemicals can damage and kill red blood cells. G6PD prevents this from happening, as it produces agents that reduce the oxidant nature of the oxidizing agent. For example, G6PD is involved in a cascade of reactions that help convert hydrogen peroxide to water. In those who are genetically deficient in G6PD, an accumulation of oxidizing agents can occur and lead to hemolysis, also known as hemolytic anemia.⁵ Hospital pharmacists should be alert for ways to prevent hemolysis in individuals with G6PD deficiency.

G6PD deficiency is particularly prevalent among Kurdish Jews, with about 70% of this population having G6PD deficiency. G6PD deficiency is also prevalent in Nigerians (22%), Thai people (17%) and African Americans (12%).⁶ G6PD deficiency is an X-linked condition, meaning it is passed down via the X chromosome. Since males only have one X chromosome, if they inherit this mutation, G6PD deficiency affects all of their red blood cells. Females are not usually affected by the deficiency, as females have two X chromosomes. If a female inherits mutation from one parent, half of their red blood cells would have the normal G6PD gene, while the other half wouldn’t. If a female inherits the mutation from both parents, she would be affected, though this is very rare.⁶ There are over 200 different variants of G6PD, and the World Health Organization has divided these variants into classes based on severity of hemolysis and amount of enzyme deficiency.⁷ Most people with G6PD deficiency live a healthy life with no symptoms. However, these individuals are at risk for an episode of acute hemolysis if they experience oxidant injury from medications, illness, or food.⁶

One study noted that 46% of acute hemolysis episodes in patients with G6PD deficiency were caused by medication.⁶ Hospital pharmacists must be aware of the medications that could potentially precipitate an acute hemolytic episode.^6,8 Among others, such medications include: chlorpropamide, dapsone, fluoroquinolones, methylene blue, nitrofurantoin, phenazopyridine, primaquine, rasburicase, and sulfonylureas. Hospital pharmacists, as part of a care team, can proactively recommend medication alternatives. For example, in treating urinary tract infections, fosfomycin tromethamine can serve as an alternative therapy to nitrofurantoin, ciprofloxacin, and sulfamethoxazole/trimethoprim.^6,9 It is also important for hospital pharmacists to review home medications upon hospital admission to ensure that G6PD-deficient patients are not taking any medications that could precipitate an acute hemolytic episode. If a patient with G6PD deficiency is taking a medication that could cause harm, an intervention can be made to switch to a different medication. Patients in this population should also be told to avoid eating fava beans, which can cause hemolysis; they contain compounds that are metabolised to potent oxidizing agents.⁶

Hospital pharmacists should be proactive in screening a patient’s demographic characteristics and medical history for G6PD deficiency. Patients can be asked about their ethnic background when it is medically relevant. If the patient identifies as Kurdish Jewish, for instance, they should be screened for G6PD deficiency using laboratory testing. Furthermore, newborn babies with G6PD deficiency may experience jaundice within the first few days after birth.⁶ Patients and parents can be asked if they themselves or their children experienced jaundice as a newborn prior to initiating testing. These screening methods are important to prevent acute hemolytic episodes in people with suspected G6PD deficiency, especially if the care team is considering using a medication that could be problematic. It is also important to counsel patients about what it means to have G6PD deficiency, what medications to void, and what they can do to prevent acute hemolytic episodes.

 

Response to Angiotensin-Converting Enzyme (ACE) inhibitors among Black individuals

Angiotensin-converting enzyme (ACE) inhibitors are a class of medications that are used to treat hypertension and heart failure after a heart attack, and to reduce the likelihood of heart attacks and stroke in patients at risk. For patients with uncomplicated hypertension, diabetes, heart disease, a recent heart attack, heart failure, or chronic kidneys, the drug class of choice is ACE inhibitors such as ramipril.¹⁰ However, compared to other populations, studies show that Black patients tend to respond poorly to ACE inhibitors, angiotensin receptor blockers, and some beta blockers when these drugs are used as monotherapy. According to several studies, when using either medication in these classes, Black patients have a smaller blood pressure reduction compared to other patient populations.^11,12 The cause of this is uncertain; some studies point to a genetic factor indicating that Black individuals’ bodies tend to retain more salt, which can also put this population at a greater risk for hypertension.¹³

The prevalence of hypertension is highest among Black individuals relative to any other patient population.¹⁴ This highlights the need for hospital pharmacists to be aware that Black patients may respond differently to first-line anti-hypertensive medications, and that alternative regimens should be considered. If a Black patient was recently diagnosed with hypertension, the American College of Cardiology and the American Heart Association recommends that the patient be given a dihydropyridine calcium channel blocker (such as diltiazem) or thiazide diuretic (such as chlorthalidone).^11,14 Black patients with hypertension tend to respond favourably to these classes of anti-hypertensives. If a combination of drugs is required, an ACE inhibitor can be combined with a dihydropyridine calcium channel blocker. A diuretic such as chlorthalidone can be used if this treatment does not work.^11,15,16 Although ACE inhibitors are not typically first-line treatment for uncomplicated hypertension, they can be used in combination with other antihypertensives for Black patients with proteinuric chronic renal disease and hypertensive nephrosclerosis.^{11, 17} In an interprofessional care team, hospital pharmacists can highlight the difference in response to ACE inhibitors among Black populations to influence decisions regarding drug treatment and to improve health outcomes.

Along with drug therapy, hospital pharmacists can counsel patients about lifestyle modifications to lower the risk of developing hypertension and to lower blood pressure for those who have hypertension. Such modifications include reducing dietary salt consumption, increasing exercise, avoiding excess alcohol, and, in case of obesity, weight loss. One study noted that regular exercise along with medication reduced blood pressure more than medication alone.^11,18 To determine if a person should use an ACE inhibitor or another class of anti-hypertensives, a clinician or pharmacist can ask the patient about their ethnic background, and state that evidence shows race-based differences in response to certain medications.

 

Conclusion

Being cognizant of ethnic and genetic differences that affect patients’ response to medications can help clinicians make better medical decisions and improve health outcomes, both for chronic health conditions such as hypertension, and for emergent situations such as acute hemolysis and angina attacks. Pharmacogenetic testing is not always readily available, especially in emergent situations, so it is wise to respectfully ask patients about their ethnic background to identify the ways their genes might affect their reactions to drug therapies. It is also important to educate patients about the implications of their ethnic and genetic characteristics. Hospital pharmacists can discuss with patients which health conditions they may be at higher risk for, recommend lifestyle changes as appropriate, and proactively work with the patient to take preventative measures.

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References

1. Chen CH, Ferreira JCB, Joshi AU, Stevens MC, Li SJ, Hsu JH, et al. Novel and prevalent non-East Asian ALDH2 variants; Implications for global susceptibility to aldehydes' toxicity. EBioMedicine. 2020;55:102753. doi: 10.1016/j.ebiom.2020.102753.
2. Gross ER, Zambelli VO, Small BA, Ferreira JC, Chen CH, Mochly-Rosen D. A personalized medicine approach for Asian Americans with the aldehyde dehydrogenase 2*2 variant. Annu Rev Pharmacol Toxicol. 2015;55:107-27. doi: 10.1146/annurev-pharmtox-010814-124915.
3. Brooks PJ, Enoch MA, Goldman D, Li TK, Yokoyama A. The alcohol flushing response: an unrecognized risk factor for esophageal cancer from alcohol consumption. PLoS Med. 2009;6(3):e50. doi: 10.1371/journal.pmed.1000050.
4. McAllister SL, Sun K, Gross ER. Developing precision medicine for people of East Asian descent. J Biomed Sci. 2016;23(1):80. doi: 10.1186/s12929-016-0299-3.
5. Glader B. Genetics and pathophysiology of glucose-6-phosphate dehydrogenase (G6PD) deficiency. UpToDate [Internet]. 18 September 2020 [cited 13 March 2022]. Available from: https://www.uptodate.com/contents/genetics-and-pathophysiology-of-glucose-6-phosphate-dehydrogenase-g6pd-deficiency
6. Glader B. Diagnosis and management of glucose-6-phosphate dehydrogenase (G6PD) deficiency. UpToDate [Internet]. 17 March 2021 [cited 13 March 2022]. Available from: https://www.uptodate.com/contents/diagnosis-and-management-of-glucose-6-phosphate-dehydrogenase-g6pd-deficiency
7. Glucose-6-phosphate dehydrogenase deficiency. WHO Working Group. Bull World Health Organ. 1989;67(6):601-11.
8. Bubp J, Jen M, Matuszewski K. Caring for Glucose-6-Phosphate Dehydrogenase (G6PD)-Deficient Patients: Implications for Pharmacy. P T. 2015;40(9):572-4.
9. Nicolle L. Urinary Tract Infection | CPS [Internet]. Canadian Pharmacists Association. 12 April 2021 [cited 13 March 2022].
10. Padwal R, Gibson P, Tsuyuki RT. Hypertension. [Internet]. Canadian Pharmacists Association. 21 April 2021 [cited 13 March 2022].
11. Egan BM. Treatment of hypertension in Black individuals. UpToDate [Internet]. 6 April 2021 [cited 13 March 2022]. Available from: https://www.uptodate.com/contents/treatment-of-hypertension-in-black-individuals
12. Mann JFE. Choice of drug therapy in primary (essential) hypertension. UpToDate [Internet]. 5 August 2021 [cited 13 March 2022]. Available from: https://www.uptodate.com/contents/choice-of-drug-therapy-in-primary-essential-hypertension
13. Spence JD, Rayner BL. Hypertension in Blacks: Individualized Therapy Based on Renin/Aldosterone Phenotyping. Hypertension. 2018;72(2):263-269. doi: 10.1161/HYPERTENSIONAHA.118.11064.
14. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):1269-1324. doi: 10.1161/HYP.0000000000000066.
15. Ojji DB, Mayosi B, Francis V, Badri M, Cornelius V, Smythe W, et al. Comparison of Dual Therapies for Lowering Blood Pressure in Black Africans. N Engl J Med. 2019;380(25):2429-2439. doi: 10.1056/NEJMoa1901113.
16. Flack JM, Sica DA, Bakris G, Brown AL, Ferdinand KC, Grimm RH Jr., et al. Management of high blood pressure in Blacks: an update of the International Society on Hypertension in Blacks consensus statement. Hypertension. 2010;56(5):780-800. doi: 10.1161/HYPERTENSIONAHA.110.152892.
17. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19):2560-72. doi: 10.1001/jama.289.19.2560.
18. Kokkinos PF, Narayan P, Colleran JA, Pittaras A, Notargiacomo A, Reda D, et al. Effects of regular exercise on blood pressure and left ventricular hypertrophy in African-American men with severe hypertension. N Engl J Med. 1995;333(22):1462-7. doi: 10.1056/NEJM199511303332204.

 

University of Toronto Preceptor Development Program: Student Rotation at Baycrest Hospital

From left: PharmD student Jesse Ropat with Baycrest preceptor Andrew Messiha

As a pharmacist at Baycrest Hospital, Andrew Messiha connects with patients every day. “We are involved in rounds, we learn about each individual patient and create plans to make sure their medications are appropriate,” he said. Beyond the technical side of medication management, it is the ability to listen, communicate and provide care in a way that supports a patient and their family that enhances a pharmacists’ impact on patient care.

This past May, Messiha was paired with Jesse Ropat, a second year pharmacy student from the University of Toronto’s Leslie Dan Faculty of Pharmacy for an Early Practice Experience rotation. The Doctor of Pharmacy program at the University of Toronto emphasizes experiential education, and each year students take part in hands-on learning through four-week rotations in a variety of direct patient care environments. The final year of the program is fully dedicated to advanced experiential rotations giving students a chance to build skills and sample a diverse range of potential career paths.

Read the full article on the University of Toronto's website.

Interested in becoming a pharmacy preceptor? Learn more about the University of Toronto's Preceptor Development Program.

ICYMI: PAM 2022 highlights

Thanks to your efforts and enthusiasm, it's been a vibrant and fun-filled Pharmacy Appreciation Month! In case you missed it, keep reading for a round-up of some of our favourite moments of #PAM2022 so far. 

1. Listen to CSHP President Zack Dumont's interview with HealthPRO. Zack highlighted the valuable work of hospital pharmacy "unsung heroes," the challenges we face, and big practice changes on the horizon. Watch the conversation here.
2. Read a Victoria Hospitals Foundation interview with Sean Spina, CSHP President-Elect. Sean shared his perspective on hospital pharmacy's essential role in the Hospital at Home program, and the importance of evidence-based advocacy: "I have dedicated much of my career to using data to advocate for recognition in the healthcare system of the essential role that our teams play in care delivery." Read the interview here.
3. Check out a recent interview with CSHP's 1999 Distinguished Service Award winner Bonnie Salsman, who reflects on her legendary pharmacy career and the many changes she's witnessed in the profession. See the conversation here.
4. Read the inspiring story of two young patients, ages 6 and 7, whose debilitating drug-resistant epilepsy was treated with life-changing medications thanks to a pharmacy team at Hamilton Health Services. Read the story here.
5. Check out all the amazing stories and hospital pharmacy love on social media: Tributes to pharmacy teams from hospitals, kudos and special shoutouts, advocacy highlights, and your awesome lists of reasons you're proud to be a hospital pharmacy professional. 

News Story Title

 

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CSHP’s contributions to the Best Brains Exchange on antimicrobial business models

Three ways for pharmacy professionals to support healthcare in Ukraine

 

Representing you in Ottawa: CSHP’s response to CADTH national formulary framework