Welcome to Marvelous Pharmacist

 

diabetes hand custom designI am personally struggling with being a newly diagnosed type 2 diabetic. 

All these years of dispensing oral meds and insulin to diabetics, you think, would have made me more vigilant and fearful of the disease. 

I am the perfect candidate. Sedentary and overweight.

I could feel the progress. The increased urination. The tiredness after eating sugar and carbs. All enough to force me to see a doctor.  

Blood Sugar and A1c

Sure enough, my fasting blood sugar was 138 mg/dL and my A1c was 6.6. 

The doctor started me on metformin ER 500mg once daily. Told me to diet and exercise. And I said, “OK”.  A follow up appointment was made for 4 weeks later.  

The Publix pharmacist was so nice. A younger graduate from Massachusetts College of Pharmacy ( ACP’s old rival) very knowledgeable combined with compassion. It felt strange being on the other side of the bench. 

Now, if you read some of my earlier posts, I am a fan of metformin. Its benefit/risk profile is tremendous. It doesn’t cause hypoglycemia. Gastrointestinal side effects are the major issues, if any. Causing stomach upset, making me not hungry, is a good thing. 

a complete metformin drug information sheet from the Mayo Clinic is here

The medication worked right away. (I’ve been dispensing drugs for 40 years and I’m still surprised when they work)  When I ate the carbs and sugars, there was no fatigue or drowsiness. 

I took my dose in the evening. I was a big evening eater, so I figured it would kick in max at 6 hours. But, because I didn’t feel like crap after eating, I found myself eating more. 

Because of this, I actually gained weight. It certainly didn’t make me feel like going out to exercise in any capacity. 

To be continued  …

 

 

example of rx

Have you ever said to yourself when waiting for prescriptions, “Wow, this pharmacist is really busy”? Well, there are certain key points that you can recognize to get a feel of how busy that pharmacist is.  

Notice how many people are working in the pharmacy. There is the cashier. The pharmacist. Maybe 2 or 3 assistants – or we call them – technicians (techs). 

The pharmacist will be there the full 12 hour day. The cashier is there during the busy 4 to 5 hour rush.  Two techs will be scheduled for 6 to 8 hour days. The third tech will be the afternoon overlap and closing person. 

Everyone working with the pharmacist is licensed by the State. If the cashier just stays behind the cash register, they do not have to be licensed. The States allow 2 to 3 technicians  per pharmacist. This is why, unless there are 2 pharmacists, a small number of people are working. 

In addition to the state license, each tech passes a training program provided from the pharmacy of employment.

The Technician 

Each tech is assigned a different ‘station’ or task for a period of time, then they rotate. 

The tech taking the prescription from you,obtaining your personal and insurance information is the ‘input’ person. After they obtain the information, they enter the data into the computer along with drug and direction information.   

Once this information is entered, a label is generated and placed into a container. The ‘picking/floating’ tech will pick up this basket and attach the prescription number to the paper script. Reviewing the prescription, they pick the drug(s) off the shelf and place them in the basket. 

The basket is placed in the counting area for the ‘counting’ tech. This person reviews the label against the prescription, scans the medication bottle for the right drug with strength, and then counts out the correct number of tablets. The medication is placed in the container and labeled. 

The Pharmacist

This basket is then sent to the pharmacist. The pharmacist reviews the written prescription to the information on the label. They match the drug bottle to the drug in the vial. The vial gets opened and the actual tablets reviewed. 

After the pharmacist is satisfied the right drug and directions match the prescription, they turn their attention to the computer. 

They scan the barcode on the prescription label to ‘bring up’ the image of the prescription and the patient’s profile. The prescription is reviewed again then matched against the patients profile for any potential drug interactions. 

When everything falls into place, 100% correct, the pharmacist will either approve the prescription biometrically or with a passcode. 

Only the pharmacist can give final approval of any prescription leaving the pharmacy. The pharmacist holds responsibility and liability for every person and steps in the filling process. 

Once approved, the pharmacist or tech  removes the paperwork and medications and ‘bags’ them. These ‘bagged’ items are then placed on the will call shelf for the patient to pick up. 

When you have a store filling 350 prescriptions per 12 hour day, this allows 2.05 minutes for this total procedure for each prescription. 

Interject the above procedure with  insurance and doctor office calls, counseling patients and delivering flu shots, the pharmacist is very busy.  


Soda Fountain Pharmacist

The pharmacy in Albany was an old fashioned kind. There was the traditional shopping area, prescription area and a soda fountain area.

The soda fountain had black and silver napkin holders, salt and pepper shakers and menus set up towards the grill area on a long green counter.Just in front of the counter sat 20, permanently secured, spinning bar stools. Green plastic covered the stools which was tucked into silver bands surrounding the spinning part. We kept them clean and polished so the light would bounce off when spun.

The pharmacy was located at the busy intersection of Lark and Washington. It was the location of most of the major bus route transfers. Probably a few thousand people a day would be in front of the pharmacy at the bus waiting areas. Of course, many people that could (or should) not drive took the bus from home to work using this transfer point.

One group of individuals that could not drive were those with epilepsy. Every Thursday night a group of epileptics would take the bus to the corner of Lark and Washington to attend their epilepsy group support meeting. Quite a few of them filled their prescriptions at the pharmacy so I was fortunate to have them eat dinner at the counter prior to the support meeting.

They would all take their places on the bare spinning stools having a good time talking, laughing and joking. This group had bonded over their shared experiences and had become close over time. One evening one of the members had a seizure. You could hear the thud of them falling to the floor off the stool. The seizure was tonic so there was no danger of flailing and banging. Everyone at the counter would slightly turn their stools, look over their shoulders to see if that person was safe and comfortable,   then turn back to the counter continuing to eat.

Since I filled most of their prescriptions, I could anticipate which person would most likely have a seizure because of their compliance record.

Once the seizure stopped, the member would rejoin the counter pack (although exhausted) and finish their meal. This group of friends never let epilepsy get in the way of fun and friendship. They continued to meet each week, never letting their condition get in the way of life.  

epilepsy end button

 

Prescription Expenses

My pharmacy in Albany defined the demarcation point between communities.These two neighborhoods were vastly different from each other. One was a wealthy, upscale area where the legislators lived while in session. The other was a working-class neighborhood with blight and neglect. The pharmacy was the only thing in common that they shared.   

 We were the only pharmacy in the area, and people from both communities brought their prescriptions there. Despite the economic differences, the patients all shared a common bond: the need for medical care. 

One busy day I had two interactions that classically portrayed such economic extremes. 

Early in the morning, a customer asked if they could speak to me privately. As we snuck around the corner he placed his hand inside a paper bag and showed me a vial full of  40 cephalexin capsules. He had just had the prescription filled at the CVS downtown. He wanted to know if I would be willing to buy those capsules to sell in my pharmacy later. Even though he had a terrible skin infection, he needed money to live for the day. 

Later that afternoon, a well dressed man came in with a new prescription. When I was obtaining his personal information, it occurred to me he was the person responsible for the retirement fund for the State of New York.  A person who was responsible for over $100 billion dollars and had an indirect responsibility to the money seeking, soon to be extremely infectious, cephalexin charge.  

If you can not afford a prescription, you need to speak with your doctor or pharmacist. Many times a medication can be changed to one less expensive. Some drug companies offer savings programs. However there is an application process. 

There are prescription discount plans that are free.  Below is a link to at least one.


Example of a Poison Register
The Poison Register

The Poison Register

Controlled substances take up so much of a Pharmacist’s time.

The meds are classified from CII through CV. The CII meds have a high probability of addiction and death while the CV meds are less addictive.

In some states, patients can purchase CV medications without a prescription. They just need to sign the poison register.

When I first started practicing pharmacy, an anti-diarrheal named Parapectolin could be purchased this way. Parapectolin was a CV drug. Parapectolin contained the tincture Paragoric. Paragoric is now a CIII med containing anhydrous morphine, 45 percent alcohol (90 proof), anise oil (smells and tastes like licorice), water, glycerin and benzoic acid. Each teaspoonful contains 2 mg of morphine derived from opium.

Just reading the ingredients makes a person’s central nervous system quiver with excitement and anticipation.

Now, the positive thing about Paragoric and Parapectolin was it worked. Just a couple of doses and loose stools disappeared. But, you know where the story is going from here.

The chronic usage of the med was more from the abuse than from people just having diarrhea on a daily basis. The more creative customers had a network of friends and family traveling to the pharmacies purchasing the Parapectolin. This presented an issue because the Board of Pharmacy Inspector wanted to see the poison register and who was signing for CV meds. (They still require you to have a poison register in the pharmacy)

At the end of the day, the inspector would figure out the commonality of all the names and addresses in each pharmacy pinpointing the ‘opium addict’. The inspector would tell us not to sell to the selected local resident.

Of course, this would lead to a heated discussion when the person came in for their med. I would hide in the back and let my dragon lady pharmacy tech deliver the bad news.


tube of hydrocortisone cream

The Case of the Strange Rashes

Skin: rashes, pimples, bumps, redness, striations, infections. Skin,skin, skin. So many patients came into the pharmacy and asked about skin issues.

When I worked in a small pharmacy in upstate New York, there was a drug/alcohol recovery center that contracted their prescription services with us.

Most of the prescriptions were for routine meds that helped the residents with recovery.

Probably 90 percent of the recoverees were from the metropolitin New York City area. This center was actually preferred because of its quiet, rural location. Mountain views. Rolling valleys. Dairy farms eminating moos and methane gas. Really idyllic.

The residents had their own little farmland gardens where they could cultivate seasonal foods. Both for learning and consuming.

Well, all of the sudden, we started getting orders for tubes of hydrocortisone. First just one or two orders. Then, as the week progressed, we were up to 15 tubes of Mycolog cream. This product was a combination of an antifungal and hydrocortisone.

This was being prescribed for the males only. The directions were to apply it to their genital areas three times a day.

Obviously, there was some strange, contagious fungal skin condition being passed around the center that necessitated the use of their penises.

Or, we thought.

Upon further investigation, along with interrogation, the true cause of this rash was revealed.

It seems as though, as the amatuer gardeners were harvesting, they came across the warm cantalopes.

One of the men, out of desire and curiosity, decided to cut a hole in the warm melon and insert their penis into the warm, seed filled inners.

Upon finding this successful, he spread the word around to at least 15 more friends.

Unfortunatly, the combination of moist melon, dirt and seeded seeds was enough to cause a minor fungal infection and rash.

This, to us pharmacists, turned out to be both amusing and profitable.

Believe me, there are no shortage of elements in the universe that will affected your skin.

Most skin conditions can be treated initally by OTC products. Many times, the doctor will recommend using a simple OTC medication just to help differentiate the diagonosis. Of all the products available, they really just fall into seven or eight catagories.

These catagories would be the antihistamines, corticosteroids, keratoplastics, blockers, colloidals, analgesics and more. Many are combinations of the same drugs just marketed differently.

However, here is a great article explaining skin rashes authored by Lars Grimm, MD.

It is titled “Eight Skin Rashes You Need To Know”.

It’s a good one to read because the photos are accurate.


Dupixent Advertised Endlessly

I’m watching TV and every other advertisement seems to be for Dupixent.

Back in the 1980’s, when I was a Pharmaceutical Rep, manufacturers just started to use TV for direct advertisement to consumers. The doctors did not like this at all. Patients would come into their offices demanding prescriptions for the advertised drug.

When I was detailing an urologist about antibiotics, he was on the phone telling a parent the rash on her 13 year old sons penis was not from eczema, but secondary to him masturbating five times a day. She wanted the doctor to prescribe a cream she saw on TV.

Of course, this interfered with the precious few minutes I had while detailing the doctors about our wonderful medications. We sales reps became informational parrots while performing consoling listening.

But the advertisements were totally effective driving sales. Now TV viewers can’t escape the barrage.

Dupixent works by helping your body reduce inflammation. This is done by telling your body not to produce 2 different proteins that start the inflammation process. Dupixent is considered a biologic medication that is administered by injection. You can find out more at https://www.dupixent.com .


Sunglasses at the Bench

It never failed when I was working the bench there was the patient who was always in that rush stage. But I could tell that would be the case far earlier then them wandering back to the counter.

And, I would also know, without knowing the patient, what the rush would be. How, do you ask? Well, it’s always the customer who walks in with their sunglasses on.

Now, I know you’re going to say, I always walk into a store with my sunglasses on. Yes, that’s true. But when you head back to the pharmacy, that is when you become a statistic.

There are 3 categories of sunglass patients. One, the earlier controlled substance refills. Two, the early sleeping pill refills. And three, the post ophthalmologist.

If you are the latter, you get a pass and you would also be in the minority.

However, early refills on sleeping pills and controlled substances are total stories in themselves to be continued in the next series.


Six Healthy Lifestyle Habits Linked to Slowed Memory Decline

  • Physical exercise (weekly frequency and total time)
  • Smoking (current, former, or never-smokers)
  • Alcohol consumption (never drank, drank occasionally, low to excess drinking, and heavy drinking)
  • Diet (daily intake of 12 food items: fruits, vegetables, fish, meat, dairy products, salt, oil, eggs, cereals, legumes, nuts, tea)
  • Cognitive activity (writing, reading, playing cards, mahjong, other games)
  • Social contact (participating in meetings, attending parties, visiting friends/relatives, traveling, chatting online)

FDA Approves Daprodustat, First Oral Anemia Treatment


Recall on BP Med

Lannett Company Inc. is recalling 25,680 bottles of triamterene and hydrochlorothiazide capsules because samples failed to meet impurity/degradation specifications during routine testing, according to the January 25, 2023, US Food and Drug Administration (FDA) Enforcement Report.

The recall affects the following products, which were distributed by the Lannett Company, Philadelphia, Pennsylvania, throughout the United States:

  • triamterene and hydrochlorothiazide capsules (37.5 mg/25 mg), 100-count bottles (NDC 0527-1632-01) and 1000-count bottles (NDC 0527-1632-10), from lots 21000279A (Exp. 1/23) and 20256320A (Exp. 12/22); and
  • triamterene and hydrochlorothiazide capsules (37.5 mg/25 mg), 1000-count bottles (NDC 0527-1632-10), from lots 20256318A (Exp. 12/22), 20256321A (Exp. 12/22), and 21000238A (Exp. 1/23).

Lannett Company voluntarily initiated the recall November 9, 2022. On January 16, 2023, the FDA designated the recall Class III. Per the recall classification, use of the affected capsules is not likely to cause harm.

Triamterene and hydrochlorothiazide capsules are available with a prescription for the treatment of hypertension and edema in certain patients.


Roles of a Pharmacist

Pharmacists can give a variety of advice to patients online, including:

  1. Medication management: pharmacists can help patients understand how to take their medications properly, including how often to take them and any potential side effects. They can also help patients understand why they are taking a particular medication and what it is intended to treat.
  2. Drug interactions: pharmacists can help patients understand if their medications may interact with each other or with certain foods or supplements.
  3. Over-the-counter medication recommendations: pharmacists can recommend over-the-counter medications to help patients manage common conditions, such as allergies, pain, or heartburn.
  4. Disease state management: pharmacists can help patients understand how to manage their chronic conditions, such as diabetes or high blood pressure, through lifestyle changes and proper medication use.

It’s important to note that pharmacists cannot diagnose patients or prescribe medications online. If a patient has a specific medical question or concern, it is important for them to speak with a healthcare provider.


Dosing Directions Mix-up

Unfortunately, mistakes happen in the interpretation of dosing directions. When working with patients taking oral chemotherapy, communicating the correct directions is important.

A husband came in and filled a prescription for his wife for Leukeran. The directions on the prescription was for one tablet daily for one week then stop for 3 weeks and then repeat. The prescription should have been written for just 7 tablets with enough refills for the course of therapy. However, the prescription was written for 21 tablets which were all dispensed.

The wife took one tablet a day for the full 21 days. The husband came in at that time and wanted the medication refilled. Upon questioning, I realized the wife had taken all the medication within the 3 weeks. The doctor was immediately notified.

Her blood was affected but she did recover. The husband and wife both said they never read the directions. The husband was counseled. He said he didn’t understand the importance of stopping for those 3 weeks during that conversation.

Woodward Pharma has introduced LeukeranTabloid and Myleran tablets with new NDC numbers. This means the pharmacy will submit your billing with these new codes. If you need financial help, Woodward Pharma is offering a copay card.

You can find the information here:

COPAY CARD INFO


Pharmacist Brown Bag

Many times patients would bring their medications to the pharmacy in large, clear baggies. They would ask us to peruse through the many bottles of pills and liquids. They wanted to set up dosing schedules that met their needs and made the meds therapeutic.

Surprisingly, or maybe not, many of the medications were in the wrong bottles. This was secondary to dumping medications into old pill bottles without regards to the labels containing the drug name and directions.

Some people were taking multiple doses of the same medication. Always it was from them getting a different looking generic pill. Thinking they were a different med, the dose became doubled.

The most amusing were the pill bottles that were cut with a knife or a saw. Not able to remove the safety caps, the patient would cut through them, leaving a small hinged part. This allowed the tablets to conveniently spill out into the baggie adding to the confusion.

Much of this could be avoided with the introduction of a polypill. Medication adherence is much better with a polypill. A polypill is a tablet or capsule that includes multiple medications in one unit. Each medication would treat a different disease state. This could consolidate three or four tablets into one. The benefit is obvious.

You can read more about polypills at:

POLYPILL INFORMATION


Pharmacy Tech ‘Feelings’

I had my own pharmacy in New York many years ago. One of the pharmacy technicians used to disappear in the bays for short periods of time. I could always hear the pills rattling around in the bottles, as if she was shaking them, like a child would a rattle.

At the time, I assumed she was looking for an open bottle of a medication we needed to fill. This was the sophisticated way we did things in the pharmacy back then. But, she usually came back empty handed.

One day, I wasn’t busy at the moment she was rattling the bottles and I went back to inspect. She had a large bottle of metformin open and was pouring the tablets through her fingers, funneling them back in the bottle and then pouring them through her fingers again.

I could see her greedily sliding her phalanges over and around those big tablets. (metformin are large tablets and would come in big bottles of 1000’s) When I asked her why she was doing this, she explained she loved the feeling of the large tablets sliding through her fingers and the visual of them pouring over her hand. Obviously, this was the consequence of working in a pharmacy since no other occupation would have access to such an idiosyncratic combination.

Which brings me to todays drug information.

Pharmacist, Yvette Terrie, has published an article titled “Potential Benefits of Metformin Beyond Diabetes”. She explains metformin could also be beneficial for the prevention of age-related macular degeneration and have a protective effect with colorectal cancer.

I predict metformin will become an OTC within several years or a Pharmacist prescribed medication.

You can read the whole article here:Potential Benefits of Metformin Beyond Diabetes

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