Jeannette Y Wick, RPh, MBA, FASCP

At least 15% of people with diabetes suffer from dry eye disease (DED), which blurs vision and causes pain, itchiness, and dryness. DED results from reduced corneal nerve density that impairs the lacrimal gland (main gland responsible for diluting tears) as diabetes progresses.

Consequently, the eye releases hyperosmolar tears, which cause ocular irritation and dry eye.

The American Diabetes Association (ADA) recommends environmental and lifestyle changes in mild cases, including taking breaks while using technology&#151;such as a television, computer or smartphone—for long periods, using humidifiers, and employing warm compresses.

Clinicians have prescribed ocular lubricants including artificial tears  as mainstay treatment for DED but are only used for symptomatic relief. Topical insulin helps acinar cells proliferate and speeds the repair and healing of the lacrimal gland by stimulating the insulin-like growth factor-1 receptor (IGF-1R).

, researchers studied the efficacy of topical insulin compared to artificial tears. People with diabetes who exhibited the symptoms and signs of DED applied topical insulin 1 unit per mL, 1 drop 4 times per day for 4 weeks in this randomized, double-blind interventional study. The control was standard artificial tears. To measure efficacy of treatment, the study evaluated Baseline Ocular Surface Disease Index

Improvement occurred in both those administering topical insulin and standard artificial tears. Additionally, the study concluded that the treatment and standard artificial tears were equally efficacious. They suggest that topical insulin 1 unit 4 times daily (dissolved in normal saline) may be an option for patients because it is inexpensive and readily available.

Even though clinicians prescribe the treatments mentioned above often for DED, it is important to know when the patient should be referred. The ADA recommends seeing a doctor or ophthalmologist if symptoms persist or cause serious pain despite trying over the counter eye drops and anti-inflammatory medications.

The ADA also warns that this disease is incurable, but can be managed effectively.

A version of this article was originally published by Pharmacy Times.

Aniah Azmi N, Bastion MC. Short-Term Results of Trial of Topical Insulin for Treatment of Dry Eyes in Diabetics.

. 2019 May 22. doi: 10.1097/ICL.0000000000000623. [Epub ahead of print]

Conrady CD, Joos ZP, Patel BC. Review: The Lacrimal Gland and Its Role in Dry Eye.

. 2016;2016:7542929. doi:10.1155/2016/7542929

Articles

In a recent study published in Eye & Contact Lens, researchers studied the efficacy of topical insulin compared to artificial tears.

Patients with Diabetes and Dry Eyes May Find Relief with Topical Insulin

The drug store business has evolved from just dispensing prescriptions. Many pharmacies now host retail health clinics that provide basic primary care services and pharmacists now immunizations, too.

Retail settings also sell junk food, sugary drinks, tobacco products, and alcohol. Annual alcoholic beverages and soft drinks sales at drug stores has skyrocketed, reaching approximately $3.9 billion in 2017. Selling these products replete with empty calories in a health care setting, like selling cigarettes, is counterintuitive.

address the dual role pharmacies play as health care and prescription medication providers and beverage and food retailers. The authors also propose opportunities for change and policy-making to improve the retail drug chain food environment.

Most Americans live within a 5-mile radius of a retail drug store. Retail drug stores also serve numerous underserved and low-income communities with high rates of diet-related chronic diseases and childhood obesity. Obesity is linked to several chronic conditions: hyperlipidemia, cardiovascular disease and hypertension.

Robust prescription drug sales increase the opportunities to market and sell unhealthy food and sugary drinks to this population. Availability of healthy food choices, counseling from all of the pharmacy’s health care personnel, medication therapy management, immunizations, health-related information, and promotion and presence of retail health clinics can serve as positive cues toward better health outcomes.

The authors propose 5 measures to limit the exposure to unhealthy food choices in a retail setting

Pharmacies that sell food and beverages could implement food-free or healthy-food-only checkout lanes; place healthier foods in preferred locations; maintain minimum stocking requirements for healthy foods; and offer nutritional education programs. Pharmacy benefit managers (PBM) could consider nutritional standards as a prerequisite for inclusion in the pharmacy benefit network.

Pharmacists can offer medication synchronization and help patients avoid making multiple trips to pharmacy and exposure to unhealthy foods. (If this service is offered, retail health care providers should encourage their patients to use it.)

Retail clinicians can offer nutrition and wellness information and direct patients to healthy foods and beverages.

Health systems operating retail health clinics can require a food-free entrance path, waiting areas, pharmacy counters, and endcaps adjacent to clinics.

Unlike alcohol or tobacco regulation to protect the public against chronic illness, retail food environment is unregulated. Presence of health clinics in a retail setting makes a convincing case for formal regulation.

Cara Wilking, Mark A. Gottlieb & Nathaniel Rickles (2019): The role of chain pharmacies to promote healthy food retail: Current trends, legal limits, and policy opportunities, Health Marketing Quarterly, DOI: 10.1080/07359683.2019.1575058

A recent review addresses the dual role pharmacies play as health care and prescription medication providers and beverage and food retailers.

Addressing Obesity and Disease in an Environment with Junk Food

Cigarette smoking accounts for 8 of 10 chronic obstructive pulmonary disease (COPD) related deaths. Among the 16 million adults diagnosed with COPD, 38% continue to smoke.

The most effective intervention for halting COPD’s progression is smoking cessation. The public should be informed about the COPD-smoking connection, as patients often mistake symptoms of dyspnea for normal aging.

Smokers with COPD have higher rates of depression and nicotine dependence, and often find it difficult to quit smoking. Smoking cessation studies have shown that an initial quit rate of 50% to 60% can be achieved in the first 3 months. The 1 year quit rate is only 25% to 35% because almost 50% of COPD patients relapse.

Most smokers take 4 to 7 attempts to successfully quit smoking.

A combination of behavioral interventions and pharmacotherapy is required in smokers with COPD to break this cycle. Offering retreatment and counseling at every step increases the abstinence levels in these patients.

Behavioral interventions of self-help programs, brief advice and counselling (individual, group or telephonic) have all been shown effective in smoking cessation.

In smokers with COPD, the behavior change techniques most effective for smoking cessation were development of a treatment plan, prompt self-recording, advice on weight maintenance, and use of social support.

Nicotine replacement therapy (NRT), bupropion, and varenicline are the available pharmacologic options for smoking cessation. A nurse-conducted smoking cessation trial in an outpatient pulmonary clinic evaluated the efficacy of nicotine tablets (2 mg) in COPD patients. Abstinence rates were significantly higher in the intervention group at 6 (23% vs 10%) and 12 months (17% vs 10%) compared to the placebo group.

Varenicline is an agonist at the nicotinic acetylcholine receptors and prevents nicotine binding at receptor sites. In a double-blind randomized controlled trial (n=504), researchers evaluated varenicline’s efficacy and safety in smokers with mild to moderate COPD. For 9 to 12 weeks, continuous abstinence rate (CAR) was significantly higher in the varenicline group (42.3%) than the placebo group (8.8%). In patients with mild to moderate COPD, varenicline was more effective than placebo for smoking cessation.

In patients on long term NRT, varenicline with counseling was effective in assisting patients to quit NRT.

In the stage of change model proposed by Prochaska and colleagues, quitting smoking is compartmentalized into 5 stages: precontemplation, contemplation, preparation for action, action and maintenance. With each patient, tailor interventions appropriately to each stage to increase the chances of quitting. The Agency for Health Resources and Quality offers information here: Tobacco Use Counseling Fact sheets and resource, www.ahrq.gov

Despite pharmacotherapy’s evidence of effectiveness for smoking cessation in COPD patients, the average prescription rate for any smoking cessation medication was only 3.64% between 2007 and 2012. Patients with COPD have a greater urgency to quit smoking than an average smoker to improve disease prognosis.

Evaluate smoking status at every clinic visit and encourage patients to quit smoking at every available opportunity. In COPD patients, quitting smoking leads to better outcomes and reduced risk of death, hospitalization and emergency department visits.

CDC Tobacco Free. Smoking and COPD. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/diseases/copd.html. Published April 1, 2019. Accessed April 11, 2019.

. 2013;22(127):37-43. doi:10.1183/09059180.00007212

Jiménez-Ruiz CA, Andreas S, Lewis KE, et al. Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit.

. 2015;46(1):61-79. doi:10.1183/09031936.00092614

Tønnesen P, Carrozzi L, Fagerström KO, et al. Smoking cessation in patients with respiratory diseases: a high priority, integral component of therapy.

. 2007;29(2):390-417. doi:10.1183/09031936.00060806

Bartlett YK, Sheeran P, Hawley MS. Effective behaviour change techniques in smoking cessation interventions for people with chronic obstructive pulmonary disease: a meta-analysis.

. 2014;19(1):181-203. doi:10.1111/bjhp.12071

Tønnesen P, Mikkelsen K, Bremann L. Nurse-conducted smoking cessation in patients with COPD using nicotine sublingual tablets and behavioral support.

. 2006;130(2):334-342. doi:10.1378/chest.130.2.334

Tashkin DP, Rennard S, Hays JT, Ma W, Lawrence D, Lee TC. Effects of varenicline on smoking cessation in patients with mild to moderate COPD: a randomized controlled trial.

. 2011;139(3):591-599. doi:10.1378/chest.10-0865

Tønnesen P, Mikkelsen K. Varenicline to stop long-term nicotine replacement use: a double-blind, randomized, placebo-controlled trial.

Nicotine Tob Res Off J Soc Res Nicotine Tob

. 2013;15(2):419-427. doi:10.1093/ntr/nts146

Offering retreatment and counseling at every step increases the abstinence levels in patients who take multiple attempts to quit smoking,

Counseling COPD Patients on Smoking Cessation on Every Visit

The North American Menopause Society last issued a Hormone Therapy Position Statement in 2012. Now, they’ve issued a much-anticipated update that helps health care providers determine a course of action for vasomotor symptoms and the genito-urinary syndrome of menopause.

, the update provides information that can help clinicians choose appropriate hormonal therapies, and explain those therapies to patients.

In this document, hormone therapy means either estrogen therapy or estrogen-progestogen therapy, and the authors differentiate between ET and EPT when significant differences deserve mention. In addition, this document differentiates criteria for hormone therapy in cultural and minority populations, such as those with surgical menopause, early menopause, older age, or primary ovarian insufficiency.

The authors make a key point: clinicians who see menopausal women in their practices need to understand the difference between relative risk, absolute risk, and odds ratios clearly. Relative risk which is also called the risk ratio is the ratio of events that occur in 2 groups. Absolute risk is the difference in risk between 2 groups. Odds ratios measure the association between exposure and outcome, and if an odds ratio is 2 or lower, it is statistically difficult to assign strong validity to the finding if it is derived from observational studies. Odds ratios are most useful if they have been derived from randomized controlled trials.

Hormone therapy is still the most effective means of treating either vasomotor symptoms or the genito-urinary syndrome of menopause. The bottom line finding is that estrogen safety profile is quite good, and many women may benefit from longer durations of therapy. One of the most effective sections of this document describes each hormone therapy’s effects on specific target organs. The charts help health care providers choose an appropriate treatment for patients who have or have had heart disease, breast cancer, stroke, pulmonary embolism, colorectal cancer, or hip fracture.

One recommendation has not changed. Health care providers need to choose the lowest dose that treats symptoms effectively to minimize risk, although treatment duration might be longer than previously recommended. And, dosing should include progestogen to counter systemic estrogen’s effects on the endometrium. This translates to individualizing therapy key for each woman based on her symptoms, and her total health picture.

Health care providers should also remember that in addition to treating vasomotor symptoms, hormone therapy can prevent bone loss and reduce fractures in postmenopausal women. It’s also an effective means by which one can restore genitourinary tract anatomy and treat vulvovaginal atrophy.

Women often have questions about bioidentical hormone therapy, which is usually prepared by a compounding pharmacy. This document explains that bioidentical hormones are similar to endogenous hormones. The authors report that compounded bioidentical hormone therapy has minimal government oversight, and healthcare providers need to be aware that this can be a safety concern. These hormones are dosed based on salivary hormone testing, a procedure that has been noted to be unreliable. Clinicians who choose to use bioidentical hormones should document carefully indicating why they are using these products, including an allergy to available products or the need for formulation that is not yet FDA approved.

This document, which is 26 pages in length, also covers special populations in many different conditions. It is comprehensive in its detail, noting conditions in which evidence indicates that hormone therapy will help and also documenting when evidence indicates that hormone therapy will probably not help.

The authors don’t deny that there is still a considerable amount of controversy surrounding hormones therapy. They suggest that health care providers replace the concept of “lowest dose for the shortest period of time” with “appropriate dose, duration, regimen, and route of administration.”

The 2017 hormone therapy position statement of The North American Menopause Society.

Hormone therapy is still the most effective means of treating either vasomotor symptoms or the genito-urinary syndrome of menopause. 

Jeannette Y Wick, RPh, MBA, FASCP

Articles

Patients with Diabetes and Dry Eyes May Find Relief with Topical Insulin

Addressing Obesity and Disease in an Environment with Junk Food

Counseling COPD Patients on Smoking Cessation on Every Visit

Recommendations for Hormonal Treatment: Still Evolving