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. 

Recommendations for Hormonal Treatment: Still Evolving

Parkinson disease (PD) affects approximately 2% of Americans older than age 80 years. Although patients who have PD generally see a neurologist or a movement disorder specialist, they receive care from primary care providers frequently. Recently, 2 studies of medication use in people who have PD have been published. Both of them indicate that this population is at high risk for medication misadventure.

The first study, which looked at dementia treatment and prescribing error in older adults with PD, indicates the dementia is a common comorbidity. One problem in treating patients with PD who also develop dementia is that acetylcholinesterase inhibitors and anticholinergic medications should not be used concurrently. Acetylcholinesterase inhibitors are a cornerstone of treatment for dementia, while anticholinergics are critical for PD.

, looked at more than a quarter of a million of Medicare beneficiaries who were diagnosed with PD. In the subset of individuals who received dementia-directed treatment, almost 45% received a high potency anticholinergic drug plus and acetylcholinesterase inhibitor. Retail health clinicians should note that coadministration of these drugs is considered a “never event” because it is highly likely to contribute to the patient’s increasing disability. Individuals at highest risk were women and Hispanic beneficiaries. Geographically, this never event was most likely to occur in the southern and midwestern United States.

The second study, published in the journal

, looked at a different population — individuals who carried a diagnosis of PD and were hospitalized. Here too, the study size was large (N  = 1736) and reviewed over a 4 year time span. Among this population, 77 patients received 175 potentially inappropriate medications. The authors note that patients who received these medications were significantly more likely to have longer durations of stay. This study differs from the other and that it looked for a wider assortment of inappropriate medications including antiemetics, antipsychotics, analgesics, lithium, some antidepressants, metoclopramide, and valproate.

The drugs that were most likely to be prescribed inappropriately were droperidol, numerous antipsychotics, meperidine concurrently with a monoamine oxidase B inhibitor, and metoclopramide. Many of these patients were admitted on these drugs, and the hospital’s electronic medication order entry system lacked specific alerts that would have notified prescribers that they were making an error. This points to one area where clinicians might increase the likelihood of averting error; they should look at their order entry alert system and ensure that these drug interactions are coded into it.

The message to retail healthcare providers is that when they see patients who have Parkinson’s disease, it’s critical to look at the patient’s entire indication regimen. Adding any new drug should be done only with considerable forethought. And, transitions of care are hazardous and every attempt should be made to reconcile drug lists after a hospitalization or similar change and healthcare location. Here, there’s an opportunity to involve the local pharmacist to screen for potential drug interactions in advance.

Cox N, Louie JM, Sederholm BH. Inappropriate medication use in hospitalized patients diagnosed with Parkinson's Disease.

(Basel). 2018 Sep 15;6(3). pii: E100. doi: 10.3390/pharmacy6030100.

Mantri S, Fullard M, Gray SL, et al. Patterns of dementia treatment and frank prescribing errors in older adults with Parkinson Disease.

. 2018 Oct 1. doi: 10.1001/jamaneurol.2018.2820. [Epub ahead of print]

A pair of studies indicate that patients with Parkinson Disease are at high risk for medication misadventure.

Patients with Parkinson Disease: Mind the Medication

How many times do pharmacists and pharmacy technicians muse, ‘I wish I spoke Spanish?’ Many practicing healthcare professionals in the United States see a large number of Spanish-speaking patients, but don't speak the language.

When it comes to diabetes, that lack of a shared language can be a tremendous barrier to care. Hispanic patients are at elevated risk for diabetes and its complications compared with Caucasians, according to a recent study.

Pharmacists at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences in Aurora, CO knew that many Hispanic patients receive care at federally qualified health centers (FQHCs), with more than half of their patients members of this patient population. They also knew that Hispanic patients prefer to receive care in their native language. These professionals established a Collaborative Drug Therapy Management—driven bilingual clinical pharmacy service on diabetes outcomes, and measured its impact.

They published the results of this successful intervention in the

. These investigators included patients diagnosed with diabetes (n=211) who visited the pharmacy for the first time between July 1, 2015, and March 31, 2016. At that time, patients' median pre-intervention HbA

Over the ensuing months, they reviewed medical record data to look for HbA

blood pressure (BP) changes, number of visits, ethnicity, and primary language preference. The mean number of in-person visits with a pharmacist was 3.5 per patients.

was 9.1%. These patients also has statistically significant BP reductions. Improvement in HbA

increased as the number of visits with the Spanish-speaking clinical pharmacist.

Hispanic patients, and those who preferred their care in Spanish, had the same outcome as non-Hispanics and English speakers. This finding is important because multiple studies have shown that patients in this population have had traditionally had poorer outcomes.

This study should be incentives for healthcare professionals who serve large Hispanic populations to consider taking Spanish-language lessons. It can improve outcomes.

Chavez B, Kosirog E, Brunner JM. Impact of a bilingual pharmacy diabetes Service in a Federally Qualified Health Center.

. 2018 Jun 1:1060028018781852. doi: 10.1177/1060028018781852. [Epub ahead of print]

When it comes to diabetes, that lack of a shared language can be a tremendous barrier to care. 