Know what you don't know - a lesson in pharmacogenomics

Written by: Alicia A. Timko, PharmD.  Consultant Pharmacist Long Term Care Rx Pharmacy

Those of us in the field of medicine and health care have studied the sciences for years. As a pharmacy student, I spent hours building and rebuilding molecular structures with my molecular model kit for Organic chemistry and many more hours studying molecular pathways of metabolism in Medicinal chemistry.

Science can seem rigid and firm. It can seem certain and true. But we know that that the practice of medicine is an art, right? What does that mean? On the surface, we may accept that the practice of medicine is more gray and fluid and creative like art, but do we really? Do we accept that there are huge gaps in our knowledge of how these molecular structures interact with the unique blueprints within each person?

Practicing pharmacists can sound so certain about their knowledge of side effects of medications, so certain that “You really couldn’t be having that side effect. It isn’t in the package insert.” or “That medication HAS to be working especially at THAT dose!”. We doubt the patient. We are skeptical of their pronouncement of how this medicine is working in their body. “It couldn’t be. It can’t.” The world of pharmacogenomics is here to change all that.

Pharmacogenomics is the study of how human genes affect drug response. This field is no longer the Star Wars of pharmacy, some farfetched, futuristic potential in medicine. It is happening here and now. You may not have laid eyes on the results of any genomic lab tests, but the knowledge of specific genes and their effect on specific medications is well documented and laid out.  

Let’s take the pain medication codeine. Pharmacology has long taught us that codeine gets largely metabolized to morphine which has a 200-fold stronger affinity for pain receptors in the body vs codeine. Pharmacogenomics now reveals that individuals can have variations in their genes that cause them to have varying effects. Some can be considered “Ultra-rapid metabolizers” (convert lots of codeine to morphine), “Extensive or Intermediate metabolizers” (convert “normal” or slightly lower amounts of codeine to morphine) or “Poor metabolizers” (convert much less codeine to morphine). It is believed that approximately 5%-10% of the population are “Poor metabolizers” of codeine to morphine. Thus, not getting the pain relief the rest of us would experience. And approximately 1%-2% of the population are “Ultra-rapid metabolizers,” leading to toxic levels at doses considered “normal.” Morphine is a recommended alternative because it does not follow the same metabolic pathway.

Pharmacogenomics is helping to reveal why medicine is an art. Helping us accept the outliers. Helping to create personalized medicine over empiric medicine. A seismic shift.

So, do we need to memorize all the genes and their effects on medications? Probably not just yet. But we do owe it to our patients to know what we don’t know. Believe them when they say that this drug is just not giving them any pain relief. Try a recommended alternative (there really are published guidelines to follow! Google CPIC Guidelines*). You may not know whether your patient is an Ultra-metabolizer or Poor metabolizer but you will have an intelligent alternative to try if they are failing the empiric drug of choice.

*CPIC- Clinical Pharmacogenetic Implementation Consortium Guidelines.

Prevnar 13 vs Pneumovax 23

As cough and cold season approaches, we’ve been seeing an uptick in the amount of pneumonia vaccine orders and questions. The CDC currently recommends that adults greater than 65 years old should get both the Prevnar 13 and Pneumovax 23.  It’s especially important to make sure the residents with high risk diagnoses (diabetes, COPD, heart failure, chronic liver disease) receive these vaccines.

In residents with no prior pneumonia vaccinations, Prevnar 13 should be given first. This helps to improve the body’s immune response to the vaccine. After one year, the Prevnar 13 should be followed by the Pneumovax 23.

If your resident has already received Pneumovax 23 but not the Prevnar 13, that is alright. The Prevnar 13 can still be given one year after the Pneumovax. If your resident can’t remember if they have ever been given either vaccine, then it will not hurt to assume no vaccination was given and to start the Prevnar 13.

A few more pneumonia vaccine facts:

1. Giving both of these vaccines in seniors is estimated to prevent 230 cases of invasive pneumonia and 12,000 cases of community-acquired pneumonia in their lifetime.
2. Medicare Part B covers both vaccines at zero cost to the resident.
3. It is okay to give these vaccines at the same time as many other vaccinations, such as their annual flu shot or a shingle vaccination.

As always, if you have any questions or would like more information regarding pneumonia vaccination (or any vaccination for that matter), please contact the pharmacy.

Thanks for reading!

Drew Curtis, PharmD
Pharmacist Manager
Consultant Pharmacist

When in Doubt, Write it Out

It seems like we as a society are always looking for ways to abbreviate our everyday lives.  Twitter shortens our thoughts to 140 characters or less. Shorthand makes taking notes during a lecture much easier. Emoji remove words completely to communicate a thought or feeling with just a smiley face. Abbreviations definitely serve a purpose in our day-to-day lives, but caution should be used when we are communicating medical information.

One of the most common causes of preventable medication errors is the improper use of abbreviations. Misinterpreted abbreviations or symbols can frequently lead to mistakes that can result in patient harm, delay the start of therapy, and waste time spent trying to clarify the original order. Abbreviations that seem obvious and make perfect sense to the person writing the order can still be misinterpreted by someone else. Take a look at the following examples:

Seems pretty self-explanatory, right? Potassium chloride 10meQ, 1 tablet by mouth daily. Or is it four times daily?

What about this one? Should we give 6 units of insulin, or 60?

Imagine coming across these two handwritten orders during the middle of your work day.  The phone is ringing off the hook. You have 2 residents having behavior issues in the dining room.  It’s time for shift change over and your replacement is running late. Can you say, with 100% certainty, that these orders will be interpreted correctly? Even under the best of circumstances, mistakes can happen.

When it comes to resident safety, it’s important to remember to slow down and do our best to communicate medical information safely and effectively. I’ll leave you with a list of commonly misinterpreted medical abbreviations. Are there any that you use?

Abbreviation	Misinterpretation	Instead Use
U (unit)	Mistaken for zero, number four, or cc	Write "unit"
IU (international unit)	Mistaken for IV or number ten	Write "international unit"
QD (daily)	Mistaken for QID (four times daily)	Write "daily"
QOD (every other day)	Mistaken for QID and QD	Write "every other day"
Trailing zero (X.0 mg)	Decimal point is missed (ex: 1.0 mg read as 10mg)	Write X mg
Lack of leading zero (.x mg)	Decimal point is missed (.1 mg read as 1 mg)	Write 0.X mg
MS	Can mean morphine sulfate or magnesium sulfate	Write out "morphine sulfate" or "magnesium sulfate"
MSO4 and MgSO4	Can be confused for one another	Write out "morphine sulfate" or "magnesium sulfate"

Healthcare is a very diverse field. An abbreviation that one person may have used for years will not necessary translate to everyone else who may come across it. With medical abbreviations, when it doubt, write it out!

Drew Curtis, PharmD
Pharmacist Manager
Consultant Pharmacist

Easing the Transition

Mr. Smith is an elderly resident of a long term care facility with atrial fibrillation.  He’s been taking Coumadin for years for stroke prevention and was just recently hospitalized for pneumonia.  His Coumadin dose was decreased in the hospital due to a drug interaction with an antibiotic, and he was discharged back to the nursing facility on this new lower dose.  While he was out of the facility, he missed his routine lab draw for his Coumadin.  Within the week, Mr. Smith has returned to the hospital after suffering a stroke since his Coumadin dose was sub-therapeutic.

This is a nightmare scenario for the resident, their family, the hospital, and the nursing staff.  Unfortunately, transitions of care in our healthcare system leave much to be desired.  Our residents are on complicated medication regimens often treating numerous disease states.  Even with the rise of electronic health records and multiple electronic messaging platforms, it is still difficult for different healthcare providers to piece together the whole story.

Long Term Care Rx’s goal is to help prevent situations like Mr. Smith.  Studies have found that adverse drug events attributable to medication changes occurred in 20% of transfers between nursing homes and acute-care hospitals. One-third of these events were considered preventable (AMDA Transitions of Care CPG, 2010).  If your facility accepts five admissions or readmissions a week, the statistics point to at least one of those admissions will lead to an adverse drug event due to a medication change.  That’s fifty-two medication errors a year in population that is high risk due to age and multiple medications used concurrently.  Over seventeen of those errors are considered preventable.  That’s seventeen fewer adverse effects, hospitalizations, or even deaths.  It’s statistics like this that reinforce how important this transitions of care program can be and what type of impact it can have clinically.

Assisting in these transitions of care has been a major point of emphasis for the Long Term Care Rx pharmacy team over the last 12 months.  Within 3 business days of every admission or readmission to a skilled nursing facility, a member of our team tries to put together all of the puzzle pieces to make a complete picture of that resident’s healthcare.  We take a look at previous medications prior to the level of care change, assess why the level of care changed, and ensure that the ideal medication regimen is being provided to each resident based on his or her needs.  We look for new drugs, especially new drugs that commonly result in adverse effects, and make sure the nursing facility is aware of what needs to be monitored.  Our goal is to make sure that residents stay at your facility and reduce hospital readmissions.

We encourage all of our facilities to take advantage of our transition of care program.  With your help, we can be proactive and catch any issues before they progress into problems.  If you have any questions regarding our transitions of care program, please don’t hesitate to contact the pharmacy directly for more information.  With your help, we can be proactive and catch issues before they progress into problems.  Together, we can ensure the best possible care for each and every resident.

Drew Curtis, PharmD
Pharmacist Manager
Consultant Pharmacist

When it comes to Coumadin... Who is steering the ship?

Coumadin (Warfarin) is a well-known, but not well liked anticoagulant in the long term care setting. Well known as a “blood thinner” to help prevent and treat blood clots and related heart attacks and strokes. Not well liked for the numerous blood draws and numerous dosage changes needed to achieve therapeutic levels, all of which equate to numerous time consuming phone calls to the physician. But perhaps Warfarin’s greatest “dislike” (or justifiable concern) is the risk of bleeding associated with it.

In February 2014, the Office of Inspector General (OIG) released its report, “Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries” which found that one in three skilled nursing facility (SNF) residents were harmed by an adverse event or temporary harm event within the first 35 days of a SNF stay. Thirty-seven percent of the adverse events were related to medication. And “the second most frequent cause of medication related adverse events was excessive bleeding related to anticoagulant use causing harm ranging from hospitalization to death.”

Coumadin. Second leading cause. Hospitalization to death. In our nursing homes. What?! you might say. Yes. That is the finding. But those of us who work in long term care likely already know this to be true on some level. We see the mistakes that happen. Missed drug. Missed lab. Too much drug. Toxic INR (International Normalized Ratio used to monitor Coumadin) sending a resident to the hospital, hopefully preventing a dangerous bleed. And these are not rare events. As a consultant pharmacist I am frequently bringing to the attention of facility staff that an “INR” has been missed, a new dose has been transcribed incorrectly, or worse, a discontinued dose was not removed from the resident’s medication and both the new AND dose have been given.

The question begs to be asked, “Who is steering the ship?” Who in the nursing facility is in charge of keeping track of residents on Coumadin? Who is in charge of looking for these pitfalls and preventing them. I might be so bold as to suggest that this can be simple. It really can be if we make it a priority. I suggest these steps for a starting point:

1. Name a person in charge
2. Obtain a list of all residents receiving Coumadin.
3. Write down when their next INR is due (and even use an electronic calendar to plug in reminders!)
4. Have staff report order changes daily to this person
5. Review these charts (at least) weekly to ensure INRs have been done, new orders properly transcribed and old doses removed from current meds. Electronic health records (eHRs) should make this task even easier.

This may seem like a lot. But when you look at the actual numbers, its more manageable. My larger facilities typically have less than 10 residents on Coumadin, especially due to the newer anti-coagulants out there now. But with the risks involved, doesn’t it seem like a good idea to have someone as captain of this ship?

Alicia A. Timko, PharmD
Consultant Pharmacist
Long Term Care Rx

Don't Forget about Pain...

In Feb. 2015, CMS created a new Quality Measure for Antipsychotic Usage in long term care facilities. The new Quality Measure is another step in The Centers for Medicare & Medicaid Services’ (CMS) goal to improve dementia care and avoid the usage of potentially dangerous antipsychotic medications for dementia related disruptive behavior. One of the main goals of the National Partnership to Improve Dementia Care in Nursing Homes is to help us as long term care providers to start recognizing BEHAVIOR AS A FORM OF COMMUNICATION. We need to start asking "What is this resident trying to tell me with this behavior?". "What could be the underlying problem that this non-verbal resident is trying to relay to me?"

Some well-known underlying causes of disruptive behavior include hunger, thirst, constipation, being wet, hot or cold; however, a commonly over-looked cause is PAIN! And why? Because our dementia residents can’t always tell us they are in pain!!

Pain is undertreated among our seniors. Some studies have revealed that focusing on pain in dementia residents significantly reduced disruptive behavior. I have seen this result in my own facilities. Even a benign trial of routine Acetaminophen 650mg by mouth twice daily has shown positive results. I mean, who doesn’t get uncomfortable sitting for long periods of time?! Let alone having other more serious causes of chronic pain (arthritis, spinal stenosis, etc).

So let’s face it. If we want to reduce medication usage for disruptive behavior, we need to become better sleuths…investigate the underlying cause, and don’t forget about pain.

Alicia A. Timko, PharmD
Consultant Pharmacist
Long Term Care Rx