Robert A. Mangione

Access to multilingual medication instructions at New York City pharmacies

An essential component of quality care for limited English proficient (LEP) patients is language access. Linguistically accessible medication instructions are particularly important, given the serious consequences of error and patient responsibility for managing often complex medication regimens on their own. Approximately 21 million people in the U.S. were LEP at the time of the 2000 census, representing a 50% increase since 1990. Little information is available on their access to comprehensible medication instructions. In an effort to address this knowledge gap, we conducted a telephone survey of 200 randomly selected NYC pharmacies. The primary focus of the survey was translation need, capacity, and practice. The majority of pharmacists reported that they had LEP patients daily (88.0%) and had the capacity to translate prescription labels (79.5%). Among pharmacies serving LEP patients on a daily basis, just 38.6% translated labels daily; 22.7% never translated. In multivariate analysis, pharmacy type (OR=4.08, 95%CI=1.55–10.74, independent versus chain pharmacies) and proportion of Spanish-speaking LEP persons in the pharmacy’s census tract (OR=1.09, 95%CI=1.05–1.13 for each 1% increase in Spanish LEP population) were associated with increased label translation. Although 88.5% of the pharmacies had bilingual staff, less than half were pharmacists or pharmacy interns and thus qualified to provide medication counseling. More than 80% of the pharmacies surveyed lacked systematic methods for identifying linguistic needs and for informing patients of translation capabilities. Consistent with efforts to improve language access in other health care settings, the critical gap in language appropriate pharmacy services must be addressed to meet the needs of the nation’s large and ever-growing immigrant communities. Pharmacists may require supplemental training on the need and resources for meeting the verbal and written language requirements of their LEP patients. Dispensing software with accurate translation capability and telephonic interpretation services should be utilized in pharmacies serving LEP patients. Pharmacists should post signs and make other efforts to inform patients about the language resources available to them.

Drug absorption in celiac disease

PURPOSE Published evidence on established and theorized effects of celiac disease on drug absorption and pharmacokinetics is reviewed. SUMMARY Patients with celiac disease develop a variety of gastric disorders requiring oral medications, but the impact of damage to intestinal villi and other celiac disease sequelae on drug absorption remains poorly understood. A review of the pertinent literature (English-language articles on research in adults published during the period 1970-August 2012) identified several reports of altered drug absorption mechanisms in patients with celiac disease, including accelerated or delayed gastric emptying, increased permeability of jejunal mucosa, changes in intraluminal pH, decreased intestinal surface area, and reduced intestinal cytochrome P-450 enzymes. A small number of published studies suggest that celiac disease may be associated with altered drug absorption, resulting in higher serum concentrations of propranolol, lower peak concentrations of acetaminophen and practolol, higher dosing requirements with levothyroxine, impaired or delayed absorption of certain antibiotics, and other pharmacokinetic effects with a potential impact on medication efficacy and toxicity. However, these studies involved very small patient samples and were poorly controlled, with some yielding contradictory results. More and larger pharmacokinetic studies in patients with celiac disease-especially studies of drugs that are dosed empirically or are not amenable to dosage adjustment according to vital signs or laboratory values-are needed. CONCLUSION Given the sometimes conflicting data on drug absorption in the context of celiac disease, cautious medication selection, dosage adjustment, and monitoring for efficacy and potential adverse effects are advised.

Caring for patients with celiac disease: The role of the pharmacist

OBJECTIVE To review the epidemiology, pathophysiology, diagnosis, treatment, and complications of celiac disease, in order to provide guidance to pharmacists. DATA SOURCES Published articles identified through Medline using search terms such as celiac disease, gluten sensitivity, and gluten enteropathy. Additional resources were identified from personal bibliographies collected by the authors and bibliographies from gathered articles. DATA SYNTHESIS Celiac disease is an autoimmune disorder that is characterized by intolerance to gluten and affects approximately 3 million Americans. Although the most common manifestations of the disease are gastrointestinal, including diarrhea, steatorrhea, and weight loss, the disease is a multisystem disorder. Malabsorption is common, often leading to vitamin and mineral deficiencies and resulting in anemia and osteoporosis. Diagnosis is initiated through serology testing and confirmed by intestinal biopsy. The only treatment for celiac disease is strict, lifelong adherence to a gluten-free diet, which includes avoidance of foods, prescription and nonprescription pharmaceutical products, and cosmetics containing wheat, barley, and rye. Adherence to the gluten-free diet will promote intestinal healing and symptom relief and usually prevent complications of celiac disease. CONCLUSION Pharmacists can play an important role by identifying patients who may have celiac disease, providing information for gluten-free foods and pharmaceutical products, and encouraging adherence to the gluten-free diet.

Celiac disease and osteoporosis

The recently published “ASHP Therapeutic Position Statement on the Prevention and Treatment of Osteoporosis in Adults” is a well-written, comprehensive review of a very important disease.[1][1] I respectfully suggest that the document should have included a discussion of the important

Glycosylated Hemoglobins and Diabetic Control Assessment

The historical development, biosynthesis, analysis, interpretation, and utilization of glycosylated hemoglobin determinations (HbA1 or HbA1c alone) are presented. The relationship between glycosylated hemoglobin determinations and assessment of diabetic control is discussed. HbA1 and HbA1c levels are elevated approximately twofold in diabetic patients. A correlation exists between abnormal fluctuations in blood glucose levels and HbA1 concentrations. The results of glycosylated hemoglobin determinations are not influenced by recent meals, physical activity, emotional stress, or inherited abnormalities. Although glycosylated hemoglobin determinations are subject to fewer variables than blood and urine glucose assessments, the clinician must be aware of the indications and limitations for their use. These indications and limitations are discussed.

Exploring the Community Pharmacist's Knowledge of Celiac Disease.

Objective. To evaluate pharmacists’ knowledge of celiac disease, and identify potential areas where additional continuing education may be needed. Methods. A survey was sent to community pharmacists practicing in a national chain pharmacy in one region of New Jersey and New York. Results. There were 418 pharmacists who responded to the survey with a response rate of 38%. Only 27% of all respondents who reported their understanding of celiac disease to be basic or advanced correctly defined celiac disease as both an autoimmune and a chronic lifelong disease. The majority (60%) of respondents correctly stated there are no federal regulations requiring manufacturers to designate medications as gluten-free. Twenty percent of respondents said they often recommended a change in diet to people suspected to have celiac disease before a confirmed diagnosis. Conclusion. Community pharmacists possess some knowledge of the disease and would benefit from and desire additional education about this disorder.

Theoretical pharmacokinetic drug alterations in pediatric celiac disease

Introduction: The incidence of pediatric celiac disease has risen and many of these children will receive medications at some time in their life. However, the absorption of drugs in pediatric patients with celiac disease has never been studied. The few studies that do exist have only been performed in adults and indicate that drug concentrations can be altered for some drugs. It is also noteworthy that few researchers have conducted studies to determine if the distribution, metabolism, and excretion of drugs are altered in celiac disease. Areas covered: The pharmacokinetics of drugs greatly differ between children and adults. Combined with the pathophysiological changes known to occur with celiac disease, there is compelling evidence to support that drug exposure in pediatric celiac disease may be altered. Relevant characteristics of celiac disease that may affect drug disposition include intestinal atrophy, hypoalbuminemia, reduced CYP3A enzymes, and thyroid dysfunction. Expert opinion: The safety and efficacy of drug dosing in children with celiac disease can be enhanced with additional pharmacokinetic studies of commonly prescribed drugs in this population. Ideally, these studies should include drugs that have high bioavailability, are highly protein bound, undergo extensive CYP3A enzyme metabolism, and/or have a narrow therapeutic range.

Selected Pediatric Emergencies in Community Practice

In children, the signs and symptoms of serious infection often mimic those observed with minor, self-limiting diseases. One of the most important steps in making a diagnosis of an infection of the central nervous system is to suspect that an infection may be present. Acute epiglotitis predominantly affects children 2 to 7 years of age; delays in its diagnosis or treatment may result in death within a matter of hours. Pharmacists should be aware of the signs and symptoms of child abuse and neglect and understand the reporting procedures and requirements.