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February 15, 2024

Do Not Crush List

From time to time, questions arise as to whether oral dosage forms can be safely crushed or chewed without compromising the integrity or accuracy of the product.
 
The Institute for Safe Medication Practices (ISMP) used to post a list to its website, but has since removed it, stating that it “does not own, update, or review content on the List of Oral Dosage Forms That Should Not Be Crushed”, leaving some clinicians in the dark.
 
There’s good news, however.  Pharmacist’s Letter maintains and updates a Do Not Crush list of their own.  Normally, Pharmacist’s Letter requires a paid subscription to access their content, but this resource appears to be available free of charge.  Consider adding it to your list of favorites.

If ready access to this resource is not available, consider the following general guidelines to assist patients and staff in making reasonable recommendations:

  • Patient/caregiver considerations
    • If the patient or caregiver lacks the skill, dexterity, visual acuity, strength, or cognitive ability to accurately split a tablet, recommend that they AVOID doing so.
  • Product considerations
    • Do NOT split hazardous* or teratogenic medications
    • Do NOT split controlled-, extended-, sustained- or modified-release formulations unless the product is scored.  Doing so destroys the slow release properties.
    • Do NOT recommend splitting tiny, brittle/friable, or irregularly-shaped, enteric coated (EC), sublingual (SL) or orally disintegrating (ODT) tablets.  
      • Splitting any of these dosage forms may result in inaccurate or full/partial loss of dosing. 
  • Equipment considerations
    • Always recommend a tablet splitter and/or pill crusher to assist with splitting or crushing oral medications.
      • Using knives, razor blades or other splitting or pulverizing tools may result in harm and/or inaccurate dosing.

As always, you are welcome to reach out to your friendly, knowledgeable pharmacist to assist with tablet splitting/crushing recommendations.  
 
 
*National Institute for Occupational Safety and Health (NIOSH) updated their list of Antineoplastic and Other Hazardous Drugs late in 2023.  They plan to publish the updated list sometime in 2024.  Until then, the 2016 version linked here is the most current version.     

New Method to Access Obesity Drugs

The newest GLP1-RA to get FDA approval for an obesity indication is tirzepatide.  This drug is a dual glucose-dependent insulinotropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonist.  The brand name product (Mounjaro®) was approved as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes.  

In late 2023, an additional brand name version of tirzepatide, Zepbound® was FDA approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial BMI of 30 kg/m2 or greater or 27 kg/m2 or greater in the presence of at least one weight-related comorbid condition (e.g., type 2 diabetes mellitus, hypertension, dyslipidemia, obstructive sleep apnea or cardiovascular disease).

The ongoing GLP1-RA shortage has left many patients and providers scrambling to access these medications, and Lilly has come up with a direct-to-consumer solution to assess and dispense the medication from the manufacturer.  

How it works:

  • Using the telehealth platform (FORM) – patients complete an online form that gets sent to an independent telehealth provider
  • The portal offers the ability of the person to explore diabetes, migraine, or obesity resources
  • After choosing one of these disease states, the options are:

  

   1. Explore Telehealth:

  •  Obesity telehealth connects the person to FORM, where they complete a short quiz inquiring about their motivation to lose weight
  • Before connecting with a weight loss physician and registered dietician, they check if your state has coverage, obtain BMI, health history to rule out contraindications, a short list of medications, type of insurance, and age.
  • If eligible, they request email address, and give you a link to the overview and to make an appt in the coming months
  • The plan includes: working with an MD and RD, creating a personalized plan for nutrition, physical activity, and mindset, with educational and tracking tools, online community support and a personal scale.
  • Depending on insurance, there is a cost.  My trial showed a cost of $149/month, which is HSA eligible for the MD visit, with payment required before making the telehealth visit.
  • At enrollment, they do request medical records and have the person sign a medical release to share information with their PCP

    

   2. Find in-person care:

  • Links the person to a search engine for locally available physicians to explore using various filters

    

   3. Explore pharmacy services:

  • Coordinates access to their medications via an online pharmacy service who will help with prior authorizations and deliver the med to their home.
  • These services can be used via the telehealth providers or the local provider sending the prescription to LillyDirect, who then connects with the person to help with necessary next steps.  

 

 

Savings cards:

  • Person chooses commercial/Medicaid/Medicare/VA/Tricare to find out what their insurance currently covers
    • Commercially insured persons (co-pay discount)
    • Cash-pay (discounts the price down to $550 for 1 month supply)

 

References:

Mounjaro PI

Zepbound PI

Lilly direct

Study Shows Risk of Severe COPD Exacerbation with Use of Gabapentinoids

A recent study published in the Annals of Internal Medicine has provided more insight into the risk of gabapentinoid use in those with chronic obstructive pulmonary disease (COPD).  The study helped to show that the use of such medications specifically can increase the risk of severe COPD exacerbations.  

The study, conducted in Canada, was a population-based cohort study that looked at patients with COPD between 1994 - 2015 who used gabapentinoid-type medications for either epilepsy, neuropathic pain, or other chronic pain.  They were matched against patients with COPD who did not use such medications.  The primary outcome measured was severe COPD exacerbations requiring hospitalization.  The data revealed 356 gabapentinoid patients taking the medication for epilepsy, 9411 with neuropathic pain, and 3737 with other chronic pain-type indications.  When these patients were matched against gabapentinoid non-users, this class of medications was associated with increased severe COPD exacerbations across all three groups:

  • epilepsy (HR, 1.58 [95% CI, 1.08 to 2.30])
  • neuropathic pain (HR, 1.35 [CI, 1.24 to 1.48])
  • other chronic pain (HR, 1.49 [CI, 1.27 to 1.73])
  • overall risk (HR, 1.39 [CI, 1.29 to 1.50]).

The results of the study showed that for those taking these medications for neuropathic pain and other chronic pain, this risk was observed regardless of age, sex, number of prior COPD exacerbations, prior use of inhaled corticosteroids, number of respiratory medications used, or opioid/benzodiazepine use.  Of note, authors did note that they did not have information regarding current or previous smoking history in the studied populations.

Gabapentinoid-type medications include medications commonly used in daily practice, including gabapentin and pregabalin.  Although initially developed as anti-seizure medications, they have become significant treatment modalities for neuropathic pain and other off-label pain syndromes.  Compared with opioids, the thought may exist that gabapentinoids are a “safe” alternative.  As providers have been faced with the challenge of finding alternative treatment options in light of the opioid epidemic, these medications have often filled the gap.  Despite their perception, however, their pharmacologic profile is not risk-free.  More specifically, their ability to cause central nervous depression can lead to both sedation and respiratory depression.

Severe exacerbations of COPD are considered signs of rapid disease progression that are often linked to poor long-term prognosis.  The authors of the study cited that “approximately 85% of all patients with COPD have had at least 1 pain-related diagnosis, including 27% with neuropathic pain, and 70% were reported to use at least 1 prescription pain medication(1).”   As a result, there is a high potential for gabapentinoid medication use in such populations and caution should be exercised.

The Food and Drug Administration (FDA) has previously issued a Drug Safety Communication highlighting the concerns discussed above, however this recently published study has provided better details of the risk involved.  Despite the FDA warning, neuropathic treatment guidelines have not reflected any specific cautions.  Although the authors do not necessarily suggest these medications should not be used, they do feel that prescribers and patients should be aware of the risk involved.

 

Reference:

Rahman AA, Dell'Aniello S, Moodie EEM, Durand M, Coulombe J, et al. Gabapentinoids and Risk for Severe Exacerbation in Chronic Obstructive Pulmonary Disease : A Population-Based Cohort Study. Ann Intern Med. 2024 Jan 16. doi: 10.7326/M23-0849. Epub ahead of print. PMID: 38224592.

Clinical Pharmacy Practitioner in Primary Care

Mike Grunske, PharmD, BCPS

Mike Grunske is a Board-Certified Pharmacotherapy Specialist (BCPS). Mike transitioned his practice to the Clement Zablocki VA Medical Center where he has since practiced in the Primary Care Clinics as a Clinical Pharmacist Practioner. Within this role, his practice involves direct care and management of patients’ medication regimens. He has worked as an active preceptor for both pharmacy students and residents throughout his entire career. Mike is also Past-President and former Foundation Chair of the Pharmacy Society of Wisconsin (PSW).

Mike is married to a fellow PharmAid contributor (Vanessa Grunske). Together they have a teenage daughter and son. He enjoys traveling with his family, attending his kid’s cheer, baseball, and basketball events, and spending any available leftover time running and hunting.

Pharmacist at Advocate Aurora Health

Vanessa Grunske, PharmD, BCACP

Vanessa practices with Advocate Aurora Health in Milwaukee, where she sees patients at Aurora Sinai Medication Management Clinic and maintains a dispensing practice at St. Luke’s Medical Center. Board-certified in ambulatory care pharmacotherapy, her practice interests include diabetes, hypertension, smoking cessation, geriatrics, improving health literacy, and medication adherence. She particularly enjoys and spends a good share of her work hours teaching and mentoring pharmacy students, family medicine residents and pharmacy residents.  

She and her husband, Mike, live in the Milwaukee area with their two teenage children. In her free time, she enjoys cooking, baking, visiting our national parks with her family or relaxing on a beautiful Caribbean beach.

Professor at Concordia University Wisconsin School of Pharmacy

Beth Buckley, PharmD, CDCES

Beth Buckley, PharmD, CDCES (Certified Diabetes Care and Education Specialist), is a Professor of Pharmacy Practice at the Concordia University Wisconsin School of Pharmacy, where she has a teaching role within all years of the curriculum with a focus on Applied Patient Care Skills Lab, Diabetes Pharmacotherapy, and electives in the areas of diabetes and wellness. Her current role is ambulatory care pharmacist where she works with a Collaborative Practice Agreement to provide chronic disease state management within a primary care clinic.

When not working, she enjoys reading, gardening, traveling with her husband, volunteering within the community, and active fun: hiking, biking, dog walking, practicing yoga, mindfulness, and living with intention and gratitude. 

Disclaimer: The Wisconsin Academy of Family Physicians (WAFP) has entered into a business relationship with Pharm Aid to offer our members discounts and exclusive savings. This or other affinity program relationships presented by the WAFP in no way implies a WAFP endorsement of the program, supplier, or vendor.

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