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Each issue will include an editorial on a topic that is important for the profession of pharmacy, as well as a review of a new drug that includes a comparison of the new drug with previously marketed drugs that are most similar in activity, and a New Drug Comparison Rating (NDCR) for the new drug. Read on for this month's issue.
May 2008 Issue
New Drug Review
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Consumer Reports' Readers Rate Independent Pharmacies as the Best (but Some Opportunities are Being Missed)
The June 2008 issue of Consumer Reports includes an article, "America's Best Drugstores: 40,133 Readers Rate Service, Speed, and Advice (But Too Few Ask For It)." I would like you to think that The Pharmacist Activist is sufficiently visionary that we can report in our May issue what will appear in the June issues of other publications; however, I must acknowledge that the June issue of Consumer Reports was actually distributed in early May.
As in each of the previous pharmacy surveys of Consumer Reports readers, independent pharmacies were ranked above the other types of pharmacies (i.e., chain pharmacies, supermarket pharmacies, mass merchant pharmacies). Although independent pharmacies earned the highest numerical reader score (92 out of a possible 100), pharmacies with less than a five point difference in their reader score were considered to be in a statistical tie and include Medicine Shoppe (91), the supermarket pharmacies Publix (91), Hy-Vee (90), Hannaford (90), and Wegmans (88), and the mass merchant pharmacies Kmart (88) and Shopko (88).
It is noted in the article that readers gave pharmacists at independent pharmacies high marks "for being accessible, approachable, easy to talk to (when sought out), and knowledgeable about prescription as well as nonprescription products. Independents also stock medical supplies (wheelchairs, walkers, canes, and braces) that might be missing from other types of stores and will customize medicines for patients with special needs. Waits were uncommon, and many independents offer home delivery."
Other observations in the article that are especially pertinent for independent pharmacists include:
"Though they weren't the cheapest overall, many mom-and-pops were highly competitive, and our survey showed they offer top-notch service."
"A decade ago, independent pharmacies were an endangered species, but they rebounded...Unfortunately for consumers, independent pharmacies are again being threatened, this time by the federal government, which administers Medicaid and Medicare, including the Part D prescription-drug program for seniors. Independents rely on government reimbursement for almost 40 percent of all payments, and the government is a notoriously slow payer," (the latter statement being attributed to Lisa Miller of the National Community Pharmacists Association).
Opportunities Being Missed
The Consumer Reports article begins: "As new prescription drugs, over-the-counter remedies, and dietary supplements migrate into medicine cabinets across the U.S., consumers should be asking pharmacists more about dosage and interactions. Yet many aren't talking to pharmacists at all...Readers sought pharmacists' advice about prescription drugs at just 38 percent of walk-in visits during the course of a year, and they asked about over-the-counter remedies at just 29 percent. That's far less than in our 2002 survey, when the figures were 50 percent and 37 percent, respectively." Even in independent pharmacies, the observation that pharmacists are easy to talk to is qualified parenthetically with "when sought out."
For several reasons, many pharmacists are very busy and the time available for discussions with individual patients seems limited. However, what can be more important than being certain that patients understand both the benefits and risks of their medications, and how to use them in a manner that optimizes benefit and minimizes risk? Society and the organizations and others that are assuming much of the cost for health care will not tolerate much longer the extent to which drug-related problems continue to occur (the article refers to an estimated 18 million emergency room visits a year because medications have been taken incorrectly). Pharmacists have the expertise and most are strategically positioned to substantially reduce the occurrence of drug-related problems. I recognize that if pharmacies can't be successful financially, pharmacists will not be able to provide the types of professional services and counseling I advocate. However, if pharmacists do not provide these services, someone else will have to (physician assistants? nurse practitioners?). We can't expect to continue to be recognized as health care professionals, or be paid at current salary levels, based on a distribution function alone.
Independent pharmacists come closest to practicing pharmacy the way it should be practiced in the community setting. However, even they must guard against any compromise in the provision of services and take steps to initiate communication with patients and further enhance their services.
The Consumer Reports article should be "must reading" for all pharmacists.
Daniel A. Hussar
I was speaking recently with pharmacist Tom Genco of New Jersey who practices in a pharmacy that receives many prescriptions electronically (i.e., e-prescribing). During our discussion he referred to "neat mistakes" and I noted that I was not familiar with that term. He responded that prescribing mistakes still occur but they are "neat" because they can be easily read.
I am an advocate for e-prescribing and feel that it has the potential to substantially reduce the number of prescribing/dispensing errors. However, there are some who seem to have an expectation that e-prescribing will eliminate errors and, clearly, this is not the case. Tom's observation is of value in maintaining our awareness that there is always a potential for error, regardless of the systems that are used.
Daniel A. Hussar
On Memorial Day we honor the courage and sacrifice of those of our country who died in the wars in which we have been engaged. The media coverage given to the current war in Iraq almost exclusively reflects politics and criticism and, much too infrequently, addresses the bravery, stress, and sacrifice of our military personnel and their families. Regardless of our individual opinions regarding our country's involvement in this war, we should do more to demonstrate our support and encouragement, not just on Memorial Day but every day, for those who are placing their lives at risk.
Daniel A. Hussar
New Drug Review
Agent for Crohn's Disease
New Drug Comparison Rating (NDCR) = 3
(no or minor advantages/disadvantages)
in a scale of 1 to 5, with 5 being the highest rating
Administered subcutaneously for reducing the signs and symptoms of Crohn's disease and maintaining clinical response in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy.
Adalimumab (Humira); infliximab (Remicade).
- Less frequent administration (compared with adalimumab that is administered every 2 weeks);
- Is administered subcutaneously (compared with infliximab that is administered intravenously);
- May be less likely to cause injection site reactions (compared with adalimumab).
Most important risks/adverse events:
- Labeled indication is more limited (indication does not include inducing and maintaining clinical remission);
- Has not been directly compared with other agents in clinical studies;
- Fewer labeled indications (adalimumab and infliximab also have other labeled indications [e.g.,
rheumatoid arthritis, psoriatic arthritis, plaque psoriasis, ankylosing spondylitis);
- More frequent administration (compared with infliximab that is administered every 8 weeks);
- Is not indicated for use in pediatric patients (compared with infliximab).
Serious infections (boxed warning; e.g., tuberculosis, invasive fungal infections, and other opportunistic infections [patients should be evaluated for tuberculosis risk factors and be tested for latent tuberculosis infection; treatment should not be initiated in patients with active infections including chronic or localized infections; treatment should be discontinued if a patient develops a serious infection]); concurrent use with anakinra (Kineret) is not recommended; malignancies; exacerbation or new onset of demyelinating disease; exacerbation or new onset of congestive heart failure; lupus-like syndrome; hepatitis B virus reactivation; hypersensitivity reactions; hematological reactions; live or attenuated vaccines should not be use concurrently.
Most common adverse events:
Upper respiratory tract infection (20%), urinary tract infection (7%), arthralgia (6%).
400 mg (administered as 2 subcutaneous injections of 200 mg) initially, and at weeks 2 and 4; in patients who obtain a clinical response, the recommended maintenance dosage is 400 mg every 4 weeks.
Vials - 200 mg (should be stored in a refrigerator); doses should be prepared and administered by a health professional.
Certolizumab pegol is a recombinant, humanized antibody Fab fragment that is conjugated to a polyethylene glycol. It binds to tumor necrosis factor alpha (TNF alpha) and is the third of the TNF blockers to be approved for the treatment of patients with Crohn's disease, joining infliximab and adalimumab. However, whereas the labeled indication for the latter 2 agents includes maintaining clinical remission, the indication for certolizumab includes maintaining a clinical response that reflects a less pronounced effect as determined using a Crohn's Disease Activity Index. The effectiveness of the new drug was demonstrated in placebo-controlled studies; it has not been compared directly with other agents in clinical studies. The risks and adverse events associated with certolizumab are generally similar to those of adalimumab, infliximab, and the other TNF blockers, and include the risk of serious infections.
Like adalimumab, certolizumab is administered subcutaneously. However, adalimumab may be self-administered whereas the new drug should be administered by a health professional. The frequency of maintenance doses for adalimumab, certolizumab, and infliximab, is every 2, 4, and 8 weeks, respectively.
Daniel A. Hussar