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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.

November 2013 Issue [Download PDF format]
In this issue:
• Editorial • New Drug Review
EDITORIAL:

Inspiration!

My students are a continuing source of inspiration who make it a pleasure to continue teaching on a full-time basis even though many of my contemporaries have retired. My students keep me young, at least young at heart if not chronologically. Often there are additional opportunities for professional stimulation and encouragement, and sometimes these situations even occur in bunches as they did this past week.

They started with my class on Wednesday afternoon from 4 - 6 pm. My former student, Steven Chang, owner of Parkway Pharmacy in Atlantic City, was the guest speaker in the course. In addition to being actively engaged in our profession and his community, Steven has attained credentials in the area of nutrition that he applies in seminars and personal consultations based in his second practice site, Essential Elements. One of the most satisfying parts of being a faculty member is to invite accomplished pharmacists whom I first came to know when they were my students to speak in my current course in which I am among those learning from them. On this occasion, however, I had informed Steven that I would be introducing him to the class and would then have to leave for the airport to catch a flight to Seattle.

I had been invited by my former student Joe Gerber, Senior Director of Educational Affairs of the American Society of Consultant Pharmacists (ASCP), to speak at the ASCP annual meeting in Seattle. My presentation was at 8:15 am on Thursday morning and I arrived at the room one-half hour early. I was surprised by the large size of the then unoccupied room and wondered how many pharmacists would be attending my session. By 8:15 am, several hundred pharmacists filled the room and most had already attended another educational program earlier that morning. I started by commending them on their professional commitment to extend their personal education and for their support of ASCP.

I wish that I could have stayed for the entire ASCP meeting as there were so many programs that I would have liked to attend. However, I needed to return to Philadelphia on Thursday for a commitment the following day. And fortunately, my flights were uneventful and on schedule, something I do not take for granted.

On Friday morning I drove to Chambersburg Hospital in central Pennsylvania. I had been invited to give a Medical Education presentation on the topic of New Drugs. Most of those in attendance were physicians and I couldn't help but reflect on my early years in pharmacy when only a few would have ever anticipated that physicians would attend an educational program presented by a pharmacist. It was a pleasure to observe the positive dialogue among the physicians and pharmacists at this hospital and recognize the substantial progress that has been made in interprofessional communications and practice.

A tour of pharmacies

My travel to central Pennsylvania provided the opportunity to visit some pharmacists whom I do not often see. My first stop was at Park Avenue Pharmacy in a quiet residential section of Chambersburg. Tom Stonesifer owned the pharmacy for many years and, in addition to providing a highly professional practice environment and services, he was a mentor for numerous individuals including his son Ben who is also a community pharmacy owner, and also Jenny Hopple. Jenny started working at Park Avenue Pharmacy when she was in high school, was inspired to study pharmacy, came back to Chambersburg to practice in this pharmacy and, several years ago, purchased the pharmacy from Tom. She is thrilled that her daughter who is now a high school senior is planning to study pharmacy.

My next stop was at Carl's Drug Store in Greencastle, PA. Owned by Frank Ervin for many years, Carl's Drug Store has the distinction of being the oldest continuously-operated pharmacy in the United States, having been founded in 1825 (only 4 years after the founding of the Philadelphia College of Pharmacy in 1821Ñand, no, I was not on the faculty then). Following decades of distinguished service to the Greencastle community, Frank has sold the pharmacy to Rodger Savage, another community pharmacy owner who is committed to continue this service to the community and preserve the historical legacy of Carl's Drug Store.

Dave and Jeanne Lutz own Rhoads Pharmacy and Gift Shop in Hummelstown, PA and I arrived there shortly after 4 pm. Dave provided me with a demonstration of his new RxMedic robot with many state-of-the-art features. As impressive as the pharmacy and pharmacy staff are, it is impossible to capture the magnificence of the gift shop with just words (and The Pharmacist Activist [for free] can't afford photos). Under Jeanne's capable and loving attention, this is a decorative showplace of unique gifts and displays that attracts individuals from all over central Pennsylvania. If you are anywhere close, you must visit! Among their collectibles are the Byers' Choice Carolers of which my wife and I have a small collection. I commented to Jeanne that it was unfortunate that Byers did not have a pharmacist among its hundreds of different figures. Jeanne responded, "I have a surprise for you." Soon thereafter, she and Dave presented me with the new Byers pharmacist, complete with mortar and pestle and bottle of leeches. A perfect gift for your favorite pharmacist! In their brochure, Dave and Jeanne include the statement, "If you don't say ÔWOW' when you enter or leave our store, we haven't done our job." "WOW."

Detour to Mt. Joy

Not far from Hummelstown is the community of Mt. Joy. There is no mountain but there is a lot of joy to which my son and daughter-in-law (Eric and Terra) and their five children (ages 7 to 1) greatly contribute. I knew that my grandchildren would be delighted if I surprised them with a visit. However, just to be sure they would be, I stopped at the nearby bakery to buy some cookies to take with me. It was a delightful visit (even before they knew I had brought cookies).

While in Mt. Joy I stopped at Sloan's Pharmacy in which three generations of the Sloan family have served this community. There are now five Sloan's Pharmacies in this region that are owned by Jake Sherk who has extended the excellent reputation established by the founding family.

Read the small print

On Saturday morning I had an errand to do in my home community of Newtown Square. A new free-standing Rite Aid had been constructed to replace one in a strip mall across the street, and it had just celebrated its grand opening. I needed a can of shaving cream and thought this would be a good opportunity to visit the newest pharmacy in our area (as a matter of principle I do not obtain prescriptions or other medications in places that sell cigarettes). The store is impressiveÑvery spacious and colorful, well lit, and well-marked sections and aisles. The one prominent blemish is the cigarette section featuring Marlboros.

After finding the shaving cream I passed a candy aisle and noted a special price for bags of Life-SaversÑ2 bags for $3.00. Not being one to resist such a bargain (or candy), I picked up two bags and proceeded to the cashier. As I was waiting for the cashier, I noted the size and clarity of the monitor on which customers, as well as the several people standing behind them, could view the names and prices of each of their purchases. As my purchases were being entered on the cash register, I observed that each bag of Life-Savers was being recorded at a price of $2.39. I stated to the cashier that the sale price was two bags for $3.00. She called the manager over the loudspeaker who came over and explained that the sale price was only for customers who have a Rite Aid Wellness Card. Oh, the humiliation of not having a Wellness Card! The woman waiting behind me wanted to help and said that I was welcome to use her Wellness Card. However, I politely declined her kind offer (I could envision Rite Aid charging me with fraud for using another customer's Wellness Card) and told the cashier that I did not want the Life-Savers at the higher price. By this time there were four customers waiting behind me so I resisted the temptation to ask whether customers who have Wellness Cards receive large discounts on cigarettes, or whether Wellness Cards have expiration dates.

When my purchase was completed I went back to the candy aisle to check again about the special price for Life-Savers. There it was in small print that the lower price was only for customers with Wellness Cards. I also looked at my cash register receipt to confirm the accuracy of the information printed on it (everything was accurate). The reason I did this was that about two years earlier a new CVS had opened up in our community. When I visited soon after the CVS opened, I bought a bottle of soda and happened to look at the receipt as I was leaving the store. It was very surprising to note that both the name of our town and the name of the street were spelled incorrectly. I periodically returned to make small purchases and it wasn't until about 8 months after the store opened that the mistakes on the cash register receipts were corrected.

Renewed inspiration

Following my Rite Aid experience, I was all the more appreciative of the services and professionalism of the pharmacists at Paoli Pharmacy that I and my family use. Paoli Pharmacy and Gateway Pharmacy are owned by two husband-wife pharmacy couplesÑHenry and Patty Katra and Mark and Sandy Szilagyi. Their children, Nick and Krissy Katra and Mark and Jenn Szilagyi are also pharmacists in these pharmacies that provide very comprehensive pharmacy services including compounding and medical equipment/supplies. Paoli Pharmacy has recently moved to a new larger facility in which the entire second floor is devoted to medical equipment/supplies and services. Henry and Krissy recently gave a presentation on this topic at a meeting of the student chapter of the National Community Pharmacists Association at the Philadelphia College of Pharmacy (PCP).

I serve as the faculty advisor for the organizations of Christian students at our University and each semester my wife and I host a dinner for these students at our home (to give credit where credit is due, my wife does all the meal preparation and other work). On Saturday evening, 60 students visited with us. It was a wonderful time of fellowship and the courtesy, personal qualities, and enthusiasm of these students was a source of encouragement and inspiration for both Sue and me.

And, in my mail, is a letter with a check representing a substantial gift from Mark Lawson. Mark received his Doctor of Pharmacy degree just 11 years ago. He now owns or is a partner in three pharmacies. He recently contacted me to indicate that he wants to give something back to the profession that has provided him with excellent opportunities. He has chosen to do this by paying the membership dues in the Pennsylvania Pharmacists Association for all of the PCP students in the P3 and P4 years who are Pennsylvania residents. What a wonderful investment in our students and in their future involvement in our professional associations!

Although there are issues and challenges facing our profession and individual pharmacists, we have so much for which to be thankful every day, but especially as we celebrate Thanksgiving.

Daniel A. Hussar
 NEW DRUG REVIEW:

Crofelemer
(Fulyzaq - Salix)
Antidiarrheal Agent

New Drug Comparison Rating (NDCR) = 4
(significant advantage[s])
in a scale of 1 to 5, with 5 being the highest rating

Indication:
For symptomatic relief of non-infectious diarrhea in patients with HIV/AIDS on antiretroviral therapy.

Comparable drug:
Loperamide (e.g., Imodium).

Advantages:
  • Has a unique mechanism of action (inhibits chloride channels and normalizes the flow of chloride and water in the gastrointestinal tract [GIT]);
  • Is more effective in some patients;
  • Is the first drug to be approved for the treatment of diarrhea in patients with HIV/AIDS.
Disadvantages:
  • Has not been directly compared with other antidiarrheal drugs in clinical studies;
  • Labeled indication is more limited;
  • Is a botanical product and composition is incompletely characterized.
Most important risks/adverse events:
Is not indicated for the treatment of infectious diarrhea, and infectious etiologies of diarrhea must be ruled out before initiating therapy.

Most common adverse events:
Upper respiratory tract infection (6%), bronchitis (4%), cough (4%), flatulence (3%), increased bilirubin (3%).

Usual dosage:
125 mg twice a day.

Product:
Enteric-coated, delayed-release tablets - 125 mg; tablets should be swallowed whole and should not be crushed or chewed.

Comments:
Crofelemer is a botanical substance that is derived from the red sap of Croton lechleri, a tree that grows in several countries in Central and South America. It is an oligomeric proanthocyanidin mixture that is primarily composed of units of various catechins. The new drug inhibits the cystic fibrosis transmembrane conductance regulator chloride ion channel, as well as the calcium-activated chloride channels. By blocking chloride secretion and accompanying high volume water loss in diarrhea, it normalizes the flow of chloride and water in the GIT.

The effectiveness of crofelemer was established in a placebo-controlled study of HIV-positive patients on stable antiretroviral therapy with a history of diarrhea lasting at least one month. Some patients had already used other antidiarrheal medications on a regular basis. A clinical response was defined as two or fewer watery bowel movements per week and was experienced by 18% of the patients treated with crofelemer, compared with 8% of those receiving placebo. The antidiarrheal effect persisted in some patients for 20 weeks.

Crofelemer is absorbed to only a limited extent and patients are not likely to experience systemic adverse events or interactions with other drugs. As a botanical product, the composition of crofelemer is incompletely characterized and inconsistent, and rigorous attention must be given to the control of raw materials, agricultural and collection practices, and testing of the mixture.

Daniel A. Hussar