PHARMACY MEDICATION ISSUES FOR SHELTER/FIELD COMMUNITY SUPPORT MISSIONS

1. PHARMACY MEDICATION ISSUES FOR SHELTER/FIELD COMMUNITY SUPPORT MISSIONS Saundra J. Martino, RpH

2. DISASTERS *Each disaster is different in the health care/medical needs that it creates *Epidemiological differential across the types of disasters—helps to predict exacerbations in patients with pre-existing conditions FIRES/VOLCANIC ERUPTIONS/EARTHQUAKES increase in particulate matter in the air which can exacerbate underlying pulmonary conditions HEAT WAVES added stress on people with underlying cardiac issues HURRICANES AND FLOODING see an increase in gastrointestinal illnesses and dermatological conditions

3. DESTRUCTION OF HOUSING increased risk of venous thromboembolism STRESS OF DISASTERS can exacerbate underlying cardiovascular and psychological issues *recent disasters have highlighted the need for medications to treat chronic disease states in addition to the usual acute ones that present in these situations *after Hurricane Katrina the majority of medications dispensed were for chronic diseases of people displaced by the storm

4. SHELTERS/FIELD MISSIONS *acute issues *cardiovascular disease *diabetes *pulmonary issues/asthma *mental illness Chronic conditions (cardiovascular disease, diabetes, pulmonary issues) impair an older adult’s ability to prepare, respond, or recover from a disaster

5. Pharmacy Specific Related Issues *limited medication availability *limited drug selection *increased need for therapeutic substitution *missing, incomplete, or inaccurate health care records *increased risk of adverse effects *compromised ability to maintain continuous care *poor access to fresh food and clean water *inability to store medications properly *donated drugs---often “dumped” –not useful for that particular situation/also short dated or expired

6. Addressing Some of The Problems • ICE Rx provides dispensing information from major PBM’s, and participating state Medicaid programs available to “credentialed” physicians and pharmacists • RxResponse collaboration of healthcare organizations involved in the manufacturing, distribution, and dispensing of medications pharmacy status reporting tool • Emergency Prescription Assistance Program (EPAP) federal program to pay for prescription medications and a limited amount of durable medical equipment (DME) in federal disaster areas one time fill of medications up to a 30 day supply for people with no prescription insurance

7. ACUTE ISSUES • Wound care • Rashes • Burns • Hypothermia • Crush injuries • Acute diarrhea • Infections • Immunizations OTC’s Antibiotics Analgesics Pedialyte Loperamide Kaopectate Xifaxan Meclizine Ondansetron inj

8. TETANUS Spores of C. Tetani reside in the soil and enter the body through open wounds ---travels to CNS ---block neurotransmission ---disinhibit the motor cortex --- extensive nerve spasms Tetanus Immune Globulin Prophylaxis of infection in patients with traumatic injuries Pediatric Dtap Adult Tdap

9. CARDIOVASCULAR DISEASE HYPERTENSION systolic bp> or= 140mmHg diastolic bp> or = 90mm Hg CONGESTIVE HEART FAILURE MYOCARDIAL INFARCTION *83.6 million American adults have 1 or more types of CVD *20% of adults over age 65 have coronary heart disease * 1 in every 5 individuals has hypertension=18.38% of the population or 50 million people *STRESS is a known risk factor for the development and progression of heart disease *physically limited *on oxygen *complex medication regimens *food in shelters is high in sodium, carbohydrates and fat SITUATIONS *heart attacks spiked in Japan after the 2011 earthquake and tsunami *Katrina: admissions to Tulane University Hospital heart attacks represented 2.4% of patients in the 6.5 years following the storm whereas they only represented 1% in the 2 years prior to the storm

10. CARDIOVASCULAR DRUGS • ACE INHIBITORS • BETA-BLOCKERS • CALCIUM CHANNEL BLOCKERS • DIURETICS • CARDIAC GLYCOSIDES • DIRECT VASODILATORS • NITRATES • CENTRALLY ACTING ALPHA2 AGONISTS ACE INHIBITORS *chf *hypertension Lisinopril 20mg tablets Enalapril 1.25mg/ml inj 2ml BETA BLOCKERS *angina *hypertension *arrhythmias Atenolol 50mg tablets Metoprolol tartrate 50mg tablets Metoprolol inj 1mg/ml 5ml Propranolol 20mg tablets Propranolol inj 1mg/ml

11. CARDIOVASCULAR DRUGS CALCIUM CHANNEL BLOCKERS *angina *hypertension *supraventricular arrhythmias Nifedipine 10mg caps Verapamil 80mg tabs Verapamil SR 240mg tabs Diltiazem hcl inj 5mg/ml 5ml DIURETICS *edema *hypertension Hydrochlorothiazide 25mg tabs Furosemide 40mg tabs Furosemide inj 10mg/ml 10ml CARDIAC GLYCOSIDES *chf *atrial fibrillation Digoxin 0.125mg tabs Digoxin inj 0.25mg/ml 2ml DIRECT VASODILATORS *hypertensive crisis Hydralazine 20mg/ml 1ml NITRATES *relief of angina pain Nitroglycerin SL 0.4mg tabs Nitroglycerin transderm 0.2mg/hr Nitroglycerin inj 5mg/ml 10ml Isosorbide 10mg tabs

12. CARDIOVASCULAR DRUGS CENTRALLY ACTING ALPHA 2 AGONIST *hypertension Clonidine 0.1mg tablets

13. DIABETESaffects 25.8 million Americans Katrina *11% of the population living in New Orleans and Jefferson parishes had diabetes *1 million people evacuated=100,000 displaced diabetics *Civic center at Baton Rouge housed > 6000 individuals would have to care for >600 diabetics Considerations: *dietary intake *physical activity *stress *other comorbidities hypertension dyslipidemia neuropathy kidney disease macular degeneration Diabetic Supplies alcohol pads lancets blood glucose monitors test strips syringes sharps containers glucose tabs/gels Drugs Glucagon for injection Glyburide 5mg tabs Pioglitazone 15mg tabs Humulin N/Novolin N Humulin R/Novolin R Humulin 70/30 / Novolin 70/30

14. DIABETES GLUCAGON FOR INJECTION emergency treatment of severe hypoglycemia increase in blood glucose levels >44lbs 1mg IM/IV/SQ GLYBURIDE 5MG TABLETS second-generation oral sulfonylurea stimulates pancreatic islet cells which results in an increase in insulin secretion onset of action is within 2 hours maximum decrease of serum glucose occurs in 3 to 4 hours once daily dosing with the first meal of the day PIOGLITAZONE 15MG TABLETS thiazolidinedione (TZD) “insulin sensitizer”—target insulin resistance in type II diabetics increased risk of heart failure, edema, weight gain once daily dosing INSULINS *various manufacturers/not normally what the patient uses *refrigerated (36-46 F) unopened is good until the expiration date on the box * un- refrigerated (59-86F) maintains its potency up to 28 days *>86F loss of potency and loss of blood glucose control over time General Rule: insulin loses its potency according to the temperature it is exposed to and the length of the exposure INSULIN SWITCHING Humulin/Novolin Humulin R/Novolin R Humulin N/Novolin N Humalog/Novolog Substitutable on a unit-for-unit basis—just monitor

15. DIABETES INSULIN PUMPS TO INJECTABLE Can substitute intermediate acting (NPH) for the 24 hour total basal dose of infused insulin on a unit – per-unit basis make sure total dose of NPH is split between morning & evening doses if regular insulin is available patients should administer mealtime insulin according to their previous system for calculating their bolus insulin doses

16. PULMONARY ISSUES/ASTHMA ASTHMA 2011= 25.9 million Americans highestprevalencein 5-17 year olds characterized by swelling and inflammation of the lining of the airway…muscles tighten around the airway and mucus clogs the airway…narrows the airway and breathing becomes difficult often occurs in response to specific “triggers” pollen, tobacco, mold, etc. COPD (chronic obstructive pulmonary disease) characterized by an obstruction to airflow that interferes with normal breathing affects 13 million LUNG CANCER SITUATIONS WORLD TRADE CENTER 9/11/01 July 2002-April 2004 rescue and recovery workers … 61% developed respiratory symptoms HURRICANE KATRINA respiratory issues increased due to mold produced by the flooding

17. RESPIRATORY TRACT AGENTS STEROIDS QVAR 40 mcg inhaler (beclomethasone dipropionate) Dexamethasone 4mg/ml inj Methylprednisolone 4mg dosepak Methylprednisolone 125mg inj Methylprednisolone 1000mg inj Prednisone 5mg tablets Prednisone 20mg tablets RESPIRATORY ANTIMUSCARINIC Ipratropium Bromide HFA inh (atrovent) RESPIRATORY SMOOTH MUSCLE RELAXANTS Theophylline ER 200mg tablets BRONCHODILATORS Albuterol HFA inhaler Albuterol soln for inh 0.083% Albuterol syrup 2mg/5ml Albuterol tablets 4mg Terbutaline sulfate inj 1mg/ml Terbutaline sulfate tablet 5mg

18. MENTAL ILLNESS *Psychological distress *Anxiety *Insomnia *Depression *Post-traumatic stress disorder

19. MENTAL HEALTH AGENTS ANTIMANIC AGENT Lithium 300mg tablets ANTIPSYCHOTIC Haloperidol 1mg tablets Haloperidol 5mg/ml inj Risperidone tabs 1mg ANXIOLYTIC Diazepam 5mg tab Diazepam 5mg/ml SEDATIVE/HYPNOTIC Zolpidem 10mg TRICYCLIC ANTIDEPRESSANT Nortriptyline 25mg caps HETEROCYCLIC ANTIDEPRESSANT Trazodone 50mg tabs SSRI Fluoxetine 20mg caps

20. CONCLUSION CHALLENGE Continuity of care—chronic medication use Attacks on the World Trade Center on 9/11/01 created greater awareness for the needs of the chronically ill population When the catastrophic hurricanes hit the Gulf Coast in 2005 public health and other professionals fully grasped the urgency to address the chronic health needs of the vulnerable populations during disasters