THE RESIDENT STAR. Vitamin B 12 : A forgotten micronutrient. January Inside this issue: Steven Huang, Pharm.D.

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1 1 THE RESIDENT STAR January 2015 Inside this issue: Department of Pharmacy University of Washington, Box H375 Health Science Building Vitamin B 12 : A forgotten micronutrient Steven Huang, Pharm.D. UWPC Pharmacy Resident Vitamin B 12: A Forgotten Micronutrient PGY2 Pharmacy Residency & Project Gluten Free Medications 101 Clinical Service: Diabetes Prevention Program Seattle, WA Phone: (206) Fax: (206) pharmres@uw.edu Cobalamin or vitamin B12 is a water- soluble vitamin that plays an important role in various physiological functions. It is common health knowledge that vitamin B12 supports the formation of red blood cells and metabolism. However, B12 Clinical Service: Influenza Immunization and Treatment Influenza Update 6 7 also plays an essential role in the brain and nervous system with deficiencies potentially causing a variety of neuropsychiatric symptoms. 1 Neurological manifestations may be asymptomatic. Deficiency in vitamin B12 has been associated with dementia, depression, acute psychosis, and neuropathy that not only include motor- sensory, but optic and olfactory systems as well. Common neurologic manifestations of B12 deficiency include paresthesias, weakness, gait abnormalities, and cognitive or behavioral changes which can mimic Alzheimer s disease. The specific mechanism which B12 deficiency affects the neurologic system is unknown at this point. 1,2 It is also important to note that neurological symptoms of vitamin B12 deficiency can occur without anemia. 3 Absorption of vitamin B12 requires the

2 Continued presence of intrinsic factor that is produced by parietal cells in the fundus of the stomach. The two forms a complex that is later absorbed in the ilium. As people age, many can lose function of their parietal cells which leads to B12 deficiency. Other populations that are at risk of B12 deficiency include people with gastrointestinal disorders or who have had gastrointestinal surgery, vegetarians, and those with prolonged use of certain medications. 4 A daily consumption of 2.4 mcg of vitamin B12 for adolescents and older is currently recommended to prevent B12 deficiency. For adults older than 50 years of age and vegetarians, it is recommended that they consume foods fortified with vitamin B12 or supplement with B12, rather than attempting to get their intake strictly from dietary sources. Moreover, because of the high incidence of B12 deficiency in people that have undergone gastric bypass surgery, daily prophylactic supplementation of 1 mg is recommended. Clinical vitamin B12 deficiency has been traditionally treated with intramuscular injection of crystalline B12 at a dose of 1 mg weekly for eight weeks, followed by 1 mg monthly for life. However, high oral doses of B12 (1 to 2 mg daily) shows an improvement in serum vitamin B12 similarly to those who received intramuscular injections. There are also sublingual preparations and gel formulations applied intranasally, but there is no current evidence suggesting a difference in efficacy. 2,4 Table 1: Recommended Dietary Allowances (RDAs) for Vitamin B 12 Age Male Female Pregnancy Lactation 0 6 months* 0.4 mcg 0.4 mcg 7 12 months* 0.5 mcg 0.5 mcg 1 3 years 0.9 mcg 0.9 mcg 4 8 years 1.2 mcg 1.2 mcg 9 13 years 1.8 mcg 1.8 mcg 14+ years 2.4 mcg 2.4 mcg 2.6 mcg 2.8 mcg *Adequate intake 2 Risk Factors for Vitamin B 12 Deficiency 3,4 Decreased ileal absorption Crohn s disease Ileal resection Tapeworm infestation Inadequate intake Alcohol abuse Older persons Vegetarians Decreased intrinsic factor Atrophic gastritis Pernicious anemia Postgastrectomy syndrome Prolonged medication use Metformin (Glucophage) Histamine H2 blockers Proton pump inhibitors Genetic Transcobalamin II deficiency

3 References 3 1. Sethi N, Robilotti E, Sadan Y. Neurological Manifestations of Vitamin B- 12 Deficiency. Internet J Nutr Wellness. 2005; 2(1) 2. Langan R, Zawistoski K. Am Fam Physician. 2011; 83(12): Clarke R. B- vitamins and prevention of dementia. Proc Nutr Soc. 2008; 67(1): Vitamin B12 Dietary Supplement Fact Sheet. National Institutes of Health, n.d. Website. Accessed January 2, PGY2 Geriatric Pharmacy Residency & Project Steven Huang, Pharm.D. I provide consulting pharmacy services to different elder living facilities in the Seattle and Greater Seattle area. The University of Washington School of Pharmacy has developed a campus- community collaboration that allows practicing pharmacists to provide the best care for older adults, while also developing new, innovative practices in the field of pharmacy. My residency project will be evaluating the impact of a pharmacy- led educational program for assisted living facilities. The educational program will consist of providing health care workers at these facilities with both printed material and in- services with the focus of reducing inappropriate use of certain medications. Non- dispensing pharmacy services is currently not common in this type of healthcare setting, however, this small- scale study may provide data showing the benefits of pharmacy services in a non- traditional settings. Cyurry Choi, Pharm.D. QFC Pharmacy Resident Gluten Free Medications 101 As awareness of gluten intolerance grows, it seems like more people are diagnosed with celiac disease (CD), more restaurants offer gluten- free meal options, and more patients ask about whether their medications are gluten- free. Patients diagnosed with celiac disease are unable to tolerate the ingestion of gluten, an insoluble protein in most cereal grains, specifically wheat, rye, or barley (malt)- based grains. Gluten ingestion by these individuals causes an immunologically mediated inflammatory response and results in damage to the small intestine mucosa. Even a small amount of gluten can illicit this response, which is why patients are managed with a gluten- free diet. In terms of medications, gluten primarily comes from the excipient ingredients that are added to make a particular dosage form. Starches are one possible source of gluten. Although they are primarily derived from corn, potato, and tapioca which are safe for celiac patients some medications contain starch derived from wheat. Only by reading the package insert or by contacting manufacturers directly would a patient or pharmacist be able to know the source of the starch. A pharmacist should consider two questions: (1) What are the inactive ingredients or excipients? And (2) what is the source of the ingredients? Thinking about these questions will help to

4 Continued 4 determine if the drug manufacturer has to be called. Refer to Figure 1 for a flowchart. Figure 1. Flowchart of What to Look for and When to Call the Drug Manufacturer When speaking with the manufacturer, a pharmacist should be specific. Rather than asking if a product has gluten in it, the pharmacist may have to ask What is source is the starch derived from? or Does the product contain any proteins from wheat, rye, or barley? Once the information Consectetuer: has been obtained, the gluten free status of a product still has to be periodically reassessed because pharmaceutical manufacturers may change the inactive ingredients of their products. As for over- the- counter (OTC) drugs, information about gluten status is less readily available, but some resources are out there, including lists of common OTC gluten- free products. Refer to Table 1 for a list of resources on gluten free medications. The key takeaways are that gluten can be found in a lot of drug products. When the product contains starch, the source should be identified either from the package insert or from the drug manufacturers directly. Corn, rice, potato, and tapioca starch are safe for celiac patients; whereas, any products derived from wheat, rye, or barley (malt) are not. Resources are available, but obtaining the information regarding gluten status of medications may require some time.

5 5 Table 1. Gluten Free Pharmaceuticals Resources Website URL Highlights Gluten free Drugs Listed by therapeutic category Listed by alphabet Maintained by clinical pharmacist Additional links pertaining to food, medications, and fillers Celiac Disease Foundation Gluten Free Pharmaceuticals Resources celiac.org/live- gluten- free/glutenfreediet/medications/ Mainly a resource on celiac disease 800 numbers for pharmaceutical companies Gluten Intolerance Group Resource on gluten intolerance Education bulletins arranged by topic and available as.pdfs Gluten- free diet and drug instruction contains tables separating foods/drugs allowed and foods/drugs to avoid References: 1. Plogsted S. Medications and celiac disease tips from a pharmacist. Practical Gastroenterology. 2007;31(1): Available from 2. Gluten Intolerance Group. GIG education bulletin: Gluten- free diet and drug instruction. Updated 2013 Apr. Available from content/uploads/2013/12/edu_dietdrginst_ pdf on 2014 Dec 23 Diabetes Prevention Program Cyurry Choi, Pharm.D. QFC will be implementing a Diabetes Prevention Program in February, in partnership with the University of Washington School of Pharmacy and the Washington Department of Health. The Diabetes Prevention Program utilizes a CDC approved curriculum to emphasize lifestyle modifications to lower one s risk for diabetes. Lifestyle coaches, consisting of trained pharmacists and UW pharmacy students, will lead small group classes to motivate participants in making and sustaining these lifestyle changes over the course of the year. As part of the partnership with UW, QFC s pharmacists will be trained as lifestyle coaches or as facilitators for the program. In addition, UW pharmacy students, who have already been trained in the program as part of an elective, will utilize their training and their motivational interviewing skills to guide and support patients to make these lifestyle changes in the community. When the students rotations are over, QFC clinical pharmacists will continue the curriculum as a pilot program in two locations.

6 Continued 6 Later this month in January, screening events will be offered in the Seattle and Bellevue areas to screen patients at risk for diabetes. Eligible patients will then be able to participate in weekly and later monthly sessions to make and maintain healthy lifestyle changes in a supportive group setting with like- minded motivated individuals and coaches. The Diabetes Prevention Program follows a pre- designated curriculum focusing on weight loss, increased physical activity, and stress management to lower one s risk for diabetes. Discussing various topics, implementing these changes, and addressing barriers will allow patients to gain the tools and knowledge to make and maintain lifestyle changes and to better enable them to motivate themselves and each other as a group. It is not only an opportunity for pre- diabetic patients to reduce their risk for developing type 2 diabetes, but it is also a chance to get and give support in leading healthier lives. John Doric, Pharm.D. Pharmacy Resident Providence Monroe Clinic Clinical Service: Influenza Immunization and Treatment Providence Monroe has been involved in immunizations for influenza early in the season. We have also invested time for pharmacist training of staff. Residents and student pharmacists have been helping out staff pharmacists administering vaccinations for all ages in the Providence pharmacy throughout the influenza season. While this year may prove to be a mismatch with vaccine to the strains of influenza, it gives us reason to educate professionals on the treatment of influenza in our community. We presented some information on triage, utilizing a new PCR screening tool, treatment doses, and follow up for patients to walk in providers and at an all provider meeting. Providence Pharmacy is also able to split packages of Tamiflu for partial fills for patients if needed, and then dispense the remainders if needed based on positive test results and follow up.

7 7 Influenza update for at the Providence Monroe Clinic CDC recommendations are the same for treatment this year. Good work on immunizations, it is still not too late for patients who need the vaccines as well! Providence has updated policies for testing for influenza in patients you highly suspect for the condition. We now exclusively offer a new molecular flu test using RT- PCR that is ~99% sensitive and specific. However it is not available as a point of care test, and replaces rapid flu tests which are not highly sensitive or specific. Who gets treated? Antiviral treatment (Tamiflu) should be started as soon as possible after illness onset, ideally within 48 hours of symptom onset and data suggests improved recovery from influenza benefit is about 1 day. However, antiviral treatment might still be beneficial in patients with severe, complicated or progressive illness, and in hospitalized patients when started after 48 hours of illness onset and possibly up to 5 days in hospitalized patients. Consider especially empiric treatment: unimmunized infants, morbidly obese patients, poorly controlled COPD or asthmatics and frail/elderly. Post- exposure chemoprophylaxis can be indicated depending on clinical judgment in high risk patients exposed to influenza within 48 hours from a relative or close contact. Post- exposure chemoprophylaxis is not a substitute for non- vaccinated individuals. Who gets tested? Use clinical judgment, on the basis of the patient s disease severity and progression, age, underlying medical conditions, likelihood of influenza, and time since onset of symptoms. Consider especially in severe cases that may change your triage referral decision. Consideration of chest X- ray should be considered to rule out pneumonia complications. Decisions about starting antiviral treatment (Tamiflu) should not wait for laboratory confirmation of influenza per CDC recommendations. Follow- up Influenza Update John Doric, Pharm.D. For most patients who are given an antiviral, PCR testing should be considered and results can guide continued antiviral treatment to prevent viral resistance. Source: clinicians.htm

8 8 University of Washington Community Pharmacy Residency Program Personnel Amber Glass, RPh, MPH Director, UW School of Pharmacy PGY1 Community and PGY2 Geriatric Residency Programs Department of Pharmacy Clinical Assistant Professor Peggy Odegard, Pharm.D. Chair, UW School of Pharmacy Department of Pharmacy Professor of Pharmacy Don Downing, RPh Assistant Director, UW School of Pharmacy Residency Programs Department of Pharmacy Professor of Pharmacy Residency Site Coordinator: Bartell Drugs Kim Swigart, Pharm.D. Clinical Care Coordinator Bartell Drugs Residency Site Coordinator: QFC Pharmacy Marci J. Reynolds, Pharm.D. Clinical Care Coordinator QFC Pharmacy Residency Site Coordinator: Providence Pharmacy Monroe Steven Erickson, Pharm.D. Pharmacy Director Providence Monroe