A pharmacist's look at the supermarket and beyond

Month: January 2015

Neti Update: Naughty or Nice?

You may have read my earlier post about the Jala Neti. Here is an excerpt and some new information that should be considered if you are a neti user.

Basically, the neti pot allows a user to pour 8 to 16 ounces of warm saline into one nostril while letting the solution pour out the other nostril. Typically, in a kit, the packets contain 700mg of sodium bicarbonate and 2300mg of sodium chloride; however, a level teaspoonful of plain salt can suffice if your pot does not come with saline packets. Simply empty the packets into the neti pot and add warm water, give a little stir and you are ready to go.

The authors of a randomized trial published in the Journal of Family Practice in 2002 concluded “Daily hypertonic saline nasal irrigation improves sinus-related quality of life, decreases symptoms, and decreases medication use in patients with frequent sinusitis.” Another, more recent, article in that same journal again reiterated that recommendation for both adults and children with allergic rhinitis.

In some circles, the neti is called a nasal douche, or more urbanely, a nasal irrigation or lavage. This process has grown quite popular beyond India and I wondered if it is ever misused. Well, here’s a reason to be cautious:
A 20-year old man and a 51-year-old woman from suburbs of New Orleans died after using Neti pots containing tap water to flush their nasal passages. Both became infected with Naegleria fowleri, a parasite known as the brain-eating amoeba.
“If you are irrigating, flushing or rinsing your sinuses, for example, by using a Neti pot, use distilled, sterile or previously boiled water to make up the irrigation solution,” Louisiana State epidemiologist Dr. Raoult Ratard said in a statement. “Tap water is safe for drinking but not for irrigating your nose.”

The amoeba causes primary amebic meningoencephalitis (PAM), most often through getting water in the nose when swimming in water that carries the parasite. These little guys lke warm water. Sampling of lakes in the southern tier of the U.S. indicates that Naegleria fowleri is commonly present during the summer, but infections are beginning to occur in northern states. (Global warming?) Naegleria is not found in the ocean. In any case, these infections are quite rare, somewhere on the order of 1 in a million warm water swimmers. The CDC is a good place to learn more about this parasite.

Anytime you are allowing non-sterile substances to enter your body you are introducing microbes into your personal environment. Usually these are benign. However, at times they can be pathogens, as in the example above. For this reason it is important to be sure to use boiled water if you are getting it from a tap, or at least distilled water from the store, for your neti. It also would be wise to sterilize the neti pot itself every now and then. Infection control begins at home!

Urban Garden

A friend of mine that is much more involved in the evolution of downtown Mesa introduced me to the urban garden concept three years ago when the Mesa Urban Garden was started.The idea is to help create and foster sustainable urban living by providing a community-based garden site.

plotsIt was a cold and rainy day on the grand opening and I remember seeing many of the garden plots sitting empty waiting for planting. The steady, gentle rain was giving all of the plots a good soaking. There were some plots with growing plants, but most were ready for new planting. vegI was not convinced that the concept would work. I used myself as a guide. I would not be likely to have the persistence to care for my garden and I’m sure it would either wither and die or go to seed.ready

I revisited the garden on its third anniversary and I am pleased to announce that not everybody is a slacker like myself. enterThe garden looks terrific with many vegetables, flowers and even fruit trees happily growing and providing fresh produce! Obviously, many city dwellers find the chance to have a personal garden that provides fresh veggies a very attractive opportunity.IMG_0334

My son is trying his hand at a backyard garden, taking the initiative to create an irrigation system and we’ll see if his attempt at urban gardening goes well. If you have the yard space, you may have a garden waiting to happen.

I envy those that are successful in finding the time and putting in the effort to get their hands dirty and work the earth in a direct way. It sounds very fulfilling. Maybe someday, I’ll have the time and inclination for such a venture. In the meantime, I try to buy local as often as possible.
All this goes to show that urban gardening is possible and very rewarding for those who participate. The plots do cost some dough to lease, but at $80 a year for a 4 foot by 6 foot garden space complete with quality soil in a raised bed, watered by an individual drip irrigation system with timer, it’s a good deal if you can grow. We are in Arizona, land of sunshine. If you give a plant water it will grow like crazy, so i would think you could easily come out ahead. Not to mention the great time spent outdoors, working the Earth, meeting neighbors, and harvesting your own food.

A Tale of Two PharmDs

Here’s a tale of two pharmacists and how they practice their profession.

An elderly gentleman was at our pharmacy with several prescriptions which were filled and ready for pick up. Our pharmacist counseled him on his meds, one of which was albuterol 0.083% for inhalation. We always make it a point to ask if the patient has an SVN or nebulizer at home. The medication cannot be used without a nebulizer and this patient did not have one. Our pharmacist immediately processed a new Rx for a nebulizer and it was covered by his plan and we were able to show him how to use his new device and medication for effective treatment. The prescriber was contacted for a corresponding order, which we received that day. The patient was well-served and we even kept Medicare happy.

Upon witnessing this transaction one of our techs told us how impressive that was. She had recently been involved in a similar situation at a sister store where this tech told the pharmacist that the patient would need a nebulizer in order to use his medication. Our tech had already told the parent that we routinely sold nebulizers for about $36, which was acceptable to the customer. The pharmacist at the store she was helping out at, however, said they did not carry SVN machines (“we don’t do that”) and directed the customer to a vendor down the street that might have them.

Many of the techs from my pharmacy pick up shifts at other locations and stories like this are not uncommon. If you are a patient, I urge you to choose your pharmacy wisely.

Each of these pharmacists graduated from the same college of pharmacy, at the same time. The difference in their responses bears some thought and elicits some questions.

For pharmacists:

    Do you always make sure that the patient has any necessary devices or equipment to use the medications that you are supplying?

    Do you believe that your education allows you to create a “presumptive” prescription for an item such as the SVN machine in the above scenario? How about a presumptive order for syringes or pen needles with a new insulin order? Test strips and lancets with a new BG meter?

    Do you feel comfortable making clarifying decisions for things like product size or other minor discrepancies on an electronic Rx? For example, would you be OK to change an order for triamcinolone 0.1% cream 60 grams to an 80 gram tube, or would you dispense four 15 gram tubes?

You might have already guessed my answers. Young pharmacists, I encourage to use your education and serve your patients well. Delaying antibiotic treatment for a day or more because you must order amoxicillin 500mg tablets when you have thousands of capsules on your shelf is not good pharmacy. Particularly in this era of electronic prescriptions, we must stand ready to make good decisions and have the confidence to act for the benefit of our patients. Apply your knowledge appropriately!

I’m not advocating over-stepping our practice authority. Very often, you have to make a call to clarify a nonsensical Rx. Occasionally, you might even educate a prescriber!

Never forget the patient. Talk to your patients! “Mrs. Smith, is there any reason that your husband Charlie cannot take his amoxicillin as a capsule instead of a tablet?”

I will often indicate on a fax to the prescriber what action or changes I made and advise them to contact me if they disagree, otherwise please update the patient’s chart. I can recall only one call back from this procedure and that was to say thank you!