Involving Pharmacists in Smoking Cessation The ProStep Pharn1acists Educating Patients Program (PEPP), a new initiative launched by Lederle Laboratories, offers pharmacists an easy-to-implement approach to helping smokers break their cigarette habit. Pharn1acists who participate in the progralTI receive a kit that gives tips for working with patients who have prescriptions for the ProStep nicotine trans dermal systelTI. It includes a video demonstrating a typical patient counseling session; a brochure about how ProStep works; and a series of "advisory cards" that outline steps pharmacists should follow when patients COlTIe in for their nicotine patch. Lederle pays pharmacies $2 per session, or up to $16 per patient, for pharmacists' ProStep counseling efforts. To receive cOITIpensation, pharmacists must complete the advisory card, obtain the patient's signature, and send the card to Lederle. According to Jeff Hoyak, Lederle's director of public relations, checks are sent directly to independent phanTIacies and go to chain pharmacies' corporate headquarters. Each independent pharmacy or chain makes its own decision about how individual phanTIacists are compensated. Vol. NS32, No.6 June 1992/467
time to speak with trained smoking cessation counselors. A second toll-free number provides information about smoking cessation programs available in the caller's area. The project will also include a study being conducted with the New Jersey Pharmacists Association that will collect and analyze data peltinent to the effect of pharmacists' counseling on the outcome of medication use. ProStep is designed to be used for six to 12 weeks. Each patch, which delivers 22 mg of nicotine daily, is to be worn for 24 hours on a hairless portion of the
Each advisOly card-one version for the initial prescription, one for interim refills, and one for the final refill-contains such questions as "how strong was your urge to smoke last week?" and "how long since you smoked a cigarette?" The cards relTIind phar11lacists to emphasize the importance of not smoking while using ProStep, because of the risk of nicotine toxicity. Other tips to pharmacists include: • Encourage patients to join a smoking cessation progralTI . • Urge patients to keep a dialY of situations where the PJ?051Ef!») urge to smoke (nlCoHne 22 ffig!dcry tronsdermol alf'f"'m" .,~,,,, '1 occurs, and • Ph811111Jc1Nt: Record lite Follow/n 1JAre you presently enrolled Ill . 'II Pan'nt InlOl111anon discuss with Yes_ No a SmOkmg cessation program? 2) Mate __ -Female them which sit3) Date of tUrtn 4) 8etoreYOUb~ uations were <> How rna ' . .. program; oy cIgarettes (fo you ~mok!l each day?_ 11l0St difficult to waj(mg up do you e?_min. cope with. io tile las! 7 days? • Discuss with patients the physical or emotional improvements they've noticed since ent they stopped smoking. tOa As palt of the program, patients using ProStep receive a confiRlllill R.m/nd" dential toll-free YourNextPres '" 011 cnpuon Refit! tor tile PROST'EP t h -_199 pac lsdue number they can fJulttflJfI timor/iff! is nol (Ja;7' you Ctln 'fit 11$ much tlJf1/Jo~' :UI aft 111/ your 11'61, altll call between 8:00 rOil Wlnl tlmt "eed. am and 1: 30 plTI eastern standard y(lfJ
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upper trunk or upper-outer arm, then replaced by another patch, which is applied to the skin in a different spot to avoid irritation. (An II-mg patch is available for patients who weigh less than 100 pounds, or as an optional tapering dose.) Refills are typically issued after seven days, which makes it easy for pharmacists to conduct weekly counseling sessions, but
some third party payers require that a month's supply be dispensed at a time, according to a Lederle spokesman. PEPP is part of Lederle's ProStep Family Project, which has been established to encourage adults to quit smoking and help ensure that children never start. Under the program, patients who relapse after using ProStep and want to try again are entitled to rebates from Lederle. According to Hoyak, orders for ProStep have "far exceeded our expectations."
The product hit the market in late February and production was stepped up in early March to meet the demand, he said. He noted that an average of 60 to 100 callers use the ProStep counseling hot line each day for support and tips to help them quit smoking. The American Pharmaceutical Association (APhA) , NARD, and other pharmacy groups have written letters in support of the program. According to APhA Executive Vice President John Gans, the project is important because it promotes the
Nicotine Patches: Potential for Toxicity Because of the potential for adverse effects from nicotine patches, physicians and pharmacists need to educate patients thoroughly about proper use and signs of toxicity, according to Carla Goetz, PharmD, assistant director of the Maryland Poison Center. Nearly 20 reports of adverse effects, which Goetz collected from three poison centers from January through April, demonstrate the types of problems occurring: • Patients experiencing various adverse effects when following instructionswhich suggests they may need a lower dose of the medication. • Patients applying multiple patches per day. • Patients continuing to smoke while wearing nicotine patches. • Children chewing on either discarded or unused patches. • Children applying patches to "see what happens" (one reported case). • Users neglecting to wash hands after applying the patch and then inserting contact lenses, causing ocular irritation (one reported case). AMERICAN PHARMACY
The package insert for ProStep warns patients to keep both used and unused patches away from children and pets. Before disposal in a place kids and animals cannot reach, used patches should be folded over with the adhesive sides together and placed in the new patch's protective pouch. The instructions also stress the importance of stopping smoking completely while using the patches. Signs of nicotine overdose, according to the package insert, include pallor, cold sweat, nausea, salivation, vomiting, abdominal pain, diarrhea, headache, dizziness, disturbed hearing and vision, tremor, mental confusion, and weakness. Ingesting the patches can cause seizures or death. A patient wearing a patch who shows signs of toxicity should remove it immediately and seek medical care. Flush the skin surface with water and dry it, but do not use soap because it can increase nicotine absorption. People who ingest nicotine patches should call their local poison center or physician for instructions, Goetz says.
value of phannacist's services. "We feel it is imperative that we begin to document the effectiveness of pharmacists' interventions in improving the outcome of therapy, " he said. For more information on the program, contact your Lederle representative.
Avoiding and Detecting Skin Cancer Throughout much of the country, June marks the beginning of warm, sunny weather and the season for outdoor fun. To help protect against skin cancer, the American Academy of Dermatology is reminding Americans to take these precautions: • Minimize sun exposure, especially from 10 am to 3 pm, when the sun's rays are most intense. • Apply a sunscreen, with a sun protection factor (SPF) of 15 or higher, liberally and often. Apply it 20 minutes before going into the sun and reapply every two hours when working, playing, or exercising outdoors. Use even on cloudy days, when 800/0 of the sun's rays penetrate the clouds. • Wear a wide-brimmed hat, long-sleeved shirt, and pants during prolonged periods in the sun. • Avoid tanning parlors and sunlamps, which emit ultraviolet rays similar to sunlight. • Keep children out of the sun if they are under six June 1992/ 468
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Squamous ceU carcinoma
Basal ceU carcinoma
months old and minimize sun exposure for all children. Apply sunscreens to children who are more than six months old. • Teach children and teenagers about sun protection, since most damage from the sun occurs before age 20. One or more blistering sunburns in childhood or adolescence can double the risk of developing Vol. NS32, No.6 June 19921469
malignant melanoma. Everyone should learn how to examine their skin for early warning signs of skin cancer, such as changes in moles or freckles, the academy says. The Skin Cancer Foundation, which also emphasizes the importance of early skin cancer detection, has developed a series of strategies directed toward older Americans, since people over age 65 account for more than half of the 600,000 new cases of skin cancer diagnosed in the United States each year. According to the foundation' organizations that serve older people should distribute educational materials about skin cancer at senior centers, nursing homes, and health fairs; encourage the scheduling of outdoor events to avoid peak sunlight hours; teach seniors how to perform total-body self-examination of the skin; and offer skin cancer screenings. The foundation recommends that seniors receive a headto-toe skin examination from their physician at least once a year. The American Academy of Dermatology outlines the following steps for periodic skin self-examination: • Examine your unclothed body front and back in the mirror, then right and left sides, arms raised. • Bend elbows, raise arms, and look carefully at forearms, upper underarms, and palms. • Look at the backs of the legs and feet, including the
Ears Need Protection from the Sun, Study ShO\NS Wearing a hat can save lives, especially when a person's hair doesn't cover his or her ears, according to a study reported late last year at a meeting of the American Academy of Dermatology. Martin A. Weinstock, MD, PhD, director of dermatoepidemiolgy at the Brown University Program in Medicine, found that 59% of the nonmelanoma skin cancer deaths in Rhode Island between 1979 and 1987 were due to squamous cell carcinoma, and that half of these were located on the ear. "Our data suggest that most of the fatal carcinomas were sun-induced," Weinstock said. "The public should be aware that the ear area is particularly vulnerable, although it is often overlooked when sunscreens are applied."
spaces between the toes and the soles. • Examine the back of the neck and scalp with the help of a hand mirror. Part the hair or use a blow dryer to lift the hair and allow a close look. • Check the back and buttocks with a hand mirror. For information, including materials for patients, contact the American Academy of Dermatology, 930 N. Meacham Rd., P.O. Box 4014, Schaumburg, IL 60168-4014, (708) 330-0230, or The Skin Cancer Foundation, 245 Fifth Ave., Suite 2402, New York, NY 10016. (212) 725-5176.
Health Resources Medication Teaching Manual is a new book des~gned to help pharma-
cists, physicians, and nurses eliminate their patients' misunderstandings about how to take medications correctly. It is written in a jargonfree, question-and-answer format and contains 421 entries on today's most commonly used drugs. The 540-page manual costs $56 and is available from the American Society of Hospital Pharmacists, 4630 Montgomery Ave., Bethesda, MD 20814. (301) 657-4383. Intervention strategies phannacists can use to help patients with foot problems is the subject of a new videotape continuing education program and accompanying course book. The program covers an array of foot conditions and remedies ranging from diabetic foot care to the management of sports-related injuries and athlete's foot. The program, developed at AMERICAN PHARMACY
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Purdue University by an interdisciplinary faculty of health professionals, is sponsored by ScheringPlough HealthCare Products/ Dr. Scholl's. To receive a copy, contact the Purdue University of Pharmacy and Pharmacal Sciences, Continuing Education Division, 302 Robert Heine Pharmacy Building, West Lafayette, IN 47907-1335 . (317) 494-1471. Global Aging, a wall chart published by the U.S. Bureau of the Census with support from the National Institute on Aging, shows at a glance which countries
Lomefloxacin: New Quinolone Lomefloxacin HCI (Maxaquin-Searle) is a new, once-a-day, broad spectrum quinolone antibiotic. It has been approved by the Food and Drug Administration for treating both complicated and uncomplicated urinary tract infections, as well as acute bacterial exacerbations of chronic bronchitis caused by H. influenzae and M. catarrhalis. Lomefloxacin should not be used for bronchitis caused by S. pneumoniae, and has not been proven effective in treating urinary tract infections in patients with Pseudomonas bacteremia. The dlUg is also indicated AMERICAN PHARMACY
have the highest percentage of older people and provides other age-related statistics. For copies contact Mercedes Bern-Klug at the National Institute on Aging at (301) 496-3136. Urinary Incontinence in Adults is the title of a new book on clinical practice guidelines issued by the Agency for Health Care Policy and Research (AHCPR). In addition to the 125-page book-the work of a panel of physicians, nurses, and other experts-a quick reference guide for clinicians and a patient's guide are available. For free copies call the AHCPR Publications Clearinghouse at (800) 3589295.
for pre-operative prophylaxis to reduce the incidence of infections in patients undergoing transurethral surgery. It has been rated IS: a new chemical entity with similar therapeutic qualities to drugs already on the market. Adverse Effects: The most common side effects
are nausea, headache, dizziness, and photosensitivity. Contraindications: Hypersensitivity to any quinolones. Dosage: The recommended dosage in patients with normal renal function is 400 mg once a day for 10 days (bronchitis and cystitis) or 14 days (complicated urinary tract infections). For prophylaxis, a single dose of 400 mg should be administered orally two to six hours before transurethral surgery. The drug may be taken with or without food. However, food decreases the extent of absorption by 12%. Children: Safety and efficacy have not been established in children under age 18. In juvenile animals the drug causes arthropathy and lameness. The Elderly: No overall differences in effectiveness or safety have been observed between patients over age 65 and younger patients. Pregnancy: Category C. Adequate studies have not been conducted in pregnant women. Nursing Mothers: It is not known whether the drug is excreted in human milk. However, other quinolones are excreted in human milk and lomefloxacin is excreted in the milk of lactating rats. How Supplied: As 400mg tablets, bottles of 20 and unit-dose packages of 100. Storage: Store at room temperature. For More Information: Call (800) 323-1603.
Prescription Drug Notes Isosorbide mononitrate (ISMO-Wyeth-Ayerst) is a
new twice-daily antianginal nitrate compound. According to the manufacturer, it is the first nitrate compound for the prevention of angina approved by the Food and Drug Administration in 30 years. The recommended dosage is one 20-mg tablet twice daily, seven hours apart. The anti-anginal effect begins after one hour and reaches its peak one to four hours after administration. For more information: (215) 688-4400, ask for medical affairs. Glynase PresTab (The Upjohn Company) is a new formulation of glyburide for non-insulin-dependent diabetes. According to the manufacturer the product is not interchangeable with other fonnulations of glyburide because of differences in bioavailability. Physicians need to titrate the dosage of Glynase PresTab with patients' blood sugar levels. For more information: (616) 323-4000. Triazolam (Halcion-The Upjohn Company) is now available in unit-dose packages that contain 10 tablets and a patient package insert with information on proper use of the drug. Boxes of 100 tablets (10 unit-dose packages) will replace the current bottles of 100 and other bulk packages after existing inventories are exhausted. For more information: (616) 323-4000. June 1992/470
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