Can Someone Really Have This Many Medication Allergies?

Massive Allergy List adjusted

Medication allergies can get out of hand.  Most often they are not truly allergies at all.  The thing that really amazes me about patients with this many medication allergies is that they have tried this many different medications to begin with!

Some important points to remember about medication allergy lists, feel free to leave some comments on other considerations:

1.  Ask patients what the reported “allergy” is.  As I mentioned above, most often it is an adverse reaction, not a true allergy.

2.  After you ask the patients (sometimes they don’t remember especially in cases like above) about their medication allergies/intolerances, take the time to document the outcome.  Cough from an ACE inhibitor or was it angioedema, or maybe worsening renal function?  Sometimes intolerances can be just as important as allergies.

3.  Communicate with other healthcare professionals.  I’ve seen many cases where a clinic, pharmacy, home care, LTC etc. doesn’t report the allergy or intolerance to other institutions that also take care of that patient.  Critical checks can be missed in the future due to poor documentation and notification.

4.  Try to encourage and engage patients in their own care.  Make sure they have a list of their medication allergies in the event that #3 doesn’t happen.  Also tell them to write down what happened!

5.  Don’t ignore “big” allergy lists like this.  It’s easy to have a lax attitude and assume that all these allergies are intolerances.  It isn’t a good idea.  What if one of these was severe?  Are you willing to take that chance?

New to the blog? Please check out the 30 medication mistakes I see in my practice as a clinical pharmacist.  It’s FREE of course!

Eric Christianson, PharmD, BCPS, CGP

Diltiazem Induced Rash

A nice guest post from an anonymous contributor, thank you!
84 year old female residing in community was recently treated with several courses of antibiotics to treat cellulitis of the right lower leg. Several different antibiotics were tried due to ineffectiveness and an itchy skin rash.  The rash continued for months after the courses of antibiotics were completed and the infection healed.
Potential causes such as Steven-Johnson Syndrome, Leukemia were ruled out.

Med List: Synthroid, Diltiazem, Cymbalta. Triamcinolone Cream

After reviewing her medications, it was suggested to her cardiologist that a Diltiazem allergy may be causing her rash.  The Diltiazem was discontinued and Verapamil started. Within 2 weeks, the patient’s diltiazem induced rash had resolved.
Allergic cutaneous reactions to Diltiazem may occur anytime during therapy and generally not predictable with respect to onset (7days to 10 years with the average of 95 days)/Lexicomp
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Pharmacist Board Certification: Which one is Right for You?

There has been growing interest in pharmacist board certification.  I think it will only be increasing as the job market seems to be tightening up.  Another reason for the increase might be the steady progression toward provider status.

I’m not going to discuss the value of board certifications in the post, but I’ve been asked by several pharmacists; which one should I try to obtain?

There are a lot of board certifications now available for pharmacists.  Pharmacotherapy, Ambulatory Care, Geriatrics, Oncology, Pediatrics, Psych, etc.  I can’t exactly tell you which one is right for you, but I can tell you my thought process in deciding to become a Certified Geriatric Pharmacist (CGP) and Board Certified Pharmacotherapy Specialist (BCPS).

I took my CGP exam a few years back now and don’t regret it.  I work primarily in geriatrics and the certification made a lot of sense given a significant amount of my work as a clinical pharmacist was done in long term care (heavily geriatrics).

Why did I do BCPS?  I view BCPS as the most universal certification.  The topics covered in this certification are extensive and include everything from pediatrics, critical care, geriatrics, ambulatory care etc.  I want to fully disclose that I do have a BCPS mock exam for sale on this website, however, I took the BCPS exam long before I ever considered creating a practice exam.  For your reference, per accp.com, about 14,000 pharmacists have BCPS certification.  About 1,500 have ambulatory care and oncology respectively, the next two most popular certifications from BPS.

Which pharmacist board certification is right for you?
Which pharmacist board certification is right for you?

My take: If you know 100% you want to practice in a particular area/specialty of pharmacy for the rest of your career, then doing a specific certification like oncology makes a lot of sense.  If you are not exactly sure where your career path will take you as many younger pharmacist are not, I would probably recommend the BCPS certification.  Feel free to add your two cents!

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Eric Christianson, PharmD, CGP, BCPS

Case Study: Zocor and Diltiazem Interaction

66 year old female was newly diagnosed with atrial fibrillation.  Her other diagnoses included hypertension, diabetes, hyperlipidemia, and GERD.

Current medication list included:

  • Aspirin 81 mg daily
  • Simvastatin (Zocor) 40 mg at bedtime
  • Tylenol as needed
  • Protonix 40 mg daily
  • Lisinopril 10 mg daily
  • Metformin 500 mg twice daily

With the new diagnosis of atrial fibrillation, the primary provider started the patient on Diltiazem (Cardizem) CD 180 mg daily.

Within a few weeks, the patient began to feel worsening muscle pains and aching.  She could not attribute it to physical activity or anything else going on in her life.  She began taking the Tylenol as needed 2-3 times per day to try to help with the pain she was having.

Upon investigation of the medication regimen, it was discovered that the Diltiazem had been started a few weeks back.  Diltiazem can increase the serum concentration of simvastatin which is likely what happened in this case leading to the muscle pain/soreness.

photo courtesy of medimoon.com
photo courtesy of medimoon.com

Per Lexicomp, simvastatin and diltiazem used together should be avoided if other alternatives exist.  If use can’t be avoided, then a maximum recommended dose of Zocor at 10 mg daily should be considered.  The Zocor and Diltiazem interaction is one you need to be aware of!

Enjoy clinical content like this?  Please take advantage of the free resource I provide.  30 medication mistakes is a FREE PDF I created based upon my real world experiences as a clinical pharmacist.

Guest Post: Advice from a Pharmacist: What YOU can do when someone has a miscarriage

There are many things in life you can’t learn from a textbook.  I stumbled across this post yesterday and felt the need to share it with my followers.

Thanks to Crazy RxMan for sharing!  Please check out his blog!

Valentine’s Day, a day of love and the celebration of love. There will be many babies conceived on this day, but not all will be born. And that’s why I share my thoughts with you today… advice from a pharmacist FOR pharmacists, but the same ideas are for anyone who knows the mother of an angel.

A few years ago I had a close friend lose a baby. She was so thrilled and so happy. I look at photographs of her at the time and her face was just beaming. It was so thrilling and exciting. But tragedy started when she started to spot. She reached out to me for help and I didn’t know what to do. I am a doctor of pharmacy, but I didn’t know what to do. It was all very heart-wrenching and sad, and I just can’t believe that I didn’t know what to do and didn’t try to help her. To this day and with all my heart I regret my actions (and inaction) at the time. 

As pharmacists, we are in a unique position as healthcare providers, especially community and/or retail pharmacists. We are literally open to the public every day and have a responsibility to help those in need. Although not very common, there are occasions where you will encounter a patient that recently had or is having a miscarriage. They often come to the pharmacist for advice because we are so accessible and are in the top five most trusted professions. We have a duty to be ready to help in any way we can.
As pharmacists we know what medications to avoid in pregnancy. We can also recommend anxiety medications, depression medications, and even know what the doctor needs to prescribe if the bleeding gets out of hand, but… that’s academic. Often its the patient trust for the pharmacist and she wants a shoulder to lean on and a listening ear. But what do you say? Our training is in medication, not psychology.Here’s some hints and tips from what I’ve learned:

1. If you’re in the pharmacy, take her to a quiet spot… the waiting room, or somewhere private away from the noise and listening ears. You want to give her 100% of your focus and time. The metrics can wait. THIS is no longer about some guy getting his generic Lipitor filled in 3.5 minutes. This is a genuine opportunity to help someone, and that’s WHY you went into pharmacy in the first place.
2. LISTEN to her. What she’s going through right now is uniquely tragic to her. This is something she may have never experienced before and the depths of complete despair are deep. She wants to unleash her feelings of sadness and disappointment. Let her do it and be supportive. Let her direct the conversation. Don’t interrupt.
3. NEVER say something like “You can try again” or “Everything happens for a reason.” Why? Because you don’t know that. You don’t know the situation, and moreover, the little spirit and life that was lost cannot just be replaced like a car part. He or she was a unique individual with his or her own personality. You wouldn’t suggest to your grandmother that she can “try again” when grandpa passes away, would you? No. Let her grieve and mourn the unique soul that was lost.
4. Don’t say “I know how much it hurts.” Instead, listen to her as she tells you how much it hurts. Even if you’ve had a miscarriage yourself, you still don’t know her unique situation. Be gentle, be kind. Pain of the heart is the worst kind of pain. She may dream about the loss all night long, then wake up and think about it all day long, wondering what she did wrong, wondering why God kept her from having children, wondering “Why me?” until she cries herself to sleep at night. Empathize with that pain.
5. Don’t say “It’s part of Mother Nature’s or God’s plan.” That may very well be, or it may be that God wanted her to have that baby just as much as she did. We don’t know everything about this life. It’s a good bet we know even less how it works on the other side. If she is having a crisis of faith, be supportive and try to understand it from her point of view as she finds answers for herself. You couldn’t possibly have answers in this regard, only opinions, and she doesn’t need those.
6. NEVER tell her to stop feeling sorry for herself. A little life, full of love and personality, was just lost. She will always, always wonder what this little person could have been in her life, someone to hold and cherish and raise. That’s NOT something you just get over. In fact, you NEVER get over it, you only deal with the pain. So never say anything like that. A better thing to say is “Nothing in the world could have prepared you for this and I’m so sorry you have to go through it.”
7. If would be easy to just say you can’t imagine their pain. Instead of that, try to imagine what it would be like to have a little person growing inside you. Imagine the excitement, thinking of a baby name, buying little socks, building a crib, etc. Then imagine that all taken away from you. Now do you understand why this is so hard on her? Now you’ll want to hug her and hold her and console her if she’s willing.
8. Refer as necessary to people and organizations equipped for this tragedy. A good place to start is here.
I don’t pretend to an expert on the subject, but I’m a pharmacist and as a healthcare provider, I want to be ready for the next time this happens to me. You may never have this happen to you, but be prepared in case it does happen!
Also remember…
Dad's hurt to from Crazy RxMan
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