Our Partners in the Healing Arts

riCharD h. Daffner, MD, faCr

Irecently picked up a prescription for the anti-viral drug Paxlovid® at my local CVS pharmacy. The pharmacist reminded me that since I was also taking an anticoagulant, I had a higher risk of bleeding. Neither my internist who prescribed the Paxlovid® nor my cardiologist, who prescribed the anticoagulant had mentioned that risk. That experience reminded me of the important role pharmacists play as our partners in the healing arts. It also emphasized how the practice of pharmacy has changed in the sixty years since I graduated from Albany College of Pharmacy, where I earned my undergraduate degree.

So, what was the world of pharmacy like in 1963? Ninety percent of graduates at that time entered retail pharmacy; 6% worked in a hospital pharmacy. The remaining graduates pursued degrees in medicine, dentistry, or other health-related fields. A few did pharmaceutical research, working for “Big Pharma”. Most pharmacies in 1963 were operated by independent owners. Yes, there were chains at the time. Walgreens, the nation’s second largest chain, began in Chicago in 1901. (CVS, founded in 1963 is now the largest)) Several small chains included Fay’s Drugs, Brooks, and Eckerd Drugs, all of whom eventually merged into Rite Aid, founded in 1962. Today they’re the third largest.

But changes were coming. New laws were enacted by state legislatures that allowed prescription drugs to be sold in supermarkets and ultimately in “big box” stores such as Walmart, Target, and Costco. These retail giants had the advantage over the small independent pharmacist entrepreneur in that they could buy huge lots of merchandise and take advantage of volume price discounts. In the mid-tolate 60s smaller drugstores began to either sell out to one of the large chains or to fail outright. I remember when Rite Aid approached my father and my uncle with a generous buy-out offer that included guaranteed employment for all of their staff. Currently most of the chain stores are basically merchandising emporia that also happen to sell prescription drugs.

One of the biggest changes in pharmacy was the availability of generic drugs. In the 1960s the high cost of brand name medication prompted the FDA to begin licensing generics as the patents for prescription drugs expired. Although by law, generics must contain the same amount of active ingredient as its brand name counterpart, some generic formulations didn’t allow the active ingredient to be absorbed into the patient’s body and the medication passed out of the patient intact. That initial concern for physicians and patients has been largely overcome, particularly by the more reputable generic manufacturers. However, problems still exist, particularly for medication manufactured outside of the United States.

There have also been changes in the day-to-day duties of the pharmacist. In 1963 approximately 15 to 20% of prescriptions in a busy pharmacy required compounding. Dispensing Pharmacy, a major course in all colleges of pharmacy at the time began taking on a less important role and for most schools has disappeared entirely. I remember when I was in the Air Force in 1969, writing a prescription for a dermatologic cream that had to be compounded. The hospital pharmacist called me to tell me that he, as a recent graduate, had never done any compounding in pharmacy school. I went to the hospital pharmacy and showed him, and his pharmacy techs how it was done.

Computers are now an integral part of the practice of pharmacy. They have made the job of checking for drug interactions easier - provided patients use the same store or chain for obtaining their prescriptions. It matters not if I had a prescription filled at my CVS in Pittsburgh and need a refill while travelling. The information will be in the system if I go to another CVS. The challenge, however, is for the individual who fills one prescription at Rite Aid, another at CVS, and a third in the supermarket because their computer systems don’t link. My hope is that in the future, all the computers will be able to talk to each other, perhaps through a national data bank, to assure drug safety and avoid potentially lethal complications from drug interactions.

Changes were also occurring in the training of future pharmacists. I was in the last four-year class. (Ironically, my father was in the last three-year class when he graduated in 1932 and my uncle was in the first four-year class, graduating in 1934.) In 1960, the curriculum expanded to five years; in 1990 it was extended to six years, with the graduates receiving a Doctor of Pharmacy (Pharm D) degree.

The opportunities for pharmacy graduates continue to expand. I first became aware of this while working as part of the Trauma Team at our hospital. I made daily x-ray rounds with the trauma surgeons. I noticed that one member of the team was a Pharm.D. I asked her what her role on the team was, and she told me that she was there to help the surgeons with medication issues, including dosages and drug interactions. I later spoke to the Director of Pharmacy who told me that pharmacists work with each of the other medical and surgical teams throughout the hospital. I now understand why Hospital Pharmacy requires a one-year internship.

Traditionally, the main duties of pharmacists are to fill prescriptions. In most cases this entails counting pills. In larger chain pharmacies this task is usually assigned to Pharmacy Technologists, who are supervised by the registered pharmacists. Today, the role of the pharmacist has also changed. New state laws now permit pharmacists to give vaccinations, something that was in view of the public during the recent Covid-19 pandemic. The main role of pharmacists today is to not only oversee prescription preparation, but also to counsel patients regarding any medication issues, such as drug interactions, of which physicians are often ignorant. They also will question patients if two of the same kind of drug have been prescribed. I became aware of this when one of my pharmacists asked if I was aware I was taking two beta blockers at the same time after the second one had been prescribed. I told her that the first one (long-acting) was to treat my paroxysmal atrial fibrillation, and the second (shortacting) was for occasional bouts of tachycardia. I was happy to know that my pharmacists were overseeing my medications. This is particularly important when medications are prescribed by different physicians. In addition, some pharmacy chains offer “Mini Clinics” for their customers.

The shortage of pharmacists in the country in the 1990s led to an explosion of new schools of pharmacy being established. Between 1960 and 1995 there were 90 pharmacy colleges in the US. In 2014 the number was 152; today it is 1411. All the new schools were at established universities. The sudden increase in the number of pharmacy colleges erased the shortage of pharmacists, but also forced the three remaining free-standing pharmacy schools (Albany, Massachusetts, and Philadelphia) to add schools in the other health sciences, such as Public

Health as they lost potential students to the increased competition. Last year, Philadelphia College of Pharmacy and Health Sciences merged with St. Joseph’s University to remain solvent. Mergers may be in the future for the remaining two.

Much as the practice of pharmacy has changed over the past decades, so have the opportunities for graduate pharmacists. I am a member of the Board of Trustees of my alma mater, Albany College of Pharmacy and Health Sciences (ACPHS). The Board is made up of alumni and non-alumni members. When I look at the resumés of my fellow alumni members I see quite a diversity in what they are doing with their pharmacy degrees. Two are directors of pharmacy services in medical centers; three work in development of new drugs for pharmaceutical manufacturers; one is an executive of a drug manufacturer; two earned medical degrees; and two operate their own independent pharmacies. This diversity of our pharmacy partners has led me to coin a new slogan for our recruiting at ACPHS: “Pharmacy. It’s so much more than counting pills.” Times have indeed changed for our partners in the healing arts.

Reference

1.Grabenstein JD. Trends in the number of US colleges of pharmacy and their graduates, 1900 to 2014. Am J Pharm Ed 2016;80: 25 – 35.

Dr.Daffner is a retired radiologist, who practiced at Allegheny General Hospital for over 30 years. He is Emeritus Clinical Professor of Radiology at Temple University School of Medicine. He was a practicing pharmacist before and during medical school.

Helping Your Patients Navigate Seasonal Skin Care Needs Amidst the Growing Natural Skin Care Industry

While many conditions such as infections and types of injuries shift with the seasons, so do types of rashes and skin conditions. While dry skin and eczematous rashes often worsen with drier winter weather, others worsen with summer heat, sun, outdoor exposure to plants, and products being used more frequently with the better weather such as sunscreens and bug repellents. It can no doubt be challenging for physicians to determine if these changing skin conditions are truly due to summer sun exposure in the case of connective tissue diseases or skin care products being used more frequently during the same season. In both private practice and the Autoimmune Institute at West Penn Hospital, I often see patients convinced they have autoimmune disorders whereas their skin ailment often lies in either irritation or contact allergy to their of skin and hair care products. Most skin allergy presents as an eczematous dermatitis (allergic contact dermatitis) which is a type IV, or delayed-type cell-mediated hypersensitivity typically due to chronically exposed substances; whereas most chronic urticaria are not allergy related. It is critical to remember almost any foreign chemical, natural or artificial, can elicit a chronic hypersensitivity over time and with enough exposure. For example, Lanolin, a sheep-derived group of chemicals which have skin healing properties and are often found in medicinal and cosmetic skin products, is the current contact allergen of the year listed by the American Contact Dermatitis Society. Because neomycin causes a significant number of reactions in patients(upwards of 10% in various reports (1)) it is generally not advised for basic cuts and scrapes or post-operatively by most dermatologists.

Over the last few decades, the “clean” and “natural” skin care market has grown exponentially as companies hoped to improve skin care utilizing natural, plantbased ingredients. On the business end of this movement, conservative estimates place the natural skin care market around at least $6 billion with some sources stating much higher values. However, this rising trend of products has coincided with changing trends in skin conditions, specifically those involving both irritant and allergic contact dermatitis. Contact dermatitis affects close to 1 in 5 individuals and is twice as common in females (2). Preservatives, metals, emulsifiers, and fragrances top the list in sources of contact dermatitis due to skin/ hair care products with fragrances.. In their efforts to replace ingredients such as parabens and sulfates with botanical ingredient alternatives the cosmetics industry has created some potentially more irritating and allergenic products in susceptible individuals. It should be noted that some companies replace artificial versions with plant sourced versions of the same chemical, however, the allergenicity potential remains the same.

In my patients with contact dermatitis undergoing evaluation for new onset diffuse or treatment resistant eczematous dermatitis, my general rule is the fancier, better smelling, more organicm, “so good you could eat it” product the more likely it is to contain high risk contact allergens and is suspect until proven otherwise. For example, a product that describes itself as a “Vanilla Lavender Honey Almond Scrub” likely contains ingredients that benefit and stimulate our olfactory cortex and limbic system more than directly benefit our skin.

While natural skincare ingredients should not simply be viewed as bad, butas potentially both therapeutic and problematic just as we view most traditional ingredients including our medicines and rather used safely in moderation. There is data to support lavender may help with anxiety and sleep. Tea tree possesses both mild antimicrobial and anti-inflammatory properties. Researchers have discovered eucalyptus may help deter malaria-laden mosquitos and this summer your patients may choose natural bug repellants that utilize eucalyptus, citronella, cloves, or peppermint rather than traditional DEET. However, their benefit doesn’t exclude the possibility of allergy and side effects. Most patients understand the concept of allergies to the pollens from flowers in the air but fail to understand allergic response is possible if you crush up the flowers and place it into a topical product. Most of us can agree penicillin (taken intermittently over a few days) can be beneficial in the appropriate clinical setting while taking it indefinitely or in excessive doses could pose risk and consequences. It can be helpful to explain to patients if you can be allergic to penicillin, which is derived from mold, then you can become allergic to chemicals derived from any flower or plant.

An important recent trend in medicine to consider is the growth of medical marijuana and/or CBD. Providers prescribing them for their patients should recognize that these therapeutics are derived from flowering plants and contain natural terpenes specifically linalool and limonene. These chemicals are also found in numerous shampoos and soaps and are also produced by other plants such as lavender, eucalyptus, chamomile, and tea tree. Again, while potentially therapeutic medical marijuana and CBD, both have inherent hypersensitivity risks due to their naturally derived chemicals.

With sunburns, poison-ivy dermatitis, bug bites, and sports injuries on the rise in summer months your patients will surely have questions regarding skin care advice. It is crucial to consider that all topical therapeutic products, whether artificial or natural, can provide both potential harm and benefit. When evaluating your patients with warmer weather rashes consider if the rash is truly isolated to sun exposed areas or areas at high risk for contact allergy such as the eyelids, face, neck, and hands. Remember there is no FDA-standard for “hypoallergenic” or “sensitive” labeling and often many products with such labeling are quite the opposite. Lastly, for your patients with suspected chronic skin care product allergy refer them to the following web resources (https://www. skinsafeproducts.com/ and https://www. fda.gov/cosmetics/cosmetic-ingredients/ allergens-cosmetics) and refer them to a dermatologist and/or allergist who specializes in contact allergy and comprehensive allergy patch testing.

References: doi: 10.1007/s00018-011-0846-8.

1. Warshaw EM, Belsito DV, Taylor JS, et al. North American Contact Dermatitis Group patch test results: 2009 to 2010. Dermatitis. 2013;24(2):50-59.

2. Peiser M, Tralau T, Heidler J, Api AM, Arts JH, Basketter DA, English J, Diepgen TL, Fuhlbrigge RC, Gaspari AA, Johansen JD, Karlberg AT, Kimber I, Lepoittevin JP, Liebsch M, Maibach HI, Martin SF, Merk HF, Platzek T, Rustemeyer T, Schnuch A, Vandebriel RJ, White IR, Luch A. Allergic contact dermatitis: epidemiology, molecular mechanisms, in vitro methods and regulatory aspects. Current knowledge assembled at an international workshop at BfR, Germany. Cell Mol Life Sci. 2012 Mar;69(5):763-81.

Epub 2011 Oct 14. PMID: 21997384; PMCID: PMC3276771.

The author wishes to thank Dr. Ned Ketyer for his editorial expertise when the article was originally published in the Pediablog. Permission was granted by the young physician, whose story was recounted above, to include it in this narrative in the Bulletin.