Food Allergies and the Pharmacy

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Teal Pumpkin Project

As my family made our teal pumpkins this weekend I began thinking about how the Teal Pumpkin Project can (and will) help more than just people with food allergies…

My search for non-food treats had me investigating local venues as well as online sites like A quick search for teal bracelets led me to a number of ovarian cancer awareness products. I had no idea that teal was the ovarian cancer awareness color too! By sharing colors, I have been educated. I learned that only 14.7% of ovarian cancer cases are diagnosed before spreading. WOW.  Hopefully, the people supporting the ovarian cancer cause will learn from the food allergy community as well.

The second group that immediately came to mind was diabetics.  As a diabetes educator, I am a part of numerous on-line diabetes support groups. The parents of diabetic children face the same exclusion and frustration that we do. Their children cannot partake in food the same way other children do and these parents must plan ahead just like food allergy parents.  The Teal Pumpkin Project will directly help diabetic children by providing the same non-food treats that allow food allergy children to feel included.

I have been sharing the Teal Pumpkin Project with diabetic groups and encouraging them to notice and use the event.  I would like to embolden the food allergy community to embrace this shared goal:  happy, healthy children that feel loved, included, and safe.

Happy Halloween!



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Influenza Questions Answered

This is a quick run down of some of the most frequent questions I am asked about the “flu” vaccine.

Can the flu shot give me the flu? 

No it cannot. I hear people say that the flu shot gave them the flu all the time but the reality is that the flu vaccine is 1. not a live virus or 2. does not contain virus particles (aka recombinant) therefore it cannot give you the flu. However, people might get mild fever, pain/soreness/redness at injection site, and headache.

The nasal spray, also known as LAIV, is different from the shot. The nasal spray does contain weakened live flu virus. Although rare, clinical studies have shown that close contacts of those receiving the nasal spray flu vaccine have become infected. The weakened virus in the nasal spray may cause runny nose, headache, cough, and sore throat. Additionally, wheezing and fever have been observed in children.

I got the flu shot but still got the flu, how can this happen?

The “flu shot” is actually a prediction. Based on research and history, the CDC will  predict which versions of influenza will be most commonly circulating. There are two types trivalent and quadrivalent. Trivalent means the shot contains 3 components (an influenza A (H1N1) virus, an influenza A (H3N2) virus, and an influenza B virus) while the quadrivalent contains 4 (an influenza A (H1N1) virus, an influenza A (H3N2) virus, and two influenza B virus).  Influenza is a virus and viruses are constantly changing. Due to these changes, a person may come into contact with a version of the flu to which he/she is not vaccinated. So yes it is possible to get the flu even though you have been vaccinated.

“All of the 2014-2015 influenza vaccine is made to protect against the following three viruses:

  • an A/California/7/2009 (H1N1)pdm09-like virus
  • an A/Texas/50/2012 (H3N2)-like virus
  • a B/Massachusetts/2/2012-like virus.

Some of the 2014-2015 flu vaccine also protects against an additional B virus (B/Brisbane/60/2008-like virus).” (source)

How are flu shots made?

Egg-based, the most common method, is used in both the flu “shot” and the nasal spray. The flu virus is injected into a fertilized hen egg and allowed to replicate. The virus containing fluid of the egg is then harvested and ran through many levels of purification.

Cell-based methods inject the virus into mammalian cells (not hen eggs) and allow the virus to replicate. Then, like the egg based method, the virus containing fluid is harvested and undergoes a multitude of purification steps. As of right now, there is only one cell-based product available in the US: Flucelvax. Flucelvax is trivalent and inactivated.  Cell-based vaccines have been approved for use in a number of European countries.  The viruses used in this process however begin as egg-grown vaccine viruses.

Both egg-based and cell-based methods are referred to as IIV or inactivated influenza vaccine.

Recombinant flu vaccines separate the HA protein of the “wild” or naturally occurring virus. That protein is then combined with portions of another virus known to grow well in insects. That combined virus is then mixed with insect cells and allowed to replicate and grow. The HA protein is then harvested and purified.  According to the CDC, “recombinant flu vaccine is the only 100% egg-free vaccine on the U.S. market” (source)  Flublok  is the only approved recombinant vaccine in the US; it is also known as RIV3.

Can a person with egg allergy get the flu vaccine?

First and foremost, if you have any reaction to eggs, do not go to your local retail pharmacy. You will be turned away. Retail pharmacy protocol will not allow individuals with a history of egg allergy to be vaccinated. If the vaccine is indicated and recommended based on your personal history, go to an allergist for administration.

The Advisory Committee on Immunization Practices (ACIP)  “recommends the following:

  1. Persons with a history of egg allergy who have experienced only hives after exposure to egg should receive influenza vaccine. Because relatively few data are available for use of LAIV in this setting, IIV or trivalent recombinant influenza vaccine (RIV3) should be used. RIV3 may be used for persons aged 18 through 49 years who have no other contraindications. However, IIV (egg- or cell-culture based) may also be used, with the following additional safety measures (Figure 2):
    • Vaccine should be administered by a health care provider who is familiar with the potential manifestations of egg allergy; and
    • Vaccine recipients should be observed for ≥30 minutes for signs of a reaction after administration of each vaccine dose.
  2. Persons who report having had reactions to egg involving such symptoms as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention, may receive RIV3 if they are aged 18 through 49 years and there are no other contraindications. If RIV3 is not available or the recipient is not within the indicated age range, IIV should be administered by a physician with experience in the recognition and management of severe allergic conditions (Figure 2).
  3. Regardless of allergy history, all vaccines should be administered in settings in which personnel and equipment for rapid recognition and treatment of anaphylaxis are available (29).
  4. Persons who are able to eat lightly cooked egg (e.g., scrambled egg) without reaction are unlikely to be allergic. Egg-allergic persons might tolerate egg in baked products (e.g., bread or cake). Tolerance to egg-containing foods does not exclude the possibility of egg allergy. Egg allergy can be confirmed by a consistent medical history of adverse reactions to eggs and egg-containing foods, plus skin and/or blood testing for immunoglobulin E directed against egg proteins (30).
  5. For persons with no known history of exposure to egg, but who are suspected of being egg-allergic on the basis of previously performed allergy testing, consultation with a physician with expertise in the management of allergic conditions should be obtained before vaccination (Figure 2). Alternatively, RIV3 may be administered if the recipient is aged 18 through 49 years.
  6. A previous severe allergic reaction to influenza vaccine, regardless of the component suspected of being responsible for the reaction, is a contraindication to future receipt of the vaccine.”

I quoted this directly from the CDC’s Morbidity and Mortality Weekly Report dated August 15, 2014 . (source)

Translation:  The nasal spray  (LAIV) is not recommended in patient’s with a history of egg allergy  (any severity) while the inactivated influenza vaccines may be administered to patients with a history of hives only egg allergy (again not at a retail pharmacy). Any egg-allergy severity above hives only should be referred to an allergist for further evaluation.

Recombinant vaccines are 100% egg free and can be given to any level of egg-allergic individuals.  Each vaccine has its own set of approved age ranges as well which will be taken into consideration prior to administration.

Anaphylaxis in egg allergic individuals has been reported to the Vaccine Adverse Event Reporting System (VAERS) after flu vaccine administration.


And another question that is important at this time (one that pharmacists have been getting in retail pharmacies across the country):

Will this protect me from Ebola?

No. Ebola is not a strain of influenza although both are viruses.  The early signs and symptoms of Ebola are the same as the flu however:  fever, chills, muscle/joint aches,  headache, sore throat and weakness.


Please see my Influenza Vaccine Chart 2014-2015 for manufacturer specific information.


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The Food Allergy Guide to the Zombie Apocalypse (or your everyday power outage)

I bet you’ve discussed, at one time or another, what to do in case of the Zombie Apocalypse. If not, I suggest you find someone and do so immediately! I’ll wait.

[I’m assuming you are returning 30 minutes later if, in fact, you had never done this. If not, I assume you are skipping very quickly to the next part.]

When you thought about your Zombie Apocalypse/Mayan Calendar End of Times prepping, did you think of all the things you might need to do for the food allergic individual in your life? It’s one aspect most zombie movies/end of the the modern era films, books, and television shows don’t address.   But we, the food allergy community, need to  “Doomsday” prep for the everyday mishaps. And, hey, you’re already doing some of it! What do I mean? Let’s go back to elementary school and the 5 Ws: Who, What, When, Where, Why, and that sneaky, pesky, essential H–How.


Every member of the food allergy community “preps” on a regular basis. We “prep” safe foods for school lunches, special trips, and just everyday eating. We also “prep” by always carrying epinephrine and diphenhydramine (Benadryl) in addition to various creams, lotions, asthma medications, etc. Preventative measures are a part of who we are and what we do in regards to food allergy.

As we are more vigilant than many in our day-to-day lives so we need to be more prepared in emergency situations.


Stuck on the WV Turnpike via WSAZ

We are fundamentally a community of preparedness but what happens in the event of an emergency when essentials such as water and power are unavailable for extended periods of time? Could you prepare safe foods for your family in the event of a massive power outage (West Coast 2011) or a water crisis (Charleston, WV)?  What if you were stranded in your car on an impassable highway? You may think it’s not likely, but I bet that’s what people in Atlanta (aka Hotlanta), GA thought in January of this year when a snow and ice storm brought the city to a standstill.

In the last year in my in my home state of West Virginia, there have been massive statewide power outages, weeks to months of water safety concerns, and winter travelers stranded for up to  20 hours on the WV Turnpike. I know these local events have changed the way I think about preparedness for my family but particularly for my food allergic child.

The power outage in July 2012 was an eye opener  as gas stations didn’t even have the power to pump the gas needed for vehicles or generators, pharmacies were closed, and the local hospitals struggled to stay powered.  The water crisis in Charleston was horrifying on so many levels, but it made many of us keenly aware of how much we truly take clean, potable, readily available water for granted. After the Turnpike incident, I began carrying an emergency bag (based on season) in the car.

Water and power are key components in how we care for our food allergic loved ones. The health and, ultimately, lives of food allergic individuals rely on proper cleanliness to reduce risks of cross contamination.

The federal government in conjunction with various state institutions use this month as an opportunity to encourage citizens to prepare for a multitude of scenarios. Assorted government entities have even addressed, sometimes tongue and cheek, a few worst case events. has posted information on family disaster supply lists as well.

Now, don’t get me wrong, I am not advocating Doomsday Prepping.  What I am advocating is having a family plan and  an emergency car travel bag.

What and How?

1. What are the most likely scenarios in your neck of the woods? Tornado, flooding, earthquake, hurricane, snow, wild fire, etc.? Make your plan fit your location.

2. Find out the specifics of each child’s daycare or school disaster plan in the event of separation.

3. Create the family disaster plan which will include (but is not limited to): meeting places, routes of evacuation, and communication strategy.

4. Obtain two copies of important documents (and don’t keep them in the same location)

5. Stock the emergency car travel bag. Items may need rotated based on season but may include:  blankets, battery powered flash lights/radio, extra batteries, first aid kit, change of clothes/shoes, important numbers, extra phone charger, cash,  garbage bag, etc. This list is not all inclusive; please use the resources below for more ideas.

6. Food Allergy specific needs:

  • Safe for your family canned, ready to eat fruit, veggies, meat, soup, safe drinks (in addition to water), cereal, crackers, trail mix, cookies, etc.
  • Manual can opener
  • Wipes (since we know hand sanitizer will not remove food proteins)
  • Prescription and OTC medications  (this is not just food allergy specific but it is a MUST)
  • Knowing the effects of anaphylaxis and how to quickly and effectively treat our loved ones is just as important as actually having the medication.

More on the meds. (I wouldn’t be a good Food Allergy Pharmacist if I didn’t discuss the meds.)

  • As always, carrying your epinephrine auto-injector (EAI)  is key as well as any other “as needed, ” or, PRN, medications such as albuterol inhalers, nitroglycerine, etc.   Never keep medications stored in the car; extreme heat or cold can cause the medication to breakdown and become less effective.
  • Having an extra EAI, inhaler, etc. on hand could be life saving in the event of an emergency situation. However, as a pharmacist, I see “refill too soon” rejections several times per day while at work. So how can a patient get around the “refill too soon” dilemma?

            Here are a few options:

  1. Get the medication refilled as soon as the insurance will allow it.

Some plans allow for early fills up to a week or 10 days early for medications that are not controlled substances.  This is a time to be very familiar with your insurance plan; I have seen a “cumulative refill too soon” rejection which means that the insurance has kept track of how soon the fills have been and at some point, even if the fill is actually due and not early at this specific time, the insurance company will flag it. Very few insurance companies employ the “cumulative refill too soon”; it should be laid out in the policy paperwork. Cumulative refill too soon rejections shouldn’t be a huge issue since I am not suggesting stock piling medication. I am only suggesting having an extra month or so on hand.

        2. Use a coupon and don’t use your insurance.

       3. Pay the “cash price”.

“Cash price” is what pharmacy people call the price without insurance. Depending on the medication, this could be expensive or super cheap.  I will discuss how to get the best bang for your buck without compromising safety or efficacy in an upcoming post.

  • Finally, remember to always rotate your stock of medication if you have several bottles. First in means first out. In the pharmacy we mark each open/used box with an X and newly delivered medications go on the back of the shelf.

7. Practice. Just as we practice fire drills, we should practice our family emergency plan. This would also be a good time to evaluate the appropriateness of the emergency travel bag contents (i.e. different seasons means different needs).


Now. (Just because you think the Zombie Apocalypse isn’t about to—I mean, power outage/natural disaster/chemical spill, isn’t going to affect you, the reality is anything could happen at any time.)

We don’t wait to make allergist appointments. We don’t wait to administer an epinephrine shot. We shouldn’t wait on this either. Basic preparedness is something we food allergy moms and dads do everyday; take this opportunity to take another step in ensuring the safety of our food allergic loved one.  For more information on how to discuss disasters with your children (but probably not zombies) and also how to cope with behaviors after your family has experienced an emergency situation, please visit the sites below.



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Head Lice, Star Wars, and Food Allergies?

School has started again. That means homework, packing lunches, after school sports, and the crud. In the retail pharmacy world, we see a flood of prescriptions about 3-5 weeks after school starts; children come down with everything from ear infections, strep throat, and bronchitis, to head lice.  That may be why September is “Head Lice Prevention Month”.

The scenario starts by receiving the dreaded letter from the school nurse. A kid in your child’s class has lice. Duh, duh, duuuh. I remember that note coming home when I was in elementary school. My mom sat my little second grade, Food Allergy Pharmacist self on a dining room chair and began to explore hair and scalp. Maybe I have been slightly traumatized (thanks Mom), but I clearly remember my mother, who had never seen a louse before, totally FREAK OUT. I had lice (insert the “Imperial March” music aka Darth Vader’s theme song).  My head is itching just typing this post.

Don’t panic and don’t death march up to the pharmacy. Its okay. Not the end of the world.

keep calm and strike back

Yes, you will spend hours examining every single hair on your child’s head with the precision of a surgeon and the intensity of…well…Darth Vader.  (Confession: E has been on a Star Wars kick for a while now, he and my husband will be happy to see that I have been fully integrated. At this moment, my brain can only conjure Dark Side metaphors.)

Numerous methods have been employed to do away with lice including heat (not a light saber), combing, smothering or suffocating, pediculicides (aka bug killer), and more. I want to be clear that I am not going to promote one type of lice treatment over another in this post. I simply want to discuss OTC lice treatment options as they relate to food allergies. I will provide links to a number of resources; I encourage everyone to read the good, the bad, and the ugly of each option and decide for themselves. Please use caution with anything (including food items and oils) placed on the head especially for those with atopic dermatitis, eczema, and any other skin conditions. Some of the forums I reviewed listed combinations of products, long treatment durations, large quantities, and use of plastic bags and sleeping caps especially in children that I felt were potentially dangerous. I did not include those links based on my opinion of safety issues.

I feel that two paths to reaction may be possible while treating and dealing with head lice. These paths are tentative, hypothetical connections. The medical community has not found definitive data directly correlating food allergy to the lice treatments I will discuss. What I am trying to highlight is a potential for allergic reaction. I am making a logical leap based on the clinical knowledge we do have.

1. food sensitization via damaged skin

A recent article in the Journal of Allergy and Clinical Immunology  detailed a sensitization route where a food allergen applied topically to eczematous skin lead to subsequent anaphylaxis upon ingestion of the food. The researchers suggest that skin care be bland, avoiding use of sensitizing agents especially food. This is hypothesized pathway one.

“Natural” treatments have historically included food products such as olive oil, almond oil, mayonnaise, coconut oil and essential oils such as tea tree (melalueca), lavendar, eucalyptus, clove, cinnamon, and peppermint. I have also seen lotions and creams listed as alternatives to mayonnaise; keep in mind that lotions and creams may also contain food allergens e.g. Cetaphil contains nut oils. Several of the sites/forums I reviewed suggested using these “natural” treatments frequently, in some cases every other day. It was also suggested that various essential oils be used on a daily basis (spritzed onto hair or several drops placed in shampoo) as a preventative measure. Lice can be surprisingly resilient.

Never underestimate power of dark side

The article findings coupled with the suggested preventative measures of spritzing or shampooing hair daily with various food items has made me wonder whether similar sensitizations will or have taken place.

2. cross-reactivity due to similar structural features of the allergens

The second pathway (cross-reactivity) might be achieved through use of over-the-counter, OTC, lice treatments.  Some OTC products contain Pyrethrins (Brand names include: RID, PRONTO, Triple-X) which are naturally occurring extracts from the chrysanthemum flower. Permethrin (Brand name: NIX) is a synthetic pyrethroid; a product similar to pyrethrins. Use of either pyrethrins or permethrin in ragweed allergic individuals may cause breathing difficulties and “asthmatic episodes” according to package warnings of both pyrethrins and permethrin.  Allergic reactions have been seen in a few people who have used pyrethrins according to the ASTDR and the potential for contact dermatitis exists as well. Ragweed and chrysanthemums are members of the Asteraceae/Compositae plant family. Other plants in this family include: sunflower, safflower, artichoke, marigolds, and dandelions.

I have been reviewing numerous resources but have yet to find a concrete yes or no answer to my question: Will pyrethrins and permethrin cross-react to food items that are known to cause oral allergy syndrome (or Type 2 hypersensitivity reactions) with ragweed?

the force is strong with this one

Oral allergy syndrome has become common knowledge in the allergy community. It has been noted by the Asthma and Allergy Foundation of America that “ragweed cross-reacts with bananas and melons, so people with ragweed allergies may also react to honeydew, cantaloupe, and watermelons, or tomatoes. Zucchini, sunflower seeds, dandelions, chamomile tea, and Echinacea may also affect some people.”

In other words, if a person has a severe allergy to cantaloupe or tomato (as an example), will that person also react to a topical lice treatment containing permethrin or pyrethrin?

I don’t know the answer to this question but, seemingly, neither does anyone else (yet). Given the data known to be true at this time, I would use caution when selecting permethrin or pyrethrin  for lice eradication if you or your child have a severe allergy to any of the ragweed cross-reactive foods (even more so with concurrent asthma diagnoses).

For more information on diagnosing and treating head lice at home visit and the American Academy of Dermatology. It should also be noted that permethrin can be found in prescription scabies treatments, insect repellent directed to be used on gear and equipment, livestock insect repellent in the form of dust and spray, canine flea collars (permethrin is toxic to cats), and is listed on the World Health Organization’s Model List of Essential Medications Oct. 2013.

And remember , with lice “Do or do not.  There is no try.”


Images used are pieces of art for sale:




Asthma and Allergy Foundation of America:



Are you pregnant with an allergic child?

Normally, I try to give advice that combines the benefits of my education, work experience, and living with food allergies, but today I want to talk about a frustration I have with a gap in medical knowledge and what appears to be a gap in medical research.

I recently read about a study conducted at the Murdoch Children’s Research Institute in Victoria, Australia. The study’s preliminary findings indicate that children may develop allergies in utero.

As I have written in other posts and the “about me” section of this blog, my son, E, is severely allergic to eggs, soy, peanuts, and four kinds of tree nuts. During my pregnancy with him, I was sick. Very sick. One month I lost between 15 and 20 lbs due to vomiting. TMI, I know, but this severity coupled with 1. my mother’s account of becoming extremely sick every time she drank milk while pregnant with my milk-allergic sister 2. similar social media anecdotes and 3. E’s subsequent food allergy diagnoses lead me to a question: Was the reason I was so sick while pregnant with E because I was eating food to which he was already allergic?

Several years ago, while pregnant with A, my second child, I tried to convince the OB/GYN to write a script for allergy testing–just a simple blood sample, nothing that would jeopardize the pregnancy or cause an allergic reaction on or in my body. I wondered if my sample would test positive while pregnant with an allergic child whereas normally I am not allergic. Of course I wouldn’t know if this child would be allergic until later and I would need another blood test to compare; I would also need a food-reaction journal among other things. Regardless, I wanted to test my theory. I don’t think the doctor understood what I was trying to do exactly (or maybe he thought I was crazy). He repeatedly told me that I needed to wait to test for “my” allergies until after the pregnancy. In the end, I did not have the allergy testing and, so far, A is not allergic although she does have some skin issues. I was still very sick while pregnant with A but nothing like the extremes of E’s pregnancy. So my questions remain. The article reignited my thoughts on the subject.

The study is investigating whether the allergy development is due to maternal influence (weight, diet, smoking, etc) on predisposed genes. Certainly, this aspect bears much investigation.

But, what if the genetics of the child (i.e the allergy within the baby) influence the eating habits, activity, weight (obviously not smoking) of the mother during pregnancy? In these cases, could maternal eating habits and diets be the result of the “allergic” pregnancy as opposed to the allergy being the result of the maternal diet? Perhaps it’s both; a predisposed genetic mechanism catalyzed by a diet that then becomes unsustainable due to the developed allergy of the unborn child.

To be clear, I am not talking about the typical cravings, food aversions, and nausea/vomiting of pregnancy; I am talking about extreme and/or specific cases.

To further extrapolate: Could my theory, if proven correct, lead to earlier childhood diagnosis and anaphylaxis prevention by utilizing a simple prenatal maternal allergy screening process?

This very question is the crux of my theory. If a simple blood test could prescreen for significant allergic reaction then the children could be saved the months and years of itchy rashes, breathing problems, misdiagnoses, and unnecessary medications. The mothers could avoid offending foods while pregnant and breastfeeding, thus potentially eliminating signs and symptoms in both themselves and their child. Avoidance and prevention of anaphylaxis in this population would be amazing.

Of course all this is just a theory (not even a scientifically based theory) of mine established on anecdotes of pregnancy illness vs food allergies discovered early in a child’s life, including my own. This theory also does not address those that develop allergies later in life. I would love to test my theory informally via a large-scale questionnaire or poll. Maybe I will one day, but for now: What have been your experiences while pregnant with your allergic child? Were there any noticeable differences between allergic and non-allergic sibling pregnancies?


Update 6/12/2015:

Could passive transfer of allergies such as with the Canadian transfusion patient account for the maternal reactions I discussed in the blog?  The case was published in the Canadian Medical Association Journal on April 7, 2015.




Short Dated Epinephrine

Homa Woodrum, over at her blog ohmadeeness,  recently posted that numerous people are receiving short dated Epipen® and Auvi-Q®. Short dating refers to an expiration date that will expire relatively soon. Getting a short dated medication is not always a negative experience since most medications will be consumed or otherwise used within 30 to 90 days. However, as needed, or PRN medications, should not be dispensed if short dated unless absolutely necessary such as in the event of a long-term manufacturer back order, emergency event, or if the patient absolutely needs the product immediately and cannot wait for an order to be placed. PRN medications include epinephrine, albuterol rescue inhalers, nitroglycerin, and others

Homa’s post addresses the issue of what to do if you have already purchased the short dated epinephrine. Her post also provides manufacturer numbers to obtain reimbursement. I have also provided contact numbers for each manufacturer in my Epinephrine Auto-Injector Comparison Chart.  But better than dealing with the aftermath is avoiding purchasing a short dated epinephrine; I am going to outline strategies for you and the pharmacy on keeping short dated Epinephrine Auto-Injectors (EAIs) out of your hands at all.

How can a patient/parent handle a short dated EAI situation?

Try to remember to check the expiration date before leaving the pharmacy, preferably before you pay for the medication. Simply do not purchase the product unless absolutely necessary.

There are a few options in this instance:

1. Review at Drop-Off. One way to avoid short dated product is by having the pharmacy staff check the expiration date when the prescription is dropped off. This helps you avoid an unnecessary wait (if the expiration date is not acceptable) and it helps the pharmacy not fill medication that won’t be picked up. Win-Win. Plus, if the pharmacy is not crazy busy, the pharmacy staff may call other pharmacies to check on stock and expiration dates for you. Calling another pharmacy is not part of the pharmacy staff’s job, per se, but we do provide this service often, especially when asked nicely.

2. Call ahead. (I highly recommend this.) Call the pharmacy and ask them to review the expiration dates of the on-hand product. If the date is not satisfactory, do not take the prescription to that pharmacy. If your primary pharmacy does not have the product or a product with at least a year good dating, then call other local pharmacies to check their stock. Hopping from pharmacy to pharmacy in general is a bad idea, especially for people with food allergies or patients on multiple medications, but this would be one instance where it would be okay to use a pharmacy other than your home pharmacy.

3. Have the pharmacy order another box. Typically, retail pharmacies can order a product to be delivered overnight Sunday-Thursday (the orders are delivered Monday through Friday for most pharmacies). If the situation arises over a weekend or holiday, you may have to wait until the next business day for the pharmacy’s supplier. Pharmacy suppliers such as Cardinal Health and McKesson have different hours and holidays than the pharmacy; your pharmacy may be open but the supplier may not.

What if the pharmacist says she has no control over the expiration date of the medication delivered?

This statement is true. Pharmacists cannot request (or demand) specific expiration dates. However, the pharmacist can return a short dated product immediately upon delivery; I have had experience doing this with Cardinal Health. Another package can be ordered, but again, the pharmacist will not know the expiration date before it arrives.

Why would the pharmacist even fill a short dated EAI?

Pharmacies pull outdated medication frequently. Some pharmacies pull on a monthly basis, pulling all the medications that will expire the next month (i.e. anything that will expire in August is removed by the end of July), other pharmacies pull three months at a time. Additionally, technicians should be screening expiration dates at the filling/counting stage. Pharmacies have built-in redundancy, another layer of safety; this is one example. For that reason, the pharmacist may not look at the expiration date as the medication is being verified.

Overall, I believe this is a training issue. Pharmacists know that patients should be using EAIs infrequently (hopefully) and, based on that knowledge, pharmacists know that EAIs should have long expiration dates. What pharmacists may not know is that they can return a short dated product delivered by a supplier.

It’s my opinion that pharmacists should always check the expiration date on EAI at the verification stage. If the product has less than one year good dating the patient should be contacted to see how the staff should proceed.

Pharmacy Solutions

In the pharmacy, several actions can take place to prevent short dated EAIs from being dispensed.

1. Patient profile note. The pharmacy staff can add a note into the patient’s profile stating that EAIs must have one year good dating. Most retail pharmacies have some mechanism for adding patient notes and patient requests into the system.

2. Signage. (Old school but potentially very effective.)The pharmacy staff could place a sign near the shelf location of the epinephrine reminding staff to review expiration dates and return any product that is received short dated. Short dated product that cannot be returned could be stickered, or otherwise tagged, in order to alert staff of the potential problem.

3. Training. The pharmacy can focus on training by reinforcing examination of EAI expiration dates at the various stages of the filling process: when pulled from shelf, when filled by the technician, and finally when verified by the pharmacist.

4. Technology. At this point, I would settle for a prompt at the verification stage reminding the pharmacist to review the expiration date, making sure it was at least one year from the dispensing date. A hard stop mechanism requiring the manual addition of the expiration date could be another solution.

There is pharmacy technology already utilized that scans and processes the UPC codes located on each manufacturer bottle/box. The scanning process verifies that the correct medication has been selected. Ultimately, I would love to see the expiration dates and lot numbers automatically logged via the UPC scan. The data collected would help screen expiration dates but also it would aid the pharmacist in the event of mass recalls (which happen quite frequently at varying levels of severity).

Of course, number four is the most difficult action in that it would require the IT department of a corporation to become involved.




Epinephrine Auto-Injector Comparison Chart 8/3/2014

Sorry for the late post. I was having trouble adding my comparison chart to the site. This was the best solution my sister and husband (aka my personal Geek Squad) could find; I was no help at all.

Having multiple epinephrine auto-injectors (EAI) choices available is a wonderful thing for the patient/individual; not so much for the teacher or school nurse but I will discuss that in an upcoming post. EAI selection is a personal choice based on a number of factors: price, feel, perceived ease of use, size, etc. These preferences may change or evolve with time just as our lives change.