Food Allergies and the Pharmacy


Bottom of the Barrel

While traveling with E and A today, I visited one of Cracker Barrel‘s 600 locations.   E has never eaten at the Cracker Barrel but since so many restaurants have embraced the challenges of providing for allergic customers I thought I would give it a go. Welp…a half hour (and 3 bathroom breaks with a potty training 3 year old) later, we left with empty bellies, frustration, and PICTURES.

I will start with the positive. I appreciate the language added to the internal reference that specifies that the servers refer food allergy questions to a manager. I also appreciate the mention of cross contamination and the attention given to educate the server that even a small amount of a food allergen could be “life threatening” for some people.

Why did I italicize and bold internal?

Apparently, the Cracker Barrel feels that the customer should not be allowed to read its poorly developed and horribly executed allergy menu. The food allergen reference even specifies that “it should not be given to the guest or posted for public reference.”  Cracker Barrel even goes as far as to state that the server (or manager as it would seem) “must review ingredient labels and take extra care to prevent cross-contamination.”

I didn’t know any of this valuable information when I sat down. I didn’t know that I would have a server “suggesting” menu items to me off the “allergy menu” that I requested but was not allowed to read.

My waitress would not give me the menu, at first.

I simply explained that I deal with my son’s allergies every day and that there are several names for each allergen. I know these names. If you are reading this blog, you probably know them too. She, however, does not. And since I was not allowed to read the “menu,” I did not know how the information was listed or provided.  I convinced the waitress that I should be the one reading the menu.


Maybe Homa Woodrum could shed more light on this but I would assume that having the server/manager translate an allergy menu and specifically suggest food items would actually be more of a liability to the corporation.  This is even more poignant given the fact that the allergy menu specifically states that it should not be shown to the customer.

Another issue that gets me heated is their attempt to educate the waiter (who is then to educate the customer since the customers aren’t allowed to read the paper?) on the recommendation for the guest to “discuss with a physician” the need to avoid soy lecithin and soy oil.   Within the paperwork, I found a statement referencing the “Food Allergy and Anaphylaxis Network” which we know merged with the “Food Allergy Initiative” in 2012 to become FARE (Food Allergy Research and Education).  In the upper right hand corner of the menu the “revised” date of October 2013 can be seen.



So, not only was this menu updated with outdated information even at the time of its revision but also, it has not been addressed for a year and a half. Could it be possible that food venders, and potentially the food ingredients themselves, have changed over the course of a year and a half?  I think yes.

The FAAN statement talks about how soy lecithin and soy oil are not “indicated as allergens.” I guess this absolves the Cracker Barrel of the need to disclose these ingredients in the so-called allergy menu.  My son reacted to the type of soy oil to which most people do not react. I don’t need nor do I want lectured on soy from the waitress at the Cracker Barrel. I want ingredients. I want a clear, easy to understand menu that is updated frequently and does not talk down to me or belittle an allergen that is important in my family.

Needless to say, we did not eat there.  Additionally, I would not recommend any person with food allergies or sensitivities to consider Cracker Barrel unless some serious, extensive changes are made.  First and foremost, the customer should ALWAYS be allowed to read the ingredient list. Restaurants should be transparent with all aspects of food prep and content.  I am not talking about specific recipes of proprietary ingredients but simply the basic list of included food.  ALL food. Any and everything used in the making of the food. Period. Simple.


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Influenza Vaccine Chart 2014-2015

Much thanks to Andrea Brookhart, PharmD and her colleagues, pharmacy residents MacKenzie VonCanon, PharmD and Hannah Kuhn, PharmD for allowing me to use their awesome chart! There is also a link to a printable version at the bottom of the page.  These are the vaccines that will be found at most local retail pharmacy locations.

I have provided information on Flucelvax and Flublok below the chart.




  • 100% egg free
  • Indicated for people 18 or older
  • Most common adverse reactions include: pain at injection site, headache, fatigue, and muscle pain
  • Does not contain any preservatives, gelatin, thimerosal (mercury derivative), antibiotics, or formaldehyde
  • Trivalent (covers three strains of influenza virus)
  • Latex free
  • Pregnancy Category B; not evaluated in nursing mothers
  • Safety and efficacy in pregnancy has not been established per package insert (even though it is listed as a pregnancy category B). Pregnant women who receive Flublok are to be registered in the Flublok pregnancy registry.
  • Warnings: Guillain-Barre syndrome w/in 6 weeks of previous vaccine
  • According to the website, Flublok is not available in all states (based on health provider ordering practices). Use this link to (hopefully) find a site close to you.
  • All information taken from the Flublok package insert



  • Indicated for people 18 or older
  • Tip caps of pre-filled syringes contain latex
  • Most common adverse reactions include: pain at injection site, headache, fatigue, and muscle pain
  • Does not contain preservatives or antibiotics
  • Trivalent (covers three strains of the influenza virus)
  • Virus is propagated in Madin Darby Canine Kidney cells (MDCK). For more information on how this works see my post Influenza Questions Answered
  • Warnings:  Guillain-Barre syndrome w/in 6 weeks of previous vaccine
  • Pregnancy Category B; not evaluated in nursing mothers
  • Flucelvax can be found only in select retail locations. Use this link to find a location near you.
  • All information taken from the Flucelvax package insert


Printable PDF:   Influenza Vaccine Chart 2014-2015


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.

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Pharmacy Basics: DAW codes

DAW icon

I am finishing up a week of vacation but I didn’t want to miss a week on the blog. Plus, a little alone time was much needed.

We have established that the Orange Book is a fun read, but you can bypass it by using DAW codes. DAW or Dispense as Written codes are codes that specify that a particular brand or manufacturer must be dispensed without substitutions.

There are two DAW codes that I believe are most important for our food allergy discussions/issues: DAW 1 and DAW 2.


DAW 1 means that the prescriber has specified that the BRAND medication only (not the “A” rated, therapeutically equivalent, generic) must be dispensed. Laws vary from state to state but, in general, the prescriber must write DAW or Dispense as Written or Brand Medically Necessary or Brand Necessary on the prescription. At this point the pharmacy is ONLY allowed to dispense that particular product, no substitutions permitted.

This can be good and bad.

The bad:

If the brand product or a specific manufacturer is not covered on your insurance, the pharmacist cannot legally switch to the generic. The pharmacist must call the prescriber and get permission to give the generic product. This will take time. The pharmacy staff may have to leave a message and, depending on how busy the prescriber’s office is, may not receive a return call for several hours to several days.

The specific medication desired may require a Prior Authorization. A Prior Authorization is when the prescriber must call the insurance company, explain why the patient must have a certain medication, and often give diagnoses.This usually happens due to cost issues. Sometimes, the insurance company wants a patient to have tried several cheaper options before allowing a more expensive medication to be covered.

For example: Brand Singulair may require a Prior Authorization since a less expensive, “A”rated generic called montelukast is available.

The good:

Some insurances will assign different copays based on DAW 1 vs DAW 2; DAW 1 being cheaper. Additionally, in instances such as with epinephrine auto-injectors, a “B” rated auto-injector cannot be substituted as with the special circumstances discussed at the end of The Orange Book post.

Example: Adrenaclick written as Brand Medically Necessary CANNOT be substituted with Lineage’s epinephrine auto-injector under any circumstance of which I am aware without the prescriber removing the DAW 1 indication.

Another way that DAW 1 can be awesome in the food allergy world is by specifying a particular manufacturer.

As we have discussed in Pharmacy Basics: NDC numbers and Package Inserts, inactive ingredients often contain food items. If you have found a manufacturer that makes a product without your particular food allergens, stick with it.

medically necessary

As always, review the package insert before purchasing the medication.  Inactive ingredients change just like the recipes for the food we eat. We must review the inactive ingredients each time the medication is picked up.


DAW 2 is simply the patient, patient’s guardian, or patient’s representative requesting a specific brand or manufacturer of medication.

This still may require a Prior Authorization, it may not be covered at all depending on your insurance formulary, and it will not be a less expensive copay but it may be the same copay as prescriptions specified as  DAW 1.

However, with DAW 2, if one of those problems arise, you can decide that it’s not worth the copay price or the wait that may be required for a Prior Authorization to be processed.You can say “Never mind, give me the generic.” No need to call the prescriber.

At that point, you can have the pharmacist help you find another compatible manufacturer, if one exists. This will take time, please be patient. If the pharmacist cannot find a suitable alternative, she may need to call the prescriber to see if a medication change is appropriate.

Plus, you may request the brand medication or a particular manufacturer at any time, even if it’s the third refill.

Once the pharmacy staff processes the medication, they should be able to tell you how much it costs, if it requires a “Prior Auth” (as we call it), or if it is just simply not covered.

For more information on DAW codes go here:

In the next few weeks, I will be posting an epinephrine auto-injector comparison chart and Pharmacy Basics: Vocabulary. Please comment below on any particular phrases or vocabulary you would like explained.

Don’t worry, there won’t be a quiz at the end.