Food Allergies and the Pharmacy


Leave a comment

Truth and Resolutions

Happy New Year!!

I want this year to be a year of transformation. I have resolved to be a healthier version of myself (focusing a bit more on me for a change–specifically health wise) and I have resolved to be a better advocate.

To be honest, I don’t like to write. I’m not a writer; heck I don’t even consider myself a blogger.

I like to research. I like discovery. I have a full time job working 12 hour shifts; I have two kids; I volunteer at a non-profit; I am a homeroom mom; I am a wife, a friend, a daughter, and a sister. And like everyone else reading this the chef, the maid, the chauffeur, the laundress…

I never intended to be an advocate; I had to worry about my son constantly as it was. Why blog about too. Or at least that’s what I thought, when I tried to talk myself OUT of doing this.

I began being “The Food Allergy Pharmacist” because I was horrified at some of what I was reading on various sites/groups regarding medications (in relation to allergies). I didn’t out myself as a pharmacist originally but as a person that can’t help but find solutions (or at least a path toward a solution) for any problem I find, I couldn’t sit by, doing nothing, knowing what actions/consequences may develop. Based on my years (and years–dang When did I get so old!?) of experience counseling patients and the lessons I have learned as a medical professional some information should be explicit, never implied, never assuming that what is obvious to one person is obvious to another. It’s not.

So my truth is that I’m not a good blogger. I don’t like to write BUT I am a good advocate in the sense that my information will be researched, reasoned, and factual. Mistakes will be dealt with promptly and openly.

Food Allergy Pharmacist resolutions include: 1. Post more often (I may even start having some of my students research and post as well)
2. Expand on the Teal Trunk or Treat Event I planned last Halloween (See I’m not a good blogger! I didn’t even post about that!) 3. Begin working with WV State Representatives to urge changes within WV law.
4. Get my CE (Continuing Education) program into full national realization. I already have a basic presentation finished (and have presented it at the local pharmacy school).

Happy New Year!

Please comment below with any suggestions for blog posts or if you have questions about the Teal (food free) Trunk or Treat.

Advertisements


1 Comment

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.

 

 

Flublok:

  • 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

 

Flucelvax:

  • 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


Leave a comment

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 headlice.org 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:

https://www.etsy.com/listing/106430722/keep-calm-and-strike-back-poster?ref=market

http://ludovitnastisin.deviantart.com/art/Darth-Vader-Quote-360922238

https://www.etsy.com/listing/179051508/the-force-is-strong-with-this?

 

Sources:

CDC: http://www.cdc.gov/parasites/lice/head/treatment.html

Asthma and Allergy Foundation of America: http://www.aafa.org/display.cfm?id=9&sub=20&cont=728

http://www.atsdr.cdc.gov/phs/phs.asp?id=785&tid=153

http://www.aafa.org/display.cfm?id=9&sub=20&cont=728

http://www.healthline.com/health-slideshow/home-remedies-for-head-lice#1

http://healthfinder.gov/FindServices/Organizations/Organization.aspx?code=HR2088

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3362728/

http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=3cdec6f3-4da6-467f-96c3-c8941ff46b56

http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=9b44bf94-62c9-49d8-97ec-cf475824eb35

http://www.epa.gov/oppsrrd1/REDs/factsheets/permethrin_fs.htm

http://www.epa.gov/oppsrrd1/reevaluation/pyrethrins-pyrethroids-asthma-allergy-9-18-09.pdf

http://www.rxlist.com/pyrethrum-page2/supplements.htm

http://www.britannica.com/EBchecked/topic/39698/Asteraceae

http://www.skintherapyletter.com/treat/lice/permethrin_pyrethrin_piperonyl_butoxide.html

 


2 Comments

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.

 

 


1 Comment

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.

 

 


2 Comments

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.


2 Comments

Unsung Heroes of the Baby Shower

IMG_0441

I have been invited to my cousin’s baby shower this weekend which got me thinking about my standard baby shower gifts. These gifts are partially influenced by my pharmacy background but, more so, by my son E.

I remember one brutal night before my son turned one. He began vomiting and I freaked out, just a little. Ok a lot. And even though I had been a pharmacist for years, I called my Mommy.

His skin had already began cracking and bleeding (of course at this point I had no idea it was from the food; the vomiting was probably due to the food as well); he was taking diphenhydramine continuously at the pediatrician’s direction, using topical and inhaled steroids, as well as albuterol. The ear infections were non-stop and so were the antibiotics.

His humidifier ran 24/7 while the Aquaphor ointment helped his diaper area as well as all the cracked, scaly, bleeding skin on his face, arms, and legs. Ear infections lead to temperature spikes that could only be controlled by rotating acetaminophen and ibuprofen. Diphenhydramine helped E’s entire body, but only temporarily.

Of course skin care was huge; Aquaphor and either Cetaphil cream (***update:  this was before his nut allergy diagnosis so I didn’t know I was rubbing him down with something he was severely allergic to) or Cera Ve cream were a must. Poor little guy couldn’t even play outside in the grass without a rash popping up somewhere.

When I think back to those days, I am so thankful, thankful that E didn’t have anaphylaxis before diagnosis (and before we had an EpiPen),  thankful that my son’s allergies have been improving, and thankful that I am finally able to get some sleep, glorious sleep.

As you will see, I give items that have helped my family. Products that were invaluable at 4 am are my go-to gifts.

1. Humidifier

2. Aquaphor ointment

3. liquid acetaminophen

4. liquid ibuprofen   

5. liquid diphenhydramine

6. dosing syringes for all the liquids (never use the spoons used to eat to measure medication)

7. Cera Ve cream

***update: please note that Cetaphil creams and lotions contain nut oils. I originally had Cetaphil listed in #7 but removed it because I only buy Cera Ve for my family and I try to make my gifts as allergy free as possible. Also I worry about the impact of the nut oil on the damaged skin. An article confirming the link between a goat’s milk skin product and subsequent anaphylaxis recommends that skin care products be bland and contain no food allergens. 

Homa Woodrum reminded me of another wonderful product called Vanicream. Compounding pharmacies use Vanicream frequently and it received the Seal of Acceptance from the National Eczema Association. If you can’t find Cera Ve or Vanicream at your pharmacy, ask the pharmacist if she can order it for you.

8. nasal aspirator (bulb)

9. nasal saline

10. rectal thermometer  and information on how to take a temperature

Since food allergies, and allergies in general, are on the rise, I feel that it’s important to arm new parents with the products they may need to deal with unexpected illnesses. These are not the cutest gifts at the shower but, one day, you will get a phone call thanking you. I have received many calls over the years. The mommies are so appreciative and usually reveal that these gifts were not anything they had ever thought about registering for or purchasing themselves–the unsung heroes of the baby shower.

Are there any other products that you think are necessities for mother’s and father’s to be?

Have food allergies affected your choices in unexpected ways?