I am SO excited to be partnering with JORD Watches for a giveaway! My blog post reviewing these beautiful timepieces is soon to come, but in the meantime, check out the giveaway.

1 winner will win a $100 giftcode to the JORD Watches website, and every participant will get a 10% off voucher for the website. Contest ends 05/13/2018 at 11:59 pm CST, and 10% vouchers are good until 05/27/2018.

If you're looking for the wooden watch I'm wearing, it is the Frankie model in ebony and gold!


Keep on a look out for my upcoming blog post!

When I started pharmacy school, I had many assumptions about how it would be. I thought I'd be the class underdog coming into the program as someone without an undergrad degree. I thought it'd be hard, but had no real, solid gauge of how hard. I thought I'd coast through without many friends, probably without joining any organizations. I thought I would just totally and completely immerse myself in my work. I've learned so much since starting about myself, pharmacy, medicine, and people as a whole. Recently, residency interviews brought up a lot of feelings and reflections about some of the more introspective thoughts I've had about pharmacy school. So here they are.


Yeah its going to be hard, but it is all about how you adapt
I've said this time and time again to P1s. Of course pharmacy school is hard, but if you made it into pharmacy school you most certainly have the ability to learn the information presented to you. What is difficult is adapting to the amount of information you have to learn and doing it fast. In relation to studying/doing work in pharmacy school, you need to be able to try out a method, analyze the result and make the changes you need to, seamlessly. Your old methods of studying may work, they may not, either way each first exam in a class is going to tell you what did and did not work and you have to be able to look to what you could change, and implement it as soon as possible! The easier this is for you to do, the better.


Organizational involvement can be so much more than just another addition to your CV
 In my P2 year, a classmate of mine made an announcement that our APhA-ASP chapter was looking for a communications vice president, and after hearing the position details I thought "I can do that". I also had nervous thoughts of "what if it consumes too much time?", and "is an e-board position something I'm ready for?". If it hadn't been for my classmate's prodding and encouragement I probably would have never jumped into the role, and it certainly changed my life. It forced me to not only be involved but to take a relatively undeveloped position and make something of it. More importantly, in the two years I have been an active member of APhA-ASP I have been nothing short of impressed with the impact my fellow student pharmacists have made in the Philadelphia community. And that impact isn't exclusive to just APhA-ASP. Our student body org, ASHP, IPhO and many others have made enormous impacts in our small community at Jeff and also in Philadelphia. My time in pharmacy school was made so much more whole by being an active member in an organization. It gave me something to look forward to, something to keep busy with (that wasn't studying), a place to grow, and the opportunity to lead. I thoroughly encourage each and every P1 and P2 to pursue leadership positions in these organizations despite the fact that studying/exams/projects loom overhead. I promise you, you have the time and the ability, and it is more than worth it.


Your classmates are your support system not your competition
Simply put: I cannot imagine navigating the crazy journey that is pharmacy school without the friends I met in class. No one is going to understand what exactly it is you are going through during school, except for them. I have amazing friends outside pharmacy school who are wonderful and try their best to understand what it is I'm talking about, but lets be real they don't really care if I have all the major drug interactions associated with Warfarin memorized. Pharmacy school is too turbulent and exciting of a time to be making enemies, or labeling folks as competition. You all have the same end goal in mind: PharmD. Work toward that goal together and lean on one another. After all, you'll be spending a lot of late nights in the library together.


Know that your preceptors did not become incredible over night
When I was a P1 thinking about my life 4 years down the road, I pictured that I'd transition into APPEs just as confident and capable as the preceptors and professors I interacted with every day. I thought "of course I'll be ready! I'll be armed with three years of pharmacotherapy knowledge!". I wish that were enough. The transition from IPPE to APPE student was a big challenge for me because of this expectation. As an APPE student, you have a lot more autonomy and a lot more is expected of you, but you still have SO much more to learn. I spent so many of my rotations in awe of my preceptors, wondering how it was that they could cite every detail of clinical trials and if I would ever get there myself. I could never picture myself on their level, and it became a source of stress for me. I felt as though I was behind. However, I began to open up to these preceptors and asked them how exactly they got from APPE student to being an amazing clinical pharmacist. The response I got 90% of the time was: it takes A LOT of time, a lot of practice, a lot of patience and a lot of failure. This was probably the biggest takeaway from P4 year for me. Your preceptors were once in your exact same position, and you should take solace in the fact that you will get to their place one day too.

When you feel lost: remember why you started
I repeated this to myself religiously with every difficult exam, every impossible situation and every stressor I experienced during pharmacy school. Remember why you started this journey. Remember it to bring things into perspective. Remember it to get you back on track or keep you on track. Remember it when you feel like giving up and use it to inspire you to keep moving forward. The you who started pharmacy school is going to be a whole different you at the end, but hopefully your purpose remains the same. I found that reflecting back on my why was vital in keeping myself grounded.


So these are the points that have resonated the most with me as I look back on the last 4 years. I've learned so much about what I love, but also about myself. The photo below is me on the day of my white coat ceremony, about two months into my P1 year. I've changed so so much since then (including about 6 inches of hair), but I'm so incredibly happy with how it has all turned out.

Hey ya'll! It has been a while, but I've been inspired to write out some posts again because A. I am back on rotation after a very long 3 months off and B. have had many P3 students reach out to me looking for advice in regards to picking APPEs. Picking your APPEs can be a really overwhelming process, from ranking the sites, to thinking about transportation and also just the general ambiguity about where you'll be next year that hangs overhead. I'm here to tell you: don't fret, it'll all work out. Seriously. The P4 students when I was a P3 picking APPEs told me exactly the same thing and I still worried, but reflecting back now I can see that everything worked out exactly as it should.

1. Think a lot about what you are interested in, what settings you are most excited about, and what you would love to learn more about!

APPEs are your time to explore, so don't choose rotations because you think they'll be "easy". I can't tell you how many times I've heard people say that they were totally committed to doing community pharmacy as a career, went on APPE rotations and ended up applying for residency, or vice-versa. While I definitely recommend choosing a rotation in a career field you think you have an interest in, it is also a great idea to challenge yourself with rotations you know nothing about. You never know how choosing outside your comfort zone will impact your interests and goals! I chose a variety of rotations that I knew I may never get the chance to take elsewhere, like a gastroenterology ambulatory care rotation. I already knew I loved ambulatory care, and chose it as an elective because having it be GI-based was too unique to pass up on!

2. Know that you may not get your first choice in everything

AND THATS OKAY! Story time: I did not rank transplant for my inpatient APPE, at all. So when our APPE algorithm presented me with my first APPE rotation, inpatient transplant at a local hospital, I was surprised but took it in stride knowing that I'd still learn a lot even if I didn't rank the subject. It turned out to be one of the best rotations I had during the whole year, and transplant became my primary interest (and will possibly be the speciality I pursue in a PGY2 residency, granted PGY1 goes okay haha!). So my point is: embrace the rotations that may have not been your first choice, because they can have the most serendipitous effect on your life.

3. You cannot cheat the system

There is no magic way to cheat the algorithm and get your first choice in everything, no matter what the conspiracy theorist in your class says.

4. Ask P4s for their advice

Who better to advise you on which rotations are interesting/fun than the people currently in them!? I've had a ton of P3s reach out to me asking about my experiences in my rotations. Your upperclassmen are your best resources, so utilize them. We've been through it and we'll help you through it too. The best part about seeking out help from P4s is that they can also give you the inside scoop about the stuff that isn't listed in your program's APPE manual but matters just as much: is the train ride sketchy? how is the cafeteria? what does my average day look like at this rotation?

5. Consider your plan for next year when ranking

For example, I lived in Philadelphia during my P3 year and knew that my lease would be up in the summer of my P4 year while I was on APPE. Knowing this I scheduled my last two rotations to be back in NJ, where my family lives, so that I could avoid a commute into Philly. APPEs are tiring, and you're usually there all day. Sometimes you might have to pop in to get extra info on a patient, sometimes you have projects to do that require you to come in as well. Therefore it is good to think about things like: where will I be living? will I have access to a car? will I need time off for a family obligation? etc. It is much better to plan ahead when possible then to figure things out while on APPE when you have a lot more work going on.

That is all the advice I have for now. I know my school in particular is wrapping up their ranking time period but hopefully this will serve as a stress relieving post for those who are wondering whether or not they made the best choices possible. If you've already submitted, relax and keep calm till you hear. It'll all work out and soon enough you'll have your list!

Angiotensin Converting Enzyme (ACE) Inhibitors and Angiotensin II Receptor Blockers (ARBs) are two of the first line agents recommended for treatment of hypertension in guidelines such as JNC8, and ACC/AHA '17. They are also recommended first line by the ADA 2018 guidelines for patients with diabetes, hypertension and albuminuria in order to reduce the risk or slow progression of diabetic kidney disease. Additionally, we use them in chronic congestive heart failure and post-MI where there is data says they reduce cardiovascular mortality and morbidity. They're pretty much our ACE in the hole (ha ha ha) but there a few things we look out for when starting these agents in people: change in Glomerular Filtration Rate  (GFR), hyperkalemia and that weird dry cough. So, what is the story behind the ACE-I effect on these factors?


The GFR Effect 

The end goal of ACE-I is to prevent angiotensin II from causing potent vasoconstriction, a mechanism activated to increase blood pressure that can be overactive in certain types of hypertension and other disease states. In the kidney, angiotensin II vasoconstricts both the afferent and efferent arterioles, but preferentially affects the efferent arterioles. Why does this happen? The efferent arteriole is smaller than the afferent, making the effects of vasoconstriction on resistance  more capable of occurring. Also, angiotensin II stimulates release of the vasodilator nitric oxide from the afferent arteriole, meaning that angiotensin II is able to keep the afferent a little more open versus the efferent arteriole. This preferential vasoconstriction of the efferent arteriole either increases or maintains intraglomerular pressure and is an important factor in autoregulation of pressure by the kidney.

In primary hypertension, there is an increase in renal perfusion that isn't as mediated by angiotensin II, so treating with an ACE-I doesn't cause as much of a change with GFR when the patient has normal renal function. However, this is not the case in patients with renal artery stenosis where the arteries carrying blood to the kidneys are narrowed and perfusion to the kidneys is poor .When the addition of an ACE-I reduces systemic blood pressure and inhibits the auto-regulation effects of angiotensin II, patients with renal artery stenosis experience a subsequent drop in intraglomerular pressure, and a further reduction in perfusion, causing an increase in plasma serum creatinine. This can also be observed in patients with hypovolemia where there is low circulating volume, and in intrarenal disease such as nephrosclerosis. Bilateral renal artery stenosis is considered a disease-drug contraindication with ACE-I/ARBs because of the risk of kidney damage and potential failure with poor perfusion. However, the reduction of GFR is reversible with cessation of these agents.



What to look for:
This is one of the many reasons why we order 2 week follow-up labs when starting patients on ACE-I/ARBs. This change in GFR happens within the first week of starting these agents, so labs within 1-2 weeks are the best bet to catching it. We can expect to see a transient change in GFR when starting these agents but if the change in serum creatinine is >30% of the patients baseline, that is cause to consider there may be an underlying perfusion problem such as bilateral renal artery stenosis.


References:

1. Navis G, Faber HJ, de Zeeuw D, De Jong PE. ACE Inhibitors and the Kidney: a Risk-Benefit Assessment. Drug Saf. 1996; 15(3): 200-11. https://www.ncbi.nlm.nih.gov/pubmed/8879974

2. Sica DA. Angiotensin-Converting Enzyme Inhibitors Side Effects: Physiologic and Non-Physiologic Considerations. J Clin Hypertens. 2004: 6(7); 410-16. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-6175.2004.02866.x/full

3. Bauer JH, Reams GP. ACE Inhibitors in Renal Disease. Clin Cardiol. 1991:14; 38-43.


Hyperkalemia

The renin-angiotensin-aldosterone (RAAS) system is an influencer of sympathetic tone, blood pressure, and homeostasis through the regulation of sodium, potassium and fluid. The juxtaglomerular cells which are present in the wall of the afferent arteriole are meant to sense changes in this balance, and then react accordingly to any changes by releasing renin. This activates the entire RAAS cascade, ending in the creation of angiontensin II. Part of angiotensin II's action is to mobilize aldosterone from the adrenal cortex.

Aldosterone mediates potassium secretion out of the body through its effects on sodium reabsorption. It binds receptors in the collecting duct of the nephron to stimulate sodium reabsorption and therefore create a more favorable environment for potassium to be secreted through potassium channels. So it makes sense that when we use ACE-I or ARBs, we blunt this process by inhibiting angiotensin II and reducing the stimulatory its effects on aldosterone. It is unlikely that ACE-I reduction in aldosterone alone will cause hyperkalemia, because it is more likely that a greater reduction has occurred due to disease. There are many additional factors that contribute toward hyperkalemia in patients taking these agents, such as increased potassium intake, combining with other potassium-sparing drugs, reduced renal function and older age. Why do we care about increased potassium? Hyperkalemia can cause cardiac dysrhythmias, bradycardia, systole, muscle cramps, tetany, and parethesias.

References:

1. Raebel MA. Hyperkalemia Associated with Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers. Cardiovasc Ther. 2012; 30(3). 156-66.

2. Palmer BF. Managing hyperkalemia caused by inhibitors of the renin-angiotensin-aldosterone system. N Engl J Med2004;351:585–592.


Dry Cough

Probably the most recognizable/infamous side effect of these agents, is the dry cough reported in 5-35% of people who have taken ACE-I. The mechanism surrounding this side effect is mostly a mystery, but the proposed mechanism involves the RAAS system. ACE-I also prevent the breakdown of bradykinin and substance P, which are protussives and sensitize airway sensory nerves. Their accumulation in the respiratory tract is thought to be a potential mechanism of dry cough. Bradykinin is also thought to play a role in the therapeutic effects of ACE-I and a negative role in the pathogenesis of angioedema. Important to note that this side effect is not typically present in patients using ARB agents because they block the RAAS system further downstream than ACE-I, and do not inhibit ACE. In patients who experience dry cough with an ACE-I it is completely reasonable to switch them to an ARB. 



References:

1. Dicpinigaitis PV. Angiotensin-Converting Enzyme Inhibitor Induced Cough: ACCP Evidence-Based Clinical Practice Guidelines. CHEST. 2006; 129(1). 

This fall/winter have been a busy season for guideline updates! From the buzz surrounding the ACC/AHA '17 hypertension guidelines to these new guidelines from the American Diabetes Association, it is clear that there are some changes on the horizon. I just finished reading through the 2018 ADA guidelines and figured I'd put together a summarized student break-down about some notable recommendations/sections that I found interesting. I'm also going to include some of my own tables that I've created to help me remember testing criteria and risk factors, feel free to download and use them as well!


Improving Care and Promoting Health in Populations

The ADA recommendations regarding diabetes and population health are focused around the importance of patient-centered care. Care should be aligned with evidence-based guidelines, and balanced with patient preference, prognoses and comorbidities. In other words, the focus of care should really be centered around the individual and not the disease.

Something I found interesting about this section was that the national mean A1c has declined from 7.6% (1999-2002) to 7.2% (2007-2010), but despite this up to 50% of patients with diabetes do not meet their targets for glycemic control, lipids or blood pressure. Only 14% meet the recommendations for all three. This has huge implications considering the risk for cardiovascular disease associated with diabetes and the recent push to prescribe anti-diabetic agents with additional cardiovascular benefit.

In order to improve upon our current diabetes care delivery standards and quality of care delivered, the ADA introduces the Chronic Care Model (CCM). It consists of six elements:

1. Delivery system design (moving from a reactive to a proactive care delivery system where planned visits are coordinated through a team-based approach)
2. Self-management support
3. Decision support (basing care on evidence-based, effective care guidelines)
4. Clinical information systems (using registries that can provide patient-specific and population-based support to the care team)
5. Community resources and policies (identifying or developing resources to support healthy lifestyles)
6. Health systems (to create a quality-oriented culture)

Type 2 Diabetes Mellitus




Comprehensive Medical Evaluation and Comorbidities

This section stresses the importance of comprehensive medical care, where all comorbidities, psychosocial issues and patient factors are evaluated and addressed initially and at future follow-up visits. Additionally, aspects like past medical and family history, social history, medications, vaccinations, physical exam, laboratory measures and technology use should be documented initially and at each visit.

This a great section to read to understand many of the comorbidities patients with diabetes are at risk for or commonly develop and how to manage them. In particular, I'd like to highlight the recommendations for immunizations. Patients with diabetes are especially at risk to developing infections like pneumococcal pneumonia and influenza, which could led to further complications like hyperglycemia due to infection, bacteremia, and even death. It is important that vaccinations are talked about and documented at every follow up visit and that precise records are kept.

Immunizations recommendations

• Annual influenza is recommended to anyone >6 months of age including those with diabetes
• 3-dose series of Hepatitis B should be administered to patients 19yo-59yo with diabetes. Vaccination can be considered to patients with diabetes >60yo
• Pneumococcal pneumonia vaccination should include the 4-dose PCV13 before age 2yo, and then an additional PPSV23 for ages 2-64yo.
• Zoster, HPV and TdAP vaccines are recommended following the same CDC guidelines for the general public without diabetes

Glycemic Targets

There is little evidence directed us on how to prescribe self-monitoring blood glucose for patients on basal insulin and oral agents compared to those on intensive insulin regimens. That being said, the decision to prescribe self-monitoring blood glucose should take into account the patient's preference, ability and glycemic control. For patients on intensive insulin regimens, the ADA lists many situations where testing may be recommended (before meals, after meals, before driving, at bedtime, the list goes ON). The burden of testing this many times a day (6-10 if you went by their recommendations) makes it even more necessary to include patient factors in the decision on how many times to test. Otherwise, the goals themselves haven't really changed:

A1c goals

• Non-pregnant adults: <7%
• More stringent goals like <6.5% can be recommended for selected individuals if it can be achieved without hypoglycemia or other adverse effects or polypharmacy
• Less stringent goals like <8% can be considered for those with a history of severe hypoglycemia, limited life expectancy, advanced micro or macrovascular complications or extensive comorbidities