incidence of constipation is higher in older populations when compared to younger populations. And it’s even more common in older women.
While constipation is not considered a natural consequence of aging, the PACE population is affected by age-related physiologic changes that may contribute to constipation.
Some of these changes include:
The good news, though, is that through both non-pharmacological and pharmacological treatments, PACE pharmacy providers can help older adults belonging to the PACE population get a handle on constipation.
While there are various prescription and over-the-counter medications that are effective in relieving constipation symptoms, there are also a number of non-medication options that can help.
Many of these options can be used with medications to improve constipation symptoms in PACE participants. However, before employing a pharmacological treatment option, it’s worth trying the following non-pharmacologic ones:
Of course, there are pharmacologic options available to help manage constipation. Various laxatives and prokinetic agents are often used to treat constipation, including in the PACE population.
Bulk laxatives, which includes Methylcellulose, Polycarbophil, and Psyllium, work by absorbing water from the intestinal lumen to increase stool mass and soften stool consistency.
Because it can take anywhere from 12 hours to three days for bulk-forming laxatives to work, they are not recommended for the immediate relief of constipation.
Emollient laxatives or stool softeners, such as Docusate, work by allowing water to enter the bowel more readily.
These laxatives are generally well-tolerated, but are not as effective as psyllium in the treatment of constipation.
It’s important to note that in chronically ill older adults, stool softeners are not considered effective, as they generally take between 12 and 72 hours to work.
And finally, though mineral oil is a common go-to for chronic constipation, it’s not a recommended treatment. Experts have noted a severe complication of this medication—the risk of aspiration—and emphasize the importance of heightened awareness among caregivers and post-acute pharmacy providers regarding the potential dangers of inappropriate mineral oil use.
Osmotic laxatives, such as Lactulose, Magnesium Citrate, and Sorbitol, help alleviate constipation by causing water to secrete into the intestinal lumen via osmotic activity.
This class of laxatives tends to show effectiveness roughly one to two days following administration.
It’s important to note that these laxatives should be used carefully among adults in the PACE population who have congestive heart failure and chronic renal insufficiency.
Stimulant laxatives, like Senna and Bisacodyl, work by boosting intestinal motility and water secretion into the bowel.
This class of laxatives generally produces bowel movements within hours, but may cause abdominal cramping because of the increased peristalsis. Typically, stimulant laxatives take between six and 12 hours to work.
In adults belonging to the PACE population, a combination of senna and bulk laxative has shown to be more effective than lactulose in improving stool frequency and consistency. In addition, stimulant laxatives can be used on an as-needed basis, so long as participants carefully follow the manufacturer’s instructions.
Prokinetic agents, which include medications like Tegaserod and Misoprostol, have been studied for the treatment of slow transit constipation—though they haven’t been approved by the U.S. Food and Drug Administration for this indication.
Larger trials are needed to confirm the efficacy and safety of the long-term use for chronic constipation. To date, Tegaserod, in particular, has shown to not improve older adults’ symptoms of abdominal pain/discomfort, even though it increases bowel movements.
If a PACE participant is started on one of medications discussed in this article, it is extremely important to continually monitor him or her for the continuation or relief of symptoms.
Additionally, it is recommended to monitor for diarrhea and/or increased bowel movements, which may lead to needing to discontinue medication use.
Though helpful in alleviating constipation symptoms in older adults, laxatives are a drug class that may be potentially unnecessary after period of time. These agents tend to stay on participants’ medication lists for longer periods of time than may be clinically necessary, and there are potential harms associated with long-term laxative use, including:
Because of the risk of long-term harm, it’s essential to reassess the need for laxatives once the participant’s symptoms of constipation are alleviated.
By properly following treatment guidelines, together we can work to minimize the recurrence and symptoms of constipation in PACE participants.
Those in the PACE population have unique medical needs. Our Grane Rx team of geriatric-specialized pharmacists understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504 or emailing paceteam@granerx.com.
Gastroesophageal reflux disease (GERD), which develops when stomach acid frequently flows back into the esophagus, is common in long-term care residents. Similar to other conditions, older adults are at a higher risk of complications from chronic GERD, making it important for long-term care providers—including LTC pharmacy services—to stay up to date on the condition. Some common medications used to treat GERD in residents include antacids, histamine 2-receptor antagonists, and proton pump inhibitors. While these medications are readily available and effective at relieving symptoms, there are a number of lifestyle modifications that can also help. Many of these modifications can be used in conjunction with medications to provide residents with optimal outcomes. [Tweet “#GERD is a common medical condition in older adults, including #SkilledNursing Facility residents.”]
Urinary tract infections (UTIs) are one of the most common infections found in adults age 65 and older, including PACE participants. Unlike in younger adults, UTIs are often overlooked or mistaken for other conditions in seniors because older adults are less likely to present with typical symptoms. Because of this, it’s essential for PACE pharmacy providers and other members of the PACE center’s multidisciplinary team to know the symptoms associated with these infections, as well as how best to treat them. Let’s take a look at how UTIs uniquely affect seniors and how these infections can be effectively prevented and treated. [Tweet “#UTIs often present different symptoms in older adults than in younger adults.”]
Many providers are aware of some of the most tell-tale signs of a UTI, such as changes in urine color, scent, and frequency, pain or burning during urination, and a low-grade fever.
However, the elderly very often present with atypical symptoms, including:
Sometimes, these are the only symptoms that present in seniors, making it vital to keep an eye out for these sudden cognitive and behavioral changes.
There are a variety of risk factors that make older adults—including PACE participants— more susceptible to UTIs than other populations. These risk factors include decreased immune function, weakened bladder and pelvic floor muscle, and comorbidities such as diabetes, Parkinson’s disease, and dementia.
Because UTIs stem from a number of different causes and they come in multiple forms, treating these infections must be handled on an individual basis. UTI diagnoses are usually broken down into two variations:
Within each category, there is further differentiation, characterized by complicated and uncomplicated diseases. The most common form of UTI is uncomplicated cystitis, which may be characterized by the following:
It’s important to note that only female participants with no urologic abnormalities and no known kidney/bladder dysfunction or comorbidities can develop this type of UTI.
Complicated cystitis is characterized by the same symptoms as those of uncomplicated cystitis. However, complicated cystitis also includes additional criteria, such as having:
Similar to uncomplicated cystitis, gender plays a role in complicated cystitis: Whereas only females can get the former, only males can develop complicated cystitis.
For both UTI types, the first wave of antibiotic therapy, known as empiric therapy, can be provided based on symptoms alone. Empiric therapy aims to start fighting the infection and reduce the risk of further complications, and usually consists of broad-spectrum antibiotics, such as ciprofloxacin (Cipro®) and doxycycline (Vibramycin®, Adoxa®), that can fight against many different strains of bacteria. In addition to starting antibiotic therapy, a urine culture/analysis is often collected, providing more in-depth results to help guide treatment.
Antibiotic treatment of either two types depends on a variety of factors, including the severity of disease, previous history of infections, resistance rates in the local population, and kidney function, among others.
Pyelonephritis is a form of UTI that reaches the kidneys, causing inflammation in the region. Similar to cystitis, this diagnosis can be classified as either complicated or uncomplicated.
Uncomplicated pyelonephritis displays similar symptoms found in cystitis, but also presents:
The good news, though, is that other than these symptoms, the participant is generally healthy and can receive antibiotic treatment on an outpatient basis.
Complicated pyelonephritis, on the other hand, is extremely serious. In this case, the participant is hemodynamically unstable and immunosuppressed, has a form of anatomic abnormality or urologic dysfunction, and/or has a multiple-drug-resistant (MDR) strain of bacterial infection. Any participant falling into this criteria should be referred to the hospital immediately for evaluation and treatment.
Effectively treating a UTI entails eliminating the bacterial infection, providing supportive therapy to relieve pain and symptoms, and employing strategies to reduce recurrence of these infections.
For symptomatic relief of dysuria, phenazopyridine (Azo®, Pyridium®) can be given to residents without renal impairment. Moreover, non-pharmacologic treatment options—such as proper hydration, timed voiding, and heat-pad therapy—can help relieve symptoms and discomfort.
Preventive options to reduce recurrence of UTIs involve employing pharmacologic options, such as taking lactobacillus probiotics (Florajen 3®), maintaining hydration, and treating underlying diseases, like BPH or low estrogen levels in indicated participants.
While antibiotic therapy is used to treat UTIs, antibiotics generally aren’t chosen for preventive therapy, unless specific criteria is met.
If, for example, a participant is diagnosed with three or more UTIs within a year and proper non-pharmacologic steps have been unsuccessful, the participant may be a candidate for continuous, low-dose antibiotic preventive therapy. It’s important to note, though, that, if this care path is chosen, the participant must be monitored for potential side effects, prevention of symptoms, and necessity of antibiotic therapy.
Finally, once a PACE participant completes antibiotic therapy for a UTI infection, a follow-up urine culture is generally not recommended. A follow-up is only necessary if the participant complains of recurrence of symptoms, at which point an alternative antibiotic therapy and urine culture can be provided.
By taking preventive measures and properly following treatment guidelines, we can work to reduce the recurrence and symptoms of UTIs in PACE participants, and, ultimately, decrease the number of antibiotics prescribed and improve health outcomes in our participants.
Seniors, including PACE participants, have unique and specialized needs. Our Grane Rx team of geriatric-specialized pharmacists understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504 or emailing paceteam@granerx.com.
Antibiotics are one of the most widely prescribed classes of medications in the United States. They’re also one of the most overly and inappropriately prescribed medications, particularly among the senior population. Constant or inappropriate use of antibiotics can worsen a resident’s health, potentially affecting his or her gastrointestinal, renal, and/or hepatic functions. Furthermore, some antibiotics can cause neurologic and psychiatric disorders. For these reasons, it’s vitally important for post-acute care providers, including post-acute care pharmacy services, to stay informed about antibiotic best practices. Read on for a look at key factors that should be taken into consideration when selecting antibiotics for Skilled Nursing Facility residents. [Tweet “#Antibiotics are one of the most overly and inappropriately prescribed medications among seniors.”]
When choosing the most appropriate antibiotics for SNF residents, several factors must be taken into consideration. Here are four key factors that should be assessed before prescribing an antibiotic.
First things first: Determining what kind of infection the resident has. For example, is the infection pneumonia, or is it a urinary tract infection?
Once the infection type and severity have been determined, it’s important to look for the bacteria and pathogens that likely caused the infection. Often, a culture is taken to accurately identify the bacteria.
Some facilities and healthcare settings have an antibiogram, which shows known bacterial resistance rates to medications in the local area.
It’s not uncommon for SNF residents to have certain medical conditions, such as decreased kidney or liver function, or take chronic medications that can potentially be affected by specific antibiotics.
Cost can be an important factor, as some medications may offer decreased monitoring or be slightly more effective but are only available in an expensive, name-brand form.
Because residents are often on a limited income, it’s important for post-acute care pharmacy providers to discuss the various options available with residents and their families.
Once a diagnosis has been made and the likely pathogens have been determined, antibiotic therapy should be started.
The first wave of antibiotics is usually referred to as “empiric” therapy, which aims to start fighting the infection and reduce the risk of further complications. Empiric therapy usually consists of broad-spectrum antibiotics, such as ciprofloxacin (Cipro®) and doxycycline (Vibramycin®, Adoxa®), that can fight against many different strains of bacteria.
Once culture results are in and the causative bacteria is found, the resident should be switched to a narrow-spectrum antibiotic—such as gentamicin (Garamycin®) or vancomycin (Vancocin®)—that will target only specific types of bacteria. The chief benefit of this type of antibiotic is that it attacks bacteria more effectively, while also reducing the risk of increasing drug resistance in other bacteria.
If a culture comes back negative for any bacterial infection, however, empiric antibiotic therapy should be discontinued and the resident’s condition should be reassessed.
After an antibiotic has been selected, a care plan, detailing the length of therapy and date of termination, should be determined.
Finally, it is important to ensure the resident takes every prescribed dose of antibiotic until finished to ensure proper bacterial eradication and reduce bacterial drug resistance.
Regardless of which antibiotic is ultimately chosen, it is important to follow proper procedures and only use these medications when clinically appropriate. By selecting the best antibiotic and duration of therapy for each resident’s needs, we can effectively treat infections while also reducing the risks associated with overprescribing or inappropriately prescribing these medications.
The Grane Rx team stays up-to-date on the latest information related to long-term care pharmacy—and passes that knowledge along to your team. Call (866) 824-MEDS (6337) or fill out this quick form to find out how your SNF could benefit.]]>
When it comes to the medication needs of those in the PACE environment, there are unique challenges to consider. A new study has determined that the number of older Americans who take three or more medications that affect their brains has more than doubled in just a decade. The sharpest rise occurred in seniors living in rural areas, where the rate of doctor visits by seniors taking combinations of such medications—opioids, antidepressants, sedative-hypnotics, and antipsychotics—more than tripled. This “polypharmacy” of medications that act on the central nervous system is concerning because of the special risks to older adults that come with combining multiple medications with overlapping effects. Falls—and the injuries that can result from them—are the chief concern, along with problems with driving, memory, and thinking.
influenza (flu) virus is a relatively common but potentially life-threatening respiratory illness that affects millions of people every year in the United States and around the world. The effects of the flu are particularly profound among the senior population, making it important for long-term care providers, including LTC pharmacy services, to stay up to date on the condition. It is often characterized by symptoms including fever, cough, sore throat, muscle aches, vomiting, diarrhea, and chills. The flu is highly contagious and can be spread by water droplets and fluids that are released when infected individuals sneeze, cough, or talk. Furthermore, touching contaminated surfaces, followed by touching one’s own mouth, eyes, or nose, can also lead to transmission of the flu. It is important to note that the flu is not the same as the cold. While they may share some similar symptoms, colds usually go away after several days while the flu may persist for weeks and can lead to more serious complications such as pneumonia. Also, the flu can present with symptoms such as vomiting, diarrhea, and muscle aches that are not typically seen with the cold. [Tweet “While they may share some similar symptoms, colds usually go away after several days while the flu may persist for weeks.”]
While the flu affects all ages and populations, it can cause serious problems in high-risk population groups, including the elderly and those with chronic medical conditions such as asthma, diabetes, or heart disease.
This is particularly important, especially in Skilled Nursing Facilities, where residents tend to be elderly and have comorbid chronic diseases. To combat the flu, there are several recommended steps that both employees and residents should take.
The best way of treating the flu is to prevent it in the first place. Indicated residents and employees, including post-acute care pharmacy providers, should receive the annual flu vaccination when available.
Furthermore, sanitary practices should be employed, including properly washing hands with soap after contact with residents, covering one’s mouth when coughing/sneezing, and providing adequate access to hand sanitizers. Also, quarantining infected residents can reduce the risk of flu transmission to others within the SNF.
In the event of an outbreak (>2 infected residents), active surveillance must be conducted for at least one week from the last influenza case. All potentially ill residents should be tested via throat swab or other methods for confirmation of influenza.
Also, it is important to note that some immunocompromised or post-surgery residents may not show typical signs of flu such as fever—and it is important to monitor for other signs such as changes to cognitive function.
Furthermore, Standard and Droplet precautions must be implemented, including quarantining the sick resident and requiring all employees to wear a facemask prior to entering the resident’s room, in order to reduce the risk of flu transmission.
Immediate antiviral therapy should be initiated within 24 hours of detecting flu symptoms, especially if the resident has a fever. It is important to keep in mind that although these medications will not cure the flu, they will reduce the duration and severity of the resident’s flu symptoms, resolving symptoms in as short as three days.
Options include oral oseltamivir (Tamiflu®) or zamamivir (Relenza®) inhalation, which both are usually given twice daily for five to 10 days. Although commonly prescribed, oseltamivir dosing must be adjusted for residents with renal insufficiency.
For residents who cannot tolerate oral therapy or have renal failure, IV options include peramivir (Rapivab®), which is given as a single dose.
In addition to the resident receiving the medications, all residents within the same wing/hall of the infected resident should also receive antiviral prophylactic therapy, regardless of whether they are showing flu-like symptoms or not. This prophylactic therapy should continue for seven days following the last positive flu diagnosis in that wing/hall.
These medications tend to have minor side effects, which may include headache or nausea. However, for residents with asthma, COPD, or other respiratory disorders, zamamivir may exacerbate these conditions and should be used with caution.
Through both preventive and reactive measures, we can work together to reduce the risk of flu outbreaks and reduce severity of these outbreaks if they occur.
Long-term care pharmacy encompasses more than just oral medications—immunizations are also important. Our Grane Rx team stays informed about the latest related to health conditions and passes that knowledge to your team. Call (866) 824-MEDS (6337) to find out how your SNF could benefit.
PACE population, are susceptible to serious complications from the influenza, or flu, virus. In the United States, flu complications among seniors cost a staggering $56 billion annually, mainly driven by costs related to hospital admissions and death. This large clinical and economic burden has long motivated influenza vaccine manufacturers to pursue the development of an improved annual influenza vaccine for older adults. [Tweet “In the United States, flu complications among seniors cost a staggering $56 billion annually.”]
One such vaccine, the trivalent inactivated influenza vaccine Fluzone High-Dose was licensed in the United States in 2009, and was subsequently shown to offer improvements in efficacy and effectiveness compared with standard-dose influenza vaccine in adults age 65 and older.
The efficacy of the high-dose vaccine was shown in the randomized controlled FIM12 study, in which a total of 31,989 participants were enrolled from 126 research centers in the United States and Canada.
The results of this study demonstrated that among those age 65 years or older, Fluzone High-Dose induced significantly higher antibody responses and provided better protection against laboratory-confirmed influenza illness than Fluzone Standard-Dose.
Comparative effectiveness was shown by investigators from the US Food and Drug Administration, the Centers for Disease Control and Prevention, and the Centers for Medicare & Medicaid Services, who reported that the high-dose vaccine was 22 percent more effective than the standard-dose vaccine for the prevention of probable influenza disease. It was also 22 percent more effective for prevention of influenza-related emergency department visits and hospital admissions, both important factors to consider among PACE participants.
The next key public health question for the high-dose vaccine concerns its cost-effectiveness: What role could the vaccine have in reducing the substantial economic burden of influenza in adults age 65 and older?
In one cost-analysis study, the findings show that the high-dose trivalent inactivated influenza vaccine is a cost-saving alternative to the standard-dose vaccine. More specifically, the additional cost of administering high-dose instead of standard-dose vaccine yielded a 587 percent financial return to the healthcare system alone.
Most of the savings were driven by reductions in cardiorespiratory hospital admissions plausibly related to influenza. As such, the results of the study suggest that the high-dose vaccine was cost saving over the analyzed 2-year period, and therefore had a better cost-effectiveness proposition than most other strategies used in the prevention of infectious disease.
Only one other study has performed this type of analysis, also demonstrating the cost-effectiveness of the high-dose vaccine when compared to the standard-dose vaccine.
Though upfront costs for the high-dose trivalent inactivated influenza vaccine are higher than the standard-dose vaccine, results of cost analysis have been majorly in favor of the high-dose vaccine, mainly driven by a reduction in the number of hospital admissions.
With patient-centered care in mind, PACE providers must consider the well-being of the participant as well as cost savings when recommending immunizations during the coming flu season.
Seniors, including PACE participants, have unique and specialized needs. Our Grane Rx team of geriatric-specialized pharmacists understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504.]]>
long-term care pharmacy. The Final Rule for long-term care facilities participating in Medicare and Medicaid programs was published by CMS on Oct. 4, 2016. The three phases of these regulations have implementation dates of Nov. 28 in 2016, 2017, and 2019. Because these are the most significant and comprehensive regulation changes in recent history, there are multiple sections that have implications for medication use. One of the most important medication-related changes concerns psychotropic medications. These changes affect both how psychotropic medications are defined and how they are prescribed, both of which impact post-acute care pharmacy.
According to the final rule, a psychotropic medication will be defined as any medication that affects brain activities associated with mental processes and behavior. This includes—but is not limited to—medications in the following categories: antianxiety, antidepressant, antipsychotic, and sedative-hypnotic. Previously, the focus was primarily centered around antipsychotic medications, so added attention will need to be provided to these additional classes of medications. Several of the required provisions are intended to reduce or eliminate the need for psychotropic medications, if not clinically contraindicated, to safeguard residents’ health.
As part of phase 2, there are several changes related to the prescribing of psychotropic medications. According to the final rule, when prescribing psychotropic medications based on a comprehensive assessment of a resident, the facility must ensure that:
Resident-centered care with the goal of maintaining the highest mental, physical, and psychosocial well-being is a focus of these requirements.
One provision that will be implemented in phase 2 is that the resident’s medical chart must be reviewed every month as part of the monthly medication regimen review.
The facility must develop and maintain policies and procedures for the monthly medication regimen review that include timeframes for the different steps in the process as well as steps that the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
These changes have already been previously implemented by your Grane Rx LTC pharmacy services team.
The final rule implements regulatory changes that may lead to a reduction in the unnecessary use of psychotropic medications (such as antipsychotic medications) and improvements in the quality of behavioral health care. Medications are often an integral part of interventions and plans of care, which require ongoing interdisciplinary collaboration. Medication stewardship needs to be a multidisciplinary effort that includes the ongoing participation of the post-acute care pharmacy team.
Access to information is critical for all team members. Overcoming obstacles to accessing and documenting medication care plans within electronic medical records across the continuum of care needs to be part of this ongoing work. Continuing advocacy and interprofessional engagement are needed to improve the delivery of care for the post-acute care setting and the residents who are served.
The Grane Rx team works diligently to analyze and review regulatory and guideline changes, then put that information into action. Could your SNF benefit from our services? Call (866) 824-MEDS (6337) to find out more.
post-acute care pharmacy providers. In fact, the American Diabetes Association reports that 11.2 million Americans age 65 and older—or approximately 26 percent of that population—have been diagnosed with diabetes. Many more have prediabetes, meaning they’re at risk of developing Type 2 diabetes. These numbers are important because those with diabetes are at an increased risk of developing cardiovascular disease, which is the leading cause of death among seniors. The most common type of heart disease is coronary heart disease, in which there is a buildup of plaque in the heart’s arteries that can lead to angina, heart attack, and stroke. Those with diabetes are also more likely to have other risk factors for heart disease, including high blood pressure, abnormal cholesterol, obesity, and lack of physical activity. Luckily, these risk factors for heart disease are modifiable, meaning that they can be controlled in order to decrease the risk of complications from heart disease, including heart attack and stroke. Medications and medication management are one facet of care for diabetes, but there are other ways to help residents decrease their risk of heart disease and stroke. Your Skilled Nursing Facility’s multidisciplinary team should work with residents to manage their “ABCs”—A1C, Blood pressure, Cholesterol, and Smoking.
PACE participants, to treat chronic obstructive pulmonary disease or asthma. Each inhaler works a little differently, and proper administration technique is important to ensure participants receive the appropriate amount of medication to make a difference in their disease state and improve lung function. With any type of inhaler, it’s important for PACE pharmacy providers and other members of the PACE center’s multidisciplinary to provide careful, clear instructions to participants and their caregivers.
These devices come in the form of a pressurized canister containing the medication mixed with propellants and other agents to assist the medication in properly reaching the lungs. Hydrofluoroalkane (HFA) is the propellant used in these inhalers. They work well in participants who have lesser inspiratory flow because they do not rely only on the participant’s own breath for actuation to the lungs. However, timing is important for these devices to allow for the release of the medication at the same time as the participant inhales. Spacers and holding chambers are devices that may be used with an MDI to give the medication time to slow before reaching the mouth. These devices decrease the amount of medication lost to the mouth and pharynx and also allow for stepwise administration, rather than simultaneous medication release and inhalation. Spacers and holding chambers may be helpful for participants who have trouble coordinating inhalation with activation. Priming must be performed prior to each initial use and if the inhaler has not been used for two weeks or longer. This is done by shaking the inhaler for five seconds and then pressing down on the canister to release a puff of air four times. Cleaning of the inhaler should be done by rinsing the mouthpiece with warm water weekly after removing the canister. It should be left to dry overnight before the next use.
Diskus® devices, Twisthalers®, and Handihalers® are all DPIs, designed to administer medication in a solid form via the PACE participant’s breath. They contain a capsule, blister, or reservoir containing medication mixed with lactose or glucose that is inhaled. Because the medication is actuated by breath alone, a deep and steady rapid inhale is required to properly aerosolize the medication. This means participants who cannot breathe deeply, such as those suffering from COPD, may not be good candidates for these inhalers. HandiHaler and other single-use inhalers must be loaded with a capsule prior to each use. The capsules should be removed one at a time from their packaging only when a participant is ready to administer the medication. Each inhaler can be opened to reveal a hole where the capsule should be placed. The inhaler should be closed until a click sounds, which indicates the puncture of the capsule to release the medication. Once the capsule has been punctured, the device should not be tilted, since doing so can result in a loss of medication. The punctured capsule should be disposed of after each use. Diskus and other multi-use inhalers already contain all doses of the medication. These medications are loaded in different ways, depending on the medication. With Diskus, Breo®, Twisthaler, and Respiclick®, each dose is loaded prior to use by opening the inhaler fully until a click is heard. With Pressair®, you press a button, while with Flexhaler®, you twist the inhaler in one direction and then the other. It should then be inhaled immediately without tilting the device, since doing so may cause loss of medication. Cleaning should be done on the outside of the mouthpiece with a damp cloth, only if necessary. No water should be used inside the inhaler. [Tweet “A look at #inhaler best practices for PACE participants. #postacutecarepharmacy”]
The Respimat® is a common SMI, which releases medication without propellant but in a form that remains aerosolized for six times longer than an MDI. Because the particles of medication are released at a lower velocity, less medication is lost to the mouth and pharynx. In addition, because the medication remains in the air longer, the need to carefully time inhalation and medication release is lessened.
The first use requires loading of the canister by removing the clear base and inserting the narrow end of the cartridge into the inhaler firmly by pressing it down on a hard surface until it clicks. The base can then be replaced and turned for half a turn until it clicks and is ready to be primed by opening the cap fully and pressing the button. Turning, opening, and pressing the button should be repeated until a mist is released.
Participants should be instructed to exhale normally prior to the use of any inhaler. Then, after the inhaled medication is used, participants should hold their breath for at least five to 10 seconds to ensure the medication properly deposits in the lungs.
After use of any medication containing a corticosteroid (such as fluticasone, budesonide, betamethasone, and mometasone), the mouth should be thoroughly rinsed with water to prevent oral thrush.
Between puffs of the same medication, wait at least 15 to 30 seconds. When using multiple inhaled medications, the fastest-acting bronchodilator should be used first, followed by other bronchodilators.
Corticosteroids should be administered last, once the airways have been dilated by the fast-acting inhaler. Each administration of a different medication should be spaced by at
least 60 seconds.
Your goal is to provide comprehensive care for your PACE participants, and our goal is to provide you the PACE pharmacy services to do just that. To learn more or get started, call (412) 449-0504 or email paceteam@granerx.com.
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