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Travel Health Medications: An overview and discussion
Veronia Guirguis, PharmD PGY1 Community Pharmacy Resident
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Colorado Coalition of Travel Health Professionals
Objective Topic Length End Time Introduction Guest Speaker Kick-Off Icebreaker & Introductions Objectives & Learning Agreements 15 min 20 min 5 min 8:40am Discuss how your leadership directly impacts business results Challenges of Middle Management Value Chain Intro Group Activity: How can I increase my team’s engagement? Individual Activity & Debrief: Defining your customer Value Chain Summary & ACT Overview 10 min 9:35am BREAK Insert before or after ACT activity depending on energy of group 9:45am Use ACT to identify the shift from leading self to leading others Activity Intro Individual highlighting exercise Table Group Discussion Debrief 10:15am Commit to aligning your actions with your values Define Values Andrew License to Lead License to Lead Exercise 10:45am Focus, intentionally, on your own development Focus on Development 10:55am Closing Conclusion, Logistics, Course Eval 11:00am Total Workshop Length 3 hours Welcome Before Workshop Order 6 flipcharts w/stands Schedule guest speaker for kick-off Print Roster and Name Tents Participant Handouts Participant Guide ACT Brochure center of tables (1 per participant) center of tables Pre-prepared Flipcharts Welcome, with instructor name Learning Agreements What do you impact? SMs – instead of internal customer, how can backstage help them serve the customer Value Chain debrief (see notes for slide 14) Picture of Value Chain (slide 14) Colorado Coalition of Travel Health Professionals
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outline Background Traveler’s diarrhea (TD) medications
Malaria medications High altitude medications Tips for traveling * Cost prices listed in the presentation were obtained from the free coupon locator: GoodRx
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background
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Travel health American Pharmacists Association. Pharmacy-Based Travel Health Services. 2016 Increasing numbers of international travelers and increasing awareness of their role in spread of disease 1990: 457 million 2009: 880 million. U.S. residents 61 million trips globally Expected 2020: 1.6 billion 22%-64% of travelers reported travel-related problems 36% traveling to areas at risk for malaria or hepatitis A sought travel health advice Aims to promote health among international travelers Addresses a broad range of health risks Infectious diseases Personal safety Environmental risks American Pharmacists Association. Pharmacy-Based Travel Health Services. 2016
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Overall considerations
Reason for travel: helps define risks – tourism, business, study abroad, visiting friends, adventure or mission work Age: discuss what age would have to do with the meds, including that certain meds can’t be given to children Overall considerations Destination Duration Reason for travel Mode of transportation Common diseases Patient specific Pregnancy Age Allergies Cost Centers for Disease Control and Prevention. Travel's Health. 2017 American Pharmacists Association. Pharmacy-Based Travel Health Services. 2016
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Traveler's diarrhea
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background Defined as ≥ 3 loose stools in 24 hours
E. coli is most common bacteria, Giardia is most common protozoa Young adults are riskier in their behaviors Defined as ≥ 3 loose stools in 24 hours 80%-90% of cases due to bacterial pathogens 10%-20% of cases due to intestinal viruses or protozoal pathogens Occurs in 30-70% of travelers depending on destination Occurs equally in male and female travelers More common among young than older adults Destination risk Low: United States, Canada, Australia, New Zealand, Japan, Northern and Western Europe Intermediate: Eastern Europe, South Africa, some of the Caribbean islands High: most of Asia, the Middle East, Africa, Mexico, Central and South America American Pharmacists Association. Pharmacy-Based Travel Health Services. 2016
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Treatment depending on clinical presentation
Mild loose stools without other symptoms Antibiotics probably not necessary Use Bismuth Subsalicylate (BSS) or loperamide Moderate loose or frequent stools with cramps or nausea Antibiotic for up to 3 days Severe diarrhea with intense cramps, nausea, bloody stools, dehydration, or fever and chills Seek medical attention if blood or high fever is present or if symptoms do not rapidly improve American Pharmacists Association. Pharmacy-Based Travel Health Services. 2016
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Chemoprophylaxis of TD: Bismuth subsalicylate (bss)
Salicylate toxicity: Nausea, vomiting, diaphoresis, and tinnitus [10] are the earliest signs and symptoms of salicylate toxicity. Other early symptoms and signs are vertigo, hyperventilation, tachycardia, and hyperactivity. As toxicity progresses, agitation, delirium, hallucinations, convulsions, lethargy, and stupor may occur. Hyperthermia is an indication of severe toxicity, especially in young children. Antisecretory drug (anti-si-kree-tŏri) n. any drug that reduces the normal rate of secretion of a body fluid, usually one that reduces acid secretion into the stomach. Such drugs include antimuscarinic drugs, H2-receptor antagonists (see antihistamine), and proton-pump inhibitors. Not just the sweating thing, even though that was my initial thought. This makes sense as to how these drugs would work to stop the diarrhea. Probably don’t need to go into too much detail about this Chemoprophylaxis of TD: Bismuth subsalicylate (bss) Uses Adverse Effects Not routinely recommended Blackening of tongue and stool - Brush teeth and rinse mouth Antimicrobial agent Nausea, constipation, tinnitus Anti-secretory properties Salicylate toxicity: do not taken with aspirin 2 oz. of liquid or 2 chewable tablets 4 times per day Risk of Reye’s syndrome in children, do not use < 3 years old Increased risk of bleeding with concomitant use of anticoagulant American Pharmacists Association. Pharmacy-Based Travel Health Services. 2016 Lexicomp. Bismuth subsalicylate. 2017
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Management of TD: Loperamide
Diphenoxylate = lomotil Antisecretory – need some kind of secretory and can’t ex. If you need to sweat, your body blocks Loperamide is contraindicated in children younger than 2 years of age Anticholinergic = anti-SLUDD (Salivation, Lacrimation, Urination, Digestion, and Defecation) Management of TD: Loperamide Loperamide (OTC) and diphenoxylate/atropine provide symptom relief Loperamide is preferred Appears to have anti-secretory properties Safe for children May not be preferred, preference to hydrate children and continue to excrete stool and bacteria than reduce excretion Diphenoxylate/atropine Rarely prescribed Risk of bowel obstruction (has anticholingeric side effects) Best when combined with an antibiotic Antibiotic use is preferable in children with occurrence of first stool American Pharmacists Association. Pharmacy-Based Travel Health Services. 2016 Lexicomp. Loperamide. 2017 Micromedex. Loperamide. 2017
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Chemoprophylaxis and treatment of TD: Antibiotics
TMP/SMX also known as Bactrim antibiotic resistance What others resources do you guys use? Chemoprophylaxis and treatment of TD: Antibiotics Bacterial pathogens are leading cause (80%-90%) Chemoprophylaxis: Trimethoprim-sulfamethoxazole (TMP/SMX) and doxycycline no longer considered effective Treatment: Fluoroquinolones are first line Azithromycin Rifaximin an option Things to take into account and resources Antibacterial Areas of visitation/resistance Resources: Infectious Diseases of America (IDSA) American Pharmacists Association. Pharmacy-Based Travel Health Services. 2016
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Treatment of TD: Fluoroquinolones
All TD treatment can be used in patient with penicillin allergy GoodRx coupon prices Infectious Disease Society of America (IDSA) recommends 3 days treatment Adverse events have been observed in some animal reproduction studies. Ciprofloxacin crosses the placenta and produces measurable concentrations in the amniotic fluid and cord serum.Ref Based on available data, an increased risk of teratogenic effects has not been observed following ciprofloxacin use during pregnancy Benefits: First line – effective for prophylaxis and treatment Ciprofloxacin or levofloxacin (500mg every 12 hours for 1 to 3 days)* Ciprofloxacin #6 tablets $7.69 Levofloxacin #6 tablets $7.49 Pregnancy category C 80% effective at one dose Limitations: Increasing resistance among Campylobacter especially in Thailand Recommended to take with food to reduce GI upset Avoid antacid use: iron, zinc and calcium (including dairy products) Adverse effects Nausea/diarrhea/vomiting Tendon rupture [US Boxed Warning] Reported <1% of patients Increase risk with concurrent use of corticosteroid and/or patients > 60 years of age *One dose of fluroquinolone may be sufficient to relief symptoms and continuation of regimen may not be necessary Lexicomp. Ciprofloxacin/Levofloxacin. 2017 Micromedex. Ciprofloxacin/Levofloxacin. 2017
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Treatment of TD: azithromycin
Younger children as young as 6 months More nausea may occur with 1 g Enteropathogens – microorganism that causes disease in the digestive tract Adverse events were not observed in animal reproduction studies. Azithromycin crosses the placenta Benefits: Alternative to fluoroquinolones resistance areas First line in younger children Single 1 gram oral dose or 500 mg once daily for 1 to 3 days* 1 gram dose $9.10 500 mg for 1 to 3 days $7.42 to $10.77 Pregnancy category B Limitations: Some enteropathogens have decreased susceptibility to azithromycin Recommended to take with food to reduce GI upset Adverse effects: Loose stools/diarrhea/vomiting/nausea Abdominal pain *One dose of azithromycin may be sufficient to relief symptoms and continuation of regimen may not be necessary Lexicomp. Azithromycin. 2017 Micromedex. Azithromycin. 2017
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Treatment of TD: rifaximin
Do not use rifaximin tablets in patients with diarrhea complicated by fever or blood in the stool or diarrhea due to pathogens other than E. coli. No worries about resistance Benefits: Effective for treatment Off-label use for prophylaxis Non-absorbable, low potential for resistance 200 mg 3 times a day for 3 days $164.87 Pregnancy category Due to limited oral absorption, exposure to the fetus is expected to be low Limitations: Not for invasive species such as Shigella and Campylobacter Used in patients 12 years and older Adverse effects: Peripheral edema Dizziness/fatigue/headache Nausea Lexicomp. Azithromycin. 2017 Micromedex. Azithromycin. 2017
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Malaria medications
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background 350 million to 500 million cases globally/year
Plasmodium where they are found Screenshot of Thailand 350 million to 500 million cases globally/year 1,691 U.S. cases of imported malaria in 2010 10% severe malaria (9 died) Malaria transmission patterns can change rapidly; check for current information at Malaria is a protozoal infection transmitted primarily by Anopheles mosquito bites due to 5 species of the genus Plasmodium P.falciparum, P.vivax, P.ovale, P.malariae and P.knowlesi Symptoms usually ≥ 14 days after initial exposure Mild: fever and influenza-like symptoms, chills, headache, myalgia and malaise Severe: seizures, mental confusion, acute respiratory disease syndrome, kidney failure, coma and death American Pharmacists Association. Pharmacy-Based Travel Health Services. 2016 Centers for Disease Control and Prevention. Travel's Health. 2017
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Malaria: Plasmodium P. falciparum, which is found worldwide in tropical and subtropical areas, and especially in Africa where this species predominates. P. falciparum can cause severe malaria because it multiples rapidly in the blood, and can thus cause severe blood loss (anemia). In addition, the infected parasites can clog small blood vessels. When this occurs in the brain, cerebral malaria results, a complication that can be fatal. P. vivax, which is found mostly in Asia, Latin America, and in some parts of Africa. Because of the population densities especially in Asia it is probably the most prevalent human malaria parasite. P. vivax (as well as P. ovale) has dormant liver stages ("hypnozoites") that can activate and invade the blood ("relapse") several months or years after the infecting mosquito bite. P. ovale is found mostly in Africa (especially West Africa) and the islands of the western Pacific. It is biologically and morphologically very similar to P. vivax. However, differently from P. vivax, it can infect individuals who are negative for the Duffy blood group, which is the case for many residents of sub-Saharan Africa. This explains the greater prevalence of P. ovale (rather than P. vivax ) in most of Africa. P. malariae, found worldwide, is the only human malaria parasite species that has a quartan cycle (three-day cycle). (The three other species have a tertian, two-day cycle.) If untreated, P. malariae causes a long-lasting, chronic infection that in some cases can last a lifetime. In some chronically infected patients P. malariae can cause serious complications such as the nephrotic syndrome. P. knowlesi is found throughout Southeast Asia as a natural pathogen of long-tailed and pig- tailed macaques. It has recently been shown to be a significant cause of zoonotic malaria in that region, particularly in Malaysia. P. knowlesi has a 24-hour replication cycle and so can rapidly progress from an uncomplicated to a severe infection; fatal cases have been reported. Centers for Disease Control and Prevention. Malaria. 2016
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Centers for Disease Control and Prevention. Travel's Health. 2017
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Treatment of malaria Effective when given early in illness
Delay can be fatal Treatment varies depending on: Species of malaria Likelihood of resistance Age of patient/pregnancy status Severity of infection Medications most often used: Doxycycline Atovaquone-proguanil (Malarone®) Mefloquine (Lariam®) Chloroquine Primaquine American Pharmacists Association. Pharmacy-Based Travel Health Services. 2016 Centers for Disease Control and Prevention. Travel's Health. 2017
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Chemoprophylaxis: doxycycline
It crosses placenta but unlikely to produce substantial teratogenic risk. Accumulates in developing teeth and long tubular bones Calcium binding Tabs better than capsules? Dosing: 100mg; start 1-2 days pre-trip, take daily and for 4 weeks post-trip Benefits: Preferable for last-minute travelers Chronically used to prevent acne, no additional therapy needed Preferred by people planning to hike, camp, and swim in fresh water Prevent rickettsial infections, leptospirosis Cost (14 day trip = 44 capsules) $31.71 Limitations: Pregnancy category D Cannot be used by children <8 years old Caution in patients taking anticoagulant/antiplatelet medications Administration may be reduced by chronic ethanol ingestion, high fat meal and iron or calcium Adverse effects: Sun sensitivity Nausea/indigestion/diarrhea Lexicomp. Doxycycline. 2017 Micromedex. Doxycycline. 2017
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Chemoprophylaxis: atovaquone-proguanil
- Must be taken with food to increase bioavailability Dosing: Start 1-2 days pre-trip, take daily and for 1 week post-trip Benefits: Used for prophylaxis and treatment Preferable for last-minute travelers and for shorter trips Pediatric tablets are available and may be more convenient Pregnancy category C Limitations: Cannot be used by children weighing <5 kg and by patients with severe renal impairment Caution in patients taking anticoagulant/antiplatelet medications More expensive than doxycycline Cost (14 day trip = 23 tablets) $97.52 Must be taken with food or milk-based drink at the same time each day Adverse effects: Abdominal pain/nausea/vomiting/diarrhea Lexicomp. Atovaquone and proguanil. 2017 Micromedex. Atovaquone and proguanil. 2017
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Chemoprophylaxis: mefloquine
- Which cardiac conditions? Dosing: Start 1-2 weeks pre-trip, take weekly and for 4 weeks post-trip Benefits: Preferable for long trips Cost (14 day trip = 8 tablets) $50.03 Pregnancy category B Limitations: Not a good choice for last-minute or short trip travelers Should not be used in patients with major psychiatric or seizure disorders (boxed warning) Not recommended for people with cardiac conduction abnormalities Caution in patients taking anticoagulant/antiplatelet medications Take with food and with at least 8 oz of water If vomiting occurs within 30 minutes after the dose additional full dose should be given If vomiting occurs within minutes after dose additional half-dose should be give Adverse effects: Vomiting/dizziness Lexicomp. Mefloquine. 2017 Micromedex. Mefloquine. 2017
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Chemoprophylaxis: chloroquine
- Which cardiac conditions? Dosing: Start 1-2 weeks pre-trip, take weekly and for 4 weeks post-trip Benefits: Preferable for long trips Hydroxychloroquine chronically used for rheumatologic conditions, no additional therapy needed Cost (14 day trip = 8 tablets) $37.10 Pregnancy category C Can be used for children, weight-based dosing Limitations: Not a good choice for last-minute or short trip travelers Should not be used in patients allergic to quinidine/quinine Adverse effects: Diarrhea/nausea/vomiting Lexicomp. Chloroquine. 2017 Micromedex. Chloroquine. 2017
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Chemoprophylaxis: primaquine
G6PD testing required before giving. May be expensive and time-consuming Dosing: Start 1-2 days pre-trip, take daily and for 1 week post-trip Benefits: Used for prophylaxis and treatment Preferable for last-minute travelers and for shorter trips Cost (14 day trip = 23 tablets) $42.74 Can be used for children, weight-based dosing Limitations: Contraindicated in pregnant women Should not be used in patients allergic to quinidine/quinine Should not be used in patients with G6PD deficiency Adverse effects: Nausea/vomiting/dizziness Lexicomp. Primaquine. 2017 Micromedex. Primaquine. 2017
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High altitude medications
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- AMS most common background High altitudes associated with cold, low humidity, increased UV radiation, and hypoxia (oxygen deficiency) Syndrome Risk factors Symptoms Treatment Acute mountain sickness (AMS) 25% of sleepers above 2,500 m Rapid ascent Within 12 hours of arrival Hangover: headache, fatigue, nausea, vomiting Resolves within hours Can progress if further ascent High-altitude cerebral edema (HACE) Rare, severe progression of AMS Profound lethargy, drowsiness, confusion Descend immediately Death can occur within 24 hours if traveler does not descend High-altitude pulmonary edema (HAPE) Occur alone or along with AMS and HACE Increased breathlessness on exertion Progress to breathlessness at rest then pink frothy sputum Oxygen and/or immediate descent
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Pearls for travelers Know and lookout for symptoms
Never ascend to sleep at higher altitude while experiencing symptoms Ascend gradually Avoid going from low altitude to higher than 9,000 ft. in 1 day Above 9,000 ft., do not go higher than 1,600 ft./day Extra day for every 3,000 ft. When not practical, use chemoprophylaxis First 48 hours: avoid alcohol and limit exercise Expose self to high-altitude within 30 days prior to trip American Pharmacists Association. Pharmacy-Based Travel Health Services. 2016 Centers for Disease Control and Prevention. Travel to High Altitudes. 2013
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Chemoprophylaxis/treatment: Acetazolamide
Dosing: 125 mg to 250 mg twice daily started 1 day before ascent and continued until at least 2 days at the highest altitude Benefits: Pregnancy category C Less severe adverse effect profile May be used for extended duration Limitations: Cost (7 day trip = 20 tablets) $53.55 Not recommended in children under 12 years of age Avoid with sulfonamide allergy May be taken with food to decrease GI upset. May cause alteration in taste, especially carbonated beverages Adverse effects: Diarrhea/decreased appetite/ nausea/vomiting Reduced adverse effects seen with 125 mg dosing Photosensitivity, flushing Lexicomp. Acetazolamide. 2017 Micromedex. Acetazolamide. 2017
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Chemoprophylaxis/treatment: dexAMETHASONE
Dosing: 4 mg every 12 hours started 1 day before ascent and continued until at least 2 days at the highest altitude or if descent is initiated Benefits: Cost (7 day trip = 10 tablets) $8.25 Pregnancy category C May be used in children, dose is weight-based Limitations: Do not exceed a 10 day duration Avoid if allergic to steroids Caution in patients taking anticoagulant/antiplatelet medications May be taken with food to decrease GI upset Adverse effects: Increased appetite/nausea Hyperglycemia, weight gain Bradycardia, cardiac arrhythmia, edema Lexicomp. Dexamethasone. 2017 Micromedex. Dexamethasone. 2017
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Additional tips
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tips Overall Specific considerations Jet lag Motion sickness
Immunizations Problems related to heat and cold Sun protection Specific considerations Students studying abroad Humanitarian/relief workers The Hajj Visiting friends and relatives Families adopting internationally American Pharmacists Association. Pharmacy-Based Travel Health Services. 2016 Centers for Disease Control and Prevention. Travel's Health. 2017
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resources CDC Travelers’ Health
CDC’ Yellow Book Travel Health Notices: World Health Organization International Travel and Health International Society of Travel Medicine National Network for Immunization Information (Nnii) Immunization Action Coalition (IAC) US Department of State Google Earth American Pharmacists Association. Pharmacy-Based Travel Health Services. 2016 Centers for Disease Control and Prevention. Travel's Health. 2017
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Thank you Questions Veronia Guirguis Veronia.Guirguis@safeway.com
(Ph.)
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