1. Travel Health Medications: An overview and discussion
Veronia Guirguis, PharmD
PGY1 Community Pharmacy Resident

2. 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

3. 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

4. background

5. 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

6. 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

7. Traveler's diarrhea

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Malaria medications

17. 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

18. 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

19. Centers for Disease Control and Prevention. Travel's Health. 2017

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. High altitude medications

27. - 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

28. 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

29. 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

30. 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

31. Additional tips

32. 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

33. 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

34. Thank you Questions Veronia Guirguis Veronia.Guirguis@safeway.com
(Ph.)