Pharmacy and the Visually Impaired

How would it affect your outcome of therapy if, when you went to the pharmacy to pick up your prescription, after you were consulted, you were handed a bottle full of pills with no label.  If that was your only prescription you might be able to manage; however, once you got home you set your prescription down on the table and you have eight other prescription bottles, all without labels, it might become an issue!  This is essentially what happens when a visually impaired individual receives a prescription.

Years ago, when I was a young pharmacist a few years out of school, I would regularly help my mom set up her medications in a pill box.  We would then make sure her "as needed" medications were close by and lined up in a specific manner so it would be simple and easy for her to locate what she needed when she needed them.

Due to Mom's medical condition, she took an anti-diarrheal medication on a fairly regular basis.  This medication decreases propulsion through the GI tract and can quite significantly slow diarrhea.  One morning this was a particular issue.  Mom had taken one of these tablets every 2 or 3 hours throughout the morning and afternoon.  By evening, the diarrhea had not decreased, and she was getting very short of breath and gurgling in her chest.

Here’s the deal, Mom was so familiar with how her tablets felt, she was sure she was taking the correct medication.  The bottles were the same size and the tablets felt similar.  She had not been looking at the label.  Mom was not blind; however, she didn’t have the greatest eyesight.  Evidently, she had been taking her heart medication tablets all morning and afternoon. 

This overdose significantly decreased her heart function and allowed for a backup of fluid.  Mom was quite weak already, so this didn’t help matters much.  She was admitted to the hospital, stabilized, then came home and passed a couple days later comfortably in her own bed.

Mom was hip, smart, and knew why she was taking each and every medication.  One would not expect that she would have mistakenly taken the wrong medication. 

It is difficult to imagine how an elderly patient, living on their own, who is prone to slight confusion, and some level of visual impairment, can manage their medications without some help. 

In 2012, the President of the United States signed into law the Food and Drug Administration (FDA) Safety and Innovation Act (s.3187), requiring pharmacies to provide accessible prescription drug labeling for the blind, low vision and seniors. Under Section 904 of the Act, the U.S. Access Board, comprised of representatives of the visually impaired community as well as large pharmaceutical companies, were tasked to determine the best practices for accessible prescription drug container labels. In developing the best practices, the Access Board confirmed the use of braille, auditory means and enhanced visual means.

Their goal was to create and publish best practices guidelines for accessible prescription drug container labels, including "guidance to pharmacies on how to provide accessible prescription drug container labels to patients with visual impairments to enable them to manage their medications independently and privately, and have the confidence that they are taking their medications safely, securely, and as prescribed."

The completed best practices guidelines were published in July of 2013.  Currently, these best practices guidelines are just that, guidelines without regulatory enforcement or penalties for non-compliance; however, after 18 months, beginning January, 2015, the Government Accountability Office will begin monitoring how well pharmacies are participating in these guidelines and require that barriers to access are addressed.

Currently, two different companies are in the business of providing label reader options for the visually impaired.  Each has a different mechanism for providing the prescription label information to the visually impaired consumer; however, they utilize differing technologies.  You may review them yourself here:

Back in the early 90's, if my mother would have had ACCESS to a Prescription Label Reader, I am sure she would have avoided treating her diarrhea with her heart medication. 

Of course, in addition to the prescription label, patients are also handed a plethora of written Patient Medication Information.  As an alternative to the written PMI, consumers may visit and LISTEN to their medication information. 

If you or your family members are visually impaired, please ask your pharmacist for an accessible prescription label.


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Diabetes Medications De-Mystifyed

Insulin helps blood sugar enter cells where it is utilized by the body to produce energy.  In Type I Diabetes, sometimes called Insulin Dependent Diabetes, the pancreas does not produce, or produces very little insulin.  Type II Diabetes, termed Non-Insulin Dependent Diabetes, is a situation where the body has, over the years, become resistant to the effects of insulin or simply does not make enough insulin to keep up with the intake of sugar.

As technology has advanced, many different medication therapies have emerged for the treatment of both Type I and type II Diabetes.  In this blog, I will summarize the current FDA approved medications available for both Type I and Type II Diabetes treatment.  Please be aware, this is only a partial list of current therapies; however, it does include the most common medication treatments.  Over time I will continue to add to the blog in order to complete the list.  Medication Specific Counseling Sessions may be found at the AudibleRx website for any of the medications listed in this blog.


Insulin treatment has been refined significantly over the past 20 years.  Initially, bovine, or pig, insulin was common practice.  Later, technology advance to produce synthetic insulin in the laboratory.  Included here are the two most recent developments in synthetic insulin therapy.

·       Insulin Lispro (Humalog-TM),  Insulin Aspart (Novolog-TM): These are a synthetic form of insulin very similar (in fact almost identical) to human insulin.  These medications helps regulate sugar metabolism by stimulating the transfer of sugar from the blood to the cells and also by decreasing the production of sugar by the liver.   These insulin's are usually used in conjunction with longer acting insulins to treat type 1 diabetes and may also be used in conjunction with longer acting insulins or oral diabetic medications to treat type 2 diabetes. 

·       Insulin Glargine (Lantus-TM), Insulin Detemir (Levemir-TM) These are synthetic form of insulin very similar to human insulin.  These medications help regulate sugar metabolism by stimulating the transfer of sugar from the blood to the cells and also by decreasing the production of sugar by the liver.   These insulins may be used in conjunction with a shorter acting insulins to treat type 1 diabetes and may also be used in conjunction with a shorter acting insulins or oral diabetic medications to treat type 2 diabetes.

Type II Oral Medication

·       Sulfonylureas: Glimepiride (AmarylTM), Glipizide (GlucotrolTM), Glyburide (DiabetaTM, MicronaseTM)   This category of medications stimulates specific cells in the pancreas to release more insulin. 

·       Biguanides: Metformin (GlucophageTM) Metformin works by decreasing production of glucose in the liver, decreasing absorption of glucose in the intestines and increasing our body’s sensitivity to the insulin we already produce.  If you take metformin, please take the time to educate yourself about the Black Box Warning by listening to the AudibleRx counseling session discussing metformin or by calling your pharmacist and discussing it. 

·       Thiazolidinediones:  Pioglitazone (ActosTM), Rosiglitazone (AvandiaTM)    This category of medications simply works by sensitizing the body to its own insulin.  .  If you take one of these medications, please take the time to educate yourself about the Black Box Warning by listening to the AudibleRx counseling session discussing pioglitazone or rosiglitazone or by calling your pharmacist and discussing it. 

·       DPP-4 Inhibitors:  Linagliptin (TradjentaTM), Sitagliptin (JanuviaTM)   The body produces natural hormones called incretins.  These incretins are produced at a low level on a regular basis, and in a larger amount in response to eating.  Incretins help control the body’s natural release of insulin in response to blood sugar.  The issue is, there is this enzyme called DPP-4 which breaks down the incretins really quickly.  This category of mediations works to block this enzyme so that the incretins stay around longer to help the body balance its own blood sugar.

Type II Diabetes Injectable Medications
  • GLP-1 Agonists: Exenatide (Byetta-TM), Exenatide ER (Bydureon-TM), Liraglutide (Victoza-TM)  This category of medications mimic the body's natural sugar-lowering hormone called incretin. They work by stimulating the pancreas to release insulin when blood sugar levels are high, such as after a meal. Insulin then helps move sugar from the blood into other body tissues where it is used for energy. This medication also slows the emptying of the stomach and causes a decrease in appetite.  Please note, this category is not a replacement for insulin.  These medications will not work in Type I diabetics where insulin injections are necessary for treatment.
To learn about the important patient counseling information on any of the medications listed in this blog, please visit the Diabetes page at and LISTEN to the Medication Specific Counseling Session you want to learn more about.

You may also be interested in reading:

·         A1C Test, what is it?

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Luka Tehovnik is a student finishing his pharmacy degree in Slovenia.  During his final year he completed a study exploring the Quality of Life in Lung Cancer Patients.  This is his description of the study.  You may contact Luka through LinkedIn or Twitter.

Lung cancer is a disease that affects lungs. It is characterized by the worst prognosis. Its incidence and mortality rates are the highest in the world, taking the lead among all newly discovered cancers. Chemotherapy is the cornerstone of treatment of advanced lung cancer. Since treatment is palliative, the Quality of Life (QoL) is at least as important as the length of survival. QoL in lung cancer patients is affected by several factors related to the patients, stage of disease and treatment characteristics. Therefore, the effect of treatment on QoL has become progressively more relevant.

Lung cancer is the leading cause of cancer death in the United States. It may primarily form in lung cells or it can spread from the other body parts as metastases. It is divided into two major types as small cell (SCLC) and non-small cell lung cancer (NSCLC). Those types differentiate from each other by their biology, therapy and prognosis. SCLC is more aggressive compared to NSCLC. Prognosis is bad for both types of cancer; however, odds for being cured are improved with early-stage disease at diagnosis. Smoking is the primary risk factor, which accounts for more than 85-90 % of all lung-cancer related deaths.

Common symptoms of lung cancer include cough, shortness of breath (dyspnea), weight loss and chest pain; patients, presenting with those symptoms are more likely to have chronic obstructive pulmonary disease (COPD). Most patients are diagnosed with advanced, metastatic disease. Those patients are treated with chemotherapy for palliation. The term palliation implies improvement in either the duration or QoL remaining.

The treatment of lung cancer depends on the type of lung cancer, how spread it is (stage of the disease), molecular-biological characteristics of tumor, patient’s fitness for treatment (performance status) and other diseases (comorbidities). Lung cancer can be treated by surgery, irradiation and systemic treatment. Those approaches can be used differently depending on the disease and patient characteristics as described above. Disease stage remains the most powerful prognostic factor. Treatment can be aimed to cure (in early-stages of the disease) or just to put the disease into remission, which is defined as a state of absence of the disease. Most patients are diagnosed with advanced disease and the goal is to put them into remission for as long as possible. Since the treatment goal is extending their survival and easing the disease symptoms, improving patient’s QoL is also very important.

In the past, clinical trials had focused only on endpoints like physical or laboratory measures of response in form of disease progression and survival. More recently, endpoints that reflect the patient’s perception of their well-being and satisfaction with therapy have been included. Changes in biomedical outcomes may reflect as improvement in patient’s QoL but not always.

The World Health Organization (WHO) defines health as a “state of complete physical, mental and social well-being and not merely the absence of infirmity and disease.” This definition reflects the focus on a broader picture of health that includes health-related quality of life (HRQoL). Even though there is no exact definition, a general agreement says that it is a multidimensional concept that focuses on the impact of disease and its treatment on the well-being of an individual. Sometimes other aspects like economic and existential well-being are also included. It depends on the nature of a study which aspects of QoL will be included and studied. Those aspects or dimensions can include general health, physical functioning, physical symptoms and toxicity, emotional functioning, cognitive functioning, role functioning, social wellbeing and functioning, sexual functioning and existential issues. There are different instruments for measuring QoL which differ in aspects of QoL and diseases they cover.

QoL is a subjective multidimensional construct. Consequently, it must be assessed by patients alone using validated multidimensional instruments - questionnaires. Those questionnaires include different aspects of QoL, which are needed to obtain all the relevant data to track all the changes and for a complete evaluation of overall QoL. It is important that patients complete QoL questionnaires by themselves since their physician, nurse or relatives are unable to appropriately evaluate it.

There are a lot of different tools to evaluate QoL. It is important to choose the correct one when designing a clinical trial. Probably the most known questionnaire, developed specifically for cancer patients include EORTC QLQ-C30. There is also another one, which supplement the core questionnaire and was developed specifically for lung cancer patients – EORTC-LC13. It was found that those instruments respond to changes in clinical state and are strongly predictive of survival.

Cancer diagnosis may have a major psychological, disease and treatment related impact on a patient’s health-related QoL. Majority of lung cancer patients are diagnosed with metastatic disease. Since prolonging their life is generally unsuccessful, improving QoL is a more realistic goal. QoL is important aspect and should become implemented in a common clinical practice and considered when making treatment decisions. However, further research is necessary to build upon our existing findings on QoL.

  1. Fairclough DL. Design and Analysis of Quality of Life Studies in Clinical Trials, 2. Ed. Boca Raton: CRC Press, 2010.
  2. Michael M, Tannock IF. Measuring health-related quality of life in clinical trials that evaluate the role of chemotherapy in cancer treatment. CMAJ 1998; 158(13): p. 1727-34.
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One Leading Factor in Hospital Readmission

Now and again you meet someone who is enmeshed in their field...and loves it.  Carol Marak has a passion for educating individuals about senior living issues.  She writes regularly for multiple sources; and we have the good fortune of presenting her as a guest blogger today on AudibleRx.

One Leading Factor in Hospital Readmission

Reducing the revolving door syndrome at hospitals is on the radar of every health care system, physician's office, home health company, skilled nursing and assisted living facility nationwide.

Or is it?

It's so bad that one in every five older patients land back in the hospital within 30 days of discharge.

Most trips back are unplanned.

And most are preventable.

Here's one reason why some patients go back: They return to a lifestyle and an environment that got them there in the first place. They're left to their own unhealthy devices.

I know one patient in particular.

He's overweight. Doctors call him obese. He eats foods with lots of preservatives. He never exercises. He rarely moves, for that matter. And he's 75 years of age.

He landed in the hospital because of a bad case of cellulitis. That's just for starters. He has lung cancer, and kidney cancer - in both kidneys. And he’s addicted to pain killers due to former back problems (a story for another time).

Once discharged, he went home and began his unhealthy routine all over again... motionless, which is the worst case scenario for cellulitis.

Was he unable to follow instructions? No. He could have but chose not to.

It's not the hospitals fault.

Since the startup of the Affordable Care Act, Medicare penalizes hospitals financially on 30-day readmissions for some health conditions. Cellulitis may not be on that list of conditions, but a patient not following discharge orders is one of the reasons for a return.

The idea behind the Affordable Care Act and penalizing hospitals is to encourage them to increase the quality of care. I’m sure he received very good care. He’s still alive.

Yet, no one can teach another to take better care, if one’s not motivated to. So, maybe this particular patient is a lost cause. And how many people do you know like this?

For me one is too many.

And hospitals and discharge planners can only do so much for what seems a lost cause.

For patients that get discharged from a hospital and go directly home, one must be educated for medication adherence, post-discharge instructions, given timely follow-up visits, and receive better communication. 

Here’s Dr. Steve Leuck’s, Pharmacist and Medication Education Expert, recommendation on Hospital Readmission Rates & Care Costs can be reduced with Education. (

Using the example of the patient described earlier, here’s how his discharge went:

No follow-up care – a follow-up visit to the physician’s office was made over a week later. (No nurse ever called to check in, even as a courtesy call).

Discharge instructions were given, but only a few were followed.

There were problems with medications, the anti-biotic dosage was too low, that was discovered a week later by the attending physician (which almost sent him back to the hospital).

The lack of timely follow-up appointments, if the patient had an earlier appointment, medication (low-dosage) could have been spotted and remedied earlier. But instead, he lived with a lot of pain (since the antibiotics weren’t working properly).

It’s a known fact that many people leave the hospital confused about their medications and lack proper understanding about their illness and treatment plan.

Maybe in this patient’s case, there’s little hope. I don’t know. I’d like to think that if he’s taken off the pain meds and learn to manage the back pain, there might be hope for him. But as it stands today, there’s little hope… at least in his heart.

Carol Marak is a contributor for the senior living and health care market. Carol writes on tough topics that older adults and family caregivers face. Her work is found on ( and ( Contact Carol at

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Time for Pharmacists to Step Up

So, yesterday at work, I received a phone call from this pleasant, yet concerned individual who has some medication questions.  No problem I thought.  I always advocate the process of developing a relationship with your community pharmacist so, when questions arise, you have a reliable resource that you may call and ask questions.

The idea is that you may call in to the pharmacy where you fill your prescriptions, ask to speak with the pharmacist, and then proceed to ask your medication question.  The pharmacist should have, at their fingertips, your patient profile, including a list of your allergies and all of the medications you are currently taking and have recently taken.

This individual immediately breaks into her question about anti-depressant therapy in combination with some other medication, the dosages etc…  Before she gets too far I interrupt and ask who I am speaking with so I may look up her profile to get a better idea of what we are talking about.  The issue is, she has never filled a prescription with us.

She goes on to explain that she uses XYZ Chain Store Pharmacy in town that is close to her home; however, she states she can never speak to the pharmacist.  She has tried calling in but she states she gets put on hold for an extended period of time and when she finally gets someone on the line she gets put on hold again.  She continues with the process, describing that when she is in the store she always declines the consultation because the make her feel like she is interrupting their busy schedule.

I explain to this individual that before we go any further we need to have a short discussion.  I tell her that I understand her concern about bothering the pharmacist; however, that is exactly what she needs to do.  The pharmacy where you fill your prescriptions is the pharmacy that you need to call for questions about your medications. 

We continue the process of her question, with the understanding that I would be more than happy to transfer her prescriptions to our store, and then continue to provide medication counseling services to her on a regular basis.  We again discuss the importance of maintaining a relationship with a pharmacy and a pharmacist so that they may reasonably evaluate your medication profile prior to answering any significant medication questions.

OK, so now we can discuss the current question at hand.  After a couple minute conversation we have come to a reasonable understanding and we say our goodbyes. 

The problem is, pharmacists work under tremendous pressure and quite often, the extra time spent with a patient means less time to get the work done behind the counter.  This is not a new problem, we all know about it and it is currently being addressed on many levels.

One simple solution; visit three or four local pharmacies.  Include an independent pharmacy, chain store, supermarket and big box retail store.  Stand back and watch the pharmacy for 5 or 10 minutes and take in what you see.  Do the pharmacists look like they have enough time do the work in front of them, is there a patient counseling area that appears relatively private, are the clerks at the front counter pleasant with the customers, and how many patients are in line or waiting for their prescriptions?

Next, step up to the counter and ask to speak with the pharmacist.  Explain to the pharmacist that you are considering transferring prescriptions to their store and you would like to know what sort of service they offer.  Believe me; if you visit four different pharmacies and follow through with this little exercise, you will have a clear idea of which pharmacy is the one for you.


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