MEDICATION MANAGEMENT WITH CELIAC DISEASE: PEARLS FOR TECHNICIANS

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MEDICATION MANAGEMENT WITH CELIAC DISEASE: PEARLS FOR TECHNICIANS SATURDAY/10:15-11:15AM ACPE UAN: 0107-9999-17-233-L01-T 0.1 CEU/1.

Describe celiac disease presentations and pathway to symptoms. 2. Discuss major treatment principles in celiac disease. 3. Utilize resources to determine if a medication is gluten free. 4.

1 MEDICATION MANAGEMENT WITH CELIAC DISEASE: PEARLS FOR TECHNICIANS SATURDAY/10:15-11:15AM ACPE UAN: L01-T 0.1 CEU/1.0 hr Activity Type: Knowledge-Based Learning Objectives for Pharmacy Technicians: Upon completion of this CPE activity participants should be able to: 1. Describe celiac disease presentations and pathway to symptoms. 2. Discuss major treatment principles in celiac disease. 3. Utilize resources to determine if a medication is gluten free. 4. List common gluten free medications. Speaker: Pamela Wiltfang, PharmD, MPH, BA, CHES Pamela Wiltfang graduated from the University of Iowa in 2012 with Doctor of Pharmacy and Masters in Public Health degrees. She is currently the Director of Clinical Services & Innovative Practice for NuCara Management Group, LLC, headquartered in Conrad, Iowa and oversees all clinical pharmacy services for NuCara locations in Iowa, Illinois, Minnesota, North Dakota and Texas. In Wiltfang s current position, she is responsible for developing, implementing and ensuring success and sustainability of all the clinical programs that NuCara is involved in. Examples include transitions of care, Wellmark Value Based Pharmacy Practice, New Pharmacy Practice Model, ACO coordination, care coordination physician-pharmacist programs, and disease state specific education programs. Wiltfang is also Owner of PFW Consulting, LLC, where she provides high quality medication therapy management counseling services to high risk patient populations, identifying and addressing current drug therapy problems with the patient s primary care providers to improve patient outcomes and overall health. Speaker Disclosure: Pamela Wiltfang reports no actual or potential conflicts of interest in relation to this CPE activity. Off-label use of medications will not be discussed during this presentation.

Medication Management in Celiac Disease:

reports no actual or potential conflicts

2 Medication Management in Celiac Disease: Pearls for Technicians Pamela Wiltfang, PharmD, MPH, BA, CHES Director of Clinical Services Disclosure Pamela Wong Wiltfang reports no actual or potential conflicts of interest associated with this presentation 1

3 Learning Objectives Upon successful completion of this activity, participants should be able to: - Define celiac disease presentations & its symptoms - Discuss major treatment principles in celiac disease - List common gluten free medications - Utilize resources to determine if a medication is gluten free Definition Celiac disease is a serious autoimmune disorder that can occur in genetically predisposed individuals where the ingestion of gluten leads to damage in the small intestine -Celiac Disease Foundation Accessed: Dec 1,

4 Close-Up Finger-like villi absorb nutrients in the small intestine In patients with celiac disease, the gluten from wheat, barley, rye, and other grains is attacked by the body s immune system This immune system s attack destroys villi on accident, leading to nutrients not able to be absorbed Nutrients in GI tract Nutrients villa villa Nutrients still in GI tract Normal small intestine Nutrients in bloodstream Celiac patient small intestine bloodstream Screening & Testing Estimated to affect 1 in 100 people worldwide Two populations that should talk with their doctors about celiac disease: - Patients with first-degree relatives who have celiac disease - Patients with Type 1 diabetes mellitus If suspected, a blood test is performed - A biopsy of the small intestine is required for diagnosis if the blood test suggests celiac disease Am J Gastroenterol 2013 May;108(5):656 Evid Based Med 2007 Feb;12(1):24 3

5 Non-Celiac Gluten Sensitivity Your blood test for celiac disease came back negative, but you still don't feel well. Now what? - Gluten Sensitivity vs. Gluten Intolerence Approximately 18 million Americans have gluten sensitivity 6X s the amount of Americans who have celiac disease Accessed: Jan 20, 2017 Non-Celiac Gluten Sensitivity Non-specific immune response less severe than celiac disease Causes minimal intestinal damage Does NOT appear to be genetically based Symptoms typically appear hours or days after gluten has been ingested Overlap of symptoms with celiac disease - abdominal pain - fatigue - headaches - tingling/numbness - foggy brain Both celiac disease and wheat allergy must be ruled out Accessed: Jan 20,

6 Disease Presentation Infants Classic presentation in infants aged 4-24 months When cereals are added to the diet - Failure to thrive Slowed or stopped physical growth Caused by malabsorption of nutrients - Diarrhea, gas, bloating - Pale, foul-smelling, or fatty stools More common to be diagnosed as a child than adult Stanford Children s Health National Institute of Diabetes and Digestive and Kidney Diseases Disease Presentation Adults Symptoms vary greatly some patients present with no symptoms Most common among white, year old women with non-specific symptoms: - Fatigue - Anemia - Changing bowel habits (diarrhea, constipation, bloating, gas) - Joint pain - Low-impact bone fracture BMJ 2014 Mar 3;348:g1561 5

7 Management NO CURE YET PREVENTING GLUTEN INTAKE IS KEY! Lifelong gluten-free diet helps manage & avoid symptoms Symptoms of Gluten Intake (vary greatly but commonly include): Abdominal discomfort or pain Bloating Swelling Cramping Diarrhea Headache & sudden brain fog Reducing Symptoms of Gluten Intake: OTC antihistamine - Benadryl (diphenhydramine) Natural antihistamine - Nettle leaf tea Warm castor oil pack - Place over abdomen What is Leaky Gut? Complication or result of celiac disease Leaky gut is when the small intestine is damaged and allows food particles, toxic waste products, and bacteria to leak into the blood stream which causes symptoms of celiac disease 6

8 musclegainingsecrets2review.blogspot.com Disease Management Leaky Gut Normal gastrointestinal (GI) tissue is like a tight fabric: keeping fluids on each side while allowing movement through the fabric only in certain places In celiac disease, it is thought the attack by the immune system punches holes in the fabric; thus, allowing fluid to leak back into the small intestines, causing diarrhea and loose stool - Commonly called loose junctions Certain foods have the ability to help prevent this from happening 7

9 Disease Management Leaky Gut Moderately use or avoid alcohol & NSAIDs NSAIDs: Aspirin, Ibuprofen, Naproxen, etc. Maintain low & stable blood glucose Probiotics with Lactobacillus or Bacillus coagulens Controversial: Experts are split on this idea Glutamine Supplementation Maintains intestinal metabolism & function Carnitine (amino acid) Supplementation Improves absorption & transportation of essential fatty acids into cells Protects nerve membranes from free radical damage Anti-inflammatory diet ARE PROBIOTICS GOOD OR BAD FOR CELIAC PATIENTS? More than half of the top-selling probiotic supplements contained some gluten, including ones that were labeled as gluten-free - A product must contain less than 20 parts per million (ppm) of gluten to be labeled gluten-free by the FDA Some bacterial species belonging to the Lactobacillus and Bifidobacterium families exert protective properties in patients with celiac disease Gluten Free Probiotic Brands: - Align, Culturelle, Country Life Power-Dophilus, Kirkman Labs Pro-Bio Gold Hypoallergenic, Florastor Probiotics Accessed: Jan 16, Clin Microbiol Rev Jul; 27(3): Accessed: Jan 16,

Anti-Inflammatory Food Pyramid Best Better Good Myths of a Gluten Free Diet The gluten-free diet is healthier for people with gluten-related disorders (celiac disease or gluten sensitivity) - NO

10 Anti-Inflammatory Food Pyramid Best Better Good Myths of a Gluten Free Diet The gluten-free diet is healthier for people with gluten-related disorders (celiac disease or gluten sensitivity) - NO evidence that it is beneficial for people who do not have these conditions The presence or absence of gluten alone is not related to diet quality - What s important is the overall food choices made within the diet, whether it s gluten-free or not Accessed: Jan 16,

11 Myths of a Gluten Free Diet Video: The Truth About Gluten - Common Patient Questions What foods do not contain gluten? What medications contain gluten? How can I see if my medications contain gluten? Is there any resources to quickly see if a product contains gluten? 10

12 What Should Patients AVOID? Omega-6 s promote inflammation oil-rich seeds & oils extracted often in snack foods & fast food Carbs promote inflammation bread, potatoes, chips, crackers, pastries, sweet beverages, high fructose corn syrup Meat & poultry promote inflammation - SUBSTITUTE with vegetable proteins beans, whole grain, nuts Fiber products often contain gluten - Daily Fiber Recommendations: Margarine 25g for women 35-40g for men Vegetable shortening Disease Management Larazotide Knowledgeable patients may have heard about it at their doctor s office or online Tight junction regulator under development - Helps with leaky gut Randomized control trial done in 2015 by Leffler et. al found the drug reduced signs and symptoms of disease when used together with a gluten free diet Still in clinical trials & not yet approved for the management of celiac disease Gastroenterology 2015 Jun;148(7):

13 Common Gluten-Free Grains, Flours, & Starches Amaranth Arrowroot Bean flouts Buckwheat Corn Cornmeal Potato Flour Potato Starch Quinoa Brown Rice White Rice Wild Rice Sorghum Flour Soy Flour Tapioca Gluten-Containing Products & Ingredients that Indicate Gluten May Be Present Alcohol Barley Beer (most contain barley or wheat) Bleached Flour Bran Bulgur Cookie Dough Couscous Durum Flour Durum Wheat Einkorn Emmer Farro Gluten Gluten Flour Graham Flour Kamut Malt Malt Extract - Malt flavoring Oats Oat Bran Rye Spelt Triticale Wheat starch 12

14 Case #1: Patient AL A 42 year old male has recently been diagnosed with celiac disease. Current medications include the following: - bupropion SR 150mg (Mylan) - fluticasone 50mcg nasal spray (Apotex) - levothyroxine 100 mcg (Sandoz) - lisinopril 5mg (Solco) - montelukast 10mg (Mylan) - tamsulosin 0.4mg (Actavis) - zolpidem 10mg (Mylan) How Do I Know a Product is Gluten-FREE? The safest way to ensure a product is GLUTEN-FREE is to contact the manufacturer The Drug Manufacturers Directory 13

Comprehensive List of Medications http://www.glutenfreedrugs.com/newlist.htm Dr.

any final testing they won t guarantee it to be GF but it is very unlikely that it is contaminated with gluten 3 = Contains maltodextrin which occasionally is derived from a wheat source although it

gluten is a sugar alcohol/polyol which are considered gluten free by most experts and generally safe to take CS = it contains corn starch (Y = it contains corn starch, N = it does not contain corn

15 Comprehensive List of Medications Dr. Steven Plogsted & Student Pharmacists (Columbus Childrens Hospital, Columbus, OH) Last Updated 4/28/17 LEGEND 1 = Gluten Free (GF) 2 = Manufacturer doesn t knowingly add gluten -- since they don t do any final testing they won t guarantee it to be GF but it is very unlikely that it is contaminated with gluten 3 = Contains maltodextrin which occasionally is derived from a wheat source although it has been deemed safe for persons with celiac disease -- If the source is known it is marked 4 = NOT Gluten Free 5 = According to the manufacturer it is not gluten free however the stated source of gluten is a sugar alcohol/polyol which are considered gluten free by most experts and generally safe to take CS = it contains corn starch (Y = it contains corn starch, N = it does not contain corn starch) PS = it contains potato starch (Y = it contains potato starch, N = it does not contain potato starch) LF = lactose free (Y = it is lactose free, N = it contains lactose) SF = soy free (Y = it is free of any soy, N = it contains some form of soy Common Gluten-Free Medications (By Brand Name) Keep in mind that companies constantly change the ingredients or the way in which the product is manufactured. Contact the manufacturer directly to ensure the product is gluten-free. INPATIENT technicians Medication Reconciliation: If patients require gluten free medications, BRAND name medications may be necessary or personal supply may need to be used if not stocked by the hospital 14

the way in which the product is manufactured.

free before dispensing to a known celiac patient. 15

16 Common Gluten-Free Medications (By Brand Name) Keep in mind that companies constantly change the ingredients or the way in which the product is manufactured. Contact the manufacturer directly to ensure the product is gluten-free. Common Gluten-Free Medications (By Brand Name) Keep in mind that companies constantly change the ingredients or the way in which the product is manufactured. Contact the manufacturer directly to ensure the product is gluten-free. Remember to ALWAYS verify that the product is gluten free before dispensing to a known celiac patient. 15

17 Case #1: Patient AL A 40 year old male has recently been diagnosed with celiac disease. Current medications include the following: - bupropion SR 150mg (Mylan) GF = gluten free - fluticasone 50mcg nasal spray (Apotex) GF - levothyroxine 100 mcg (Sandoz) NOT GF Switch to Mylan brand generic levothyroxine (GF) - lisinopril 5mg (Par) call manufacturer Call Par Pharmaceutical: montelukast 10mg (Mylan) GF - tamsulosin 0.4mg (Actavis) NOT GF Switch to Mylan brand generic tamsulosin (GF) - zolpidem 10mg (Mylan) GF Dispensing Information Make sure to clean the workplace area first as well as the counting tray if a patient has a gluten allergy Cross contamination can be a huge concern with this patient population Although it may take extra time, it is important to keep patients safe and provide the best care possible 16

18 Technician Checklist 1. Ask if the patient has any food allergies in addition to medication allergies 2. If patient has gluten allergy, confirm prescribed medications are gluten-free 3. Clean workplace & counting tray before dispensing 4. Provide patient with diet education & celiac disease resources Ask patient about any food allergies Confirm prescribed medications are gluten free Clean workspace & counting tray Patient education and celiac disease resources Gluten-Free Cosmetics A surprising number of cosmetics contain gluten Very little, if any, gluten crosses the skin into the bloodstream Lipstick application close to the mouth Several brands now make gluten-free cosmetics and patients can always call the manufacturers if they are wanting to know if it contains gluten Afterglow, Lily Lolo, Red Apple Lipstick, The Celiac Diva 17

Helpful Websites Celiac Disease Foundation (celiac.

community and advocacy efforts News updates & webinars icureceliac Free online

with a wheat/gluten sensitivity. Celiac.

questions Safe food lists and forbidden food lists Helpful Websites Beyond

19 Helpful Websites Celiac Disease Foundation (celiac.org) Meal plans & recipes Information on how to get involved in the celiac community and advocacy efforts News updates & webinars icureceliac Free online portal for people who are living with celiac disease or caregivers to people with a wheat/gluten sensitivity. Celiac.com Articles, blogs, and frequently asked questions Forum for asking your own questions Safe food lists and forbidden food lists Helpful Websites Beyond Celiac Patient handouts Gluten in Medications Frequently Asked Questions (FAQs) 18

Smart Phone Apps The Gluten Free Scanner Uses camera to scan barcodes and

Find Me Gluten Free Locates local gluten free food in your area Contains links

Healthy Diet & Grocery Food Scanner Scan the barcode of food to find it s

20 Smart Phone Apps The Gluten Free Scanner Uses camera to scan barcodes and determine if GF Over 500,000 products as of Dec 17 Free for ios and Android Find Me Gluten Free Locates local gluten free food in your area Contains links for more information from restaurants Free for ios and Android ShopWell Healthy Diet & Grocery Food Scanner Scan the barcode of food to find it s ingredients Best for busy moms, students & home cooks Free for ios and Android Smart Phone Apps 19

21 Take Home Points Patients with celiac disease cannot ingest gluten Screening & testing should be recommended for those that experience symptoms or have risk factors Anti-inflammatory food pyramid is a great resource The safest way to ensure a product is gluten-free is to contact the manufacturer Use cross contamination techniques Refer patients to helpful websites as well as smart phone apps Questions? 20

Functional Medicine Is the application of alternative holistic measures to show people how to reverse thyroid conditions, endocrine issues, hormone

Functional Medicine Is the application of alternative holistic measures to show people how to reverse thyroid conditions, endocrine issues, hormone issues, fibromyalgia, autoimmunity diseases and the like.