April 30th, 2017

Celebrating the Invaluable Knowledge and Expertise of ID Specialist PharmD’s

Since expression of gratitude makes you happier — hey, I read it on the internet — and whining does the reverse, I’ve decided to turn what was going to be a typical rant about dealing with insurance companies into an expression of thanks to a remarkable group of professionals.

Namely, the Doctors of Pharmacy (PharmD’s) who specialize in Infectious Diseases. About whom I am extremely, exceedingly grateful.

And I’m not alone in holding that view — you’ll find it’s universal among ID doctors who are lucky enough to work with one or more ID PharmD’s, whether it’s as part of an antibiotic stewardship program, an HIV or transplant clinic, or on the inpatient ID consultation service.

Although I could cite numerous examples of how the two primary ID PharmDs help us out (thank you Dave and Brandon!), here’s a recent case from my outpatient practice.

A patient of mine, receiving TAF/FTC, darunavir/cobicistat for HIV treatment, needed a nasal steroid inhaler for seasonal allergies. For the non-HIV specialists, recall that when inhaled, injectable, or even topical corticosteroids are given with these potent cytochrome p450 inhibitors, systemic levels of cortisol can dangerously increase.

Result:  Full-blown hypercortisolism (Cushing Syndrome), which usually takes months to resolve and can leave permanent damage. This ritonavir/cobicistat-inhaled steroid interaction is emphatically not one of those EHR alerts to ignore.

So this isn’t a simple matter of telling him to go grab whatever over-the-counter spray is on sale at his local CVS or Walgreens. As a result, I sent a prescription to his pharmacy for beclomethasone because it can be safely given without interacting with cobicistat or ritonavir.

Per his insurance pharmacy benefit manager, however, they wouldn’t cover the beclomethasone. They sent along an annoying notice about “formulary alternatives”, specifically:

… flunisolide spray, fluticasone spray [hey guys at insurance company, this is the WORST POSSIBLE SUGGESTION!], mometasone spray, or triamcinolone spray.

So what to do? Obviously fluticasone would be a terrible option. Furthermore, I’ve seen iatrogenic hypercortisolism several times after triamcinolone injections, so cross that one off the list too.

What about mometasone? UpToDate has an easy-to-use drug interaction program, and it showed no significant interaction. However, the invaluable University of Liverpool HIV Drug Interactions checker disagreed, and did so strongly (that’s their report to the right).

This left flunisolide, which for some reason isn’t listed on the Liverpool site. At this point, I needed help with determining whether flunisolide would be safe to administer with cobicistat. Cue up the query to our ID PharmD’s.

Shortly after sending an email, I received the following incredibly helpful response:

Hi Paul,
Beclomethasone is the only corticosteroid that has been shown to have no clinically significant interaction, likely due to the fact that it is not primarily metabolized by CYP3A4. Flunisolide is also not primarily metabolized by 3A4 and has similar physicochemical properties as beclomethasone (less systemic absorption and more highly protein bound) — here’s a good review. Theoretically it would have the lowest likelihood of an interaction out of the alternatives they recommended, but there are no studies or case reports of flunisolide use with ritonavir or cobicistat. If you decide to prescribe flunisolide, you could start at the initial dose of 2 sprays in each nostril BID, which is half of the maximum dose of 8 sprays in each nostril daily. Let me know if you have any further questions.

Thank you, Brandon!

And to the other ID PharmD’s out there, thanks for the advice on the innumerable other drug interactions, for guidance on dosing in renal failure, for questions about formulations (about which doctors know shockingly little), for interpretation of voriconazole, vancomycin, and aminoglycoside levels, for researching adverse drug effects — and for the whole gamut of expertise you bring to our specialty.

16 Responses to “Celebrating the Invaluable Knowledge and Expertise of ID Specialist PharmD’s”

  1. Max Voysey says:

    Aren’t there computer programs that give multiple drug interaction ideas?

    • Paul Sax says:

      Yes. They are very good but, as in the clinical anecdote above, they are not 100% correct and don’t always agree.


  2. Loretta S says:

    Couldn’t agree with you more, Paul. Although I don’t work in ID, I have the greatest respect for the incredible depth of knowledge specialist PharmDs have. Thank goodness we prescribers can lean on them.

  3. John Brooks says:

    PharmD’s are critical to delivering competent, high quality care in infectious diseases. It’s not just drug interactions but also their deep knowledge of a multitude of other details (e.g., pill size, alternative dosing strategies, administration requirements such as with or without food) that bring value. PharmD’s help tailor decisions to patients’ lifestyles. And when someone has an unexpected interruption in therapy (e.g., traveled without meds) it’s the friendly PharmD in our clinic who is usually called first by our patients.

  4. Dan Gillis says:

    Having spent 20 years as an ID clinical pharmacist I appreciate the shout out. I would also encourage those who appreciate their PharmD to let their administrators know as well. Because we are not able to bill for our services, our cost-effectiveness has to be maintained through improvements in care and safety. The C-suite often sees us as expensive luxuries. Support from other disciplines, especially medicine, is always helpful in maintaining the availability of the resource we provide. Thanks again.

    I also have a dumb@ss insurance company anecdote: My son is a severe Type A hemophiliac who requires FVIII infusions 3x per week. After our insurance changed to a new drug provider we were told that each month’s supply was going to require a new PA. OK, PITA, but whatever needs to be done… The kicker comes in when the first PA was declined because he “had not failed DDAVP therapy.” It would be nice to be able to think that the people making these decisions had a clue.

    DG, PharmD, BCPS

    • Kimberly Couch says:

      I feel your pain. When I was pregnant and required anticoagulation, my hematologist prescribed Fragmin. I called my insurance to see if it needed a PA and what the copay was. I was told it was not on the preferred drug list and was told the alternative was….Lantus! I demanded to talk to the pharmacist.

  5. Paul-I do some CDC consulting work around doc-pharmacist Collaborative Practice Agreements. I love the idea, but I find a lot of resistance from community docs about sharing patient care responsibilities. Any thoughts or experiences with CPAs?

    Great story. Warms my little endocrinology heart.

  6. Agnes Cha says:

    Thank you so much for your support of our profession! I have formed a cult following of your blog with my pharmacy residents and was thrilled to read your post. Especially because it highlights my current battle with managed care companies who are now no longer covering beclomethasone OR flunisolide.

  7. Jake says:

    I am grateful for our excellent inpatient ID pharmacists. Rounding with them throughout my fellowship year has been a critical part of my education. I am sure they measurably improve patient care (someone who is not me should do a study or something…)

  8. Emilio says:

    Dear Paul. Excellent gratitude note which I shared completely based on my regular interaction with my peer Pharm ID at the Hospital in EU. Cheers

  9. Jo Ann Kieller, BSN, CIC says:

    I’m a retired infection preventionist and appreciated working with ID Specialized PharmaD’s as members of our antibiotic stewardship teams. They were invaluable to our efforts. Now, I greatly appreciate the advice of the PharmD who monitors my husband’s complicated anti-coagulation. We have great confidence in his expertise.

    This is certainly one of those (behind- the- scene) professional fields similar to infection prevention that add to improved patient care. Patients often don’t realize how many are on teams that attend to their health..

  10. Lynn says:

    Hi Paul,
    Great article – here in the UK we have many clinical pharmacists doing ‘back-room’ work that goes unnoticed and seemingly unappreciated… I am one, so thanks for the shout-out!

    By the way, flunisolide isn’t licensed for use in the UK… probably explains why it isn’t listed on the Liverpool site…

    • Paul Sax says:

      flunisolide isn’t licensed for use in the UK… probably explains why it isn’t listed on the Liverpool site

      Thanks! That explains it. Maybe I’ll send them a note.


  11. nan elias says:

    A shout out to two wonderful PharmD’s who have made my life easier over the course of my career: Dr Ian McNicholl ( formerly of UCSF) Dr Daftary at Howard.
    Their knowledge and expertise is invaluable!

  12. Brisson Muia says:

    This goes along way to show how the health care cadres work together to deliver to their clients… Each needs the other and its essential that everyone be good at his thing….

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

Learn more about HIV and ID Observations.