{"id":8368,"date":"2017-04-30T17:29:09","date_gmt":"2017-04-30T21:29:09","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=8368"},"modified":"2019-08-01T16:39:06","modified_gmt":"2019-08-01T20:39:06","slug":"celebrating-invaluable-knowledge-expertise-id-specialist-pharmds","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/celebrating-invaluable-knowledge-expertise-id-specialist-pharmds\/2017\/04\/30\/","title":{"rendered":"Celebrating the Invaluable Knowledge and Expertise of ID Specialist PharmD’s"},"content":{"rendered":"

\"\"<\/a><\/p>\n

Since expression of gratitude makes you happier — hey, I read it on the internet<\/a>\u00a0— and whining does the reverse, I’ve decided to turn\u00a0what was going to be a typical rant about dealing with insurance companies into an expression of thanks to\u00a0a remarkable group of professionals.<\/p>\n

Namely, the Doctors of Pharmacy (PharmD’s) who specialize in Infectious Diseases. About\u00a0whom I am extremely, exceedingly grateful.<\/em><\/p>\n

And I’m not alone in holding that view — you’ll find it’s universal among ID doctors who\u00a0are 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.<\/p>\n

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\u00a0from my outpatient practice.<\/p>\n

A patient of mine, receiving TAF\/FTC, darunavir\/cobicistat for HIV treatment, needed a nasal steroid inhaler for seasonal allergies.\u00a0For 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\u00a0dangerously increase.<\/p>\n

Result: \u00a0Full-blown hypercortisolism (Cushing Syndrome), which usually takes months to resolve and can leave permanent damage. This ritonavir\/cobicistat-inhaled steroid interaction is emphatically not<\/em> one of those EHR alerts to ignore.<\/p>\n

So this isn’t a simple matter of telling him to go grab whatever\u00a0over-the-counter spray is on sale at his local CVS or Walgreens. As a result, I\u00a0sent a prescription to his pharmacy for beclomethasone because it\u00a0can be safely given without\u00a0interacting with cobicistat or ritonavir.<\/a><\/p>\n

Per his\u00a0insurance pharmacy benefit manager, however, they wouldn’t cover the\u00a0beclomethasone. They sent along an annoying notice about “formulary alternatives”, specifically:<\/p>\n

… flunisolide spray, fluticasone spray [hey guys at insurance company, this is the\u00a0WORST POSSIBLE SUGGESTION!<\/strong><\/a>], mometasone spray, or triamcinolone spray.<\/p><\/blockquote>\n

\"\"<\/a>So what to\u00a0do? Obviously fluticasone would be\u00a0a terrible option. Furthermore, I’ve seen iatrogenic hypercortisolism several times after triamcinolone injections, so cross that one off the list too.<\/p>\n

What about mometasone? UpToDate<\/a><\/em>\u00a0has an easy-to-use drug interaction program, and it showed\u00a0no significant interaction. However, the invaluable University of Liverpool HIV Drug Interactions<\/a> checker\u00a0disagreed, and did\u00a0so strongly (that’s their report to the right).<\/p>\n

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.<\/p>\n

Shortly after sending an email, I received the following incredibly helpful response:<\/p>\n

Hi Paul,
\nBeclomethasone 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.<\/a>\u00a0Theoretically 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.\u00a0Let me know if you have any further questions.
\nBrandon<\/p>\n

Thank you, Brandon!<\/p>\n

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.<\/p>\n","protected":false},"excerpt":{"rendered":"

Since expression of gratitude makes you happier — hey, I read it on the internet\u00a0— and whining does the reverse, I’ve decided to turn\u00a0what was going to be a typical rant about dealing with insurance companies into an expression of thanks to\u00a0a remarkable group of professionals. Namely, the Doctors of Pharmacy (PharmD’s) who specialize in […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,4,5,8],"tags":[292,423],"class_list":["post-8368","post","type-post","status-publish","format-standard","hentry","category-health-care","category-hiv","category-infectious-diseases","category-patient-care","tag-drug-interactions","tag-hiv"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8368","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=8368"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8368\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=8368"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=8368"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=8368"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}