THE PCCA BLOG

COVID-19 & Vertigo Could Betahistine Be A Good Option?

Tue, 12 Sep 2023 16:13:07 GMT

by Deborah H. Clark, RPh, FACVP, PCCA Clinical Compounding Pharmacist

Several post infection complications have been linked with SARS-CoV-2 (COVID-19) since the beginning of the 2020 pandemic. In addition to known effects on the respiratory-system, other complications can manifest in other organ systems such as the cardiovascular, gastrointestinal and neurologic systems post COVID-19 infection.¹

Vertigo

Neurologic manifestations were widely reported and include anosmia (loss of smell), encephalopathy, encephalitis, headaches, vertigo, dizziness, Guillain-Barré syndrome, meningitis and stroke. Authors of a case study discussing the onset of vertigo in a post-COVID-19 patient defined vertigo “as a false sense of movement brought by the asymmetry in the vestibular system due to damage to the labyrinth, vestibular nerve, or central vestibular system of the brainstem or the cerebellum. Depending on the location of the pathology, it is classified as peripheral vertigo (vestibular components) or central vertigo (brain).”²

What Studies Indicate

There are several studies that examined the role of viral infections in vertigo pathogenesis. Viruses that were studied included Epstein-Barr, cytomegalovirus, rubella, adenoviruses, influenza A & B and herpes simplex. Many of the studies propose direct vestibular nerve infection as a possible mechanism and potential cause of vestibular neuritis.³ A novel link between COVID-19 and newly diagnosed tinnitus, vertigo, hearing loss and otalgia was reported; however, this link has not been fully elucidated and requires further study.⁴

Nevertheless, some studies reported an association between recent COVID-19 infection and newly diagnosed vestibular neuritis. Vestibular neuritis is a benign, self-limiting condition normally presenting with vertigo, nausea, vomiting and gait abnormality. It is thought to be due to viral or post-viral inflammation of the vestibular component of the eighth cranial nerve.² Patients who developed acute vertigo symptoms post-COVID 19 infection reported symptoms that lasted varying periods after their COVID recovery.

Case Studies – How is this Managed?

In addition to previously mentioned studies, there have been several case reports of patients entering the emergency room complaining of new onset vertigo associated with previous SARS-CoV-2 infection, with or without nausea and vomiting.1-3 These patients did not have any previous history of ear disease. Most of these patients were managed with either anti-vertigo agents, antihistamines, IV fluids or anti-nausea agents.

In one case, a 64-year-old patient reported to the emergency department with acute vertigo and without nausea and vomiting. The patient had a 9-day history of fever, cough, runny nose, dyspnea, myalgia and fatigue. After the patient was stabilized and several diagnostic tests performed, it was determined the patient had no neurologic or auditory disorders. The patient also reported contact with a confirmed COVID-19 patient who lived nearby. From the patient’s history of symptoms and lab confirmation, it was determined the patient was infected with SARS-CoV-2, which the practitioner determined to be the cause of vertigo. The physician prescribed betahistine 24mg daily as anti-vertigo medication. The patient was also prescribed other medications to treat COVID-19. The patient returned one month after recovering from COVID-19, reporting improvement of vertigo but not complete resolution. The physician continued betahistine therapy for a total of three months; vertigo resolved a month and a half after COVID-19 recovery.¹

Another study discussed a patient who reported to the ER with vertigo, nausea and vomiting lasting for three hours. As with the previous case, the patient had a history of COVID-19 infection. The patient was tested for neurological and auditory deficits and none were found. The patient was treated with ondansetron and IV fluids to control nausea and vomiting. The patient’s vertigo was managed with betahistine 16mg and an antihistamine. The patient subsequently reported complete resolution of symptoms within seven days.²

Betahistine Dihydrochloride

Betahistine dihydrochloride is a structural analog of histamine, a weak agonist of H1 receptors and antagonist of H3 receptors. It is approved for use in the treatment of Ménière’s disease and symptoms of vertigo in more than 115 countries.

In animal models of vestibular dysfunction, betahistine was observed to improve vestibular compensation by increasing blood flow in the vestibulocochlear region and decreasing the excitatory response in vestibular cells by blocking the H3 receptor cells locally. Several clinical trials have shown that betahistine improved vertigo-related symptoms — including nausea and vomiting — and effectively reduced the frequency and severity of vertigo.⁵

Betahistine dihydrochloride is not commercially manufactured in the United States. Therefore, it must be compounded for patients. Compounding pharmacists may formulate this API in a capsule to meet a patient’s need. For example, PCCA Formula #10963 – Betahistine Dihydrochloride 16mg Capsules Size #1 (LoxOral®) — is an example of a formula that may be used to help patients with COVID-19-related vertigo.

Members with clinical services access may contact our Clinical Services team to discuss compounding betahistine for COVID-19 and other compounding-related concerns.

References

Motawea, K.R., Monib, F.A. (2022) New Onset Vertigo After COVID-19 Infection. A Case Report. Indian J Otolaryngol Head Neck Surg 74 (Suppl 2), 3009–3011. Accessed September 2023 at https://doi.org/10.1007/s12070-021-02715-5
Devaragudi, S., Mohit, G. (2023) Vertigo in the Setting of COVID-19 Infection: A Case Report. Cureus vol. 15,2 e34708. Accessed September 2023 at doi:10.7759/cureus.34708
Beukes, E., Ulep, A.J., Eubank, T., et al. (2021) The Impact of COVID-19 and the Pandemic on Tinnitus: A Systematic Review. J. Clin. Med. 10, 2763. Accessed September 2023 at https://doi.org/10.3390/jcm10132763
Maharaj, S., Bello Alvarez, M., Mungul, S., et al. (2020) Otologic dysfunction in patients with COVID-19: A systematic review. Laryngoscope investigative otolaryngology vol. 5,6 1192-1196. 17. Accessed September 2023 at https://pubmed.ncbi.nlm.nih.gov/33365394/
Parfenov, V. A., Golyk, V.A., Matsnev, E.I., et al. (2017) Effectiveness of betahistine (48 mg/day) in patients with vestibular vertigo during routine practice: The VIRTUOSO study. PloS one V 12,3 e0174114. Accessed September 2023 at https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0174114

Post-COVID Loss of Smell: 3 Possible Treatment Options

Wed, 06 Jul 2022 14:12:56 GMT

By Deborah H. Clark, RPh, PCCA Clinical Compounding Pharmacist

Since the appearance of the first cases of COVID-19 in Wuhan, China, there have been several symptoms commonly associated with SARS-CoV-2 infection. Two of them, partial or full loss of taste and smell, are considered more predictive of infection than all the other symptoms, including cough, fever and fatigue. A systematic review of six studies showed that 60% of infected patients had loss of smell and 56% had loss of taste prior to the appearance of other common signs and symptoms of COVID-19.¹ This is not as prevalent since the emergence of the delta variant, with anosmia occurring in 13% of the patients according to a study by the U.K. Health Security Agency.² Considering the infection rates, however, it’s still a significant issue for many patients. This article brings together research on possible treatment options for persistent partial loss of smell (hyposmia) and persistent complete loss of smell (anosmia).

Prevalence of Hyposmia and Anosmia in COVID-19 Patients

A study of patients with COVID-19 conducted by Parma et al. (2020) looked at 4,039 patients in 41 different countries and found that 89% of them reported some degree of loss of smell.³ Another study by Lichien et al. (2021) reported that 81.6% of infected patients experienced total loss of smell and 18.4% experienced partial loss of smell.⁴ These studies set the background for the emergence of this issue over the first year of the pandemic. As mentioned above, this has become less of an issue in patients infected with later variants compared to the original SARS-CoV-2 virus, but it’s still a clinical need for patients.

Hyposmia and anosmia can also persist for long periods as part of what the CDC has called “long COVID,” or persistent post-COVID syndrome, which is when symptoms continue beyond four weeks after initial infection. ⁵ Lichien et al. (2021) also found that after 60 days, 24.5% of the total patient population in their study still had not recovered their sense of smell.⁵ Renaud et al. (2021) looked at a group of 97 patients who were treated at the University Hospital of Strausberg over the period of one year. They found that hyposmia or anosmia can persist in patients for four months to a year without self-resolution.⁶ All of these studies show us the need for treatment options for this symptom when it persists beyond the original infection period.

Proposed Mechanisms of Olfactory Dysfunction

Researchers still aren’t certain how the virus causes olfactory dysfunction. In their systematic review of studies, however, Neta et al. (2021) identified several hypotheses proposed by experts. One proposed mechanism is based on the ability of the virus to cross the blood-brain barrier via the bloodstream. Other possible routes of entry include the olfactory nerves, the cribriform plaque or the peripheral trigeminal nerve. Another study looked at the increase in levels of interleukin 6 and how inflammation in the nasal cavity can potentially affect olfactory neuronal function similar to chronic rhinosinusitis.¹ Since we currently have no definitive answer as to the actual mechanism, it is prudent to look at literature that discusses treatment of hyposmia or anosmia caused by infections for clues as to what therapy may possibly be effective.

Possible Treatment Options

Regardless of the mechanism of dysfunction involved, there are several proposed treatment options for prolonged hyposmia or anosmia discussed in literature. Most of these options were researched prior to the COVID-19 pandemic as treatment for post-infectious or post-traumatic hyposmia or anosmia.

Olfactory Training

One possible treatment option discussed in the literature is olfactory training. There are several types of olfactory training that may be employed. Most involve the use of a series of substances with significant odor qualities that the patient is exposed to multiple times in a day. This therapy can continue for weeks to months depending upon response. ¹ It has also been studied in combination with other treatments, as outlined below.

Intranasal Vitamin A

Another possible treatment option is intranasal vitamin A. Vitamin A can promote olfactory neurogenesis because of its ability to regenerate the olfactory neuroepithelium.⁷ A retrospective study from 2017 by Hummel et al. compared the effectiveness of intranasal vitamin A in post-infectious and post-traumatic smell disorders with olfactory training. Patients were treated with either olfactory training alone or a combination of olfactory training and intranasal application of vitamin A 10,000 units daily over a period of two months. Patients applied vitamin A in a drop method with the head tilted back. Researchers followed up with the patients after 10 months and found that patients in the group that used combination therapy had the best response, with a 37% improvement compared to 23% improvement in the group with olfactory training alone. This study shows us that intranasal vitamin A 10,000 units applied daily for two months may be useful in treating these patients.⁸

Theophylline

A third possible treatment option is theophylline. Henkin and Velicu (2009) performed a study to understand why and how hyposmia and hypogeusia (loss of taste) occur. They determined that patients with this disorder have lower levels of cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP) in the saliva and nasal mucosa compared to healthy subjects. They found an association between these levels and the severity of symptoms as well.⁹

In general, theophylline has several proposed mechanisms of action for its activity in several different conditions. It is thought to inhibit phosphodiesterase, thus increasing secondary messengers like cAMP and cGMP. This helps assist in the regrowth and restoration of the olfactory neuroepithelium.¹ In an open-label, controlled trial of 312 patients with hyposmia and hypogeusia, oral theophylline was administered to test this proposed mechanism. The dosing range was from 200-800 mg daily for periods of two to 12 months. The results of this study showed that oral theophylline treatment successfully corrected hyposmia in more than 50% of the patients.¹⁰

The challenge with this study was that as the dosage of theophylline increased, adverse events also increased. Therefore, the researchers chose to test whether a lower dosage of theophylline in a nasal spray would give the same result with less adverse events. They chose 10 patients from the original study group of 312. These patients had submaximal results from the oral theophylline, and they hadn’t increased their dosages because of adverse events. They were also required to have a mean serum theophylline level that was unmeasurable before starting the second phase.¹⁰

Theophylline 20 μg per dose was administered as a nasal spray in each nostril daily over a four-week period. The researchers evaluated the patients each week over the course of four weeks. This smaller study showed that intranasal theophylline was safe and more effective than oral theophylline in correcting hyposmia and hypogeusia. The researchers measured improvement as early as one week, and maximal improvement varied from one to four weeks. The lowering of the dosage also avoided systemic adverse events.¹⁰

The literature gives three options as possible therapies for patients experiencing post-COVID hyposmia or anosmia: olfactory training, intranasal vitamin A or intranasal theophylline. For two of the options, vitamin A and theophylline nasal sprays, the dosage form is not currently commercially available. This is a patient need that could be fulfilled by a local compounding pharmacist in consultation with the patient’s prescriber.

Deborah Clark, BSPharm, RPh, PCCA Clinical Compounding Pharmacist, is a graduate of the University of North Carolina at Chapel Hill’s Eschelman School of Pharmacy and is currently licensed to practice in North Carolina. Deborah worked for 14 years in community pharmacy compounding to meet the needs of a variety of patients before joining PCCA’s Clinical Services team in 2009. She co-authored PCCA’s C4 Veterinary Compounding course and is a member of the Society of Veterinary Hospital Pharmacists.

A version of this article originally appeared in PCCA’s members-only magazine, the Apothagram.

References

Neta, F. I., Fernandes, A., Vale, A., Pinheiro, F. I., Cobucci, R. N., Azevedo, E. P., & Guzen, F. P. (2021). Pathophysiology and possible treatments for olfactory-gustatory disorders in patients affected by COVID-19.Current Research in Pharmacology and Drug Discovery, 2, Article 100035. https://doi.org/10.1016/j.crphar.2021.100035
U.K. Health Security Agency. (2022, January 14). SARS-CoV-2 variants of concern and variants under investigation in England: Technical briefing 34 . Retrieved February 24, 2022, from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1050236/technical-briefing-34-14-january-2022.pdf
Parma, V., Ohla, K., Veldhuizen, M. G., Niv, M. Y., Kelly, C. E., Bakke, A. J., Cooper, K. W., Bouysset, C., Pirastu, N., Dibattista, M., Kaur, R., Liuzza, M. T., Pepino, M. Y., Schöpf, V., Pereda-Loth, V., Olsson, S. B., Gerkin, R. C., Rohlfs Domínguez, P., Albayay, J., … Hayes, J. E. (2020). More than smell — COVID-19 is associated with severe impairment of smell, taste, and chemesthesis. Chemical Senses, 45(7), 609-622. https://doi.org/10.1093/chemse/bjaa041
Lechien, J. R., Chiesa-Estomba, C. M., Vaira, L. A., De Riu, G., Cammaroto, G., Chekkoury-Idrissi, Y., Circiu, M., Distinguin, L., Journe, F., de Terwangne, C., Machayekhi, S., Barillari, M. R., Calvo-Henriquez, C., Hans, S., & Saussez, S. (2021). Epidemiological, otolaryngological, olfactory and gustatory outcomes according to the severity of COVID-19: A study of 2579 patients. European Archives of Oto-Rhino-Laryngology, 278(8), 2851-2859. https://doi.org/10.1007/s00405-020-06548-w
Chippa, V., Aleem, A., & Anjum, F. (2021). Post acute coronavirus (COVID-19) syndrome. In StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK570608
Renaud, M., Thibault, C., le Normand, F., Mcdonald, E. G., Gallix, B., Debry, C., & Venkatasamy, A. (2021). Clinical outcomes for patients with anosmia 1 year after COVID-19 diagnosis. JAMA Network Open, 4(6), Article 2115352. https://doi.org/10.1001/jamanetworkopen.2021.15352
Yan, C. H., Faraji, F., Prajapati, D. P., Boone, C. E., & DeConde, A. S. (2020). Association of chemosensory dysfunction and COVID-19 in patients presenting with influenza-like symptoms.International Forum of Allergy & Rhinology, 10(7), 806-813. https://doi.org/10.1002/alr.22579
Hummel, T., Whitcroft, K. L., Rueter, G., & Haehner, A. (2017). Intranasal vitamin A is beneficial in post-infectious olfactory loss. European Archives of Oto-Rhino-Laryngology, 274(7), 2819-2825. https://doi.org/10.1007/s00405-017-4576-x
Henkin, R. I., & Velicu, I. (2009). Decreased parotid salivary cyclic nucleotides related to smell loss severity in patients with taste and smell dysfunction. Metabolism: Clinical and Experimental, 58(12), 1717-1723. https://doi.org/10.1016/j.metabol.2009.05.027
Henkin, R. I., Schultz, M., & Minnick-Poppe, L. (2012). Intranasal theophylline treatment of hyposmia and hypogeusia: A pilot study.Archives of Otolaryngology — Head & Neck Surgery, 138(11), 1064-1070. https://doi.org/10.1001/2013.jamaoto.342

These statements are provided for educational purposes only. They have not been evaluated by the Food and Drug Administration, and are not to be interpreted as a promise, guarantee or claim of therapeutic efficacy or safety. The information contained herein is not intended to replace or substitute for conventional medical care, or encourage its abandonment.

6 Pharmacy Owners Explain How They’ve Adapted to the Pandemic

Wed, 31 Mar 2021 12:31:10 GMT

By PCCA

The COVID-19 pandemic has forced pharmacies to balance the safety of their staff and customers with the need to serve their communities, all while weathering reduced revenue and supply shortages. They needed personal protective equipment (PPE) that was hard if not impossible to find, and they had to adopt new modes of business or revamp existing ones, from portable point-of-sale (POS) systems for curbside service to plexiglass shields at checkout registers.

The pandemic will likely have lasting effects on pharmacy practices just as it will on societies around the world. To help pharmacies who have struggled and continue to struggle with the challenges brought on by this unprecedented time, we asked six compounding pharmacy owners about how they have successfully steered their practices through the pandemic and what they have learned from the experience:

Steve Branch, RPh, of Central Drug Compounding and Wellness in Victoria, Texas (pictured bottom left above)
Dawn Ipsen, PharmD, FACA, FACVP, of Kusler’s Compounding Pharmacy in Snohomish, Washington, and Clark’s Compounding Pharmacy in Bellevue, Washington (pictured top right above)
David Miller, RPh, PhD, FAPC, FACA, of Keystone Pharmacy in Grand Rapids, Michigan (pictured top left above)
Michelle Moser, RPh, FACA, FACVP, of Makers Compounding Pharmacy in Mount Vernon, Washington (pictured middle left above)
Masoud Rashidi, PharmD, of Innovative Compounding Pharmacy in Folsom, California (pictured middle right above)
Terry Vasenden of Sierra Compounding Pharmacy in Reno, Nevada (pictured bottom right above)

What are the biggest challenges your pharmacy has had to face because of the pandemic?

Steve Branch : Safety is the first challenge. I have to protect my staff for obvious reasons. Finding ways to protect them from patients as well as from each other was difficult. I do not want them taking COVID-19 home to their families or bringing it from home to the pharmacy.

The second challenge has been financial. Initially, we closed our lobby for six months for the safety reasons mentioned above. We lost a lot of revenue due to loss of foot traffic — people weren’t there buying supplements and other wellness products. The cost of PPE has skyrocketed, too. It can cost $20, $30, even $40 to outfit each employee on a daily basis. It has been very difficult to add that back into the cost of making a compound.

Dawn Ipsen : Initial decreased revenue that required us to change how we help our community. The hardest months were when we went closed door and didn’t allow customers to enter the store. During that time we used social media, bag stuffers and phone conversations to provide clear information to patients about our services and options available to receive their prescriptions and supplement orders. We also initiated a wellness/refill-reminder calling system. Patients were identified within PK Software when they were due for refills. We used that information as an opportunity to telephone our patients and check in on their health, mental well-being and prescription refill needs. We reminded patients that taking care of their health was the one thing that they could control in this challenging time. Our pharmacist team researched and put together flyers that would guide patients on what supplements would be most helpful for immune support, sleep and anxiety/depression. We did this because we were listening to our patients and hearing loud and clear what their concerns were and how the pandemic was negatively affecting their daily lives and health. Luckily, our efforts paid off, and we were able to turn that trend around within two months.

PCCA was tremendously helpful during this time in providing weekly networking opportunities for us to share best practices from across the nation. Together, we are better and we can do more! I love my community of friends and colleagues. Also, the business webinar by PCCA’s Bryan Prescott was so vital in our hardest of days. The messaging I still remember is to control the portion of revenue that you can control. At that time, it was refills! New prescriptions weren’t happening because almost all providers had closed their doors and they were trying to figure out telemedicine. It took a few months before we started seeing offices reopening and people seeking out treatment for things that had been put on the back burner.

Processes and communication changes I implemented to keep my team healthy, supported and safe presented some additional challenges. Fortunately, we were 100% successful in preventing any COVID-19 cases within our team or our immediate families. This was an amazing feat since the first confirmed hospitalized case and the first nursing home outbreak were literally just down the road from our pharmacies. At the height of the pandemic, we hit over 400 cases per 100,000 people! My team has mentioned many times how grateful they have been to have clear planning, guidance and safety measures. We closed our doors for about six weeks at one point and used drive-thru, curbside and shipping. Even today, we still require masking and hand sanitizer use by all employees and patrons, as well as plexiglass shields at our registers and social-distance markings on the floors. Our staff continues to be vigilant in their time off, and we all work together to make smart choices in our personal lives for the betterment of our team and community.

In-person consultations for hormone replacement completely became a back-shelf item as well. I wasn’t comfortable conducting them in person while in a small room for an extended amount of time with an unknown patient. I have transitioned all of those types of appointments to an online model. It is more efficient for both me and the patient, too. I find I get the same amount of value via a camera as I do in a room. The patient has the convenience of doing these types of appointments from anywhere. I’ve had patients do them in their car while on lunch break or from their vacation home in the mountains and even from another state! This has actually opened the door and normalized a new way for patients to receive information that can be helpful to their health.

David Miller : We have been unable to obtain supplies necessary to help our patients. PPE has been difficult if not impossible to obtain. We are also having increasing challenges obtaining the pure pharmaceutical ingredients and excipients necessary to compound certain dosage forms.

Of course, in times of shortage and supply chain disruption, the best value products that tend to be affordable disappear first. This puts compounders and their patients in a bind: either raise prices — which negatively impacts patients, especially those unemployed or underemployed — or absorb the increased costs ourselves. It has been a very delicate juggling act.

The last big challenge we are having is over burdensome governmental oversight. During the pandemic, we were limited to a very strict formula for compounding hand sanitizer. This is just one example, but governmental oversight is making it increasingly difficult to provide customized care for our patients.

Michelle Moser : E-commerce has been a challenge! We bought a hand-held POS tablet to help with transactions curbside too. We pushed our seminars and international conference to a Zoom platform just like everyone else. The expense was covered by a grant.

Human resources needs have been a challenge as well. This has been so, so very stressful to keep up with documenting the little pieces associated with COVID-19, the changes allowed and not allowed.

Masoud Rashidi : One of the biggest challenges we had was obtaining PPE during the pandemic and staying up to date with all the new CDC guidance, which was changing every few days. We had to create new sets of SOPs, which was very time consuming. We would have to implement a new SOP, and a few days later, we had to do the same thing all over again.

Keeping the employees and customers safe was our top priority, so getting used to curbside service and shipping was a bit challenging at the beginning, but we got used to it after a while.

Letting patients and prescribers know we were open was also a challenge. Most people thought that with the shutdown, we had to close as well. This caused a lot of downtime in the pharmacy.

Terry Vasenden : A big challenge was the loss of income for the months last spring when doctor’s offices were closed, resulting in a drastic drop in new prescriptions. In-person marketing was not possible because their office lobbies were closed, too. Keeping our team and patients safe was the other big challenge.

How have you overcome those challenges?

Steve Branch : Once we reopened our lobby, we began to offer weekly promotions to increase supplement sales. For example, we started Wellness Wednesday, where we offer 10% off all supplements. Also, we began using social media posts and emails. This has helped. While our numbers are not what they were, we are seeing an upward trend in sales.

David Miller : We have had to become creative. We have had to change excipients where appropriate and work with doctors to achieve therapeutic interchanges where appropriate.

We had a program last year during the height of the pandemic that ensured no one would go without their compounded medication for financial reasons. If we called them because they were late ordering their refill and their response was, “I am out of work and cannot afford my medication,” we would send them up to two months at no charge if they did not have insurance covering the medications. We did not want any patient to have interrupted therapy because of this terrible virus.

Michelle Moser : I tried really hard to take each day as it came. My staff is very supportive and have stepped up to help with the changes in human resources and state guidelines.

Masoud Rashidi : One of the most rewarding parts of my job is being part of PCCA’s Advisory Council and Concierge Compounding program. This became especially important during the pandemic. Our groups were meeting via Zoom one to two times a week and exchanging ideas. This helped all of us to overcome some of the challenges. Networking and being able to call a colleague if we ran out of PPE or a chemical was crucial.

Bryan Prescott with PCCA’s Compounding Pharmacy Management Services helped a lot with some of the COVID-19-related policies and how to stay afloat. He was very informed about all the employee-related COVID-19 coverage and obtaining the grants via the Paycheck Protection Program to be able to keep our employees and stay in business.

Terry Vasenden : We established goals for growth, and once doctor’s offices were open, we found creative ways to market and pursue our goals for growth, even though it looked very different from prior years. For example, we used the PCCA Speakers Bureau to provide education to practitioners via Zoom, we offered women’s wellness classes via Zoom, and we sent marketing materials via mail (rather than dropping them off at the office in person) and followed up with a phone call.

What advice would you give to other pharmacies about how to deal with the continuing effects of the pandemic?

Steve Branch : Our philosophy has always been, “Central Drug is bigger than all of us who work here; without it, none of us have jobs,” so what are we willing to do to ensure that it stays open? We have asked employees to make sacrifices, and we as owners have made sacrifices knowing that this is short lived. At the same time, we have continued to do the things that got us here, the things we do well, and we have not compromised our integrity or the integrity of our compounds — the things that set us apart.

Dawn Ipsen : Communicate, communicate, communicate. Be in front of your audience as much as you can. In these times, I think it is impossible to over-communicate. How are you doing your business transactions, what is expected of your staff from a safety and health standpoint, what services and products do you have that your community needs? Always remember to give your audience the “what’s in it for me” in your messaging.

If you don’t have one already, get a business coach. Make sure you start with your pharmacy’s vision, mission and values. When those are clear, it is easy to lead a team, make hard decisions, set clear expectation and cultivate a culture that you can be proud of. Also, a business coach is so important when setting contingency plans. Instead of constantly carrying the worry of the health of the business, we had what it needed to look like recorded on paper. I communicated this information to the team, and they knew what was needed in order to maintain the current staffing and spending level. They had less worry about their job security, and we then had a whole team working toward the same goals and objectives through our consistent vision and mission by living and working with our values.

David Miller : Be flexible and find creative ways to reward your staff. Everyone is on edge right now, and it is difficult to recruit and retain talent. They are torn between having to care for children that are home when they are not. They have little to look forward to because all they can do is go to work and go home. Don’t get me wrong, home and family are blessings. But not being able to travel, go out to eat, go to concerts or congregate with friends is really challenging for patients and team members alike. Find ways to connect. Give them something to look forward to like Hawaiian shirt Friday or Chic-fil-A Wednesdays. Let your team know they are appreciated. If you are a leader, study emotional intelligence and work the concepts.

Michelle Moser : Let’s talk, share information and keep in touch with one another. You are not alone. Together, we are stronger.

Masoud Rashidi : Always keep well stocked, keep informed and do not ever think you are alone. Rely on your colleagues, call them up and call PCCA member support. I had a lot of great information coming to me through the PCCA network. It is very hard to try to come up with the ideas yourself, so get help.

Terry Vasenden : Continue to think outside the box and be creative on how you can accomplish growth and serve your patients and practitioners even when conventional methods are not available.

After the pandemic is over, will you continue any of the practices and policies you’ve implemented in your pharmacy because of it? If so, what are they, and why will you continue them?

Steve Branch : We’ll continue social distancing where and when we can. We’ll have fewer chairs in the lobby as well. Plexiglass shields will become permanent at the checkout and patient-consultation areas. These changes are really common sense, and we should have done them a long time ago considering that nearly everyone coming to a pharmacy is sick, especially in the wintertime.

Dawn Ipsen : I really don’t think the pandemic will magically reverse our processes. I believe many, if not most, will be here to stay for many years. I see social distancing and plexiglass shields at registers staying forever. I see masking in some public venues staying for years. In Asia, masks have been considered quite normal at certain times of the year and in social settings. I think we now have more of a social acceptance of that look in the U.S., and it won’t be uncommon for many to have physical and mental health needs that are fulfilled by continuing to mask. I think touchless, no-contact purchasing will stay, as well as the uptick in online sales. Although my personality type doesn’t align with it, I wonder if we will become a society of less hugging and handshaking, too. I think if we look at history, we can maybe see some previous generations that have gone through that transition due to health issues that they faced in their generation.

There are many silver linings too! I think we’ve all had a significant amount of time to really think about and prioritize what is important — more time for family, prioritizing activities that truly bring value, finding improved efficiency in our commuting, meetings, etc.

David Miller : I think we are in a different society now. People have changed tremendously over the past year. They are looking for more work-life balance. We have to make their work experience rewarding and satisfying so they are willing to sacrifice time away from home and their families to entice them to keep serving our patients. As the evolution of the team culture continues to advance, we must continue to stay ahead of the evolution.

We are all incredibly flexible as compounders. That is what we do and who we are. We must continue to be nimble and innovate everywhere. We must continue to keep seeking creative solutions for our patients’ problems in order to be able to continue to serve them into the future.

Michelle Moser : Yes, the e-commerce has been amazing! We will keep our portable POS system, too. I am considering expanding our Zoom seminars as well.

Masoud Rashidi : Here are a few of the policies we implemented that we would like to keep:

Conducting Zoom meetings instead of in-store patient seminars. Expanding from our local area
Zoom meetings with providers during their lunch, before they open or after they go home (or whatever works for them) instead of going to their offices. This has given us the opportunity to meet doctors over 100 miles away, and they are becoming great partners
Keep up the social-media marketing. That has helped us a lot to inform our patients
Keep the online supplement store
Still thinking about offering curbside service

Terry Vasenden : Patients really appreciate our curbside service, so that is a practice we will continue to offer. It was a great idea that came about because of the pandemic but turned into one more service we can offer that is valued by our patients.

Professional Opportunities for the Pharmacy Technician of Today

Wed, 03 Mar 2021 14:52:42 GMT

By Erin Michael, MBA, MS, CPhT, PCCA Director of Member Engagement

It’s hard to believe that my first job in pharmacy was over 31 years ago. Little did I know it would be the beginning of my lifelong career. I had been highly interested in science in school, so when I started as a clerk at a community pharmacy in Southern California, it was easy to see that this field was the perfect match for me. While the roles and responsibilities of a pharmacy technician were few back then, we have evolved into being a vital part of the health care team. Responsibilities included working the front register, faxing doctors for refill authorizations (yes, I said faxing) and occasionally some data entry. But gone are the days where a pharmacy technician can only count, pour, lick and stick for prescription after prescription.

The Pharmacy Technician of Today

The pharmacy technician of today includes positions in traditional retail, academia, institutions, compounding and pharmacy ownership, just to name a few. Over the years, I have enjoyed roles in many of those areas, including traditional community pharmacy; compounding; pharmacy ownership; corporate management; sales and marketing; consultant work; and one of my biggest passions, advocacy. We’ve raised the bar over the years, and today’s pharmacy technicians often hold graduate degrees and advanced certifications. We are very specialized in our niche of health care. As the pharmacy profession continues to evolve, the role of the pharmacy technician only becomes more and more vital to the success of patient outcomes.

Mike Johnston, CEO of the National Pharmacy Technician Association (NPTA) — and a pharmacy technician himself — recently shared with me that he has seen the role evolve significantly over the years, and as a result, we are seeing it become more advanced and career oriented. Looking ahead, as the scope of practice and responsibilities of pharmacy technicians continue to grow, pharmacists will be better able to provide valuable clinical and consultative support to both patients and prescribers. Mike also shared that he started NPTA because of an unmet need in the industry for advocacy and advancement for pharmacy technicians.

A Certification Opportunity for Pharmacy Technicians

An example of recognizing the vital role that pharmacy technicians play occurred in October 2020 when the U.S. Department of Health and Human Services (HHS) authorized pharmacy technicians to administer COVID-19 vaccines as long as they are certified to give immunizations. The American Society of Health System Pharmacists has a great summary .

Mike and his team are also a part of this incredible milestone: They offer immunization certification classes through their association. NPTA’s Immunization Administration Training Program is accredited through the Accreditation Council for Pharmacy Education, and they developed it using HHS guidance. Technicians can complete this certification program online in a matter of days. As states are starting to create their own individual plans to immunize the public, pharmacy technicians can now add one more certification to their résumés while helping to end the pandemic one patient at a time.

Not “Just a Pharmacy Technician”

I often cringe when I hear a colleague say, “I am just a pharmacy technician.” There is no such thing as just a pharmacy technician, and I have never been prouder to be an integral part of the health care team. Our roles and responsibilities will continue to evolve, and I am looking forward to a bright future ahead of us.

My advice to any current or future pharmacy technician is to have pride in your role, never stop learning, get involved in advocacy for the profession and always be looking for ways you can help the pharmacy team enhance patient lives. If you’re looking for a rewarding career where you can achieve great things, share your passion about patient care and make a difference, then being a pharmacy technician is the perfect career for you!

Erin Michael, MBA, MS, CPhT, PCCA Director of Member Engagement, joined the PCCA staff in July 2006. She has been working in pharmacy for more than 25 years, of which 23 have been in compounding and promoting the practice of pharmacy. She previously worked for an independent pharmacy owner and was the general manager of multiple locations. Erin was instrumental in developing and implementing programs to promote and grow the compounding and traditional parts of that business. She holds an MBA in healthcare administration and an MS in hospitality management. She was recognized as PCCA Technician of the Month in August 1999 and California Pharmacists Association Technician of the Year in 2003.

What the Updated PPP Means for Pharmacies in 2021

Thu, 14 Jan 2021 14:26:44 GMT

By Bryan Prescott, PharmD, MBA, PCCA Director of Management Coaching Services

The Consolidated Appropriations Act, 2021 is the much-anticipated U.S. COVID-19 relief bill signed into law on December 27, 2020. Notably, it updates the Paycheck Protection Program (PPP) that has helped many businesses, and it includes some changes that may be very helpful for your pharmacy. Here are some of the important updates.

Are the expenses covered by PPP funds tax deductible?

There is a lot of concern regarding the tax implications for PPP loans distributed in the spring and summer of 2020. As recently as December 2020, the IRS held the position that funds used to cover business expenses during the covered period would not be deductible if the expenses were forgiven (or were likely to be forgiven). Essentially, this would mean that these funds would be taxed as ordinary revenue. Given that, businesses would need to prepare themselves for a significantly higher 2020 tax bill and would need to readjust their forecasted cash flow positions.

But here is the great news: The latest COVID-19 bill declares that the expenses paid with the proceeds of a forgiven PPP loan are deductible, overruling IRS Notice 2020-32. The new act further declares that “no tax benefit shall be denied, and no loss carryovers or basis adjustment will be required as a result of the tax-free forgiveness of a PPP loan. This will prevent the IRS from taking the position that a company must reduce loss carryovers or the basis of its assets by the amount of the forgiven loan.”¹

“But here is the great news: The latest COVID-19 bill declares that the expenses paid with the proceeds of a forgiven PPP loan are deductible, overruling IRS Notice 2020-32.”

At the time of this writing, the IRS is publishing its own guidance on these issues (and others), but the benefit is undeniable — pharmacies that received a PPP loan in 2020 will be the beneficiaries of an unprecedented economic benefit: tax-free revenue. This is welcome news for your pharmacy’s cash position as we transition out of 2020 and step into 2021 with a little more certainty.

Is there another round of PPP loans in 2021?

The December 2020 COVID-19 relief bill also includes $284 billion for a second round of PPP funds. Even if your business received funds during 2020, you may be eligible for this next round of forgivable loans. Unfortunately, the eligibility requirements for this round of loans are more restrictive than the PPP loans offered in 2020.

“Even if your business received funds during 2020, you may be eligible for this next round of forgivable loans.”

Who is eligible for a PPP loan in 2021?

In the spring and summer of 2020, businesses only needed to claim they had reasonable suspicion that revenues would be negatively affected in the coming months. Of course, there was no way to accurately predict what might happen. In retrospect, many pharmacies finished the year with similar revenues to 2019, if not better. Regardless, asking for PPP funds in 2020 was an appropriate thing to do given the uncertainties at the time.

However, regarding 2021 PPP funding, businesses must demonstrate at least a 25% reduction in gross receipts in the first, second or third quarter of 2020 relative to the same quarter in 2019. We in PCCA’s Compounding Pharmacy Management Services (CPMS) encourage our clients (and all pharmacies) to immediately consult with your accounting partners and compile your quarterly statements for 2019 and 2020 to help with this requirement.

Additionally, in 2021, businesses cannot have more than 300 employees in order to qualify for a PPP loan (as opposed to 500 employees in 2020). Businesses must also have used the full amount of their first PPP loan. This would likely not be a concern for pharmacies as far as we can tell.

How much can a business get from a PPP loan in 2021?

If eligible, PPP borrowers may receive a loan amount of up to 2.5 times their average monthly payroll costs in the one year prior to the loan or the prior calendar year. The maximum loan is capped at $2 million. The same calculation was used to determine loan amounts in 2020.

“If eligible, PPP borrowers may receive a loan amount of up to 2.5 times their average monthly payroll costs in the one year prior to the loan or the prior calendar year.”

What expenses are eligible for PPP loan forgiveness in 2021?

The scope of forgivable expenses in 2021 is expanded compared to the original 2020 loans. In addition to the 2020 covered expenses (payroll costs, mortgage, rent and utilities), 2021 eligible expenses include:

Payment for any software, cloud computing, human resources and accounting needs
Costs related to property damage due to public disturbances that occurred during 2020 that are not covered by insurance
Expenditures to a supplier pursuant to a contract, purchase order or order for goods in effect prior to taking out the loan that were essential to the recipient’s operations at the time at which the expenditure was made. Supplier costs of perishable goods can be made before or during the life of the loan
Personal protective equipment and facility adaptive measures put in place to comply with federal health and safety guidelines or any equivalent state and local guidance related to COVID-19 during the period between March 1, 2020, and the end of the national emergency declaration

Please note that borrowers are still required to use at least 60% of PPP loan proceeds on eligible payroll costs in order to receive full forgiveness .

What is the covered period for PPP loans in 2021?

The 2021 PPP updates give borrowers the option to choose between an eight-week covered period and a 24-week covered period. This will allow some flexibility for pharmacies to make the most strategic use of payroll versus other covered expenses. I encourage our CPMS clients to consult with your CPMS coach and accounting team to determine what route is best for you.

More information will undoubtedly be forthcoming about the 2021 updates to the PPP, including when applications will be accepted. PCCA will continue to lead, providing further guidance when that information is available. In the meantime, we in CPMS encourage everyone to speak with their accountants and financial institutions as soon as possible. As was the case in 2020, there is no guarantee that additional funding will be granted once the $284 billion allotment for loans has been exhausted.

Bryan Prescott, PharmD, MBA, PCCA Director of Management Coaching Services, currently provides business coaching for compounding pharmacies, including financial analysis, marketing and human resources expertise. Before joining the staff of PCCA in 2012, he worked at Pharmcare in Pearland, Texas, for 10 years, where he was the PIC and operations manager for the long-term care department. He has been a featured speaker at many PCCA and A4M seminars focusing on pain, palliative care, wound, scar, ENT and marketing. Bryan obtained his Doctor of Pharmacy from the University of Houston in 2001 and Master of Business Administration from Texas A&M University in 2019. He is a member of the Rho Chi Society and a lifetime member of Phi Delta Chi.

Reference

1. Jones, B. A., Kirsner, M. A., Mangas, R., Fornaris, C. A., Grimaldi, B. X., & Musyl, M. J. (2021, January 4). Paycheck Protection Program — Expected impact of “second draw” loans . Greenberg Traurig. https://www.gtlaw.com/en/insights/2021/1/paycheck-protection-program-expected-impact-of-second-draw-loans

Compounding Ideas for Fall and Winter

Tue, 12 Jan 2021 14:56:55 GMT

By Nat Jones, RPh, FAPC, PCCA Clinical Compounding Pharmacist

As colder weather descends in the fall and winter months, a few health challenges come with it. Because of the use of heating systems that dehumidify the air, we consequently dry our skin and mucous membranes, decreasing the functionality of our natural barriers to dermatological and respiratory conditions. This puts more stress on our immune systems. Some of the various common fall and winter health issues include viral infections (COVID-19, flu, common colds, sore throat (pharyngitis is most likely viral)) and a couple of unique dermatological problems as a result of mask-wearing. I will cover some compounding and nutritional suggestions for these problems in this article. There are additional commonly observed problems this time of year that involve poor indoor air quality, sedentary living, unhealthy eating habits and seasonal depression, to name a few, that are beyond the scope of this article. However, I will also provide some practical tips for keeping your pharmacy customers informed so that they can make healthy decisions, and I’ll point out a few additional resources you can look to if you want to learn more.

Preventive Measures for Common Fall & Winter Conditions

The potential of viral infections is certainly heightened during flu season. People are understandably concerned about exposure. While there is no guaranteed method of protection, many patients will be seeking advice for nutritional supplements to support their immune systems during this time of year. Common recommendations include vitamin D3, curcumin, antioxidants (buffered vitamin C, vitamin E, quercetin, epigallocatechin-3-O-gallate (EGCG)) and zinc.

EGCG, the major catechin component of green tea, has been shown to have antiviral activity by interfering with the viral membrane protein functions and inhibiting attachment.¹ Vitamin D3, quercetin and zinc have been shown to lower interleukin-6 levels,^2,3,4 which may therefore support a healthy immune response and help control inflammation.^5,6 Wellness Works offers all of these options and many more to pharmacies, which allows them to provide their patients professional-grade supplements.

Addressing Symptoms of Common Fall & Winter Conditions

In some upper respiratory infections or after endoscopic sinus surgery, patients may need nasal and sinus irrigation with formulations including ingredients such as antihistamines, corticosteroids and even leukotriene antagonists in combination for symptomatic relief. Nonsterile compounding options would include formulas made with our dispersion powder bases LoxaSperse ^® and XyliFos ^® . If the clinician suspects microbial involvement other than a virus (i.e., bacteria or fungi), they may request the addition of antibiotics such as aminoglycosides or fluoroquinolones, or antifungal ingredients such as itraconazole and even amphotericin B to these combinations. Many of these ingredients are not water soluble, and inclusion of LoxaSperse^® and XyliFos^® improve the solubilization and dispersion of these drugs.

Additionally, upper respiratory symptoms often include cough, but some patients don’t want or can’t have alcohol in their cough medicine. Formulations in SuspendIt ^® (our all-in-one base for oral suspensions that has a patented polymer complex) with the opioid cough suppressant hydrocodone in combination with guaifenesin and pseudoephedrine can serve a real need in these cases. Prescribers and pharmacists might also consider other compounded multi-ingredient formulas using decongestants, antihistamines and dextromethorphan for non-opioid options.

Nasal symptoms including rhinitis and congestion often associated with nasal polyps may be treated with combinations of mast cell stabilizer/antihistamines like azelastine and corticosteroids such as budesonide. Prescribers commonly request compounded formulations like this.

Something else to consider is an indirect complication of COVID-19 known as “maskne.” It is a new term describing acne caused by wearing masks. The current pandemic and the need to cover our mouths and noses has led us to an increase in dermatological problems for many people in various fields, especially those who work long hours wearing a mask. Dermatologists describe maskne as a variation of “acne mechanica,” which usually occurs when skin is pressed against heavy clothing or bulky protective gear. In other words, having to wear a mask for protection has created the perfect conditions for facial acne and other types of skin irritation. Some people are not getting comedones (the small bumps we think of as acne), so they technically do not have acne, but they are getting redness, inflammation and irritation caused by the effects of wearing a mask.

If the mask-wearing is truly causing comedones, then patients should try a regimen of washing the face twice with a gentle cleanser that removes dirt and oils but does not strip all of the natural barrier from the skin. Additionally, practitioners might consider prescribing a compounded formula based on age and severity of acne to possibly include tretinoin, clindamycin and/or niacinamide in either PCCA’s Clarifying^™ Base or WO6^® Anhydrous Topical Gel . Research has shown that niacinamide may decrease sebum production. ⁷ Using WO6 as the base will allow for longer BUDs. If mask-wearing is only causing irritation and not acne, prescribers might consider a compound containing ketotifen and possibly naltrexone in either Clarifying, WO6 or VersaBase^® Cream .

Helping Your Patients Make Healthy Decisions

Prevention starts with the knowledge your patients need to make good decisions for their health, so it might be helpful to share practical tips for cold and flu season. Pharmacists may want to consider adding public service messaging to their websites and on-hold messaging for their phone systems that can possibly include variations of these messages:

Get immunized, especially if you or your loved ones are at risk; wash your hands; and cover your mouth when you cough or sneeze
Stay active, maintain a healthy diet and be sure to get enough sleep each night
Don’t wait for winter health problems. Get proactive and take your supplements to help support your immune system
Talk to our pharmacist when you experience symptoms. You don’t have to wait for your symptoms to get “bad enough” before seeking advice or treatment

Where You Can Learn More

We have more information and related resources available for helping your community stay healthy during the colder months of the year. You can read these articles on The PCCA Blog:

“ What is ‘maskne,’ and what can we do about it? ”
“ Compounding Opportunities for Winter ”

PCCA members can also find our extensive document Commonly Requested Compounding Ideas and Products for Patients During the Winter & Flu Season (PCCA Document #97852) on our Members-Only Website. It has many commonly requested formula examples, including some that are related to what I have covered above.

PCCA members can hear Nat talk more about compounding ideas for fall and winter in our October 2020 Marketing & Sales Power Hour recording on PCCA Play

Nat Jones, RPh, FAPC, graduated from the Virginia Commonwealth University, Medical College of Virginia’s School of Pharmacy in 1979. In 2014, after 20 years of owning a compounding pharmacy, he joined PCCA’s staff. Nat has given continuing education lectures at medical professional seminars and webinars on numerous topics, including general compounding, wound care, pain management, nutrition, otolaryngology, women’s health, sexual dysfunction, insulin resistance, hormone replacement therapy, neurotransmitter imbalance and dermatology. He has published many articles and case studies in magazines and professional journals along with an open-access ebook titled Advances in Psoriasis with Avid Science. Since 2016, Nat has served on the Texas State Palliative Care Interdisciplinary Advisory Council.

References

1. Kaihatsu, K., Yamabe, M., & Ebara, Y. (2018). Antiviral mechanism of action of epigallocatechin-3-O-gallate and its fatty acid esters. Molecules, 23(10). https://doi.org/10.3390/molecules23102475

2. De Haes, P. Garmyn, M., Degreef, H., Vantieghem, K., Bouillon, R., & Segaert, S. 1,25-dihydroxyvitamin D3 inhibits ultraviolet B-induced apoptosis, Jun kinase activation, and interleukin-6 production in primary human keratinocytes. Journal of Cellular Biochemistry, 89 (4), 663–673. https://doi.org/10.1002/jcb.10540

3. Mlcek, J., Jurikova, T., Skrovankova, S., & Sochor, J. (2016). Quercetin and its anti-allergic immune response. Molecules, 21(5). https://doi.org/10.3390/molecules21050623

4. Hatakeyama, D., Kozawa, O., Otsuka, T., Shibata, T., & Uematsu, T. (2002). Zinc suppresses IL-6 synthesis by prostaglandin F2alpha in osteoblasts: Inhibition of phospholipase C and phospholipase D. Journal of Cellular Biochemistry, 85(3), 621–628. https://doi.org/10.1002/jcb.10166

5. Tanaka, T., Narazaki, M., & Kishimoto, T. (2014). IL-6 in inflammation, immunity, and disease. Cold Spring Harbor Perspectives in Biology, 6(10). https://dx.doi.org/10.1101%2Fcshperspect.a016295

6. Aziz, M., Fatima, R., & Assaly, R. (2020). Elevated interleukin-6 and severe COVID-19: A meta-analysis. Journal of Medical Virology, 92(11), 2283–2285. https://doi.org/10.1002/jmv.25948

7. Draelos, Z. D., Matsubara, A., & Smiles, K. (2006). The effect of 2% niacinamide on facial sebum production. Journal of Cosmetic and Laser Therapy, 8(2), 96–101. https://doi.org/10.1080/14764170600717704

Potential COVID-19 Treatments: What Is the Evidence?

Mon, 28 Sep 2020 13:13:09 GMT

By Deborah Clark, BSPharm, RPh, PCCA Clinical Compounding Pharmacist; Sebastian Denison, RPh, FAARM (candidate), PCCA Clinical Compounding Pharmacist; Yi Liu, PharmD, PhD, PCCA Research Pharmacist; and Matthew Glisch, PharmD (candidate), PCCA Clinical Services Intern

This article was updated September 28, 2020

COVID-19 has changed many aspects of our lives as individuals and as practitioners. The novel coronavirus, SARS-CoV-2, has presented many challenges to entire health care systems. Since patients with the virus had not been treated before, treatment protocols had to be developed from prior experience with viruses that have similar genomics to SARS-CoV-2. As the outbreak has swept across various countries in turn, we learn more and more. Professional organizations, such as the American Society of Health System Pharmacists (ASHP), have collected data on various agents that are being studied for the treatment of SARS-CoV-2. Treatment and scientific data are evolving quickly as we navigate this pandemic, making recommendations challenging. PCCA Clinical Services has received questions regarding treatment options for COVID-19 daily since the beginning of March 2020. As always, we’re providing information based on the best scientific evidence available. In this article, we will first review some of the research into the morbidity, mortality and pathogenicity of SARS-CoV-2. Then, we will explore some potential non-prescription and prescription options based on research.

Please note that we collected the information presented in this article in March, April and May 2020, and since we are gaining new knowledge on this subject all the time, new studies, reviews and analyses likely have been published since we wrote this. Therefore, we present this information as a starting point and encourage you to stay abreast of the evolving research landscape that is developing around SARS-CoV-2.

Illustration of SARS-CoV-2 from the Centers for Disease Control and Prevention (CDC).

Morbidity, Mortality & Pathogenicity of SARS-CoV-2

As this pandemic has played out, certain morbidity and mortality trends have emerged. The original group of individuals thought to be more at risk included individuals who are 65 years of age or older and those with chronic conditions, such as cardiovascular disease, diabetes mellitus, asthma and a compromised immune system. Interestingly, this original grouping was not entirely correct. As age demographics were collected, it became clear that all age groups were susceptible to the possibility of severe effects from COVID-19. There were several reports of elderly individuals who had mild cases of COVID-19 and younger individuals in their 20s and 30s with more severe cases that placed them in the ICU.

What factors make some younger people susceptible to severe cases? According to a research team from Italy, nutritional status appears as a relevant factor influencing the outcomes of patients with COVID-19. ¹ Uncontrolled hyperglycemia, with or without the diagnosis of diabetes, also is a factor significantly affecting mortality rates in COVID-19 patients.² Higher body mass index is also associated with poor prognosis, especially in patients with comorbidities.¹ From this data, we can conclude that overall well-being, food quality and lifestyle can affect outcomes.

When SARS-CoV-2 infects an individual, it binds to the epithelial cells in the nasal cavity and starts replication. There is a local propagation of the virus and suppression of the initial innate immune response. ³ Usually, this occurs within the first one to two days. Over the next few days, the virus continues to spread along the respiratory tract, causing a “robust” immune response. Laviano et al. state that COVID-19 patients show an increased inflammatory response upon hospital admission.¹ COVID-19 patients possess different levels of cytokines and chemokines at different points in the progression of this disease. There are increases in numerous inflammatory markers, including interleukin (IL)-1β, IL-7, IL-8, IL-10, interferon (INF)-γ, macrophage inflammatory protein (MIP), and tumor necrosis factor (TNF)-α. COVID-19 patients also have high plasma IL-6. This dysregulation of the immune system accompanied by an abnormal chemokine and cytokine response can result in a “cytokine storm,” which in turn causes significant tissue damage.⁴This is seen in more severe cases of COVID-19.

Recently, some researchers have proposed another mechanism by which the virus works. This involves an observed interaction of the virus with red blood cells. It was observed that the viral protein ORF8 and other surface proteins bind to porphyrin. At the same time, other viral proteins attack the heme found on the 1-beta chain of hemoglobin to remove the iron from it.⁵ This causes decreasing quantities of hemoglobin that are able to carry oxygen and carbon dioxide. This also increases the amount of oxidized iron in the bloodstream that adds to the oxidative-stress load already present in the body. The body tries to compensate for this overload by releasing zinc to balance it.⁶ Over time, the body can become zinc deficient. This has been indirectly validated by numerous reports from COVID-19 patients of a loss or alteration in taste and smell, which has been shown in the past to be a symptom of zinc deficiency.⁷ Some clinicians state that the symptoms they are seeing in many patients in a way mimic high altitude sickness or even malaria.

More COVID-19 information on The PCCA Blog: “ What is ‘maskne,’ and what can we do about it? ”

Potential Non-Prescription Options

Given this information, it would theoretically be a good clinical approach to consider supplements that would support the immune system, reduce the inflammatory response and complement the action of any pharmaceutical interventions. Here are some potential options for clinical consideration.

Zinc

Zinc has been used to decrease the length and severity of the common cold. ⁸ It has also proven effective as adjunctive treatment in severe pneumonia in pediatric patients.⁹ Zinc is crucial for the growth, development and maintenance of immune function. It contributes to a number of innate and adaptive immune signaling pathways.¹⁰ Zinc also has antioxidant and anti-inflammatory properties.⁷ A 2020 article in The BMJ stated that “since zinc boosts the overall immune response, all patients with COVID-19 would derive some benefit from zinc supplementation, especially those with latent zinc deficiency.”¹¹ Zinc has shown activity in other coronaviruses in vitro, such as those that cause SARS, MERS and EAV. Specifically, the addition of a zinc ionophore blocks the replication of some of these viruses in cell culture.¹¹

This evidence would theoretically make zinc a supplement that could be of benefit to patients with COVID-19. To date, one article by Carlucci et al., a non-peer-reviewed retrospective study looking at hospitalized SARS-CoV-2 patients in several countries, shows promising results. Through univariant analyses, it showed that zinc sulfate as an add-on therapy to hydroxychloroquine and azithromycin did increase the frequency of patients being discharged home. It also decreased the need for ventilation, admission to the ICU, and mortality or transfer to hospice for patients who were never admitted to the ICU. It did not affect length of hospital stay, ventilation (when used) or length of stay in ICU.¹² The clinician should consider this in making therapeutic choices.

Some researchers have proposed a dosage of 30–50 mg elemental zinc. ¹³ One should consider the oral bioavailability of the form of zinc used in an individual formulation. Also, appropriate conversion calculations should be performed in order to achieve the correct elemental zinc dosage. It is also important to remember that copper should be given in the appropriate ratio to maintain balance with zinc.

Vitamin D

Vitamin D has been proven to reduce the risk of upper respiratory tract infections, modulate innate and adaptive immunity, and enhance the expression of antioxidation-related genes (glutathione reductase and glutamate cysteine ligase modifier subunit). Vitamin D induces cathelicidins, LL-37 and defensins that can decrease viral replication rates, decreasing levels of pro-inflammatory cytokines (TNF-α and INF-γ) that can produce the inflammation associated with lung-lining injury that can progress to pneumonia. Vitamin D also increases the levels of anti-inflammatory cytokines.¹⁴

These mechanisms would theoretically make vitamin D a good candidate for supplementation. In a review by Grant et al., clinical and epidemiological findings showed serum levels of 25-hydroxyvitamin D (25(OH)D) inversely correlated with severe cases associated with pneumonia, increased production of pro-inflammatory cytokines, increased C-reactive protein (CRP), increased risk of sepsis and acute respiratory distress syndrome (ARDS). The authors of this study suggested a dosage of vitamin D3 10,000 IU daily for a month to rapidly increase circulating levels of 25(OH)D into the preferred range of 40–60 ng/mL, then take 5,000 IU daily as a maintenance dose.¹⁴

Another study by Alipio suggested a strong association between serum 25(OH)D levels and clinical outcome in patients with confirmed SARS-CoV-2 infection. This study is a retrospective, multicenter study that looked at 212 patients from three different hospitals in Southeast Asia.¹⁵ A different study also showed that CRP is a surrogate marker for severe COVID-19 and is associated with vitamin D deficiency. The authors’ findings suggest that vitamin D may reduce COVID-19 severity by suppressing the cytokine storm in COVID-19 patients.¹⁶While the data shows a strong association in both studies, a randomized clinical trial that measures actual vitamin D levels should be done to validate this association. Vitamin D has also shown action against respiratory syncytial virus, influenza and dengue.^14,17 However, no in vitro or clinical trials have been done to determine the effectiveness of vitamin D in suppressing SARS-CoV-2 to as of May 2020.

“This dysregulation of the immune system accompanied by an abnormal chemokine and cytokine response can result in a ‘cytokine storm,’ which in turn causes significant tissue damage.”

Melatonin

Melatonin has an antioxidant effect and consistently shows anti-inflammatory activity in vitro and in human studies. In vitro, melatonin shows anti-inflammatory effects by inhibiting SIRT1, which regulates macrophages. It also inhibits NF-kB activation in T cells and lung tissue, which is involved in ARDS. Other pro-inflammatory cytokines that can be suppressed by melatonin in vitro are TNF-α, IL-1β, IL-6 and IL-8.¹⁸

Melatonin is highly effective in protecting cells from damage related to severe inflammatory conditions.¹⁹ In animal models with sepsis or ischemia-reperfusion induced acute lung injury, melatonin pretreatment showed protective effects to the lungs via reduced oxidation and inflammation.^20,21 In a lipopolysaccharide-induced acute lung injury mice model, melatonin was able to reduce the pulmonary injury and decrease the infiltration of macrophages and neutrophils into lungs by inhibiting the NLRP3 inflammasome.¹⁸ NLRP3 is known to be involved in sepsis and other hyper-inflammatory processes. However, its role in SARS-CoV-2 infection is unclear.

The previous evidence would suggest that melatonin would also be a good candidate for supplementation. A meta-analysis from 2019 showed a decrease in inflammatory markers TNF-α and IL-6 within the dosage range of 3–25 mg per day for 4–60 days.²² One note of caution, though: Melatonin can also be pro-inflammatory in patients with rheumatoid arthritis, so health care practitioners should take care when administering in these patient groups.

Vitamin C

Clinical trials have shown that vitamin C decreases the frequency, length and severity of the common cold as well as the incidence of pneumonia. ²³One of the actions of ascorbic acid is inhibition of NLRP3 inflammasome activation.²⁴ There have been many vitamin C trials with varied results. A meta-analysis in 2019 by Hemila looked at 18 controlled trials with 2,004 patients and evaluated whether vitamin C altered the length of stay in ICU and duration of mechanical ventilation. The patients were all critically ill with mixed conditions. Most were cardiac patients; however, there were also septic, burn and pulmonary patients. In 12 trials with 1,766 patients, IV vitamin C reduced the length of ICU stay on average by 7.8%. In six trials, orally administered vitamin C reduced the length of ICU stay by 8.6%. In three trials in which patients needed mechanical ventilation for over 24 hours, vitamin C shortened the duration of mechanical ventilation by 18.2%. All differences were significant.²³

There is no direct evidence on the effects of vitamin C against SARS-CoV-2, but at least one clinical trial using a 24 Gm daily dose in COVID-19 patients is ongoing. Typical daily dosing of vitamin C ranges from 500–3,000 mg, with even higher doses used during times of acute infection. ²⁵

Transmission electron microscope image of SARS-CoV-2 (colorized blue) from the CDC .

Potential Prescription Options

As health care professionals, we must emphasize any health strategies for our patients — nutrition and supplementation, as noted above, as well as activity and sleep — and focus on treating preexisting conditions. As compounders who innovate, we have medications that we are already formulating that may have the potential to immunomodulate and prevent the cytokine storm.

Two specific drugs with which we are currently compounding have literature discussing how they each have immunomodulatory effects: naltrexone and oxytocin. Below are a few selected discussions pertaining to how they may offset the cytokine storm cascade and potentially prevent patients from significant consequences of a COVID-19 infection.

Naltrexone

In a hypothesis article, Brown and Panksepp noted that patients with preexisting conditions that are inflammatory in nature would potentially benefit from the use of naltrexone.²⁶ This hypothesis on health benefits has been borne out by multiple literature references, all pointing to immunomodulatory effects of naltrexone by regulation through the toll-like receptor (TLR) system, interacting with both TLR 4 and TLR 9. ^27,28,29 In a small study on women with fibromyalgia, low-dose naltrexone “was associated with reduced plasma concentrations of interleukin (IL)-1β, IL-1Ra, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12p40, IL-12p70, IL-15, IL-17A, IL-27, interferon (IFN)-α, transforming growth factor (TGF)-α, TGF-β, tumor necrosis factor (TNF)-α, and granulocyte-colony stimulating factor (G-CSF).” Although the study was limited in size, the changes were considered significant.³⁰ These findings suggest that naltrexone has the potential to modulate the secretion of inflammatory cytokines in response to intracellular TLR activity. The authors of another article noted that by anatomization of the TLRs, naltrexone causes immune cell down-regulation and, in some cases, halts production of IL-1, IL-6, TNF-α and TGF-α, as well as down-regulating and controlling IL-10 and IL-1a, thus potentially preventing the inflammatory cascade and a cytokine storm.³¹

Therefore, it may be beneficial to initiate low-dose naltrexone for any patient who has an underlying health condition, or any patient who is over the age of 45 with risk factors for future health concerns (obesity, hypertension, pre-diabetic). Practitioners might start the patient at 1.5 mg and titrate up to 4.5 mg as a target, which would be similar to a clinical trial initiated in May 2020.³²

“As compounders who innovate, we have medications that we are already formulating that may have the potential to immunomodulate and prevent the cytokine storm.”

Oxytocin

Oxytocin has long been known as the snuggle hormone, but recently, literature has shown this to be a dynamic chemical with multiple effects, including anti-anxiety properties and neuro-immunomodulatory effects.^33,34,35 In a review article, the author indicates that proper regulation of the immune system relies on appropriate oxytocin, and is involved in both humoral and adaptive immune responses.³⁶ Furthermore, another review article shows a direct effect of oxytocin levels and concomitant inflammatory cascades both centrally and in the periphery in the cardiovascular system.³⁷

This indicates that oxytocin may be useful as an adjunct treatment of COVID-19. A potential suggestion might be 24 IU of oxytocin nightly to promote sleep and decrease stress. It may even be beneficial to combine oxytocin with naltrexone in one formulation, such as PCCA Formula #13535 ( naltrexone, oxytocin and melatonin sublingual suspension ).

None of these recommendations are indicated to treat an active COVID-19 patient, but we present them to health care practitioners for clinical consideration to potentially prevent the cytokine storm that may ultimately be the decider of the outcome.

More information about the new coronavirus on The PCCA Blog: “ Hand-Washing, Nasal Sprays and Masks — What Research Is Saying ”

We are still in the midst of this pandemic, and in years to come, we will still be arguing what “should” have been done, and more importantly, how we treat those infected to minimize harm and prevent death. Currently, many strategies for treatment are controversial and will require time to properly vet and develop.³⁸ To see ASHP’s data collection on various agents that are being studied for the treatment of SARS-CoV-2, which we mentioned above, go to their COVID-19 evidence table.

Non-pharmaceutical interventions have a significant role in transmission and will continue to have a positive role in our containment of this outbreak (i.e., social distancing, wearing masks and good hand hygiene).³⁹ Pharmaceutical treatment will require better science to determine the best treatment protocols and a safe, effective vaccine, although even with over 200 individual sites researching and testing, that may still be months if not years away.^38,40 Finally, the overall well-being of the individual can play a significant role in impact and outcome, with age, weight, sex, nutritional status, preexisting conditions, and even mental health all being examined as factors.^41,45 Hopefully through continued research and ongoing global efforts, we will come to proven solutions for patients soon.

Deborah Clark, BSPharm, RPh, is a Clinical Compounding Pharmacist at PCCA. She previously worked in two independent hybrid pharmacies in Charlotte, North Carolina, managing compounding operations. While there, she worked with a local veterinary specialty and emergency hospital providing compounded medications for challenging veterinary patients. She also worked with the Carolina Raptor Center and several smaller veterinary clinics in the Charlotte Metro area. Deborah’s compounding experience also includes hospice, hormone replacement therapy (HRT), pain management, wound care, sterile products and pediatrics. She is certified in medication therapy management, and she is an associate member of the Society of Veterinary Hospital Pharmacists.

Sebastian Denison, RPh, FAARM (candidate), PCCA Clinical Compounding Pharmacist, received his BSc in Pharmacy at the University of British Columbia. He worked at Northmount Pharmacy in North Vancouver for 11 years, specializing in HRT, veterinary, pain and sports compounding. He also was the Manager of Pharmacy Operations with the 2010 Vancouver Winter Olympic/Paralympic Games, and then the Manager of the Whistler Olympic Village Polyclinic Pharmacy. Sebastian speaks at physician, pharmacist and other health care professional education symposiums and events. He has recently lectured for the American Academy of Anti-Aging Medicine on nutrition and pain, pharmacy compounding and collaborative practice, and alternative uses for naltrexone. Sebastian is currently completing the Metabolic Medical Institute's Fellowship in Metabolic & Nutritional Medicine.

Yi Liu, PharmD, PhD, is a research pharmacist in the Research and Development department at PCCA. She joined PCCA as a clinical pharmacy researcher in the Clinical Services department in 2018 and started her current role in 2019. Yi graduated from Ohio University with a PhD in molecular and cellular biology in 2012. She also worked as a postdoctoral research fellow in the Houston Methodist Research Institute for three years prior to starting pharmacy school. Yi received her PharmD from the University of Houston College of Pharmacy in 2019.

Matthew Glisch, PharmD (candidate), PCCA Clinical Services Intern, is pursuing his Doctor of Pharmacy at the Creighton University School of Pharmacy and Health Professions.

A version of this article was originally published in the Apothagram, PCCA’s members-only magazine.

References

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2. Antrim, A. (2020, April 17). Study: Patients with COVID-19, diabetes, uncontrolled hyperglycemia have significantly higher mortality. Pharmacy Times. www.pharmacytimes.com/news/study-patients-with-covid-19-diabetes-uncontrolled-hyperglycemia-have-significantly-higher-mortality

3. Mason, R. J. (2020). Pathogenesis of COVID-19 from a cell biology perspective. European Respiratory Journal, 55. https://doi.org/10.1183/13993003.00607-2020

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5. Wenzhong, L., & Li, H. (2020). COVID-19: Attacks the 1-beta chain of hemoglobin and captures the porphyrin to inhibit human heme metabolism. ChemRxiv. https://doi.org/10.26434/chemrxiv.11938173.v7

6. Read, S. A., Obeid, S., Ahlenstiel, C. & Ahlenstiel, G. (2019). The role of zinc in antiviral immunity. Advances in Nutrition, 10(4), 696–710. https://doi.org/10.1093/advances/nmz013

7. Pisano, M., & Hilas, O. Zinc and taste disturbances in older adults: A review of literature. The Consultant Pharmacist, 31(5), 267–270. https://doi.org/10.4140/TCP.n.2016.267

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9. Rao, G., & Rowland, K. (2011). PURLs: Zinc for the common cold — Not if, but when. The Journal of Family Practice, 60(11), 669–671.

10. Qasemzadeh, M. J., Fathi, M., Tashvighi, M., Gharehbeglou, M., Yadollah-Damavandi, S., Parsa, Y., & Rahimi, E. (2014). The effect of adjuvant zinc therapy on recovery from pneumonia in hospitalized children: A double-blind randomized controlled trial. Scientifica, 2014. https://doi.org/10.1155/2014/694193

11. Dave, V. K., & Hylton, C. A. (2020). Rapid response: Zinc supplementation and containment of COVID-19 virus pandemic. The BMJ, 368(8236). https://doi.org/10.1136/bmj.m864

12. Carlucci, P., Ahuja, T., Petrilli, C. M., Rajagopalan, H., Jones, S., & Rahimian, J. (2020). Hydroxychloroquine and azithromycin plus zinc vs hydroxychloroquine and azithromycin alone: Outcomes in hospitalized COVID-19 patients. MedRxiv. https://doi.org/10.1101/2020.05.02.20080036

13. McCarty, M. F., & DiNicolantonio, J. J. (2020). Nutraceuticals have potential for boosting the type 1 interferon response to RNA viruses including influenza and coronavirus. Progress in Cardiovascular Diseases. Advance online publication. https://doi.org/10.1016/jpead.2020.02.007

14. Grant, W. B., Lahore, H., McDonnell, S. L., Baggerly, C. A., French, C. B., Aliano, J. L., & Bhattoa, H. P. (2020). Evidence that vitamin D supplementation could reduce risk of influenza and COVID-19 infections and deaths. Nutrients, 12(4), 988. https://doi.org/10.3390/nu12040988

15. Alipio, M. (2020). Vitamin D supplementation could possibly improve clinical outcomes of patients infected with Coronavirus-2019 (COVID-2019). SSRN. http://dx.doi.org/10.2139/ssrn.3571484

16. Daneshkhah, A., Agrawal, V., Eshein, A., Subramanian, H., Roy, H. K., & Backman, V. (2020). The possible role of vitamin D in suppressing cytokine storm and associated mortality in COVID-19 patients. MedRxiv. https://www.medrxiv.org/content/10.1101/2020.04.08.20058578v4

17. Martínez-Moreno, J., Hernandez, J. C., & Urcuqui-Inchima, S. (2020). Effect of high doses of vitamin D supplementation on dengue virus replication, toll-like receptor expression, and cytokine profiles on dendritic cells. Molecular and Cellular Biochemistry, 464 (1–2), 169–180. https://doi.org/10.1007/s11010-019-03658-w

18. Zhang, R., Wang, X., Ni, L., Di, X., Ma, B., Niu, S., Liu, C., & Reiter, R. J. (2020). COVID-19: Melatonin as a potential adjuvant treatment. Life Sciences, 250. https://doi.org/10.1016/j.lfs.2020.117583

19. Favero, G., Franceschetti, L., Bonomini, F., Rodella, L. F., & Rezzani, R. (2017). Melatonin as an anti-inflammatory agent modulating inflammasome activation. International Journal of Endocrinology, 2017. https://doi.org/10.1155/2017/1835195

20. Chen, H.-H., Chang, C.-L., Lin, K.-C., Sung, P.-H., Chai, H.-T., Zhen, Y.-Y., Chen, Y.-C., Wu, Y.-C., Leu, S., Tsai, T.-H., Chen, C.-H., Chang, H.-W., & Yip, H.-K. (2014). Melatonin augments apoptotic adipose-derived mesenchymal stem cell treatment against sepsis-induced acute lung injury. American Journal of Translational Research, 6(5), 439–458.

21. Wang, M.-L., Wei, C.-H., Wang, W.-D., Wang, J.-S., Zhang, J., & Wang, J.-J. (2018). Melatonin attenuates lung ischaemia-reperfusion injury via inhibition of oxidative stress and inflammation. Interactive Cardiovascular and Thoracic Surgery, 26(5), 761–767. https://doi.org/10.1093/icvts/ivx440

22. Zarezadeh, M., Khorshidi, M., Emami, M., Janmohammadi, P., Kord-Varkaneh, H., Mousavi, S. M., Mohammed, S. H., Saedisomeolia, A., & Alizadeh, S. (2019). Melatonin supplementation and pro-inflammatory mediators: A systematic review and meta-analysis of clinical trials. European Journal of Nutrition. Advance online publication. https://doi.org/10.1007/s00394-019-02123-0

23. Hemilä, H. (2004). Vitamin C supplementation and respiratory infections: A systematic review. Military Medicine, 169(11), 920–925. https://doi.org/10.7205/milmed.169.11.920

24. Choe, J.-Y., & Kim, S.-K. (2017). Quercetin and ascorbic acid suppress fructose-induced NLRP3 inflammasome activation by blocking intracellular shuttling of TXNIP in human macrophage cell lines. Inflammation, 40(3), 980–994. https://doi.org/10.1007/s10753-017-0542-4

25. Alschuler, L., Weil, A., Horwitz, R., Stamets, P., Chiasson, A. M., Crocker, R., & Maizes, V. (2020). Integrative considerations during the COVID-19 pandemic. Explore. Advance online publication. https://doi.org/10.1016/j.explore.2020.03.007

26. Brown, N., & Panksepp, J. (2009). Low-dose naltrexone for disease prevention and quality of life. Medical Hypotheses, 72 (3), 333–337. https://doi.org/10.1016/j.mehy.2008.06.048

27. Selfridge, B. R., Wang, X., Zhang, Y., Yin, H., Grace, P. M., Watkins, L. R., Jacobson, A. E., & Rice, K. C. (2015). Structure-activity relationships of (+)-naltrexone-inspired toll-like receptor 4 (TLR4) antagonists. Journal of Medicinal Chemistry, 58(12), 5038–5052. https://doi.org/10.1021/acs.jmedchem.5b00426

28. Cant, R., Dalgleish, A. G., & Allen, R. L. (2017). Naltrexone inhibits IL-6 and TNFα production in human immune cell subsets following stimulation with ligands for intracellular toll-like receptors. Frontiers in Immunology. https://doi.org/10.3389/fimmu.2017.00809

29. Voogdt, C. G. P., & van Putten, J. P. M. (2016). The evolution of the toll-like receptor system. In D. Malagoli (Ed.), The Evolution of the Immune System: Conservation and Diversification (pp. 311–330). Academic Press. https://doi.org/10.1016/B978-0-12-801975-7.00013-X

30. Parkitny, L., & Younger, J. (2017). Reduced pro-inflammatory cytokines after eight weeks of low-dose naltrexone for fibromyalgia. Biomedicines, 5(2). https://doi.org/10.3390/biomedicines5020016

31. Imai, Y., Kuba, K., Neely, G. G., Yaghubian-Malhami, R., Perkmann, T., van Loo, G., Ermolaeva, M., Veldhuizen, R., Leung, Y. H. C., Wang, H., Liu, H., Sun, Y., Pasparakis, M., Kopf, M., Mech, C., Bavari, S., Peiris, J. S. M., Slutsky, A. S., Akira, S., … Penninger, J. M. (2008). Identification of oxidative stress and toll-like receptor 4 signaling as a key pathway of acute lung injury. Cell, 133(2), 235–249. https://doi.org/10.1016/j.cell.2008.02.043

32. Sims, M. (2020). Study of immunomodulation using naltrexone and ketamine for COVID-19 (SINK COVID-19) [NCT04365985]. https://clinicaltrials.gov/ct2/show/NCT04365985

33. Jurek, B., & Neumann, I. D. (2018). The oxytocin receptor: From intracellular signaling to behavior. Physiological Reviews. https://doi.org/10.1152/physrev.00031.2017

34. Koch, S. B. J., van Zuiden, M., Nawijn, L., Frijling, J. L., Veltman, D. J., & Olff, M. (2016). Intranasal oxytocin normalizes amygdala functional connectivity in posttraumatic stress disorder. Neuropsychopharmacology, 41(8), 2041–2051. https://doi.org/10.1038/npp.2016.1

35. Yuan, L., Liu, S., Bai, X., Gao, Y., Liu, G., Wang, X., Liu, D., Li, T., Hao, A., & Wang, Z. (2016). Oxytocin inhibits lipopolysaccharide-induced inflammation in microglial cells and attenuates microglial activation in lipopolysaccharide-treated mice. Journal of Neuroinflammation, 13. https://doi.org/10.1186/s12974-016-0541-7

36. Wang, Y.-F. (2016). Center role of the oxytocin-secreting system in neuroendocrine-immune network revisited. Journal of Clinical & Experimental Neuroimmunology, 1 (1).

37. Wang, P., Wang, S. C., Yang, H., Lv, C., Jia, S., Liu, X., Wang, X., Meng, D., Qin, D., Zhu, H., & Wang, Y.-F. (2019). Therapeutic potential of oxytocin in atherosclerotic cardiovascular disease: Mechanisms and signaling pathways. Frontiers in Neuroscience. https://doi.org/10.3389/fnins.2019.00454

38. Kakodkar, P., Kaka, N., & Baig, M. N. (2020). A comprehensive literature review on the clinical presentation, and management of the pandemic coronavirus cisease 2019 (COVID-19). Cureus, 12 (4). https://doi.org/10.7759/cureus.7560

39. Lai, S., Ruktanonchai, N. W., Zhou, L., Prosper, O., Luo, W., Floyd, J. R., Wesolowski, A., Santillana, M., Zhang, C., Du, X., Yu, H., & Tatem, A. J. (2020). Effect of non-pharmaceutical interventions to contain COVID-19 in China. Nature. https://doi.org/10.1038/s41586-020-2293-x

40. U.S. Food & Drug Administartion. (2020, May 12). Coronavirus Treatment Acceleration Program (CTAP). https://www.fda.gov/drugs/coronavirus-covid-19-drugs/coronavirus-treatment-acceleration-program-ctap

41. Centers for Disease Control and Prevention. (n.d.) Groups at higher risk for severe illness. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html

What is “maskne,” and what can we do about it?

Tue, 22 Sep 2020 12:56:10 GMT

By Jane H. Jones, RPh, PCCA Clinical Compounding Pharmacist

This article was updated September 22, 2020

What is “maskne”? It is a new term describing the acne caused by wearing masks. It is also simply referred to as “mask acne.” The CDC is recommending everyone to wear masks to help slow the spread of COVID-19, especially when out in public, and says that “your cloth face covering may protect them. Their cloth face covering may protect you.”¹ This current health crisis and the need to cover our faces has led us to this new medical condition, particularly for health care and front-line workers who work long hours and wear one, two or even three masks as protective barriers daily. Dermatologists describe maskne as “acne mechanica,” the type of acne caused by repetitive physical trauma to the skin, usually by rubbing or scratching. Having to wear a mask for protection has created the perfect storm of oil, sweat, heat, bacteria and friction now called maskne.

Preventing Maskne

Can I prevent maskne? There are many ways to try to avoid getting mask acne. It is important to wash your face before and after wearing a mask with a gentle cleanser. You should moisturize your skin after cleansing to prevent dryness and, if possible, avoid heavy cosmetic use or wearing makeup under a mask. There are many options for face masks available out there. A 100% cotton one would be best if choosing a cloth type and washing daily after each use. It is also important to dispose of and not reuse disposable masks. But with rising summer temperatures, and especially for those who must wear masks for work, it may be difficult to prevent getting maskne.

There are already several cosmetic websites offering products to treat maskne online. There are also standard single-therapy agents to treat acne commercially, but we as compounders have so many more options to help our patients. PCCA also has many formulas that allow PCCA members with Clinical Services access to choose between bases and combine different active ingredients to potentially fit all patient needs.

Depending on patient-specific needs, a facial cleanser formulation may be recommended:

PCCA Formula #9564 – salicylic acid, niacinamide and NataPres ® cleansing pads
PCCA Formula #10096 – salicylic acid, mandelic acid and NataPres facial foam cleanser
PCCA Formula #7489 – salicylic acid and glycolic acid facial foam cleanser

Potential Compounded Options for Maskne

There are many options when choosing a base to compound with. Our PCCA PracaSil®-Plus gel has properties that nourish the skin, and when used as a base, it may promote faster relief and recovery. This base also provides moisture and protects the skin’s barrier. It is rich in skin-friendly fatty acids and lipids. PracaSil-Plus is commonly selected as a delivery vehicle in compounded medications for scar therapy but may also be prescribed in formulations for patients with other skin conditions, including acne.

For patients who have minor skin irritation, itching, redness and mild blemishes, physicians often recommend these formulas :

PCCA Formula #11966 – naltrexone and pramoxine topical gel in PracaSil-Plus
PCCA Formula #12546 – ketotifen and naltrexone topical gel in PracaSil-Plus
PCCA Formula #12683 – naltrexone, aloe vera and beta glucan topical gel in PracaSil-Plus

Our anhydrous topical gel base WO6 ® can be compounded with a 180 beyond-use date (BUD) by default, just like our PracaSil-Plus formulas, and is another consideration. PCCA’s Clarifying ™ base is a cream emulsion that compounders can recommend for patients with all forms of problem skin, including acne. It is noncomedogenic and has moisturizing properties along with natural ingredients that may improve the appearance of red and blotchy skin.

For patients with severe cases, physicians may recommend these formulas :

PCCA Formula #10012 – niacinamide and potassium azelaoyl diglycinate topical cream
PCCA Formula #13313 – niacinamide, tretinoin and hyaluronic acid topical gel in WO6
PCCA Formula #13336 – clindamycin, niacinamide and tretinoin topical gel in WO6
PCCA Formula #10901 – clindamycin and benzoyl peroxide topical gel in PracaSil-Plus
PCCA Formula #11635 – niacinamide, biotin and potassium azelaoyl diglycinate topical cream in Clarifying
PCCA Formula #11708 – tretinoin and sodium hyaluronate topical cream in Clarifying

We are all in it together during this pandemic. Stress and diets high in sugar and processed foods may exacerbate all forms of acne. Reducing stress, getting plenty of sleep, exercising and staying hydrated are simple tasks, yet sometimes they’re very difficult to do on a daily basis. With compounded options, we may be able to provide relief and help patients address the breakouts and flares caused by maskne.

How effective are different types of face mask? Check out our recent blog post “ Hand-Washing, Nasal Sprays and Masks — What Research Is Saying .”

Jane H. Jones, RPh, joined PCCA’s Clinical Services department in January of 2005. She is a 1996 graduate of the Medical College of Virginia in Richmond, Virginia. Prior to PCCA, she worked in management with several retail pharmacies. Her professional experience includes working with organ transplant patients, pediatrics and neonatal intensive care infants at Texas Children’s Hospital in Houston, Texas. Her compounding interests are in pediatrics, veterinary and topical delivery systems. She always looks forward to meeting and helping her fellow pharmacists solve patient challenges via compounding.

Reference

1. Centers for Disease Control and Prevention. (2020). Use of cloth face coverings to help slow the spread of COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html

Changes to the Paycheck Protection Program

Tue, 16 Jun 2020 14:05:34 GMT

By Bryan Prescott, PharmD, MBA, PCCA Director of Management Coaching Services

On June 3, 2020, Congress passed an amendment to the popular Paycheck Protection Program (PPP), which was originally put in place so that the Small Business Administration (SBA) could help businesses keep their employees on payroll during the COVID-19 pandemic. This amendment, the Paycheck Protection Program Flexibility Act of 2020 (PPPFA), should provide some additional benefits and ease some of the restrictions from the original PPP.

Extension of the Covered Period

The PPPFA expands the covered period (the period during which a borrower may use funds for potentially forgivable expenses) from eight weeks to 24 weeks. Borrowers who received a loan before June 5, 2020, may elect to keep the eight-week covered period if they desire. These loan recipients may have already spent the loan proceeds based on their original covered period and may wish to maintain the eight-week time frame for the sake of expense tracking and acceleration of the forgiveness process.

Maximum Wage Compensation per Employee

Expansion of the covered period will presumably increase the maximum wage compensation that can be paid to any employee from $15,385 ($100,000 annual salary, prorated for eight weeks) to $46,154 ($100,000, prorated for 24 weeks). As of this writing, however, there is no word on when clarification about this may be forthcoming.

New Payroll Expense Threshold

The original PPP conditions included a requirement that at least 75% of each loan must be used for payroll expenses in order for the loan to be forgiven. The remaining 25% could then be used to cover specific expenses, including rent, mortgage payments, utilities and interest on loans. Under the original PPP, the loan forgiveness amount would be proportionately reduced if payroll costs did not meet the 75% threshold.

Under the new PPPFA, the borrower only has to use 60% of the loan for payroll. A proportional reduction for borrowers who fail to meet the 60% threshold was not included in the new PPPFA, which could make the 60% payroll expense threshold an all-or-nothing “cliff” proposition. In other words, if at least 60% of the loan proceeds are not used for payroll expenses, no portion of the loan will be forgiven. While many believe that Congress did not intend for this to be the case, a technical fix may be forthcoming to address this issue. The new PPPFA does not change the list of expenses eligible for forgiveness (rent, mortgage payments, utilities and interest on loans).

New Loan Maturity

The original PPP required repayment of any unforgiven portion of the loan within two years at a 1% interest rate. The new PPPFA extends the maturity of any loans granted after June 5, 2020, to five years, with the interest rate remaining at 1%. For PPP loans made before June 5, 2020, the PPPFA allows lenders and borrowers to mutually agree to extend the loan term from two years to five years.

Repayment Timeline

The timeline to apply for loan forgiveness was unclear under the original PPP conditions. The new PPPFA includes a provision that suggests borrowers must apply for forgiveness within 10 months after the last day of the covered period. This provision states that eligible recipients “shall make payments of principal, interest, and fees on [PPP loans] beginning on the day that is not earlier than the date that is 10 months after the last day of such covered period.”

New Rehire Date to Maintain FTEs

The original PPP provisions reduce a borrower’s loan forgiveness proportionately based on how reduced their full-time equivalent (FTE) levels were during the covered period versus the borrower’s historical FTE levels. However, the original PPP provisions allowed full forgiveness if the borrower restored their FTE employee levels before June 30, 2020. The PPPFA extends this restoration deadline to December 31, 2020.

New Standards Based on Employee Availability or Business Activity

The PPPFA also allows borrowers to avoid the forgiveness reduction due to a reduction in FTE levels if the borrower can document either:

An inability to rehire individuals who were previously employed and/or an inability to hire similarly qualified employees for unfilled positions on or before December 31, 2020, or
“An inability to return to the same level of business activity as such business was operating at before February 15, 2020, due to compliance with requirements established or guidance issued by the Secretary of Health and Human Services, the Director of the Centers for Disease Control and Prevention, or the Occupational Safety and Health Administration during the period beginning on March 1, 2020, and ending December 31, 2020, related to the maintenance of standards for sanitation, social distancing, or any other worker or customer safety requirement related to COVID–19.”

The SBA will likely clarify what documentation is required to satisfy these conditions.

Payroll Tax Deferral Conditions

The Coronavirus Aid, Relief and Economic Security (CARES) Act, which included the PPP, permitted employers to defer deposit and payment of the 6.2% employer's portion of Social Security payroll tax for the period of March 27, 2020, through December 31, 2020. Fifty percent of the deferred amount would then be paid by December 31, 2021, and the remaining 50% would be paid by December 31, 2022. However, The CARES Act prevented an employer who received a PPP loan from seeking deferments if the lender forgives the PPP loan. The PPPFA eliminates this restriction.

You can view the entire PPPFA online. PCCA also has many resources to help you navigate your pharmacy through the pandemic. You can listen to my recent episode on PCCA’s The Mortar & Pestle podcast, where I talked about using the PPP. It’s available on Apple Podcasts , Spotify and Stitcher , among other podcast providers. PCCA published a blog post based on that as well, titled 4 Steps to Maintain Revenue & Manage Expenses during COVID-19 . I also recently co-hosted a PCCA webinar with Cindy Moon of Hart Health Strategies titled Leveraging the CARES Act & FFCRA to Support your Practice . We have many additional resources on the PCCA Coronavirus (COVID-19) Resource Center as well.

4 Steps to Maintain Revenue and Manage Expenses during COVID-19

Tue, 05 May 2020 12:36:41 GMT

By PCCA

This article was updated: June 22, 2020

We recently released a new episode of The Mortar & Pestle: A PCCA Podcast, in which Bryan Prescott, PharmD, MBA, Director of Management Coaching Services at PCCA, offered a game plan for sustaining independent pharmacies’ revenue and managing their expenses as they navigate the novel coronavirus pandemic. Below are Bryan’s four key steps that you can take to keep your community pharmacy practice financially healthy through the rest of 2020.

For an in-depth discussion of this COVID-19 strategy, you can listen to Bryan’s episode of The Mortar & Pestle on Apple Podcasts, Spotify, Stitcher and other podcast platforms.

Bryan also recently co-hosted the free PCCA Education webinar mentioned in Step 4 above. The webinar, Leveraging the CARES Act & FFCRA to Support Your Practice, features Cindy Moon of Hart Health Strategies as well and is available on YouTube. In it, Bryan breaks down new federal aid programs and Cindy shares detailed information on how prescribers can use telehealth options to serve patients during the pandemic. You can also find up-to-date information and customizable communications templates to help your pharmacy on the PCCA Coronavirus (COVID-19) Resource Center.

On June 3, 2020, Congress passed the Paycheck Protection Program Flexibility Act of 2020 (PPPFA), which should provide some additional benefits and ease some of the restrictions from the original PPP. Read more about it in our blog post, “Changes to the Paycheck Protection Program.”

Coronavirus Update: Hand-Washing, Nasal Sprays and Masks — What Research Is Saying

Wed, 29 Apr 2020 14:52:15 GMT

By Yi Liu, PharmD, PhD, PCCA Research Pharmacist; Daniel Banov, RPh, MS, PCCA Director of Research and Development; and Gus Bassani, PharmD, PCCA Chief Scientific Officer; and Matt Martin, PharmD, PCCA Clinical Services Manager

This article was updated: August 7, 2020

The COVID-19 pandemic has dramatically changed everyday life worldwide. It has also shifted the focus of researchers, including PCCA Science. As long as COVID-19 is spreading in communities, everyone is encouraged to practice social distancing and face-covering, regular and thorough hand hygiene, appropriate respiratory hygiene, and good disinfection habits. While people are trying to cope with the changes, we may face some questions in the pharmacy world. For example, what should we do with the dryness and roughness of skin resulting from frequent and diligent hand-washing? Is it possible to use a nasal spray to prevent the virus from entering the nose? What is the efficacy of different masks? We in PCCA Science have been researching published literature and would like to discuss what evidence is currently available regarding these questions.

Hand-Washing with Soap and Water

Most nonmedicated soaps for household and personal cleaning are alkali- or detergent-based and contain fatty-acid esters and sodium or potassium salts. Unlike hand sanitizer that is designed to kill microorganisms, the surfactants in soaps inactivate enveloped viruses such as the new coronavirus, SARS-CoV-2, by inserting into and disrupting the lipid bilayer of the envelope. Then the micelles formed by soap lathering encapsulate the viral debris and lift it from skin with the help of water. Loosely attached microorganisms on hands are also mechanically removed by rubbing and rinsing with water.¹ All surfactants have a similar effect in removing contaminants, and the effect is not affected by water temperature.

Nevertheless, soaps and frequent hand-washing may be associated with increased risk of skin-barrier impairment, which presents as rough, dry and scaly skin, sometimes combined with redness (erythema) and a burning sensation.² Increased pH, decreased skin components and dehydration of skin have been documented after repetitive hand-washing with alkaline soap or detergent.³ The main reason is probably the loss of the “acid mantle” of the stratum corneum (the acidic outer layer of the skin). The acidic nature of the skin surface, having a pH generally between 5.4 and 5.9, is an important aspect of the permeability barrier and acts as a cutaneous antimicrobial defense system.⁴ While studies have found that using cleansing agents with pH 5.5 can significantly prevent pH elevation and fat loss in skin after washing,⁵ skin dehydration and detergent penetration through the skin were also found to be significantly higher with soap at 98.6° F (37° C) than at 77° F (25° C.)^1,3 Therefore, washing hands with cold water and acidic detergent, especially with a pH of about 5.5, may help to prevent skin irritation and ensure compliance.

One option provided by PCCA is VersaBase® Foam, which is an amino-acid anionic surfactant complex derived from L-glutamic acid and plant-derived fatty acids. It is a mild surfactant, and it has an excellent conditioning effect to the skin, leaving a moisturized feeling without tautness. PCCA members with Clinical Services access can find examples of compounded cleansers with VersaBase Foam in our formula database:

PCCA Formula #7645 – DMAE in VersaBase Foam
PCCA Formula #8734 – Mandelic Acid/Glycolic Acid/Lactic Acid in VersaBase Foam

Nasal Sprays

Cleaning the nasal passages with a saline nasal spray has been historically used to reduce symptoms and shorten the duration of disease at the early stage of upper respiratory tract infection (URTI). (Twenty-five percent of URTIs are caused by human coronaviruses^.6) So far, there is no evidence supporting any type of nasal spray to effectively protect people from SARS-CoV-2 infection. However, in theory, it transmits by attaching to the epithelial lining of the nasal cavity or mucous membrane of the mouth or eyes, replicating there and further traveling down to the lungs. Nasal epithelial cells, specifically goblet/secretory cells and ciliated cells, are highly enriched with ACE2 receptor expression, which is the SARS-CoV-2 entry gene.⁷ According to a study analyzing the nasal and throat swabs in COVID-19 patients, the viral load is high on the day of symptom onset and higher in the nose than the throat in both symptomatic and asymptomatic patients.⁸ This observation resembles the viral shedding pattern of patients with influenza.⁸ Nasally delivered antiviral therapy may be an option to prevent COVID-19 at the early onset of infection, especially for health care workers who are at risk of exposure.

Researchers investigated hypertonic saline nasal irrigation and gargling in an open-label, randomized, controlled trial, and saw an association with significantly reduced duration of illness, transmission within a household and viral shedding for the common cold.⁹ Similar results were obtained in two randomized, double-blind, placebo-controlled trials assessing the effectiveness of carrageenan nasal spray in URTIs.⁶ SARS-CoV-2, like other enveloped viruses, can be inactivated at low pH. For instance, lactic acid and wine vinegar (6% acidity) both have viricidal activity against SARS-CoV in vitro.^10,11 An animal study using a nasal spray with pH 3.5 had consistent findings of reduced influenza virus shedding and severity of infection.¹² Tolerability of an acidic nasal spray should not be a concern under normal circumstances, as an acidified saline nasal spray with pH 2.5 has been proven safe and tolerable in a clinical trial.¹³

Researchers in the UK have recently proposed povidone iodine nasal spray as a prophylactic treatment for health care workers during COVID-19.¹⁴There is strong evidence in vitro to support the efficacy of povidone iodine against SARS-CoV-2 and its safety in nasal application.¹⁵ Nasodine, a povidone-iodine nasal spray developed for treating URTIs by an Australian company, is currently in a phase III clinical trial. Several clinical trials are currently underway worldwide examining the efficacy of intranasal povidone iodine ranging from 0.5–10% in reducing SARS-CoV-2 viral load.

There are some active pharmaceutical ingredients (APIs) that have gained interest as promising prophylactic agents that can be delivered by the nasal route. It is believed that plasmin can increase the pathogenicity of SARS-CoV-2 through cleaving the S protein on the virus surface, facilitating its binding to ACE2 receptors and subsequent entry into cells.¹⁶ Tranexamic acid, an inhibitor of plasmin and its proteolytic activity, is commonly used to stop bleeding, and has shown activity against influenza virus entry in vitro.¹⁷ It is now being re-purposed for treatment of COVID-19 in a clinical trial (NCT04338126) based on this mechanism of action. Although the ongoing trial uses oral tranexamic acid for systemic treatment, the tranexamic acid nasal spray targeting viral entry into nasal mucosa may be promising as well.

In addition to the ACE2 receptor, mast cells are also highly enriched in the nasal mucosa, and they play a role in releasing proinflammatory cytokines and exaggerating the “cytokine storm.”¹⁸ Mast cell stabilizers, specifically ketotifen — a common ingredient in nasal sprays for rhinitis — may have the potential to lower cytokine release if given both intranasally and orally.^19,20 Further clinical studies are needed to explore the clinical value of nasal use of these APIs.

The use of hydrogen peroxide nasal spray has also been discussed as a preventive therapy; however, there is no clinical evidence to prove its efficacy and safety. Hydrogen peroxide is an established viricidal disinfectant and antiseptic effective against SARS-CoV-2, but its activity on nasal mucosa is unknown. The nasal irrigation application was first suggested to treat septic sinuses in the 1910s.²¹ In a mouse model that was infected with influenza virus, the nasal epithelial cells produced hydrogen peroxide as a protective response.²² In contrast, as a strong oxidizing agent, addition of hydrogen peroxide to the in vitro nasal epithelial cells led to oxidative stress and cell injury.²³ The Agency for Toxic Substances and Disease Registry (ATSDR) has warned that inhalation of household-strength hydrogen peroxide (3%) can cause respiratory irritation, while higher strengths may be associated with severe pulmonary injury.²⁴ Therefore, more safety and efficacy studies are needed before recommending hydrogen peroxide nasal spray for COVID-19 prevention.

In spite of a limited number of studies using a nasal spray to prevent COVID-19, there is a great potential to develop an effective therapy delivered by the nasal route to inhibit virus replication at an early infectious stage. Prolonged contact time may be a desired characteristic for such an antiviral nasal spray to improve clinical outcomes. PCCA’s MucoLox™ can provide additional adhesion to the nasal mucous membrane and therefore may improve efficacy of the API. A recent phase II clinical trial conducted by researchers at Brigham and Women’s Hospital (Boston, Massachusetts) has shown the therapeutic benefits of adding MucoLox to a mucous-membrane treatment formulation.²⁵ PCCA members with Clinical Services access can see examples of compounded nasal dosage forms with MucoLox in our formula database:

PCCA Formula #11429 – Tranexamic Acid Nasal Drop in MucoLox
PCCA Formula # 12418 (with modification) – Ketotifen Nasal Spray in MucoLox (without mometasone)

PCCA’s XyliFos® is another option when choosing a base for nasal formulations. It improves solubilization, moisturization and mucosal adhesiveness. Moreover, XyliFos contains an EGCg-cyclodextrin complex, which may act as a viral-entry inhibitor.²⁶ EGCg has shown some benefits in herpes-simplex-virus and URTI management in multiple clinical trials.^27-29Overall, a nasal spray for COVID-19 is promising and feasible, yet more studies are needed to identify the optimal formulation.

Face Masks

Can SARS-CoV-2 spread through the air?
The infectivity of SARS-CoV-2 aerosol and the possibility of airborne transmission has been controversial for months. A recent preprint study completed by a collaborative group of researchers at the University of Nebraska, the National Strategic Research Institute, the University of Illinois and Harvard University revealed the infectious nature of aerosol generated by COVID-19 patients. The study proved the presence of SARS-CoV-2 RNA in aerosols sized < 1 m and 1–4 m that patients produced during respiration, vocalization and coughing. Not only RNA, the aerosols also contained infectious and replicating viral particles.³⁰ These findings support the possibility of airborne transmission as well as the necessity of aerosol prevention measures to reduce the spread of SARS-CoV-2.

Is six feet enough social distance to prevent the spread of SARS-CoV-2?
Studies have estimated that one minute of loud talking can generate more than 1,000 virion-containing aerosol particles for an average person.³¹ Aerosols can float in indoor air for hours, remain infectious and accumulate over time. It takes 12.4 hours for a 1 m aerosol particle to settle to the ground from a distance of eight feet.³² Coughs and sneezes can create thousands of aerosols being propelled over eight feet up to 20 feet, sometimes further.³³ Aerosols are found more concentrated in more crowded areas, and they travel following airflows much further than six feet. ³⁴ Therefore, without a face covering, people can still easily inhale aerosols even standing six feet away from others.

What types of face masks are effective?
The size of SARS-CoV-2 particles is approximately 50–200 nm in diameter, with an average of 120 nm.³⁰ To determine whether a face mask is suitable to reduce exposure to SARS-CoV-2, the user needs to examine the filtration efficiency of the mask using particles of similar size. ASTM has set an international standard for mask ratings based on their performance with fluid resistance, differential pressure, filter efficiency and flammability. N95 respirators should be reserved for health care workers right now due to the pandemic, and their efficacy has been well defined by National Institute for Occupational Safety and Health (NIOSH) standards. Here, we have summarized the particle filtration levels of surgical masks and homemade masks with different materials to help people identify the right masks according to their needs.

Comparison between Surgical Masks and Homemade Masks

Materials	Filtration Efficiency	Comment
ASTM Level 3 surgical mask	≥ 98% (100 nm particles) ³⁶	Resistance to Synthetic Blood penetration by pressure ≤ 160 mm Hg
ASTM Level 2 surgical mask	≥ 98% (100 nm particles)³⁶	Resistance to Synthetic Blood penetration by pressure ≤ 120 mm Hg
ASTM Level 1 surgical mask	≥ 95% (100 nm particles)³⁶	Resistance to Synthetic Blood penetration by pressure ≤ 80 mm Hg
Surgical mask (not ASTM-rated)	89.52% ± 2.65%; ³⁷ 63% – 96% ^38,39	Fluid resistance level is unknown
Dental masks	10% – 47% ³⁸	Comparable breathability with surgical masks
100% cotton	50.85% ± 16.81% ³⁷	Comparable breathability with surgical masks
Scarf	48.87% ± 19.77% ³⁷	Comparable breathability with surgical masks
Tea towel	72.46% ± 22.60% ³⁷	Poor breathability
Pillowcase	57.13% ± 10.55% ³⁷	Best breathability
Vacuum cleaner bag	85.95% ± 1.55% ³⁷	Very poor breathability
Cotton mix	70.24% ± 0.08% ³⁷	Poor breathability
Linen	61.67% ± 2.41% ³⁷	Comparable breathability with surgical masks
Silk	54.32% ± 29.49% ³⁷	Comparable breathability with surgical masks
In the fabric assessments, a single layer of fabric was tested. The masks were tested at unworn condition. If the materials were worn for a couple of hours and contained water vapor, the filtration efficacy would be different. Filtration efficacy of non-ASTM surgical mask and homemade masks were evaluated using a bacteriophage of 23 nm in diameter and delivered at 30 L/min, which is about 3–6 times per minute the ventilation of a human at rest or doing light work, but is less than 0.1 the flow of an average cough.³⁷

Recently, a group of researchers in Hong Kong compared the levels of respiratory droplets (particles > 5 m) and aerosols (particles ≤ 5 m) generated from URTI patients who were wearing a face mask or not while sitting for 30 minutes with normal breathing and coughing. The findings indicate that wearing a face mask can effectively reduce the emission of coronavirus particles into the environment in both respiratory droplets and aerosols. The face masks used were non-ASTM rated, standard, three-layer procedure masks not expected to be resistant to fluid.⁴⁰

Because the majority of the general public is wearing cloth-based face coverings, a group of engineers at Florida Atlantic University has mimicked coughs and sneezes and qualitatively visualized the respiratory jets as well as the performance of different mask materials in a lab. They found that a well-fitted, homemade mask with multiple layers of quilting fabric (70 thread count) is as effective as a commercial cone face mask in reducing the distance of respiratory jets (from eight feet when uncovered to less than eight inches when using masks). Loosely folded face masks or bandana-style coverings have minimal effectiveness in limiting the spread of aerosolized respiratory jets, but are still able to reduce the distance to within six feet, compared to an uncovered cough that expelled more than eight feet. Another important finding is that a well-fitted construction is more important than a higher thread count by itself to ensure the effectiveness of a mask.⁴¹

Multiple other studies have consistently shown that any type of mask can significantly reduce aerosol exposure compared to not wearing a mask. The best practice should be combining all preventive measures, including social distancing and hygiene, and not solely relying on face masks or social distancing.

Daniel Banov, MS, RPh, PCCA Director of Research and Development, has over 20 years of hands-on experience in pre-formulation, formulation and reformulation of a variety of dosage forms. He has extensively worked on developing novel techniques for skin-permeation enhancement. Daniel currently has 17 granted U.S. patents and many others pending. Before joining the PCCA team, Daniel was the Director of Fórmula Médica Compounding Pharmacy in São Paulo, Brazil, and was a university teacher and a cosmetic developer and consultant for physicians, spas and aestheticians. He also is the founder of the Anti-aging Society in Brazil.

Gus Bassani, PharmD, PCCA Chief Scientific Officer, has been with PCCA since September 2002. Prior to that, he was a formulation pharmacist in the product development lab of a veterinary pharmaceutical company. He has worked in multiple pharmacy practice settings and has taught extemporaneous compounding principles to pharmacy students. Gus earned his Doctor of Pharmacy degree from the Drake University College of Pharmacy and Health Sciences. He is a member of the 2015–2020 United States Pharmacopeia Council of Experts – Compounding Expert Committee, and served on the 2012–2014 Drake University College of Pharmacy and Health Sciences National Advisory Council. He is a member of the American Pharmacists Association, Alliance for Pharmacy Compounding, and American Association of Pharmaceutical Scientists.

Matt Martin, PharmD, is the Clinical Services Manager at PCCA. He joined the PCCA Clinical Services department in September 2014. Matt graduated from Morehead State University with a BS in Chemistry in 2002, and received his PharmD from the University of Kentucky College of Pharmacy in 2006. Prior to joining the PCCA team, Matt worked in pharmacy compounding for more than eight years, and has experience with both sterile and nonsterile preparations.

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Coronavirus Update: Pharmacy Communications during COVID-19

Tue, 21 Apr 2020 14:49:36 GMT

by PCCA

On Monday, April 6, PCCA hosted a webinar about how pharmacies can manage communications and engage with media during the COVID-19 crisis. Our speakers covered many subjects, including how to navigate crisis communications, contacting and working with local media, the #CompoundingHandoff movement — in which pharmacies compound hand sanitizer and donate it to local first responders and health care providers — key messaging pharmacies can use in our current situation, and best practices for using social media during the pandemic. Many of the examples and principles the speakers covered are relevant for a wide range of situations as well. Here is a brief overview of what they shared with viewers.

Crisis Communication and Engaging the Media
Mark Edgar, senior vice president at Hill+Knowlton Strategies and a former newspaper editor, gave the audience a high-level view of how to navigate crisis communication. He started by covering the 3 Cs of Crisis Communication, an approach that not only can be followed now during the pandemic, but also in other business areas.

The 3 Cs of Crisis Communication

Concern: Express and demonstrate concern for anyone affected
Control: Demonstrate control over the issue at the senior level
Commitment: Show commitment to find the cause and prevent reoccurrence

He also explained how compounders can best reach out to local media to share how their compounding pharmacy is part of the solution during the COVID-19 pandemic. This is important because it highlights your efforts to help your local community in a time of crisis, which people will remember in the future. The first step is to identify reporters from local newspapers or TV stations who are covering the impact of the crisis.

Then, contact these reporters by email and share any news updates on your expanded operations, what you are doing to support the community (such as a donating hand sanitizer) and how you have responded to safely serve your regular customers. Share PCCA’s #CompoundingHandoff press release. Local media outlets are actively are looking for these kinds of local angles, but they won’t know about your good work unless you give them a heads-up.

Finally, Mark presented a media interview checklist to help compounders prepare to speak with a reporter.

Media Interview Checklist

Control the interview. It’s your interview.
Do your homework
Stick to your key messages
Be authentic and affable
Avoid forecasting and predictions
Avoid speculating or responding to hypotheticals
Avoid sharing info you wouldn’t want to see reported
Avoid speaking for others
Avoid using acronyms, buzz words or jargon
Avoid repeating negatives

Communicating When an Employee Is Diagnosed with COVID-19
Kim Speairs, PCCA Director of Communications and Engagement, went into more detail on messaging during a crisis. She reiterated the importance of the 3 Cs of Crisis Communication, saying that those three actions should guide every communication you put out during the COVID-19 pandemic and beyond. She then walked viewers through a specific situation: when one of your employees is diagnosed with COVID-19. Before communicating in such a situation, though, you must first contact your local health authorities and follow their guidance. Then, you should gather all the facts, and after that, you can begin crafting your key messages, focusing on the 3 Cs.

Kim also shared some simple best practices for communicating with your employees, patients and practitioners in this kind of situation.

Best Practices for Crisis Communications

Stay calm
Express empathy
Be transparent, but protect your employee (HIPAA)
Anticipate and prepare for questions
Stay on message
Be the peace amid the pandemic

Finally, Kim provided guidance on different ways you can communicate with your employees, patients and practitioners. Importantly, she said that you should always start from the inside and then move out: communicate with your team members first, then share with your patients and practitioners.

Local Market Outreach

Lizzie Harbin, PCCA Vice President of Public Affairs, Communications, Education and Human Resources, walked viewers through the process for our #CompoundingHandoff movement. Compounding pharmacies all over the United States and Canada have been giving back to their communities as part of this movement, while raising awareness of the crucial role that compounding has in those communities.

Lizzie also shared some key talking points that compounders can use.

Key Messages Pharmacies Can Use during the Pandemic

"We’re in the middle of this fight, and pharmacists have a special role in helping doctors, patients and others. I’m part of a network of 3,000 compounding pharmacies nationwide, all of them PCCA members who formulate specialized medicine according to a doctor’s prescription to meet patient needs.” (For PCCA members specifically)
“Compounding pharmacists can make specialized formulations for medicine that isn’t commercially available. Using approved methods, I’ve supplied hand sanitizers to emergency responders and medicine based on doctors’ prescriptions.”
"This is what we do. It’s our profession to save lives, and that’s what our team is doing for our community.”
“I’ve also taken precautions here to ensure there’s no disruption in serving our regular customers and offering reassurance. That includes curbside pickups, etc.” (List precautions your pharmacy has in place)
“Being able to offer hope by explaining that I can still respond to the needs of the local community — there’s no better feeling. Compounding makes the impossible possible, and it can provide peace when there is panic.”

Best Practices for Social Media Sharing

Sarah DeCarlo, PCCA Marketing Manager, covered best practices for sharing the work you are doing during the novel coronavirus pandemic on social media. She walked viewers through examples of social media posts from pharmacies across the country and explained why they were effective. She then provided some key points to keep in mind as you plan, execute and post your own #CompoundingHandoff stories (below). Finally, she shared additional ways that you can connect with your community through social media.

Best Practices for Your #CompoundingHandoff on Social Media

Make sure your social media posts are public
Share video or photos
Use #CompoundingHandoff and other hashtags that can link your post to larger trends in social media, such as #covid19 and #handsanitizer (hashtags aren’t case sensitive)
Tag the recipients of the hand sanitizer you are donating, such as local police or fire departments
Tag your local, state and federal representatives, such as your mayor, governor, and U.S. Representatives or Senators (this can exponentially grow your potential audience on social media)
Post more than once to amplify your story; for example,
1. Post about compounding hand sanitizer in your lab
2. Post about delivering and donating hand sanitizer to the recipients
3. Post behind-the-scenes photos of your local news interview if you have set one up
4. Link to local news coverage of your donation when it’s available

These are just some highlights that your pharmacy can use as you navigate communications during the COVID-19 pandemic. You can learn more by viewing our free webinar about Communicating during COVID-19 on YouTube, and we’ve included a link to the webinar slides as well as communications templates, customizable social media captions and much more in the video description. We also have links to these and other helpful resources related to the pandemic on our Coronavirus (COVID-19) Resource Center. To see a step-by-step infographic about how you can participate in the #CompoundingHandoff movement and an example from a compounding pharmacy who has done it, see our blog post 4 Steps for Donating Compounded Hand Sanitizer to First Responders.

We worked hard for the CARES Act. Use it.

Thu, 16 Apr 2020 12:58:55 GMT

A Guest Post By Doug Hoey, RPh, MBA, Chief Executive Officer of the National Community Pharmacists Association

There’s no doubt about it: Our nation, our world is experiencing extraordinary times. Community pharmacies are the safety nets helping their communities in the COVID-19 crisis. But pharmacies need help, too. The Coronavirus Aid, Relief and Economic Security (CARES) Act is just one of the ways that they can get it, and we at the National Community Pharmacists Association (NCPA) are bringing that help to you.

Here at NCPA, we’re busy trying to do whatever we can to support you. Much of the NCPA team is working from home, but our work continues — at turbo speed to try to keep up with the support community pharmacies need as they serve patients on the front lines of health care. A major part of our job is to be your voice to government and media, telling them how community pharmacists can be supported. Another big part of NCPA’s job is to sift through the avalanche of information you are receiving to highlight those areas most important to your practice — while not adding to the avalanche. NCPA’s Coronavirus Resource Center is the most active part of our newly remodeled website. Over the last few weeks, thousands of registrants have come to NCPA to hear what we have to say on webinars about the most important issues to your business.

On April 2, we hosted one of our coronavirus-related webinars on the $2.2 trillion CARES Act, which had been signed into law less than a week before. This law has enormous implications for small businesses. We had unprecedented interest for this webinar; if you weren’t able to watch it in real time, we’ve posted the recording on our Coronavirus Resource Page.

The CARES Act includes important relief for small businesses, including emergency grants, a forgivable loan program, and changes to rules for expenses and deductions meant to make it easier for small businesses to keep employees on the payroll and open for business. These are provisions that you asked for and that you need.

Paycheck Protection Program
NCPA successfully lobbied for the Paycheck Protection Program (PPP). It provides for immediate, readily accessible credit and forgivable loans to independent pharmacies to ensure that you have the cash to pay your workers, rent and other costs during this crisis.

At one point during the progression of the legislation, pharmacies and other health care providers were eligible for loans and grants. NCPA worked hard to ensure pharmacies would be eligible. Also, NCPA was successful in lobbying to restore the ability of small business community pharmacies to carry back any net operating losses against previous year tax payments, payroll tax credits and other beneficial small business provisions.

Economic Injury Disaster Loan Program
In addition to the PPP, there are other coronavirus-related financial assistance opportunities that could have a positive impact for pharmacies. One is the Economic Injury Disaster Loan (EIDL) program. Under this Small Business Administration (SBA) program, pharmacies can obtain low interest, long term loans with deferred payments. This could assist pharmacies with issues like inventory financing. Further, a pharmacy can apply for an EIDL loan even if they have received a PPP loan. Another unique feature of the EIDL application process is a provision that allows you to request a $10,000 grant, regardless of whether your EIDL application is approved.

SBA Loan Forbearance Program
Finally, for existing SBA 7(a) loan holders impacted by the COVID-19 pandemic, there is an SBA loan forbearance program under which the SBA will make your payments for you for 6 months! It does not accrue, and it is not a deferral that you will owe in the future. And there’s more: This program does not prevent you from applying for PPP or EIDL assistance. The forbearance program is an automatic program for existing SBA 7(a) loan holders, so if you have not heard from your lender yet, you should reach out to them.

For more information on these and other COVID-19 resources, visit the NCPA Coronavirus Resource Center, where we have a recording of our CARES Act webinar, the webinar slides, a detailed summary of the act and much more.

Every morning in qAM, NCPA shares the creative ways that our members are responding to the unique needs of their communities while running their businesses in the midst of a pandemic. (Keep sending those stories to us!) Through phone calls, emails and texts, I’m hearing stories about community pharmacy MacGyvers all over the country doing all they can to change their practices into what their patients need.

In 2006, community pharmacists saved the Part D program when it rolled out with a big thud. Health and Human Services Secretary Mike Leavitt acknowledged pharmacies’ role in saving the day. The heroic efforts of pharmacists during this national emergency even outweigh the Herculean Part D program save. Just like stars in the sky, community pharmacies shine all year round, but it’s when the skies are darkest that people notice how bright they are. As we’ve seen over the past few weeks, pharmacies are shining brightly on their communities.

Brian Douglas (Doug) Hoey is the Chief Executive Officer of the National Community Pharmacists Association. He has spent 25+ years working in and representing community pharmacies. Hoey is a licensed pharmacist in Oklahoma, Virginia and Texas and practiced for five years in community pharmacies, including his own family's pharmacy. He is frequently quoted by media about the prescription drug supply chain. Hoey also developed and taught pharmacology courses at George Washington University and Marymount University. He is co-chairman of the board of directors for Surescripts, chairman of the Mirixa, NCPA Innovation Center and Community Pharmacy Enhanced Services Networks (CPESNSM-USA) Boards, and serves on the board of the Stabler-Leadbeater Pharmacy Museum in Alexandria, Virginia as well as advisory boards for several schools of pharmacy. He earned his pharmacy degree from the University of Oklahoma College of Pharmacy and his MBA from the Oklahoma City University Graduate School of Business.

Coronavirus Update: What the Families First Act Means for Independent Community Pharmacies

Tue, 14 Apr 2020 13:22:45 GMT

By PCCA

PCCA recently hosted a webinar on the Families First Coronavirus Response Act (Families First Act). Our guest, Charles Wilson, a board-certified labor and employment lawyer, explained what this new law means for pharmacies. Here are some questions and answers based on what Charles explained, along with a link to the webinar.

Does my pharmacy have to comply with the Families First Act?
Generally, the Families First Act applies to employers with fewer than 500 employees. Employers with fewer than 50 employees may be exempt from the law only when an employee requests leave to care for the employee’s children younger than 18 years of age when their school or daycare is closed or unavailable due to the COVID-19 pandemic, and when such leave would jeopardize the business as a going concern. The law sets forth three scenarios under which such leave would jeopardize the employer’s business. To elect this exemption, the employer must retain documentation of its determination that providing such childcare leave would jeopardize the business. This exemption cannot be claimed for leave due to other reasons (which are discussed below).

In addition, the U.S. Department of Labor, which is responsible for implementing rules as well as interpreting and enforcing the law, has also clarified that any employee of pharmacies and many other health care providers may be excluded from the Families First Act requirements. However, even if employees can be excluded from the Families First Act, it may be more beneficial for pharmacies to comply with the law even if they are not legally required, as long as they can afford to do it. Paying benefits under the Families First Act when not required could help to support and retain key talent in the long run. Additionally, pharmacies may be able to obtain assistance with protecting payroll through forgivable loans outlined in the newer Coronavirus Aid, Relief and Economic Security (CARES) Act.

When do businesses have to start complying with the Families First Act?
The Families First Act took effect on April 1, 2020, and will last until December 31, 2020. The Department of Labor is providing a grace period on enforcement until April 17, 2020.

What does the Families First Act mean for my business?
The Families First Act has two main components that affect businesses: The Emergency Paid Sick Leave Act and the Emergency Family and Medical Leave Expansion Act.

Emergency Paid Sick Leave Act

Affected employers must offer all employees up to 80 hours of paid sick leave
They must give the employees full pay or 2/3 pay, depending on the reason for the leave
There are six qualifying reasons for this emergency paid sick leave:
1. Employee is under a federal, state or local COVID-19 quarantine or stay-at-home order
2. Employee has been advised to self-quarantine by health care provider
3. Employee is experiencing symptoms of COVID-19 and is seeking medical diagnosis
4. Employee is caring for someone who meets reason 1 or 2 above
5. Employee is caring for their child if the child’s school is closed or child care is unavailable due to the COVID-19 pandemic
6. Employee is experiencing similar conditions as specified by the U.S. Department of Health and Human Services
Employers must offer full pay for reasons 1–3, with a limit of $511 per day ($5,110 total)
Employers must offer 2/3 pay for reasons 4–6, with a limit of $200 per day ($2,000 total)
If the employee is reasonably and effectively able to work from home, these reasons do not apply, and the employee is not eligible for benefits

Emergency Family and Medical Leave Expansion Act

Affected employers must offer qualifying employees up to 12 weeks of leave to care for their children if their children’s school or child care is closed due to the COVID-19 pandemic
Employees must have been employed for 30 days or more to qualify
Weeks 1–2 are not paid, but covered by the Emergency Paid Sick Leave Act
Weeks 3–12 are paid at 2/3 the employee’s pay rate, with a limit of $200 per day ($10,000 total)

The rate of pay for the purposes of this law is either the employee’s regular pay rate or the federal, state or local minimum wage, whichever is greater.

The paid leave outlined in this act is in addition to employees’ existing paid time off. Employers cannot force employees to take their existing paid time off prior to using the Families First Act paid leave. Employers and employees can agree to supplement unpaid leave periods with paid time off.

Businesses must post a notice of the Families First Act rights wherever they post similar notices, such as in break rooms. They can also send it through an email to all of their employees or post it on their intranet if they have one.

Does the Families First Act include tax breaks or other compensation to help businesses comply?
For every dollar spent on Families First Act paid leave, businesses get a dollar-for-dollar tax credit. They can get immediate tax relief for this by withholding a portion of their federal payroll taxes that they normally pay.

This is just a quick overview of the Families First Act. To learn more about this new law, watch PCCA’s free Families First Coronavirus Response Act webinar on YouTube. We also have links to helpful resources about this and other U.S. laws related to the COVID-19 pandemic on our Coronavirus (COVID-19) Resource Center.

The information provided herein does not, and is not intended to, constitute legal advice; instead, all information, content and materials provided are for general informational purposes only. Readers of this information should contact their attorney to obtain advice with respect to any particular legal matter. All liability with respect to actions taken or not taken based on the information herein is hereby expressly disclaimed. The content is provided "as is," and no representations are made that the content is up-to-date or error-free.

Coronavirus Update: 4 Steps for Donating Compounded Hand Sanitizer to First Responders

Sat, 21 Mar 2020 13:28:36 GMT

By PCCA

Compounding pharmacies are uniquely positioned to serve their communities during the novel coronavirus pandemic. Especially since the FDA is allowing the temporary compounding of certain alcohol-based hand sanitizers — provided that all of the conditions in its guidance document are met — compounders can use their ingenuity, knowledge and skills to continue providing customized medication to their patients while also supporting first responders in their communities by helping to combat the spread of the new coronavirus disease (COVID-19).

Below is a video showing how one compounder — Steve Hoffart, PharmD, owner and pharmacist of Magnolia Pharmacy in Magnolia, Texas — is helping his community by donating pharmaceutical-grade, alcohol-based hand sanitizer to local law enforcement departments. Below that, we provide a simple four-step checklist showing how you can also support first responders in your community during the COVID-19 outbreak.

Compounding Pharmacy Donates Hand Sanitizer for First Responders

How You Can Do It Too

Visit our Compounding Hand Sanitizer page for the hand sanitizer formulas mentioned above, which we developed based on the World Health Organization (WHO) guidelines cited in the FDA hand sanitizer guidance document. You can also access our social media caption template mentioned above to help you spread the word.

For more information about the FDA’s guidance for compounding alcohol-based hand sanitizer, and to see other resources for helping your community through the new coronavirus outbreak, visit our Coronavirus (COVID-19) Resource Center. We are updating that webpage as this situation develops, so we recommend bookmarking it and checking it often.

PCCA COVID-19 Resource Center Available

Wed, 18 Mar 2020 19:16:42 GMT

by PCCA

Just like you, PCCA has been closely monitoring the documented cases of the novel coronavirus disease (COVID-19) and the worldwide response to this outbreak. While this is an evolving situation with many unknowns, PCCA is committed to doing our part to help protect our members, customers, staff members and, ultimately, patients.

Therefore, we have created a Coronavirus (COVID-19) Resource Center, where you can find the latest updates about our response to the coronavirus outbreak along with resources, links and other information that may be helpful to you, your pharmacy and your patients as we navigate through the far-reaching impact of COVID-19.

Please note that we will be updating the resource center as the situation continues to develop, so we recommend bookmarking the webpage in your browser and revisiting it often.

What’s in the PCCA COVID-19 Resource Center?

Here is some of the information on the webpage:

Tools to help you be a part of the solution: Recommendations from our Formulation Development, Clinical Services and Wellness Works teams to help you and your patients. PCCA members with Clinical Services access can also view related compounding formulas
Communication tools and resources: Examples of communications that you can use to develop your own messaging to employees and patients. Along with these, PCCA is working diligently to expand our example communications and templates so that you can spend less time communicating and more time compounding
Product supply and shipment safety: How this situation is affecting product supply and shipping
PCCA Education and Training updates: Details about any PCCA events or training that we have canceled or postponed
Links to other COVID-19 resources: Links to health authority resources, including those of the Centers for Disease Control and Prevention, Food and Drug Administration, and more
COVID-19 FAQs: Answers to commonly asked questions from Houston Methodist Health System and the Centers for Disease Control and Prevention

As a reminder, please revisit our resource center often. We will be updating it as the COVID-19 situation continues to develop. We hope this will help you as your pharmacy supports your community’s health through these challenging circumstances.