PHARMACARE AND PRE-PAYS

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

“How do I grow my own spaghetti tree?”  Hundreds of people were calling the BBC with this question in 1957.  Diplomatically, they were told, “Place a sprig of spaghetti in a tin of tomato sauce and hope for the best.”  I think this is still my favorite April Fool’s story.  On April 1, 1957 the BBC ran a documentary showing the Swiss Spaghetti Harvest.  Young women were carefully plucking strands of spaghetti from trees and drying them in the sun.  The video is still remarkable and believable today.

A good April Fool’s joke is funny and no one gets hurts.  Manitoba Health should learn from the BBC.  Every year Manitoba Health plays a cruel April Fool’s joke on many people.  For people who go over their Pharmacare Deductible, in March Pharmacare pays for their medication.  In April, people have to pay for their own medication again.  If you don’t know what Pharmacare is, you are not alone. 

Manitoba Health defines Pharmacare as “…a drug benefit program for any Manitoban, regardless of age, whose income is seriously affected by high prescription drug costs.”  Some of the tax money we pay the Manitoba Government goes into a big pool.  If we need a prescription medication and meet certain conditions, Manitoba Health will pay for our medications out of that big pool.  This pool of money to pay for medications is called Pharmacare.

Under what conditions will Pharmacare pay for my medications?  First, you have to apply for the Pharmacare program.  If you don’t apply, no matter what your income is or how expensive your medications are, Pharmacare won’t pay for anything.  The good news is the application form is only one page long and you can pick one up at any pharmacy or at the Manitoba Health website.  Your pharmacist can help you fill it out.  A Pharmacare form has two options on it.  I recommend most people select Option A.  This means you will only have to apply for Pharmacare once.  Manitoba Health will keep your information on file for future years.  Option B means you will have to apply for Pharmacare every year.

Once you have applied for Pharmacare benefits, in 4 to 6 weeks, Manitoba Health will send you a letter stating your Pharmacare Deductible.  Your Deductible is the amount of money you have to spend on eligible prescription medications before Pharmacare starts paying.  Your Deductible is based on your income.  The higher your income, the more medication you will have to buy for before Pharmacare starts to pay. 

The Pharmacare year runs from April 1 to March 31.  So every year, everyone has to start paying for their medications again after April fool’s day passes.  Then as you pay for your eligible prescriptions, you may eventually spend more than your Deductible.  Once you spend more than your Deductible, Pharmacare will start paying for your eligible prescription medications until the next March 31.

What is an eligible prescription medication?  Pharmacare has a formulary.  A formulary is a list of all the medications that Pharmacare will pay for.  Not every medication a doctor can prescribe is on the formulary.  Two common questions I get asked are: “My doctor prescribed it.  I need it.  That means the government pays for it, right?”, and “This new medication is now approved for sale in Canada.  If my doctor prescribes it, it will be covered, right?”  Unfortunately, the answers to both those questions can be, “No.”  Health Canada approves medications for sale, if they determine the medication is safe and effective.  Manitoba Health determines which medications it wants to pay for.  It puts those medications on the Pharmacare formulary.  New medications are usually not covered for a few years after they are released.  Manitoba Health only has a limited amount of money with which to pay for prescription medications.  So it must make a list of medications it feels it can afford.  Unfortunately, if the medication you need isn’t on the formulary, Pharmacare won’t pay for it.

Actually, the government doesn’t make the formulary as simple as a medication is covered or not.  There are actually three different parts of the formulary.  Part 1of the formulary are medications that any doctor can prescribe for any condition and Pharmacare will pay for them.  Part 2 (EDS Part 2) are medications that Pharmacare will not pay for unless the drug is used for a specified condition for a specified time.  The doctor is supposed to indicate that the medication meets these criteria by writing “Meets EDS” on the prescription.  Part 3 (EDS Part 3) or Exceptional Drug Status is really all other medications that Manitoba Health doesn’t normally pay for.  Your doctor can contact Manitoba Health and ask for an exception in your case (exceptional drug status) and hope that Manitoba Health will pay in your exceptional case.

The last question I am often asked is about Pharmacare Pre-Pays.  A Pre-Pay is if you want to pay off your whole Deductible at once and get 10% back for doing so.  Pre-Pays are a Dauphin Clinic Pharmacy program and don’t involve Pharmacare or Manitoba Health.  Pharmacare doesn’t want all your Deductible money up front.  But, if you go to the Dauphin Clinic Pharmacy, you can pay off your whole Deductible at once.  We put your money as a credit on your account.  When you fill prescriptions, we charge them against that credit.  When the credit runs out, you will be over your Deductible and Pharmacare will start to pay for your medications.  And the best part about paying your deductible up front is the Dauphin Clinic Pharmacy will give you 10 percent of your deductible back.  So if you take advantage of the Dauphin Clinic Pharmacy pre-pay program, your medications will be cheaper than if you get them anywhere else.

So here’s to Spring!  Here’s to a bumper spaghetti crop! Even if Manitoba Health and Mother Nature don’t seem to have a sense of humor, the arrival of April is still a good thing.

As always if you have any questions or concerns about these products, ask your pharmacist.

Pharmacare application form: www.gov.mb.ca/health/pharmacare/docs/pharmform.pdf

BBC Swiss spaghetti harvest www.youtube.com/watch?v=27ugSKW4-QQ

We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us at www.dcp.ca

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

Antibiotic Resistance

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

In a world, where a scraped knee could lead to sepsis and death.  When your life is no longer your own, because everything you know about infections is wrong.  One man in a lab, in 1920’s London, will change the world…forever.  That man we now… know…as….the Penicillinator!  I am terrible at new super hero names, but I couldn’t resist when I heard of the passing of Hal Douglas.  Hal Douglas had that famous gravelly baritone in thousands of movie trainers.  He did voice over work for over sixty years and passed at the age of 89.  The age of “In a world…” is over.

The age of antibiotics might be over too.  I read an article in medium.com by Maryn McKennan about the world going into a post-antibiotic age.  In pharmacy school we learned about antibiotic resistance.  But something always sticks with you better when you witness it first-hand.  Shortly after I got out of pharmacy school, the new antibiotic azithromycin came out.  It was very popular because you only had to take it once a day and it stayed in the body for a long time.  Because azithromycin stayed in the body for a long time at low doses, azithromycin became the first antibiotic that bacteria developed resistance to during my career.  Azithromycin still works in many people for many infections, but now sometimes it doesn’t.

What are antibiotics and what is antibiotic resistance?  You have to go back to Alexander Fleming.  Sir Alexander Fleming discovered penicillin in 1928.  He was doing research on bacteria and was already known as a good researcher, but a messy lab technician.  Coming back to his lab after a few days off, he found some cultures of his bacteria that he’d forgotten had been spoiled by mold.  Instead of just throwing out all the culture plates, he noticed a zone around some of the mold was completely free of bacteria.  The mold (later named Penicillium notatum) produced a substance (now called  penicillin) that killed the bacteria.  Penicillin was eventually isolated and made in large quantities.  When it was given to people, certain infections were cured!

Penicillin was a miraculous discovery.  Bacterial infections can kill people.  Before antibiotics, strept throat, sexually transmitted diseases and infected wounds often killed people.  As miraculous as antibiotics are, they aren’t perfect.  A few years after penicillin was discovered, doctors started noticing antibiotic resistance.  In Maryn McKennan’s article, she points out that Alexander Fleming himself warned of antibiotic resistance in his Nobel Prize speech in 1945.

How do bacteria become resistant to an antibiotic?  There are different ways but it often happens when the bacteria are exposed to a small dose of the antibiotic.  This dose is either too small to kill them or given for too short a time to kill them.  For example, let’s say you go to the doctor and insist that she give you an antibiotic for your “cough”.  Then, you only take 2 or 3 days worth of the antibiotics and “save the rest for next time”.  This will kill off the most of the bacteria, but it will leave some alive.  The ones that are left will have a natural immunity to the antibiotic.  Those bacteria will reproduce and all their offspring will have a resistance to that antibiotic.  Now that original antibiotic won’t work anymore.  You now have an antibiotic resistant infection!

Another interesting possible source of antibiotic resistance is livestock.  We routinely give livestock low doses of antibiotics to promote growth.  Giving a low dose of an antibiotic for a long time is a good way to promote antibiotic resistance.  There are reports that up to 80% of all antibiotics are used in livestock.  It is possible that the antibiotic resistant bacteria in livestock can transfer to people, or sometimes the antibiotic resistant genes from one bacteria can leap into another bacteria.  The exact scope of how antibiotic use in livestock affects people is still being debated.

Why does antibiotic resistance happen at all?  Bacteria and mold have been engaged in chemical warfare for as long as there have been bacteria and mold.  Antibiotic resistance isn’t a new phenomenon.  Gerald Wright from McMaster University and his colleagues published a paper in August 2011 in Nature that showed us how old antibiotic resistance might be.  The researchers looked at Actinobacteria, which lives in soil and doesn’t cause disease.  They found some Actinobacteria was resistant to many antibiotics.  Then the researchers looked at some frozen soil from the Yukon from 30,000 years ago.  It had Actinobacteria that was resistant to penicillins, tetracyclines and vancomycin.  Why are ancient bacteria resistant to modern antibiotics?  Well we don’t really know, but one theory goes like this.  Bacteria in the soil are always competing with each other and other microbes like fungi.  Fungi, like the mold that produced penicillin, create antibiotics to kill off the surrounding bacteria.  The soil bacteria must evolve a way to protect themselves from the chemical weapon, so they evolve antibiotic resistance.  It is kind of like a microscopic arms race.  This goes to show bacteria are very capable of developing antibiotic resistance given the right conditions.

If bacteria are becoming resistant to antibiotics, why don’t pharmaceutical companies just make new antibiotics?  Maryn McKenna’s article suggests it is because there is no money in it.  It takes a pharmaceutical company about 10 years and $1 billion to bring a drug to market.  Bacteria seem to develop resistance to new antibiotics in about 1-2 years and doctors stop using them in about 5 years.  So the pharmaceutical company only has 5 years to make back its $1 billion investment.  From a financial point of view, making cholesterol and blood pressure pills makes much more sense.

Maryn McKenna’s article points out many unsettling facts about a possible future in which antibiotics don’t work.  Without antibiotics, it would be very difficult to do common procedures like caesarian sections, prostate surgery or even kidney dialysis.  Infections would kill many people who had these procedures.  In cancer treatment, we routinely knock down the patient’s immune system to treat the disease.  If you do that without viable antibiotics, the cancer treatment might become as dangerous as the cancer.  Even things like a cut finger, piercing your ear or getting a tattoo could put your life in danger.

What should we do so our antibiotics will work when we need them?  Start with non-drug measures.  Wash your hands.  Coughing and sneezing into the crook of your elbow reduces the chance of spreading bacteria.  Listen to your doctor when she says you don’t need an antibiotic for your cough.  Treating a viral infection with an antibiotic won’t make you better and can promote antibiotic resistance.  And if your doctor gives you an antibiotic, finish your antibiotics! Do not stop taking an antibiotic part way through the course of treatment without first discussing it with your doctor. Even if you feel better, use the entire prescription as directed to make sure that all of the bacteria are destroyed.  Dead bacteria don’t cause resistance.

Countries like Denmark, Norway and the Netherlands have been able to turn the tide against antibiotic resistance.  They have put in place tough government regulations on the use of antibiotics in medicine and agriculture.  So maybe one more stab at superhero names.  The villain MRSA is back and he is more evil than ever.  In a world, where The Penicillinator is on the ropes, who will save us?  One woman and her name is…The Government Regulator!

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

We now have most of the articles published in the Parkland Shopper on our Website www.dcp.ca

As always if you have any questions or concerns about these or other products, ask your pharmacist.

Maryn McKennan’s article on a Post Antibiotic Future –https://medium.com/editors-picks/892b57499e77

Hal Douglas in Jerry Seinfeld’s The Comedian Trailer –https://www.youtube.com/watch?v=fVDzuT0fXro

A few more Hal Douglas Trailers because they are fun –http://www.theguardian.com/film/filmblog/2014/mar/13/hal-douglas-trailers-voiceover-six-best

This American Life and good vs bad Super Hero Names and Powers –http://www.thisamericanlife.org/radio-archives/episode/508/superpowers-2013?act=3

Asthma Basics

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

Someone asked my son Eric when his birthday was.  He said January 12^th.  I told Eric that wasn’t quite the right month.  I thought I could prompt him.  I told him we would go through the months so he could get the right one.  I started by saying “January….” I expected him to continue “February, March…” etc.  My plan was to stop him at July, his birth month.  Instead I said, “January…” and  Eric thought for a second and continued “ Tuesday, Wednesday…”.

As a parent, sometimes you don’t know how little your children know about a subject until you ask them.  As an asthma educator, sometimes I forget how little some asthmatics know about their disease.  I hear things like: “Well, you know he has to play in goal.  He can’t skate with the other players.  He has asthma.” and “I just want to fill my daughter’s blue puffer.  If she uses the blue one four times a day, she feels so well she doesn’t need that steroid inhaler.”  When I hear these things, I realize that maybe it’s time to go back to asthma basics.

I think asthmatics have two main understanding deficits.  The first problem is many asthmatics don’t use their inhaler properly.  Many asthmatics think they’ve been using their inhalers properly for years.  However, when researchers test asthmatics, about half of them don’t have the correct technique.  The simplest way to make sure you are using your inhaler properly it to take it to your pharmacist.  The next time you fill your inhaler, ask your pharmacist to watch you use it and help you adjust your inhaler technique.

The next problem is many asthmatics have is they think their asthma is under good control, but it isn’t.  Having asthma should not stop anyone from doing any activity.  How do you know if your asthma is under control?  Let’s start with 6 easy questions:

• Do you have problems with coughing, wheezing, breathlessness or chest tightness 3 or more times per week?
• Do you need to use your fast acting inhaler 3 or more times per week?
• Do symptoms like cough, wheeze, breathlessness or chest tightness wake you up more than once a week?
• Have there been any physical activities that you were unable to do in the past 3 months due to your asthma?
• Have you missed any school or work in the past 3 months due to asthma?
• Have you had to go to the emergency room or hospital due to asthma in the past 6 months?

If you answered yes to any of these questions, your asthma is not under good control.  Don’t get excited or upset.  If your asthma is not under good control, we can do lots of things to fix the problem.  Let’s start by learning how asthma affects the lungs.

Most of the problems in asthma are from inflammation in the tubes in your lungs.  Since most of us have never seen the inside of our lungs, let’s talk about the back of your hand.  Picture your hand holding a cup of coffee.  If you rub a feather or sprinkle some sand on the back of your hand, nothing happens, right?  Now let’s put a poison ivy rash on the back of your hand.  The poison ivy will make it red, and inflamed.  Now if we rub a feather or sprinkle some sand on your hand, it will hurt, muscles will twitch, and you will spill your coffee.

To prevent you from spilling your coffee, we could treat your hand in two ways.  We could inject some muscle relaxants into the muscles.  This would mean that even though rubbing the feather on your hand would hurt, the muscles would be too relaxed to spill your coffee.  We could also rub some steroid cream onto the red, inflamed rash on your hand.  Over a few days the cream would slowly reduce the rash so that rubbing the feather on your hand wouldn’t hurt and you wouldn’t spill your coffee.

This is how we treat asthma in the lungs.  When you are having an asthma attack (like coughing, and wheezing), we can give you something that will immediately relax the bands of muscles around the tubes in your lungs.  This fast acting inhaled medication is usually called salbutamol or Ventolin which comes in a blue puffer.  Just like with your inflamed hand, if a little bit of dust, cold air, or some other irritant gets into your inflamed lungs, the muscles over-react and you cough, and wheeze.  So the fast acting inhaler relaxes the twitchy muscles in your lungs and stops the coughing and wheezing.  The short acting inhaler does NOT fix the underlying problem of inflammation in your lungs.  As an extra problem, short acting beta-agonists like salbutamol or Ventolin, speed up the heart.  So if you use too much salbutamol or Ventolin it can be hard on the heart.

So how do we fix the inflammation in the lungs and not speed up the heart too much?  Just like with your inflamed hand, we use a steroid.  In the lungs we use a steroid puffer, not a cream, but if we use it every day, over weeks and months the inflammation in the lungs will go down.  After the inflammation goes down, if you inhale a little dust or cold air it won’t make you won’t cough and wheeze.

This is why we say that ideally we want an asthma patient to use an inhaled steroid regularly every day to keep the inflammation down and only use their short acting inhaler (like salbutamol or Ventolin) three or fewer times a week.

We can fix the two most common problems asthmatics have.  Get your pharmacist to review how to properly use your inhaler.  Then if you answered yes to any of the 6 asthma control questions, talk to your doctor or pharmacist.  We can make simple changes like using a steroid inhaler regularly to make you breathe better.

Eric is doing better now at distinguishing between days of the week and months of the year.  He even knows his birthday is in July not January now.  However, now he is still bitter that he can’t go to a Kings game on his birthday, but I don’t think I can fix that.

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us at www.dcp.ca