Canadian COPD Medications

Canadian COPD MedicationsI have been doing quite a bit of work recently on COPD.  With so many new medications and inhaler formats being released over the last few years, there is some clinician confusion on the role of each of these medications in the management of COPD.

Lung Association Medication Tool

The Lung Association of Ontario has developed a  list of respiratory medications in Canada.  It is an excellent summary chart for clinicians.  It covers almost every medication in Canada but was specifically designed for asthma versus COPD.

I thought I would go through and classify the current respiratory medications approved in Canada for the management of COPD and lump them by the main classes that correspond to the GOLD and Canadian Thoracic Society COPD guidelines.  I have provided the normal doses for each of these products based on their Canadian product monographs.

This list contains each of the medications and their inhaler type.  In a previous post, I covered the Different COPD Inhalation Devices and this can help in device selection and training.

Hopefully you find the information useful.

Like always, I recommend that clinicians read the product monograph of any product before prescribing it to a patient. Also this information is current as of today, the drugs approved and doses many change.

Starting Doses for Add-On Therapy in Type 2 Diabetes

Starting Doses for Add-On Therapy in Type 2 Diabetes

add-onThe choice of antihyperglycemics used in patients with type 2 diabetes has changed dramatically over the last 5 years. We have an ever increasing number of options that allow us to customize diabetes medications to best fit the needs of the patient.

For the vast majority of individuals with type 2 diabetes, the initial agent should be metformin. This is normally initiated at 500 mg BID for 1 week and increased to the maximum effective dose of 1000 mg BID.

Over-time most patients will require additional antihyperglycemics to meet their glycemic targets. The selection of additional agents should be customized to fit the needs of the patient.

The CDA Guideline Recommendations for Additional Antihyperglycemics

The CDA guideline committee has developed several useful tools to help in the selection of agents to add to metformin monotherapy. These include:

Each of these tools can provide clinicians with some guidance on which agent to choose for a patient.

Initial Dosing of Antihyperglycemics

This weekend I thought I would develop a quick tool to help clinicians with the normal initiating doses of antihyperglycemics in adults without specific circumstances that will require dose adjustments (e.g. CKD, elderly, etc.). This map contains the “standard” starting doses for each of the different agents from their product monographs (accessed May 2015).

This information is not designed to take the place of the dosing information in the product monographs, but I put this together as a helpful guide to have the normal starting doses all on one page. My goal was to supplement the great information in the CDA guideline tools mentioned above.

Important – This is provided for education purposes only, before initiating any medication the prescriber is strongly encouraged to read the product monograph

Using Different COPD Inhalation Devices

asthma-1147735_960_720I presented on the management of COPD last week and found the use of the different COPD inhaler devices was a hot topic for healthcare professionals. There are many new devices that have come to the market over the last few years and this has led to confusion for many healthcare professionals.

It is very important for all clinicians to properly train patients on these devices and I thought I would share some great resources on the appropriate technique for the new devices used in COPD. The great news is that the Canadian Lung Association has produced some excellent videos that can help to train patients on the proper use of each of these devices. I have imbedded these YouTube videos below as well as links to the manufacturers websites for step-by-step instructions.

How to use a Breezhaler

Step-By-Step Instructions to use the Breezhaler from Novartis Canada.

How to use a Diskus

Step-by-Step Instructions are covered in Part III: Consumer Information of the Serevent Product Monograph

How to use Ellipta

Step-by-Step Instructions to use Ellipta from GSK

How to use Genuair

Step-By-Step Instructions to use the Turbuhaler from Astra Zeneca

How to use a Handihaler

Step-By-Step Instructions to use Handihaler from Boehringer-Ingelheim

How to use a Respimat

Step-By-Step Instructions to use the Respimat from Boehringer-Ingelheim

How to use a Metered Dose Inhaler (MDI)

How to use a Turbuhaler

Step-By-Step Instructions to use the Turbuhaler from Astra Zeneca

Addressing Adult Immunization with the Same Passion as the Pediatric Program

On an almost daily basis there is a media story discussing an outbreak of a vaccine-preventable disease in a pediatric patient population. Healthcare professionals, public health officials and parent groups are commonly quoted regarding the negative impact of low immunization rates and vaccine exemptions on public health. Governments and public health in most countries have media campaigns on the importance of immunization in children and most healthcare professionals actively promote immunization through the first 18 years of life. But something happens when our patients reach their 18th birthday.

The Success of the Pediatric Immunization program

Don’t get me wrong, I am firm supporter of the pediatric immunization program and strongly support the efforts to ensure all of our children are protected. High pediatric immunization rates have had such a tremendous impact and are responsible for saving more lives than any other public health intervention.1

But looking at the most recent immunization data from the United States, we are achieving 90% coverage for Measles-Mumps-Rubella (MMR), polio, hepatitis B and varicella in children 19 to 35 months.2 Less than 1% of this patient group has not received any immunization and vaccine exceptions remain low at 1.7%.3

Without question, the public health campaigns and healthcare professional focus has and will continue to impact the high immunization rate in our children.

What about our Adult Patients?

Prevention of disease by immunization is not just for children; adults require immunization to restore waning immunity against some vaccine preventable diseases and to establish immunity against other diseases that are more common in adults.4 Overall, the prevalence of illness attributable to vaccine-preventable diseases is greater among adults aged ≥19 years than among children aged ≤12 years.5 Adults are at an elevated risk of morbidity and mortality from a number of vaccine preventable diseases, such as:

  • Influenza
  • Pneumococcal disease
  • Tetanus
  • Diphtheria
  • Herpes zoster
  • Measles, mumps and rubella

Vaccine Coverage in Adults

In February 2016, the Morbidity and Mortality Weekly Report shared the most recent information on adult immunization rates in adults. Although the United States is achieving excellent pediatric immunization coverage, the adult vaccine coverage is far from optimal (Table 1).5

Only 1 in 5 patients at high risk of invasive pneumococcal disease are adequately protected

Table 1 –  United States Adult Immunization Rates August 2013-June 20145
Influenza vaccine ·         Influenza vaccination coverage among adults aged ≥19 years was 43.2%.
Pneumococcal vaccine ·         Pneumococcal vaccination coverage among high-risk persons aged 19–64 years was 20.3%

·         Coverage among adults aged ≥65 years was 61.3%

Tetanus-diphtheria (Td) vaccine ·         Td vaccination coverage among adults aged ≥19 years was 62.2%
Hepatitis A vaccine ·         Hepatitis A vaccination coverage among adults aged ≥19 years was 9.0%
Hepatitis B vaccine ·         Hepatitis B vaccination coverage among adults aged ≥19 years was 24.5%
HPV vaccine ·         HPV vaccination coverage among adults aged 19–26 years was 40.2% for females and 8.2% for males


Reasons for Low Immunization Rates in Adults

Health care providers have a responsibility to ensure that adults under their care have continuing and updated protection against vaccine preventable diseases through appropriate immunization.4 The Canadian Immunization Guide provides some of the reasons for poor vaccine uptake in adults (Table 2).4

Table 2 – Common Reasons for Incomplete Immunization in Adulthood4
·         Lack of recognition of the importance of adult immunization

·         Lack of recommendations from health care providers

·         Lack of health care provider’s knowledge about adult immunization and recommended vaccines

·         Misrepresentation and misunderstanding of the risks of vaccine and benefits of disease prevention in adults

·         Lack of understanding of vaccine safety and efficacy

·         Missed opportunities for vaccination in health care providers’ offices, hospitals and nursing homes

·         Lack of publicly funded vaccine and reimbursement to vaccine providers

·         Lack of coordinated immunization programs for adults

·         Lack of regulatory or legal requirements

·         Fear of injections

·         Lack of availability of up-to-date records and recording systems

Adapted from Reference 4

How do we Improve Adult Immunization Rates

Without question, all healthcare and public health professionals have to do more to ensure that our patients are adequately protected from common vaccine-preventable diseases. We need a different method of identifying vaccine candidates and improving the discussion on vaccines for ongoing protection.

The Canadian Immunization Guide provides a comprehensive list of opportunities to discuss adult vaccines (Table 3).  Some strategies which I feel will improve adult immunization rates are reviewed in Table 4.

Table 3 – Opportunities for General Immunization Counselling of Adults4
·         New patient encounters

·         Periodic health examinations

·         Pregnancy and the immediate post-partum period

·         Visits for chronic disease management

·         Assessment of new immigrants

·         Parents attending their child’s vaccination visits

·         Hospitalization, especially when diagnosed with a chronic disease

·         Management protocols on admission to nursing homes, long-term care institutions, and acute care institutions

·         Management protocols on admission to health professional training programs

·         New employee assessments in day care, health care and health care-related facilities

·         Persons requesting specific vaccination(s)

·         Persons with evidence of risk taking behaviour, such as illicit drug use or a sexually transmitted infection

·         Individuals requesting advice concerning travel


Table 4 – Strategies to Increase Adult Immunization Rates
Vaccine Registries ·         Canada, like other nations in the world does not have a national vaccine registry

·         The use of a registry can help to identify potential candidates and engage patients and their health care professionals to ensure they are protected

·         Through the use of this technology and the ability to audit the data, public health officials can direct resources to areas with low vaccine coverage or those patient populations with elevated disease risk

Vaccines should be given at any interaction with the healthcare system ·         In many parts of the world, there are limits on where a patient can receive a vaccine and by which healthcare professional that can deliver it

·         The more access patients have to healthcare professionals who can inject vaccines, the more frequent the potential discussions regarding their role in reducing morbidity and mortality

·         Ideally all healthcare professionals should be able to inject public health vaccines for adults. This allows them to identify a vaccine candidate and inject immediately versus missing an immunization opportunity

Universal coverage for recommended vaccines ·         Most countries have some form of publically funded routine immunization program

·         Many patients will refuse to pay for an intervention that reduces their risk of disease. They may not have the resources or do not see the value

·         Providing vaccines to high-risk patients without insurance coverage can protect this highly vulnerable patient population

Integrate vaccines into clinical practice guidelines and age-related documentation ·         Many chronic diseases increase the risk of vaccine-preventable diseases

·         Having clinical practice guidelines reviewing the need for immunization can be beneficial to stimulate healthcare professional vaccine discussions in patients with these chronic conditions

·         The Canadian Diabetes Association Guidelines does this well with a chapter on influenza and pneumococcal immunization in their guideline document

·         There is continuous information sent to high-risk adult patients (e.g. ≥ 65 years old, patients with diabetes or chronic respiratory conditions) from governments or organizations. Consider adding information on vaccines in this information to increase the awareness of adult immunization

Public health campaigns ·         Consider adding adult immunization into the current paediatric immunization media campaigns. Pictures of families where multiple members are being protected (e.g. child, father/mother, grandparent) can stress that immunization is a family issue and not just a childhood issue

Working Together to Improve Public Health

All healthcare professionals, public health officials and governments have a role to play in protecting adults from common disease states. Through the active promotion and uptake of adult vaccines, we can reduce the burden of these diseases on our population.


  1. Public Health Agency of Canada Government of Canada. Benefits of Immunization – Part 1 – General Guidelines – Canadian Immunization Guide. Published July 18, 2007. Accessed April 23, 2016.
  2. Center for Disease Control. Vaccination Coverage | NIS Child | 1994-2014 Figures by Vaccine | CDC. Accessed April 23, 2016.
  3. Annunziata K, Rak A, Del Buono H, DiBonaventura M, Krishnarajah G. Vaccination Rates among the General Adult Population and High-Risk Groups in the United States. PLoS ONE. 2012;7(11). doi:10.1371/journal.pone.0050553.
  4. Public Health Agency of Canada Government of Canada. Immunization of Adults – Part 3 – Vaccination of Specific Populations – Canadian Immunization Guide – Public Health Agency of Canada. Published July 18, 2007. Accessed February 10, 2016.
  5. Williams WW, Lu P-J, O’Halloran A, et al. Surveillance of Vaccination Coverage Among Adult Populations — United States, 2014. MMWR Surveill Summ. 2016;65(1):1-36. doi:10.15585/mmwr.ss6501a1.


Pharmacy and Cannabis – Part 1

Pharmacy and Cannabis – Part 1

Pharmacy and Cannabis – Part 1

On April 7, the Canadian Pharmacists Association released a press release announcing a change in their position on the role of the pharmacist in the distribution of medical cannabis. Since the announcement, I have been thinking about what this would mean to the distribution of cannabis in Canada. I decided to look through the possible benefits and risks associated with this change.  To be completely transparent, I am a pharmacist but do not own a pharmacy and have no relationship with any of the licensed producers. Here are some of my first thoughts. 

Recreational versus Medical Cannabis Use

Although commonly lumped together, the average medical cannabis user is often very different from the average recreational user. The primary goal of a medical user is to get cannabis to reduce the symptomology of their conditions, whereas recreational users primarily want cannabis for the psychoactive effects of THC. Although there is overlap between the two groups, I personally feel the focus for pharmacists must be on medical cannabis use. 

If we want cannabis to be taken seriously as a medical treatment, we have to start looking at it differently. If we fail to disassociate medical users from recreational users, cannabis will never be seen as a legitimate treatment for patients. 

If cannabis was to become legalized in Canada, there are a large number of retailers that can help recreational users. The dispensaries and compassionate clubs have done this in the states that legalized recreational use.

Dispensing without Education is no better than the Current Model

I can say confidently that most healthcare professionals have minimal knowledge on cannabis use. Most of us were taught that cannabis is an illicit compound and its use was similar to other drugs of abuse (e.g. opioids). We cannot blame healthcare professionals as there is no product monograph for cannabis and very little research and legitimate sources of information on its use. Fortunately, this is starting to change. 

If we look at the way cannabis is distributed today, both the legal licensed producers and the illegal dispensaries are providing cannabis to patients with some health information. I think it is absolutely crucial that pharmacists step up their knowledge on this topic. If pharmacists were to dispense cannabis without a solid foundational knowledge of the medication, they would be providing no better, and maybe inferior, service to the current distribution model. 

I should be transparent and acknowledge an emerging bias as I was one of the faculty members to develop a large cannabis certificate program:

Without a thorough knowledge of cannabis, pharmacists will fail to help patients and may provide less information than what is distributed through the current distribution model.

Pharmacies Bring Access and Legitimacy

Almost every prescription medication is filled at a pharmacy in Canada. Pharmacies have a strong distribution infrastructure in place and are readily accessible to almost every Canadian. Pharmacies are designed to distribute large volumes of medications and can do this very effectively. So adding a drug like cannabis can be done relatively easily through this distribution model. 

Pharmacies also have contracts with the vast majority of third party payers. If we continue to see the legitimization of cannabis as a medical treatment option, some of these payers may be willing to pay for the therapy. Currently, almost all medical users pay by cash or credit through a licensed producer or dispensary. By making cannabis available through pharmacies, third party payers who wish to cover cannabis may allow for the online adjudication of cannabis claims. Online adjudication of cannabis could help reduce the cost to the patient and therefore increase the accessibility of this treatment to a larger number of Canadians. 

Pharmacists are also comfortable with programs that restrict the availability of certain medications. Special access programs, limited use drugs and tiered coverages are part of daily life for most pharmacists in primary care. Pharmacists can help patients and physicians with the documentation under the MMPR and help patients who need cannabis, attain it easier than under the current system. 

All pharmacies and drug distribution wholesalers have an infrastructure that ensures a medication is exposed to a consistent temperature and storage conditions from the time it leaves the manufacturing facility until it is used by the patient. If cannabis was distributed through this model, the patient would be ensured that the cannabis they are receiving is through a reputable source and has the same safety procedures as every other prescription medication in Canada. 

Coming Soon

I’d like to explore the relationship between pharmacy and cannabis more and will post about the following issues over the next couple of weeks:

  • Changes in the cost of cannabis if it moves to pharmacies
  • Changes in the availability of strengths
  • Enhanced interprofessional collaboration
  • Reducing risks to patients

Pre-Travel Assessment Form

Travel If you are providing travel health in your practice, you need to collect a fair amount of information during the pre-travel assessment.  Here is a PDF of a form I developed for health care professionals interested in travel health.

If you regularly do travel health assessments, consider software such as Shoreland’s Travax or Tropimed as they help to collect the information and provide recommendations based on the information entered.  Both have a yearly membership fee, that is easily justifiable if you are doing sufficient travel health consultations.

Immunizations and Biologic Therapy

15138207362_74cff622fd_zI have been doing some work recently with biologic therapy, specifically TNF-alpha therapy (e.g. infliximab or adalimumab).

One of the questions that comes up over and over again is vaccine concerns for patients being considered for these therapies or are currently taking these agents.

With biologics decreasing immune response, patients are not only at higher risk of serious illness and death if they are under-immunized, but there immune response can be significantly less when administered a vaccine.1  Continue reading “Immunizations and Biologic Therapy”

Common Insulin Administration Errors

FITOne area in diabetes management where I have seen confusion for patients and clinicians is the proper administration technique of insulin therapy. Needle selection, site preparation and injection administration are common areas of confusion.

Fortunately, the Forum for Injection Technique has developed an excellent guideline document which I would encourage everyone in diabetes education to review.

Continue reading “Common Insulin Administration Errors”

CDA Guideline Update on the Management of Type 2 Diabetes

CDA 2016 Guideline UpdateOn Monday March 28, 2016, the Canadian Diabetes Guideline 2016 update on the pharmacological management of type 2 diabetes was released. This update is a significant departure from

previous recommendations, as for the first time, it has a preferential second-line therapy in patients who fail to reach blood glucose targets on metformin monotherapy.1

This update now recommends SGLT2 inhibitors in patients who are not meeting A1C targets with metformin AND have clinical cardiovascular disease.1 The update states the following:1

  • “In people with clinical cardiovascular disease in whom glycemic targets are not met, an SGLT2 inhibitor with demonstrated cardiovascular outcome benefit should be added to antihyperglycemic therapy to reduce the risk for cardiovascular and all-cause mortality (Grade A, Level 1A for empagliflozin)”

Continue reading “CDA Guideline Update on the Management of Type 2 Diabetes”

Every Medical Content Developer Needs a Reference Manager

References I have been developing medical education programs and presentations full-time for over 5 years and I am many times asked some of the tools that I use to make development easier and more efficient. Today, I thought I would review my reference manager.

What is a Reference Manager?

A reference manager (citation manager) is a tool that helps you store, organize all of your references as well as their associated PDF’s and web screenshots. It allows you to organize your references in folders based on a project or on a topic. It also allows you to “cite as you write”, this means that as I am developing in Word, I can insert a citation by the press of a button and it will be automatically be imported into the document.

The Great Features of a Reference Manager

I feel the most incredible features of a reference manager are:

  • The ability to easily insert a new citation into a developed document
  • If you need to copy and paste a referenced piece of information from one Word document into another
  • Never have to manually enter the citation
  • Citation styles
  • Free

Continue reading “Every Medical Content Developer Needs a Reference Manager”