May 21, 2020 The Role of the Pharmacist During the COVID-19 Pandemic

0:00 Joanne Lewis: Hello and welcome everyone to another webinar in Diabetes Canada’s COVID-19 and diabetes series. I'm Joanne Lewis and I’m the director of health care provider education and engagement at Diabetes Canada. Today's webinar is entitled “The Role of the Pharmacists During the COVID-19 Pandemic” and is presented by Esmond Wong and Daniel Burton. We're very happy to have them joining us today. If you have any questions during today's presentation, please type them in the Q&A box. You'll find that if you hover towards the bottom of your screen and they will be answered at the end of the presentation.

0:37 So just before we get started with the with the webinar, just a couple of polling questions. The first one will ask what… Sorry, get that going. What profession are you? So if you could just indicate your profession and we’ll give you a few seconds to respond to that. That's probably enough time and as we would expect. We have more pharmacists today than anything else but glad to see there's some nurses and dietitians joining us as well today. So welcome, everyone.

1:41 Our second polling question is asking you which province do you live in? So we'll give you some time to respond to that. Excellent. Thank you for sharing. And so, as with most of our webinars, most of our viewers are in Ontario, but wonderful to see representation, pretty much from every province. So thank you for that. So without further ado, I'd like to pass it over to Esmond and Daniel

2:33 Esmond Wong: Thanks, Joanne. And, and thanks everyone for listening in on a presentation. My name is Esmond Wong and I am a pharmacist and certified diabetes educator working in Calgary, Alberta and I have Dan Burton with me, who is also pharmacist and certified diabetes educator and we both have additional prescribing authority in Alberta, which allows us to prescribe medications. So let's jump in. So here are our objectives for today. I just want to highlight a bunch of ways that we as pharmacists can help with the COVID outbreak. I want to do a quick review of COVID. The provinces are starting to lift restriction, but COVID-19 is here to stay. It's not going to disappear overnight. And so with provinces lifting restrictions, this may lead to increased outbreaks until we have a vaccine and Dan's gonna talk a little bit about vaccines later but COVID-19 will be our new normal. So our role as pharmacists is even becoming more important as we try to manage this outbreak with the provinces reopening the economy. As you know, these are the symptoms. Fever, cough, shortness of breath and spread by respiratory droplets which is why we have this six foot distance, social distancing rule. And older people and people with chronic disease have more vulnerability, so how high of a mortality. Let's go to our first test question. So I'll just get you and to get the question to pop up. Uh… Joanne?

4:25 Joanne Lewis: Trying to get this to work.

Esmond Wong: No worries. I'm just happy no one is zoom bombing us right now. There we go. There it is.

5:00 That's probably enough time. Okay, good. So most of most of you got a lot of you got the right answer. So just close this and here. Whoops. There we go. So the answer is 7.3%. This comes from the Chinese Center for Disease Control and Prevention. As you can see, people with diabetes had the second highest case fatality rate overall whereas compared to people with no como morbidities, there is only 0.9. So as pharmacist, I think there's a number of things we can do to keep people safe and out of the hospital. So I think that we all have had an increased level of stress and anxiety with the pandemic. A lot of the things that bring us mental wellness have been disrupted. A huge amount of studies on well being and happiness have shown that relationships is the biggest predictor for happiness. Happy people have happy relationships and that's being disrupted by all this social distancing. Social isolation is distressing. So distressing that solitary confinement has been used as a form of punishment or even torture. Yet, an increasing portion of the North American population experiences isolation regularly with or without this pandemic. So as we become more digital and distanced… and distant from one another, I think we're becoming less connected and becoming more depressed. We've evolved to be social animals, and we are made for social connection and those connections are being disrupted right now. And that can have a huge impact on mental health.

6:39 So what can we do about it? I think as being one of the most accessible healthcare professionals, just ask your patients and normalize their feelings. For example, “Yes, Mr. Smith, a lot of my other patients have also been feeling really depressed or isolated lately. You are not only one. You are not alone in this. I think it's pretty normal to feel that way right now.” For some feeling down, just knowing that other people are feeling the same way it can be hugely comforting. Now, if you're comfortable and only if you're comfortable. I would suggest sharing a little bit of something that you're struggling with because that shows a lot of authenticity and vulnerability and that makes it easier for a patient to open up to you. Like for example, for myself, I like I really like playing board games and I used to play board games with my friends every Saturday but now I can't do that. And, you know, I've been feeling a bit down about that. I really missed that. And so I can kind of massage that into the conversation and say, “Hey, Mr. Smith. I've been feeling down to because I haven't been meeting with my friends. Are you feeling the same way?” Because there's a lot of… remember there's a lot of stigma attached to mental health and so you kind of need to overcome that to provide optimal care. And I think where we as pharmacists are really in an optimal position right now because doctors offices are closed or they're only doing virtual care, specialists are closed, no one wants to go to the hospital, so we are and have been the most accessible healthcare professional. And I think we're in an ideal situation where we can spend a couple extra minutes to try to improve our patients mental health. This is especially important if you know your patients don't seem themselves. They’re late on their meds or they look disheveled or depressed.

8:29 So if you're patient is isolated, try to reconnect them. FaceTime is free on iPhones, Zoom is a free download. If you have three people or less, you can talk for as long as you want on Zoom. If you have more than three people, then there's a restriction where it kicks you out after 40 minutes, but then you just make a new meeting and go back in and you can even get around the restriction by purchasing the plan for $20 a month. Microsoft Teams is free for a year and Google Hangouts is also free. When I hear you say that you know my patients are elderly, they don't know how to use technology. Well, show them. Like we teach people to use insulin, how to use warfarin and how to use epi pens. Surely insulin isn't more complicated than FaceTime. So what I've been doing is that I asked their permission to use their phones and asked if they have data and if they do have data, I just installed the app for them and show them how to use it. If they don't have data, then you can just show them the buttons you need to download it. You know with all the one month prescription fill rules to prevent hoarding, we might as well try to get people to socialize and they’ll be less cranky and more pleasant to deal with when they come in for the re-fills.

9:45 Meditation has also been shown to have a wide range of benefits such as reducing feelings of anxiety, reducing depression and increasing focus on the preset. There are lots of apps and YouTube channels on meditation. A lot of them have really helped me relax when I've had a hard day. And I think they're great for patients. So I suggest that you give certain meditations a try and recommend the ones that you like to your patients. I recommend stuff that I like to. I only recommend stuff to my patients that I really like. So the two that I really like are Headspace and Stop, Think and Breathe. They are both apps and they're both YouTube channels. Headspace requires a login, so usually I use Stop, Think and Breathe, that’s a little simpler. And I really like the mindful breathing exercise on Stop, Breathe and Think. It's really simple and patients can just follow along. Now I've had some patients who have had a religious objection towards meditation as they feel it's from a different belief system. In that case, I tell them it's just a mindful exercise and everyone seems to be okay with that. And you can also suggest various positive psychology exercises such as gratitude journal, practicing acts of kindness, or savoring positive experiences.

11:04 So what is positive psychology? Now I can talk about this for hours since it's a personal interest of mine. But basically positive psychology looks at happy people and then we try to copy them. Traditional psychology looks at childhood trauma and fixing negative thinking patterns, while positive psychology emphasizing increasing activities that make you happy. It's a newer branch of psychology, but now you can get Masters degrees in it or PhDs in positive psychology. There are lots of user friendly books. The best of which is “The How of Happiness” by Dr. Sonja Lyubomirsky. I'll show it at the end. I absolutely love that book. And I think it should be required reading for any health care professional that has to deal with mental health. So looking at some of the exercises. For the gratitude journal and you can try this yourself as well, you know, I would suggest your patients that they have a set schedule time to try to make it into a habit and then people will we should reread it when they're feeling down. And to be honest, I think we still have a lot to be thankful for during this pandemic. I'm really thankful to have a job when a lot of my patients don't. I'm grateful that my parents are healthy when so many people in this country have lost theirs. Practicing gratitude orients you to the positive in your life instead of always looking at the negative. Another positive psychology exercises encouraging your patients to do acts of kindness. So there's multiple points of positive emotion to capture here. Encourage your patients to capture the happiness when you're planning the kind act and when they're preparing for the kind act. Those two parts are in their full control and we'll make you and your patients feel good. If the other person is appreciative that's like an extra bonus, especially the positive increase in the relationship. Also to kind of extend feel good emotions, you can cross off journal about it. And then there's savoring a positive experience. So people with depression often will relive the worst parts of their life. It's kind of like you know how like river erodes a mountain, and then it's easier for water to flow the same way. The same thing it is for the brain. The more you, the more you relive and think about negative experiences, the more negative you're thinking will become. So if you do the opposite and focus more on the positive, the more positive you're thinking will become. For an extra boost of happiness, find a good friend and share that experience with them.

13:40 Now positive psychology is not pretending the world is all rainbows and cotton candy, because with all the death, suffering, plague and war, obviously it isn’t. However, happier people tend to deal with adversity better than people who are depressed since you know sadness and adversity is inevitable part of life. Also the how of happiness also discusses things that you can't control like your genetics. Unfortunately, people who had severely depressed parents will probably not be as happy as people who had really happy parents, but it's about making the most of what you have. You know, as a small Asian guy, it's unlikely have would have made the NHL, but if I practice and practice playing hockey, I would be a better hockey player than if I didn't practice. So just stuff I can talk for hours. I'll show you the books at the, at the end, but now I need to shut up and move on. And  I believe this is Dan’s part.

Daniel Burton: Alright guys, so thanks for having me everybody. My name is Dan. I'm also a pharmacist working in Calgary. My area is technically in obesity, but diabetes and obesity often go hand in hand so this is kind of my really my bread and butter here. And kind of, you know, talking to some of the points that Esmond made with regards to the disheveled look partly why I'm wearing a ball cap today is because my hair is getting a little out of control. So being mindful of where those were those judgments and where you're thinking about what that disheveled look is or if they just need a haircut, because of the current pandemic. So I want to talk a little bit about, kind of a shameless plug here, that it's a project that we're starting to move forward on here in Alberta and it's, we're looking at a randomized control trial of enhanced pharmacist’s care within the community. So basically what we've kind of seen a gap in is that a lot of patients will get started on, say, an antidepressant, anti anxiety therapy and there's a lot of the guidelines kind of really laid out well in terms of, you know, proper dose hydration augmentation of therapy and that sort of thing. And so we often don't see this is happening in terms of when it's just the physician’s care. And even then, the physicians, the family physicians, in practice aren't always the most comfortable with mental health as with most people. So it kind of is once again one of those areas that's currently being under serviced and not really being properly managed. And it coincides with a lot of our patients that do have diabetes in terms of diabetic distress and, you know, having a chronic disease definitely can lead to mental health issues down the road. So this really is an interesting area and I think something that a lot of health care providers can kind of build upon and work towards so this project that we're working on right now, we're just going through ethics approval and once the pandemic and stuff like that is all finished up, we'll start recruiting patients, but essentially it's going to be a randomized control trial, looking at our control group will just be regular care with the physicians writing a prescription and they’ll be doing dose titration, that sort of thing. The pharmacist and pharmacy will just be filling the script and then in our experimental arm, what we'll be looking at his pharmacist with APA and additional prescribing authority, increasing dosages augmenting therapy, providing like Esmond said some of that positive psychology as well as motivational interviewing and you know, some cognitive behavioral therapy skills and stuff like that. In reality, that the evidence really shows that a lot of people don't need the in depth counseling that we often, you know, sessions upon sessions or anything like that. Some people just need just a little bit more of a support and contact throughout, just to kind of ask, you know, how are you. How are you doing? What's going on? And just kind of having more that supportive role and knowing that someone is there to to be there for them. So we're really excited to get this up and running and stuff like that. And if you have any further questions or anything like that. My email is there so you can feel free to reach out to me. And yeah, yeah, we're really excited to see this kind of take off.

17:36 Esmond Wong: Thanks, Dan. So the next thing we want to talk about is encouraging physical activity for mental health. So exercise is like this free antidepressant and free anti hyper glycemic medication with no drug interactions that we should be giving out like candy. You think I should have metformin like candy, I encourage physical activity just as much. So you don't need equipment to exercise at home. YouTube has enough bodyweight exercises to like last hundred years or more, but I have something created by the Diabetes Canada to show you. So here's a bunch of resistance exercises from Diabetes Canada, which you can access right now on the Diabetes Canada website. If you go to your… go to your left and look at nutrition and fitness, then exercise and activity. Then scroll down to exercise tips and tutorials. You can find the exact PDF and there's a video that you can review with your patients as well. The video shows exactly how to do each exercises. These exercises that your patients can do in the comfort of their own homes and all you need is a resistance band or thera-band and a chair. You can sell the thera-bands if you want. You can order them from pharmacy distributors, or from Amazon. I bought a 50 yard pack from Amazon for $70 and at $1.20 per yard, I just give them to patients. There are several colours to choose from, yellow having the least resistance, then red having more than green, black, blue, bronze, silver, gold. If your patients already have weights, here's another set of exercises which you can also access on the website. To be honest, though, like for a lot of our elderly patients weight wise, they don't need heavy dumbbells. They can probably just make do with like canned soup or canned beans or something so much as that.

19:27 So of course before recommending exercise, you want to make sure that they're fit to do exercise. You can get either a doctor's okay or having them fill out this PAR-Q questionnaire which assesses patients readiness for exercise. You can Google it and download it for free. This is to ensure that the patient is safe to do physical activity. One of my goals is to go through my career without having to use my malpractice insurance. So patients also really like this option because you know, people in general hate going to a gym, and I understand why. When I went to Gold’s Gym, there was a bunch of steroid monkeys lifting twice as much as me and grunting like crazy. So I have a lot of patients who enjoy just working from home. So in summary, encouraging physical activity is a great way to improve patients mental and physical health. And so now we'll go on to the dispelling medication myths.

20:23 Daniel Burton: So this has obviously been a very, very hot topic in terms of this pandemic and I don't think we've really seen an opportunity for so much misinformation to get out there and to have such a big effect. First ones I want to touch on here are the ACE inhibitors and ARBs, so the kind of the theory behind that is because COVID-19 or coronaviruses tends to use an enzyme called ACE-2, to which is primarily found in our lung tissues. The virus uses the enzyme, binds to it, then enters the cell and actually down regulates as to expression. Now ACE-2 does have a role in other organs throughout the body, and it is thought that maybe this down regulation of the ACE-2 is kind of what leads to cool vids more effects and kind of multi organ failure and people ending up in the ICU and such. The question is whether ACE inhibitors and ARBS are beneficial or harmful. More looking at the ARBS because ARBs, what they do is they increase the expression of ACE-2. So again, the theory behind that is that if ACE-2 is being increased, more the virus will be able to bind and get into cells and wreak more havoc in that sense of things. But at the same time if ACE-2 is being down regulated by the virus and ARB increasing expression of the ACE-2, might also be beneficial. In reality we really can't say yay or nay whether they are beneficial or harmful. Most of the, like Hypertension Canada, most of the regulatory bodies, are saying, you know, definitely do not pull people off these medications. If patients are talking about stopping them, you know, making sure they're talking to their health care providers before that's happening. Just because you know if all sudden blood pressure is going uncontrolled and other issues are ongoing definitely much more of a concern. In terms of when a patient gets… is admitted to hospital kind of the same rules apply if that patient is coming in with an AKI or other issues that might be related to COVID, you know discontinuing the ACE and ARBs would be appropriate in that sense, but not just because they're coming in and they have, they've tested positive for COVID and they have a lung infection. It's not currently being recommended to discontinue it at this point in time. So, as with pretty much everything in this this current virus, the evidence is evolving. But for the most part, a lot of the researchers thing that there is no increased harm with it over all.

22:46 Now, with regards to the NSAIDs, so this has been kind of a fun topic that's been circulating. Originally, the big scare of this one came out of France, where they kind of noted that a whole bunch of people that were in the ICU were younger individuals and a number of them had been on NSAIDs or had taken NSAIDs prior to and so they kind of made the correlation that NSAIDs increase your risk of a more severe infection to the COVID. A number of different confounding factors with that in respect to that. One, it was kind of more the Health Minister of France who was saying that and not really the rest of the medical professionals that were working there. As well, they were saying, you know, large doses of NSAIDs and they didn't really quantify what is a large dose of NSAIDs, because we know NSAIDs can cause all kinds of problems in large doses. So was that what was driving them to the ICU or not. As well, we've got other confounders in terms of many European countries tend to have higher smoking rates, particularly with France, compared to, say, North American countries and that sort of thing. So the number of compound is there and so really we found it was dispelled and the WHO actually put up a statement saying that they were against NSAIDs but they quickly retracted it the next day. So the other thing that we need to be concerned about with the NSAIDs is that the idea behind it is that you know NSAIDs are anti inflammatory, they do reduce that inflated inflammation response. No evidence to say that it will negatively impact COVID infections or down regulate the body's ability to fight off the infection. What we're kind of more worried about in this sense, is the masking of symptoms. So once again, if there, if someone's taking it and said regularly, they could potentially have some low level symptoms of COVID that say the infection is building in their body and they're still out and about and maybe interacting with people, not realizing that they're sick. As well as kind of delaying that getting treatment and stuff like that so it may kind of match those symptoms as with kind of any cold and flu. That's always the tends to be the concern with the NSAIDs. But again, we sometimes do use it for managing fevers and such like that. In hospital, they tend to use Tylenol more frequently, but in some situations, they may use NSAID in that case. In general, Health Canada and the other regulatory bodies really aren't saying, definitely aren't saying stop your NSAIDs if you're using them for chronic condition. Again, if the patients coming in with things like an AKI or other complications that are due to the NSAID itself and not necessarily NSAID and COVID, yeah, we probably want to look at discontinuing but again that's a conversation to have with their clinician or qualified health care provider in that sense.

25:18 Potential treatments. So this has also been a really fun area. I don't know if Trump is still taking his hydroxychloroquine at this point in time, but you know he's he's, he's the one that's been really pushing it. And unfortunately, you know, we've been seeing all kinds of scripts and stuff like that. I think what we really need to look at is that one hydroxychloroquine hasn't been proven to provide any good. There was some initial evidence that maybe it was providing some benefit. However, a lot of hospitals and critical care units and stuff like that are actually pulling it from their treatment protocols, at this point in time, because it's really providing no benefit whatsoever and actually might be causing more harm in terms of arrhythmias and other heart issues and that sense of things. If you are getting physicians and stuff like that calling and scripts for hydroxychloroquine for themselves and families and stuff like that, it is very much your due diligence to ensure that you are, you know, not filling those prescriptions and not providing those prescriptions, if they are inappropriate. If they are seeking them for COVID-19 and that sort of thing, definitely not appropriate. And so making sure you're doing your due diligence. I know a number of the colleges across the country are looking at that and are cracking down in that sense of things, both physician colleges and pharmacy colleges. So just so you're aware of that. As well, we don't want to cause a drug shortage for the people who actually do need hydroxychloroquine. So those people that are you know they have the various conditions that we actually do have an indication for treating it.

26:47 Lopinavir, ritonavir, I always hate the anti-virals, have never been any good at pronouncing them. Again, this one has been kind of going off the shelves like hotcakes but no evidence in this at this point in time. Yeah, very, very, very limited, if anything. The one that’s showing the most promising is this Remdesivir. Maybe, the data looks good. Currently it's on a lot of treatment protocols for the hospital infections. Again, not really being used in the community, if at all, so it's more than that patients in the ICU and we're kind of throwing up a Hail Mary to try and help and treat and reduce their reduce their symptoms and hopefully clear the infection a little bit more quickly for them. A number of clinical trials are ongoing. So again, the evidence will evolve, but it's certainly not going to be the Holy Grail that's going to manage and get rid of this virus for us. There is a number of other different molecules and stuff like that that are being looked at as well as different kinds of therapies. So, some of these are looking at how can we down regulate the immune system because there seems to be a bit of an amino hyper overdrive, if you will. So if we can down regulate certain parts of the immune system, but still fight off the virus that's kind of what we're hoping to look for in that sense of things. Bleach, yeah, please. Please don't. Don't do anything with bleach. Yeah, well, we won't get too political today. But yes, being mindful of that. And just educating your patients as to, really there isn't anything. The best things that we can do for managing and preventing infection is washing your hands and doing kind of regular care, social distancing and that sort of thing. Even though the restrictions are being lifted at this point in time.

28:28 On to the next slide there. So this was just a really interesting article that I came across, and Dr. Sue Peterson was actually wrote a blog post on this. So I thought this was just more something that was really cool and just kind of wanted to share with you guys. So, it's one of the theories as to why men are at higher risk of the COVID infection and developing more severe infection. Originally it was thought that males tend to have a higher risk of cardiovascular disease and other comorbidities. But it actually might be due to hormones, in particular testosterone. So as we said before COVID uses ACE-2 to enter the cells. But there is another enzyme that's kind of more upstream is called the transmembrane protease serin 2 enzyme. So what we know is that the gene in coding this receptor is primarily driven or somewhat driven by the androgen and so testosterone and males tend to have more testosterone. So the theory is that men have more testosterone, they'll produce more of this enzyme, making it easier for COVID to essentially infect them. So now there's actually some clinical trials ongoing in terms of I think they're using estrogen patch for a few days to see if the female hormones and providing it to males might actually reduce the severity of infection. Again, this is kind of the clinical trial/ICU aspect of things. Throwing a Hail Mary and just giving it a shot. The evidence, again, is very, very limited this point in time, but an interesting, interesting point. Nonetheless, so we'll kind of see how things evolve in that respect of things again likely will not be the holy grail, but yeah, if people are asking about it or seeing it on the internet, you'll have a little bit more info in that respect.

30:04 Vaccines. So this is a really, really interesting area. There's hundreds of ongoing trials right now and you know you kind of get a little blurb, an update on this, this group has started in human trials, what have you and stuff like that. We're not really sure how this is all going to play out at this point in time, because the vaccines, you know, looking at long term immunity is it's going to be something where we do one vaccine. It's one shot and done, is it going to be, you're going to need multiple vaccines. We know the virus has been mutating so it is going to turn into something like the the flu every year where we basically have to create a new vaccine every single year. At this point in time, very, very tough to say, and yeah, like I said, we don't know where that immunity is because we're seeing some people that are getting reinfected with COVID as well. So will the vaccines even really do anything. I think right now, this is currently our best bad at getting a better control and better management of COVID but again, too early to tell. Right now, at this point in time, but hopeful and in reality it's probably still going to be about 12… 12 to 18 months before we actually have something that's completed the trials and ready to come to market. And then it becomes the whole challenge of scaling up production and stuff like that, which will be a whole other headache all on its own. So we'll see where things end up. But yeah, we'll stay kind of, keep the pulse on that one. It's still very early, and we'll see how things go.

31:29 Esmond Wong: Alright. Thanks, Dan. So another important part that will that us pharmacists can play is keeping up like patient's blood sugar's under control. So you know, when my friend Conrad sent me this, I laughed because I probably came five pounds since the pandemic. Instead of going outside and do physical activity with my friends have been kind of stuck indoors and boy that refrigerator opened up a lot more frequently. So if they're snacking at random times, then you may want to suggest adding both insulin or repaglinide. Next couple of slides will review how to start in and adjust bolus insulin for excessive snacking. And if your sugars are high all the time, then in general that it may be easier just to adjust their basal insulin. So again here are the A1C targets. If you're writing the CDE exam, which has now been postponed until October, you should have this memorized. Generally we're aiming for an A1C of seven. Fasting blood sugars of 4.0 – 7.0. And that two hour postprandial, 5.0 – 10.0. And this is appendix 9,  which is a really useful guide on how to titrate insulin. Every patient that I have on insulin, I probably have had to adjust them during the pandemic. People are either just snacking more or they’re unemployed or depressed or more sedentary or something else is going on. And I've had to adjust basically everyone's insulin. So just some tips for adjusting basal insulin, generally you increased by 10% daily or for degladec, you would adjust 4 units weekly or 2-4 units twice weekly.

33:05 So here is our first sample question to calculate a person's insulin to carb ratio. And I'll just pass things over to Joanne for a bit just to get that to pop up. Perfect. This is kind a typical like CDE exam question. This one requires a bit of math, so I'll give you a couple more seconds to answer it. And if you are looking for more questions, you can just look on our website. Okay, Joanne, can you see if most people have answered yet or?

Joanne Lewis: It looks like people are still calculating Esmond.

Esmond Wong: It's maybe. It's a Friday. It's hard to do calculations on Friday.

Joanne Lewis: It's actually Thursday.

Esmond Wong: Oh my god. See, like with this pandemic, work sometimes… working from home like this like I have no concept of time anymore. It's terrible.

34:37 Joanne Lewis: All right, I think everyone that's going to vote has already voted. So we'll end it.

Esmond Wong: Okay. Let's see. Perfect. So, that is correct. Good. So most of you got the right answer. Let me close this. So just to go through the question again. Basically, the standard formula is 500 divided by total daily dose. Because he's on degludec 80 and 15 of glulisine three times a day, it's 80 plus 45, and so basically you take 500 divided by 125 for their insulin to carb ratio. This equation generally assumes that people are eating 500 grams of carbohydrate per day. And generally, the higher your insulin, the higher your total daily dose to higher insulin resistance and more insulin you need. For the CDE exam, you would use this equation but in real life, I find this equation is only isn't really accurate. And I'll just use as kind of the ballpark for what their ICR is. If you're not sure, always use a less aggressive ICR and then you can increase it later. But you really want to avoid hypoglycemia. So going with a less aggressive ICR at first is always a good option.

36:02 Okay, so on to our next correction calculation question for the insulin sensitivity factor or correction factor or correction ratio. There's no standardized name for it. But here's Mr. Smith asking for you to calculate his ISF. Alright, good. Most of you got it. Let me just close it. So you have the calculation for this is 100 divided by total daily dose. So you take 100 divided by 125 and you get 0.8… Wonderful.

37:38 So another important role that we pharmacists can play is, you know, trying to get people to avoid going to the hospital and that involves a SADMANS list. So if you're a patients are affected by COVID or flu and become nauseated and they're not able to keep your fluids down, you need to need to remind them to stop the SADMANS meds. Remember, a lot of doctors are working remotely, a lot of energy close so we're the most accessible healthcare professional right now, especially with that one month restriction in medications. So this is appendix 8 in the diabetes clinical practice guidelines and you can see the SADMANS list right there. It's also important that we are looking out for people, this is mostly people type one, but if you're having ketones then they need extra insulin. Ketones occur when your body starts breaking down fat into ketones for energy. Normally, your body will use insulin and glucose for energy but in the absence of insulin, it will use ketones as an alternative energy source and ketones cause insulin resistance, therefore you need more insulin if you have ketones in your blood to overcome the insulin resistance and bring the sugars down. Once you have enough insulin and the sugars have come down to body will stop turning fat into ketones but if you let the ketones get too high, you can lead to this really dangerous situation where they get diabetic ketoacidosis and often they'll have to go to the hospital as a result. Dr. Alice Cheng actually has a great webinar on this, it's called avoiding hospital visits for people living with diabetes that happened a couple of days ago and it will be uploaded onto the Diabetes Canada website really soon. Yeah, okay, and then working virtually.

39:31 Daniel Burton: So yeah, so working virtually, hopefully I mean you're kind of trying to limit some patient interactions and stuff like that. I've been doing a lot of diabetes, actually I've seen more diabetes in the last three weeks and I have really my entire short career here but nonetheless, I've been, it's been a good experience because we were already doing a lot of it virtually so either via the phone or you can use your computer and webcam, just like we are here. I do podcasting and stuff like that. So I have a mic and a good set of headphones so that does make it considerably better for the sound and stuff on my end of things so I can be as clear as possible for patients. But in terms for kind of everyone else that's just doing their thing, I have been kind of recommending against using zoom. There was a security issue initially in terms of people's meetings and stuff like that getting hacked. They have since beef things up and using password protection, that sort of thing. I'm still not really using it, they do say that they're what we call HIPAA or PIPEDA compliant. So PIPEDA, the Canadian privacy impact guidelines essentially. There, but I find there's a lot of other better options out there that you can use. You can still share either documents and or share screens and stuff like that so you can explain things to patients that are on your screen or you know, showing them various slides as to kind of what you're talking about, and that sort of thing. Doxy.me is kind of one of my favorite examples. It actually is more like a virtual waiting room so you'll be able to see the patients that are waiting and then you'd basically just click on whoever whoever's there. Their face will show up your face will be there and you guys can have a conversation. Very, very simple to use that one. You just need your patients email you send them a link. They click the link put in their name and they're put into the waiting room so nice and simple in that sense of things. If you're looking for kind of a documentation software that kind of will integrate both there is one, it’s called Jane(EMR). It integrates with Physitrack. I use the Jane EMR from my weight management clinic that I operate. The EMR is great, Physitrack, not so much. It's kind of glitchy and a little bit more complicated for patients. It was originally designed for physiotherapist and such. Not, not the greatest but the good thing about both of those ones when we're looking at the PIPEDA compliance, those both have their servers based in Canada. So that's very important because what happens if you have servers that are based in the States, is that if Trump decides to lock down the States, all your patients data is in the United States, and you're not going to be able to get access to it and that could be a big privacy compliance breach on your end of things. And so it could be problematic in that sense, but with the Canadian servers, it stays in Canada, goes under Canadian law, etc, etc.

42:25 Google Hangout and stuff like that, they are technically all compliant and you want to go back… They are compliant, as I said, with the HIPAA and PIPEDA but again, I've been trying to avoid those ones and kind of using the above instead. There are other programs out there, you can kind of do research and see what works for you. Some are free, some cost some money or certain amount for membership. Really kind of looks and how in depth, you're wanting to go, but I do highly recommend it. The video conferencing works very well. And once you kind of get used to it is almost as good as working in person. Plus, demonstrating and showing patients various things like injecting and that sort of thing does certainly help in that respect of things. One other note in terms of the … HIPAA and PIPEDA compliance aspect of things, here in Alberta anyways, you'll probably have done a privacy impact assessment for your pharmacy or place of work. You may have to modify your privacy impact assessment if you aren't bringing one of these things and using one of these programs and stuff like that. Now I don't want you don't want that to limit you in jumping on board with these things right away. It's not mandatory that you have your PIA immediately updated or anything like that. It is something to kind of start working towards and get the paperwork done and given the current pandemic and stuff like that, you know, a lot of these privacy impact and privacy officers and stuff like that, it's very much a common sense. Like we know we're moving to virtual so they're kind of not being more lenient but just use common sense and respect of that and do your best to keep patient security and you know, use hardwire computers that you're using, say in your pharmacy or clinic. And yeah, kind of going from there and just doing doing everything that you normally would say if you were to talk to a patient on the phone and that sort of thing. So don't be too concerned about that respect of it or anything in that sense. A lot of the colleges also don't really have guidelines on telemedicine at the moment, it's all kind of that's in the works. And they're having to accelerate it all. Again, using common sense. The college isn't going to come and take away your license because you're doing virtual consults or anything like that. It's just we just don't have the guidelines yet so doing your best to protect patient privacy and patient data and stuff like that is the biggest thing and just yeah, providing patient care. If your patients need that care ultimately that's what you need to be there for and provide to them.

44:48 Final things, yeah good quality webcam, headphones, mic. Like I said, you don't have to go as in depth as I have, but it does help if you have a good set of both of them just because it improves the quality on your end of things. And if you can hardwire your computer into the Internet, that is the most ideal. I do find from 8 to 11, the internet is fantastic than about 11am on everyone who is currently at home and just Netflixing tends to come on and the bandwidth tends to die out a little bit so be mindful of that. And yeah, do your best to hardwire in that sense. But other than that, yeah, working virtually has been a blast on my end of things. And actually, I don't think I'll, I'm going to probably do a lot more virtual because patients have really loved it so far.

45:30 Esmond Wong: Wonderful. Thanks, Dan. So when I was creating these slides last week, pharmacy distributors like McKesson, Cole, Matrix, they've all reported shortages on various brands of salbutamol. So the Thoracic Society has created some guidelines for the shortage and you can google and find them. But basically, they want you to keep your patients asthma under control. So they're not using short actor reliever medication all the time. And the best way to do that is to encourage compliance with the control medications. And if they're not on control medications, then get the physician to prescribe some or prescribe it yourself. Some controller medications like symbolic can be used as both rescue and control and medications which is convenient and there's a list of substitutions here. The GINA, the global initiative for asthma, no, actually no longer recommends starting treatment of asthma with just short acting beta agonist on their own. Meaning that they suggest starting with a controller medication right away and using salbutamol PRN. So that's just a way you can help out with your patients on salbutamol.

46:40 This a quick summary for resources for patients who can't afford medications. So a lot of, unfortunately, a lot of my patients have lost their jobs. And so there's a couple things you can try. See if they qualify for the Canada Emergency Response Benefit. See if there's some local social worker you can contact for the options. Look into compassion supply programs or contact the drug rep. Drug reps are just like us where their work gets tracked, most of them need most of them need to make x number of contacts per week. And all the ones I've worked with worked with were really happy to give you samples or explain how to use their compassionate supply program. Now every province seems to have a little bit of a different take on pharmacy prescribing. Often a drug work will require a prescriber’s signatures for samples, but usually not for insulin. You know, in Alberta. Dan and I are lucky to be able to prescribe independently and so we signed for all sorts of samples like … and stuff like that. And I also think it's important to help patients when they're down. The way that my friends in Ontario talk, it’s like the pharmacy is giving … like every other month and I think part of the problem is that people think that pharmacists can only count pills. And so, you know, if I if I thought that all doctors did was put band aids on people I'd be wondering why they were being paid so much too. So here's a real good chance where we can, you know, help a patient out and change their perceptions of us. To get in contact with your local drug rep just call the drug manufacturer’s head office and they'll usually tell you who to contact and see if I can get samples or get their compassion supply program explained.

48:28 Here's some other resources on COVID. I wanted to also thank my team at the PCN for suggesting all these wonderful resources and yeah and thanks for the help with this presentation.

48:45 Here’s the positive psychology recommended reading. So my favorite is “The How of Happiness” Dr. Sonja Lyubomirsky. That book, you don't even have to read all of it. The first chapter talks about positive psychology and then you do a quiz on what makes you the most happiest and you just read the chapters that make you make you happy. “Happier” is also very user friendly. “Authentic Happiness” is by Dr. Martin Seligman who is kind of like the founder of positive psychology. That is a little bit more textbook but if you're looking more for the academic and the studies of what makes people happier, that's the book to go for.

49:26 Here are our references for this presentation and I want to thank everyone for their attention. I got some slides here to becoming a professional member, you can get access to the Canadian Diabetes Journal and the Diabetes Communicator. And yeah, thank you so much for your attention, and we'll just open up to questions.

49:55 Joanne Lewis: So if anyone has any questions, feel free to chat, to type them into the Q&A box if you hover towards the bottom of your screen that you'll see that that link.

50:19 Okay, it looks like there's no questions. You guys did an awesome job. Answered all the questions during your presentation. Oh, there's one that just popped up. The question is when do you think the one month restriction will be going away. 

50:35 Esmond Wong: To be honest, I'm not sure that's more of a government decision. I would guess that once the government's confident that there'll be no shortages on medications, that's probably when they will lift the restriction

Daniel Burton: I know they're starting to have some conversations around it and I've heard they're kind of getting more lenient, in the terms that we're not as concerned about drug shortages and stuff like that kind of everything's calm down. And I think that initial rush that everyone panicked and was going to be missing out on their on their medications and stuff so, I think there we're getting very close to it and even still, I've heard some pharmacies that are kind of going back to status quo of every three months because there doesn't seem to be any kind of supply issues at this point in time, but again, like Esmond said official guidance will come from government and colleges and stuff like that.

51:33 Joanne Lewis: Somebody’s asking to see slide 36 again.

Esmond Wong: 36, okay.

Joanne Lewis: That one with the books.

Esmond Wong: This one.

Joanne Lewis: Yep, That's 36.

Esmond Wong: Okay. Yeah, So there's this new a COVID interaction checker. Thanks for does Giselle for that one. Yeah, the BC pharmacist website has excellent videos, Alberta Health Services has all these advisory recommendations and Dan actually has a really great podcasts. Also, as Dr. James McCormick and Mike Allen has the best science medicine podcast and we have the Canadian Pharmacists Association has a bunch of resources as well.

52:25 Joanne Lewis: Thank you. Another question. What is your number one source of information for COVID-19 medication vaccine research info?

Daniel Burton: I tend to go right to the original sources. So looking at PubMed and stuff like that. You can, I mean Health Canada and the WHO and CDC and stuff like that do post their statements and they'll often link the articles that they're kind of basing their, their evidence on and such. Usually I do start on PubMed or something like that and will kind of look at, you know, find the meta analysis is, or the groups that are kind of pulling things as well, you know, a lot of other great resources say Dr. Sue Peterson's blog. She does a lot of great articles and she's type of number of different great topics and she links all the articles in there so you can pull the directory search and pull it from there. So yeah, those are kind of my go-to’s in that respective of it.

53:25 Joanne Lewis: Okay, and then one final question. Can you describe how you complete insulin initiation with clients virtually.

Daniel Burton: Yeah, so I mean it's just kind of like I would do it in person. It's exactly setup like this so I can, I can see them. They can see me and what we've generally done through the pharmacy that I'll work out of is we deliver the medication directly to the patient. And so once they get it, they give me a call. We set up a time and yeah we go over the pen, everything to look for how to do the injection and I actually get them to do their first injection, depending on the drug, right there in front of me and just making sure that they're injecting in the abdomen or other area, depending on what their preference is. And yeah, ensuring that they're 100% comfortable with it. And then if they need to follow up for their next injection, the following day or whatever, they'll call me back and we'll have another video call at that point in time.

52:22 Joanne Lewis: Okay, thank you. So that brings us to the conclusion of our webinar today. Thank you to Esmond and Daniel for a very informative and comprehensive presentation. If you've enjoyed our COVID-19 series, we will find the recorded archived versions on our website, diabetes.ca Also, great idea to become a member, diabetes.ca slash healthcare providers professional membership, where you'll get mailed copies of the Canadian Journal of Diabetes, be able to join our TimedRight community, a discussion forum and also receive a discount on our professional conference. Okay, thank you for tuning in, please stay tuned to our social media for information on upcoming health care professional webinars in the near future. And Diabetes Canada can use your financial support now more than ever. So to donate, diabetes.ca slash donate. Thank you, everyone. Have a wonderful day.