Preventing Liver Failure, Injury, and Death: The Pharmacist’s Role in Acetaminophen Safety
In several countries including Canada, acetaminophen overdose is the leading cause of liver failure that results in permanent injuries, transplants, and death.
Acetaminophen is a safe medication when prescribed, dispensed, and taken appropriately. Risk is introduced when acetaminophen is taken in combination with other acetaminophen-containing products. Factors contributing to unintentional overdose include:
- Lack of consumer awareness regarding the presence of acetaminophen in non-analgesic over the counter (OTC) products
- Unclear dosing instructions on product labels
- Simultaneous ingestion of prescription and non-prescription medications containing acetaminophen
In Canada, changes to product labels in 2009 and 2016 to better communicate overdose risk were unsuccessful. A research study published in the Canadian Medical Association Journal found that the new labelling standards did not lower the rates of hospital admission for accidental acetaminophen overdose. Researchers asserted that additional prevention strategies are needed, and prescribers and pharmacists have a key role to play in educating their patients to prevent accidental overdose of acetaminophen.
Some patient counselling strategies include:
- Review all OTC medications with your patients, especially if they are prescribed a prescription product containing acetaminophen
- When patients are seeking or using OTC medications containing acetaminophen such as cough and cold products or muscle pain products, discuss the potential risk of toxicity and safe dosages of acetaminophen
- Make sure that parents and caregivers understand how to dose children’s acetaminophen products and that weight-based doses are based on an accurate weight in the appropriate units (for example, kilograms versus pounds)
- Inform parents that pediatric formulas are available in different concentrations
Patient education and counselling can help prevent potential overdose of acetaminophen and risks of liver injury and death. Below is a list of other resources on acetaminophen safety issues:
- ISMP Canada Safety Bulletin: Death Investigation – Acetaminophen Overdose: Managing a Duplication Error – June 22, 2022
- Medscape Pharmacists – May 04, 2022
- ISMP Safety Bulletin Acetaminophen: Preventing Harm through Safe Use – April 27, 2017
- ISMP SafeMedicationUse.Ca Newsletter – February 6, 2014 (for the public)
Guidance for Pharmacy Professionals During Specialized Infant Formula Shortage
Due to a global shortage of infant formulas for infants with food allergies and certain medical conditions, Canada is experiencing an acute shortage of extensively hydrolyzed formula (EHF) for moderate food allergies, and amino acid formulas (AAF) for complex or severe food allergies. Several specialty formulas are now available and in stock in limited quantities in Manitoba and can be ordered from specific distributors. Canada has not seen a shortage of the regular infant formula.
When assisting patients with formula choices, please refer to the Use of Specialized Infant Formula during a Shortage Decision Tree.
A provincial working group has been convened to coordinate the response to the shortage of specialized infant formulas in Manitoba and will update healthcare providers through Shared Health and Manitoba Health communications channels.
Pharmacy professionals with questions can contact Population.PublicHealth@gov.mb.ca for more information.
The College and the provincial working group on infant formula shortage strongly recommend that pharmacists consider measures to manage supply of amino acid-based formulas and extensively hydrolyzed infant formulas via the following:
- Keeping specialty formula behind the counter to ensure supply for those infants who need it most.
- Limiting purchases of regular formula, given the potential pressure this specialized formula shortage could have on regular formula supply. It is also recommended that pharmacies consider placing purchase limits on all formula products (e.g., providing a two-week supply of formula). The CPhA has provided a resource document on typical formula consumption amounts for healthy term infants here.
- Reserving specialty formulas where possible and avoid, unless necessary, transferring children to more specialized products.
- Ordering hypoallergenic formulas only upon request by a parent or caregiver, as recommended by Health Canada, until supply has stabilized.
Resources for Pharmacy Professionals
- Use of Specialized Infant Formula During a Shortage – decision tree
- List of imported products, with printable labels – Health Canada
- Hypoallergenic infant formula shortage – Information for pharmacy professionals – Canadian Pharmacists Association
- Shortage of hypoallergenic infant formula additional information for pharmacists (availability and distribution of hypoallergenic infant formula during the shortage)
- Interim policy on importation – Health Canada
- Communicating with patients – Information for families factsheet – Health Canada
NAPRA Recruitment Notice – Language Proficiency Standard Setting Exercises
(Reprinted with permission from the Ontario College of Pharmacists)
The National Association of Pharmacy Regulatory Authorities (NAPRA) recently initiated a project to review and update its recommendations related to assessing language proficiency in English and French for safe and effective pharmacist and pharmacy technician practice in Canada.
NAPRA is looking to find qualified panelists to participate in standard-setting exercises. The full description of this opportunity can be found here.
Health Canada has issued new guidance on the control of nitrosamine impurities in medications, including active pharmaceutical ingredients (APIs) purchased for compounding.
As the responsibility for risk arising from compounding activities is assumed by pharmacy professionals in the treatment of their patients, Health Canada recommends that principles outlined in this guidance should be considered when purchasing APIs and producing compounded products.
Registrants engaged in compounding are expected to use ingredients that are of good quality, produced from an authorized API used in an authorized drug product for use in Canada or listed in a recognized Pharmacopoeia (for example, USP/NF, Ph. Eur., Ph. Int., BP, Codex – Schedule B, Food and Drugs Act) as required by Health Canada’s Policy on Manufacturing and Compounding Drug Products in Canada (POL-0051) and the NAPRA Model Standards for Compounding.
Health Canada’s Drug and Health Products Inspections Database can also be consulted to determine the inspection status and compliance rating related to Good Manufacturing Practices of establishments supplying the APIs or drug products. Pharmacy professionals are encouraged to access Health Canada’s nitrosamine web page to stay informed on affected medications and recalls due to the presence of nitrosamines.
If links aren’t working in this doc, see the word file here: Z:\PubAnjaS\Friday Five\2022\2022-07-08\Article Drafts\Health Canada Guidance [AS1]
Does Your Pharmacy Sell Naloxone? Join Your Colleagues in the Fight Against Opioid Overdose and Poisoning
Across Canada, more than 26,000 people have died of opioid overdose/toxicity from 2016 to 2021 and during the first year of the pandemic, there was a 95 per cent increase in number of deaths. In Manitoba, opioid overdose/toxicity deaths swelled to over 400 in 2021 (twice the historical average of 200).
Naloxone is a life-saving drug that has reversed thousands of overdoses in Canada. Access to Naloxone is critical to preserving the lives hundreds of Manitobans and your pharmacy has a role to play.
Community stakeholders have identified that there is a lack of reliable information to direct community members who wish to purchase naloxone. This is especially true in the case of naloxone nasal spray. Your pharmacy manager can add your pharmacy to list of naloxone providers on the Pharmacy Public Register with the following steps:
- Log into the Pharmacy Portal.
- Click Update Pharmacy Information – Naloxone Sale Declaration.
- Scroll down to the Naloxone Sale Declaration section and make your sale declaration and your publication preference.
- Click Save.
One key point to remember if you choose to make your declaration:
CPhM does not monitor or audit naloxone declarations on a regular basis. It is the pharmacy manager’s responsibility to keep their listing up to date, so it’s important that there is a documented plan in place to change the declaration should the pharmacy no-longer sell naloxone.
The Pharmacy Public Register will serve as a central directory for community members and service providers to find community pharmacies that sell naloxone products.
A listing of service providers that offer free injectable naloxone kits is still available through Street Connections. If your pharmacy would like to participate in the Take-Home Naloxone Distribution Program to distribute free naloxone to the public, please visit: https://www.gov.mb.ca/health/publichealth/naloxone.html
For additional resources to support pharmacy staff and patients during the sale or administration of naloxone, please see the Naloxone category of the cphm.ca Resource Library.
Upcoming Events & Professional Development Opportunities
Mental Health First Aid Standard (Virtual) Certification Courses
See website for dates and registration information. Please note this is a non-accredited learning activity.
ISMP Incident Analysis and Proactive Risk Assessment for Health Care Practitioners and Patient/Family Advisors
September 29-30, October 22-23, November 24-25, and December 8-9, 2022
ISMP MedRec and BPMH Training for Health Care Professionals
September 23 and November 18, 2022
Medication Safety Considerations for Compliance Packaging
Preventing and Analyzing Medication Errors