Ease The Way for Administration of Challenging Medications

Some drugs are just difficult to administer.

One such drug is varenicline solution (Tyrvaya), a prescription nasal spray used to treat the signs and symptoms of dry eye disease. Because the medication must be administered towards the anterior portion of the nasal cavity, not breathed deep into the nasal cavity, it causes some challenges.

“Using a nasal spray to treat dry eye may not inherently make sense to some,” said Meighan LeGrand, PharmD, Shields Health Solutions in Stoughton, Massachusetts, explaining that the administration of this spray is completely different from a patient’s pre-conceived ideas from their experience with other OTC nasal sprays.

Tyrvaya administration can also require many of steps, including priming the bottle with 7 initial sprays (and re-priming if it hasn’t been used in more than 5 days), coordination between administering the spray while placing one’s tongue on the roof of their mouth, and storage directions to replace both the clip and cap of the bottle after each use.

“With many steps to remember, there are more chances for error and improper administration,” LeGrand said. “There is a lot of coordination involved in administering this medication that many patients will not continue to do over time.”

But difficult to administer medications are a challenge that pharmacists are used to. Between allergy nasal sprays, inhalers, and injectables, some medications are simply harder to administer than others, as appropriate use involves several steps that must be performed with good technique and in the correct order.

“The challenges of administering certain medications can be due to the need for a device such as an inhaler or syringe to get the drug into a patient,” said Thomas So, PharmD, senior manager with consumer drug information group, FDB. “Often these are not intuitive and require dexterity and coordination.”

Further Examples

Consider nasal sprays, which come in many types, such as pressurized cannisters or pump bottles. The different types of sprays require different preparation before use. Some should be shaken, some should not be shaken, some need to be primed before a dose or non-use for a certain amount of time, and others can be sprayed without priming. This can be difficult for patients to remember, especially if they are using multiple sprays.

Chase Parks, PharmD, pharmacy manager at Intramed Plus in Columbia, South Carolina, shared several examples he’s encountered with patients having difficulty administering medications.

For instance, Hizentra, an immune globulin subcutaneous injection, can require up to 8 different injection sites in the stomach for 1 dose; injections must be given at the same time and must be 2 inches apart. This makes it very difficult for the patient to administer.

Then there’s albuterol inhalers for children, which can be very difficult because it requires a decent amount of coordination, which could be difficult for children who are not breathing well.

“The pharmacist’s role is not only counseling the patient on how to use the medication, but to continue to engage the patient to ensure they are administering the medication correctly frequently,” Parks said.

Keri Hurley, PharmD, MPH, BCACP, assistant clinical professor in the Department of Clinical Pharmacy Practice at the University of California Irvine, noted that insulin pens are also challenging, as patients have to store them correctly, attach a new needle for each injection, dial the pen to the correct dose, clean the injection site, use appropriate technique to ensure the full dose is administered, and safely dispose of needles.

“If any of these [steps] are done incorrectly, different problems can arise,” she said. “For instance, degradation by heat can make the medication less effective, plus there’s the possibility of under or over-dosing, and risk of infection.”

Counseling Patients

The pharmacist can play a key role in making sure that a patient is counseled on how to use their particular medications whether they are nasal sprays, oral inhalers, or injectable medications like insulin.

“Many of these types of medications come with Instruction for Use leaflets from the manufacturer; however, these leaflets can be in font sizes that are difficult for the elderly to read,” So said. “Pharmacists can now leverage patient education solutions that include leaflets with pictograms and the Universal Medication Schedule (UMS) calendar and instructional videos that can be viewed by patients to learn how to properly use their medication to get the most from their treatment.”

These materials are available in multiple languages, including Spanish, French, Chinese, Korean, and Russian among others, if English is not the patient’s primary language. These videos also contain language at the fifth to eighth grade level, to help patients with low health literacy and comprehension.

A significant proportion of pharmacy education is dedicated to patient counseling.

“We also have training in how medication devices work, so we can trouble shoot when patients do not experience favorable outcomes,” Hurley said. “The first thing I do when patients report that they are not having the expected outcome from their medication is to ask how they are using it, and often have them show me how they are using their device to see if there are any issues with technique.”

So recounted a story of a gentleman diagnosed with diabetes who needed to be counseled on how to administer insulin.

“The teaching included injecting the needle into an orange, because the orange skin simulates the feel of injecting the needle into the abdomen skin,” he says. “Unfortunately, after this training, the gentleman returned to the emergency room with hyperglycemia. When he was asked by emergency department staff, [if he was using his insulin], he replied, ‘Yes, I injected the orange and then I ate the orange.’”

So’s story is a reminder of why it’s important for pharmacists to ensure that their counsel is being understood by patients—and understood correctly.