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TRANSCRIPT
Rheumatoid arthritis (RA) affects more than one million
Americans and leads to deformity and disability. It is an au-
toimmune disease which means that the immune system of
the body mistakenly attacks healthy tissue. The disease is
characterized by inflammation of joint synovium, which is
the membrane that lines
and produces the fluid
that lubricates the joint.
This inflammation
leads to destruction of
the soft and bony joint
tissues with weakening
of muscles and tendons
and then deformity.
Systemic inflammation
includes not only joints,
but also blood vessels
(vasculitis), nerves
(myelopathy, myopa-
thy, neuropathy, etc)
and the heart (coronary
heart disease).
Factors linked to the
disease include infec-
tion, family history, environmental
exposures and hormone changes. The
age of onset ranges between 50-75
years, with the 60’s being the most
common. Women are three times more
likely to have RA than males. Ciga-
rette smoking is a strong risk factor
along with obesity and increased birth
weight.
Symptoms typically affect joints on
both sides of the body equally. Fingers,
wrists, knees, feet, elbows, ankles, hips
and shoulders are the most commonly
affected. Patients typically have joint
pain, stiffness and fatigue. They may
complain of morning stiffness, which
lasts more than one hour. Joints may
be swollen, warm, tender and stiff par-
ticularly when not used for an hour. Other symptoms may
include pleurisy, dry eyes and mouth (Sjogren syndrome),
and itchy, burning eyes. With severe disease, there may be
nodules under the skin, numbness, tingling or burning in the
hands and feet and possibly insomnia.
Abnormal lab tests
along with X-rays can
help determine if a pa-
tient has RA. Tests may
include CBC, C-
reactive protein (CRP),
erythrocyte sedimenta-
tion rate (ESR), anti-
CCP antibody and
rheumatoid factor (RF).
Depending upon the
stage of disease, lab
tests may be falsely-
negative and x-rays
may not show joint
changes in the early
stages; therefore a diag-
nosis must be based
upon a combination of
signs, symptoms, blood tests and x-rays. The chart on page 4
explains the symptoms and findings with mild to severe dis-
ease.
The exact cause of RA is unknown but we do know that
there are many pro-inflammatory substances which contrib-
ute to joint destruction such as tumor necrosis factor (TNF),
interleukin (IL)-6 and others. It is important to understand
the targeted area for drug therapy used to treat this debilitat-
ing disease.
ACUTE PAIN RELIEF MEDICATIONS
NSAIDs provide fast symptomatic relief because of their anti
-inflammatory properties but they do not modify disease pro-
gression. Doses of 3200mg/day of ibuprofen, 1000mg/day of
naproxen, 20mg/day of piroxicam, or 200mg/day of celecox-
ib are typical. Benefits must outweigh risks associated with
possible gastrointestinal damage, renal disease and heart fail-
ure. The medications with the lowest GI
Rheumatoid Arthritis: An Overview
A Publication of Neil Medical Group, The Leading Pharmacy Provider in the Southeast
January/February 2019
PHARM NOTES
Volume 22, Issue 1
Continued on page 4
Inside this issue:
Rheumatoid Ar-
thritis: An Over-
view
1
Andexenet Alfa 2
Drug Update:
Toujeo Max
SoloStar®
3
Conclusion:
Rheumatoid Ar-
thritis
4-5
Adrenal Fatigue:
A Real Disease?
6-7
Neil Medical
Group Contact
Information
8
Andexenet Alfa: An Antidote
Page 2
PHARM NOTES
Anticoagulant drugs are used for the treatment and prevention
of venous thromboembolism (VTE) and embolic stroke pre-
vention. Although very beneficial and life-saving, these agents
increase the risk of bleeding events that may be minor or life-
threatening. In long term care facilities, it is estimated that
34,000 adverse events from warfarin use (Coumadin) occur
each year. In clinical trials of pa-
tients receiving Factor Xa anticoag-
ulants, there is a 2.1-3.5% chance of
major bleeding per year. Oral Factor
Xa inhibitors, such as apixaban
(Eliquis) and rivaroxaban (Xarelto),
are some of the newer anticoagu-
lants that have been developed
within the past few years. Unlike
Coumadin, whose reversal agent is
vitamin K, Factor Xa inhibitors
have not had a reversal agent availa-
ble until very recently. Andexenet
alfa (Andexxa) was approved in May 2018 under accelerated
approval for the reversal of anticoagulation in patients taking
Eliquis or Xarelto who have uncontrolled or life-threatening
bleeding. It has not been approved for any Factor Xa drugs
other than Eliquis and Xarelto. Its continued approval will be
based on the completion of post-marketing trials. It is manu-
factured by Portola Pharmaceuticals.
In the normal clotting process, Factor Xa is a protein that is
responsible for converting prothrombin into thrombin. Throm-
bin then activates clot formation. Factor Xa inhibitors bind to
Factor Xa and inhibit this process, resulting in no clot for-
mation. When this happens, bleeding can occur since the
blood cannot clot to stop the bleeding. Andexxa is a recombi-
nant modified human Factor Xa protein decoy that works by
binding to and inhibiting Eliquis and Xarelto. It is available as
a powder in a single-use vial of 100 mg of the drug. It has to
be reconstituted prior to intravenous (IV) administration. Dos-
ing depends on the dose of Eliquis or Xarelto that a patient is
on. If a patient is on < 5 mg of Eliquis, <10 mg of Xarelto, or
if the last dose was given more than 8 hours ago, then the pa-
tient should receive low dose Andexxa. High dose Andexxa
should be used if the patient is on >5 mg of Eliquis, > 10 mg
of Xarelto, or if the last dose was given less than 8 hours ago.
The dosing regimen for low dose Andexxa is: 400 mg IV bo-
lus administered at a rate of 30 mg/minute, followed by a 4
mg/minute IV infusion up to 120 minutes. The dosing regimen
for high dose Andexxa is: 800 mg IV bolus administered at 30
mg/minute, followed by 8 mg/minute IV infusion up to 120
minutes.
There are no contraindications to Andexxa; however, warn-
ings include: thromboembolic, ischemic, and cardiac events,
including sudden death within 30 days after administration.
These can occur since clots are allowed to form again in the
blood. Patients should restart their anticoagulant therapy as
soon as medically appropriate after being treated with An-
dexxa. Per the American College of Cardiology, patients with
gastrointestinal bleeds should resume their oral anticoagula-
tion medications within 7 or more days after withholding ther-
apy. The most common side effects are urinary tract infec-
tions, pneumonia, and injection site reactions. There have
been no drug interactions reported
so far. Andexxa has a rapid onset
with an effective half-life of about 1
hour. It is eliminated rapidly from
the body at a clearance of 4.3 L/h
and has an elimination half-life of
around 5-7 hours. The safety and
response to treatment is the same
for older patients as compared to
adults.
The two clinical trials that paved the
way for Andexxa to be approved are
the ANNEXA-A and ANNEXA-R trials. They were conduct-
ed in healthy volunteers aged 50-75 years old. In ANNEXA-
A, participants were treated with Eliquis before receiving An-
dexxa or placebo. In ANNEXA-R, participants were treated
with Xarelto before receiving Andexxa or placebo. The prima-
ry outcome in both studies was the percentage change in anti-
Factor Xa enzyme activity from baseline to the smallest value
measured within 5 minutes after the end of treatment. In AN-
NEXA-A, anti-factor Xa activity was reduced by 94% in An-
dexxa-treated patients versus 21% in the placebo group
(P<0.001). In ANNEXA-R, anti-factor Xa activity was re-
duced by 92% in the Andexxa group versus 18% in the place-
bo group (P<0.001).
ANNEXA-4 is an ongoing clinical trial in which Andexxa is
being given to patients on factor Xa inhibitors who are experi-
encing acute major bleeding. Preliminary data so far shows a
reduction of 93% in anti-Factor Xa activity in the Eliquis
group and 89% reduction in the Xarelto group. The trial
should be completed in 2019.
To recap, Andexxa is a newly approved drug used to treat seri-
ous, life-threatening bleeding events in patients who are taking
Eliquis or Xarelto. It is administered intravenously, so there
could be injection site reactions. Infections such as pneumonia
and urinary tract infections can occur as well. In general, it is
important to keep a cautious eye on elderly patients who are
on anticoagulants for signs/symptoms of bleeding, especially
if they have renal impairment. If they are treated with An-
dexxa, they should be monitored for any signs/symptoms of
clot formation, stroke, or heart attack. Additionally, patients
should resume their anticoagulation therapy after treatment
with Andexxa. Close follow up of when to restart anticoagula-
tion treatment is warranted to prevent patients from experienc-
ing harm. Article by Linda Xiong, PharmD Candidate Wingate University School of Pharmacy
Page 3
Volume 22, Issue 1
Drug Update: Toujeo Max SoloStar® Introduction
The latest statistics from the Center for Disease Control (CDC) shows that more than 30.3 million people are diagnosed with
diabetes, and 84.1 million have prediabetes. With an increasing trend of diabetes each year, proper management of diabetes
is of utmost importance for better health outcomes of the patients and also to reduce the healthcare cost. Among many diabe-
tes medications that are available on the market, insulin is a common agent that is widely used for both Type 1 and Type 2
diabetes. Different from some other disease states where the treatment regimen may be more static, diabetes requires close
monitoring and fine adjustments to care in order to keep the blood glucose at a targeted range. Patient’s different meals and
fluctuating weight can all contribute to requiring fine adjustments of insulin requirements on a daily, weekly, and monthly
basis. Too much insulin can cause the patient to be hypoglycemic while not enough insulin can cause the patient to be hyper-
glycemic and at increased risk for complications. While some patients may be well controlled with small amounts of insulin,
other patients require more units of insulin to keep their blood glucose controlled.
Toujeo Max SoloStar® (Insulin glargine 300 units/mL; 900-unit pen)
The newest insulin that has been introduced to the market is the brand name of insulin glargine, Toujeo Max SoloStar® by
Sanofi. The Toujeo Max SoloStar® should not be confused with the brand’s Toujeo SoloStar®. Although the name is quite
similar, the Toujeo Max SoloStar® is the highest capacity pen on the market with a total of 900 units available in each pen.
The original Toujeo SoloStar® contains a total of 450 units of insulin in each pen. The insulin found in Toujeo Max So-
loStar® is still the same insulin glargine found in the original Toujeo SoloStar®. However, because there are two times
more units of insulin in the Toujeo Max SoloStar®, each dial represents 2 units of insulin compared to 1 unit of insulin per
dial for the original Toujeo SoloStar®. It is important to notice this difference between the two pens in order to administer
the correct amount of insulin to patients as it may be easy to get them confused, especially if there are multiple pens in the
cart for multiple patients. In a single injection, Toujeo Max SoloStar® can deliver up to 160 units per dose while the original
Toujeo SoloStar® delivers 80 units per dose.
The Toujeo Max SoloStar® is recommended for patients who require more than 20 units of insulin per day. Higher capacity
in the pen means that patients may go through fewer pens per month, resulting in potentially less cost spent on copays for
some patients. In the past, if a patient required a dose greater than 80 units, then two or more injections had to be given.
However, with the Toujeo Max SoloStar®, patients may need less injections since each dose can deliver up to 160 units
which is an added benefit of this product.
The Toujeo Max SoloStar® still has the smallest injection volume when compared to other basal insulins on the market.
Therefore, for both the Toujeo Max SoloStar® and the Toujeo SoloStar® the pen should be held in the injection spot for 5
seconds after the knob has been pushed down for injection instead of 10 seconds. Both pens should be stored in the refriger-
ator prior to opening but kept at room temperature at least 1-hour prior to first injection and then thereafter. Both pens are
good for 6 weeks (42 days) after the first injection and a new needle should be used in place with each injection.
The Toujeo Max SoloStar® may be beneficial for patients who require higher units of basal insulin to reduce the number of
pens and number of shots given. The original Toujeo SoloStar® may be more suitable for those who require less units of
insulin to prevent wasting of product if it is not used up on time, and it also allows adjustment of units by a single unit op-
posed to two units. Because the pens look very similar and are of equal size, familiarizing with the pen and always double
checking the pen before administration will help to minimize any potential errors.
Toujeo Max SoloStar® U-300 Toujeo SoloStar® U-300
mL in 1 pen 3 mL 1.5 mL
Units in 1 pen 900 units 450 units
Unit(s) per 1 dial 2 units 1 unit
Max # of units in 1
injection
160 units 80 units
Article by Ji-Young Park, Pharm D Candidate
Wingate University School of Pharmacy
Page 4
Rheumatoid Arthritis: An Overview…………………….………continued from page 1
PHARM NOTES
risks are ibuprofen and celecoxib. Extended use longer than
six months or use of aspirin may increase GI risk also. PPIs
should be considered for preventing NSAID-induced ulcers
and risks. If pain is not relieved with one NSAID, a trial of a
different NSAID would be appropriate as patients may benefit
from a different agent.
Glucocorticoids may also be used for acute pain in every stage
of RA and they have disease modifying benefits. Low doses
( ≤ 10mg/day of prednisone or equivalent) should be used for
the shortest duration possible in order to minimize adverse
effects. High doses (up to 60mg/day with a rapid taper) may
also be used short-term. Adverse effects may include elevated
blood pressure, elevated blood sugars, and bone loss. For use
more than a month, calcium and vitamin D supplementation is
appropriate. For osteoporosis prevention, bisphosphonates
should be considered for corticosteroid use beyond 3 months.
Other medications used to treat RA include DMARDS, which
are disease-modifying anti-rheumatic drugs. These medica-
tions treat pain by suppressing symptoms and slow joint dam-
age which leads to improved quality of life and decreased dis-
ability. There are three main classes of DMARDS: traditional,
biologic, and targeted DMARDs. It may take a few months to
see the full benefits of these medications.
TRADITIONAL DMARDS
Traditional DMARDS include methotrexate, leflunomide, hy-
droxychloroquine and sulfasalazine. Methotrexate is the pre-
ferred and gold standard for RA. Dosage is typically 7.5mg to
15mg orally once weekly. Adverse effects include stomatitis,
nausea, diarrhea and alopecia. The use of folic acid is recom-
mended to decrease side effects.
Leflunomide (Arava) is usually used for those
who do not tolerate or respond to methotrex-
ate and can not take biologic DMARDS. Side
effects are similar with the addition of periph-
eral neuropathy which may occur about six
months after starting this medication. Moni-
tor patients for symptoms such as tingling,
burning, numbness or weakness and discon-
tinue medication within 30 days for improved
outcome.
Sulfasalazine (Azulfidine) or hydroxychloro-
quine (Plaquenil) are other DMARDS. Coun-
sel patients regarding increased sun sensitivity
with sulfasalazine. A longer onset of action
(at least 2-3 months) occurs with hy-
droxychloroquine with side effects including
rash, GI issues, and retinal toxicity. Other
non-preferred DMARDS which are exempt
from the most recent guidelines are gold, D-
penicillamine, azathioprine, cyclophospha-
mide, minocycline and cyclosporine.
Remember, combination therapy may be more effective than
monotherapy and aggressive treatment is now recommended.
Typically, methotrexate is the base drug therapy with one or
two other DMARDS added depending on prognosis, disease
activity and drug response. The next consideration for treat-
ment includes targeted DMARDS and biological DMARDS.
The following diagram shows treatment modalities based on
severity of RA.
Mild disease Less than six inflamed joints No other systemic signs of disease (e.g. rheumatoid nodules) No joint erosions or cartilage loss
Moderate disease
Patient doesn't meet criteria for mild or severe disease Between 6 and 20 inflamed joints May have…
Elevated ESR or CRP Positive rheumatoid factor Evidence of bone loss in joints (joint osteopenia) Small erosions Slight joint space narrowing
Severe Disease
More than 20 inflamed joints Signs of systemic inflammation such as an elevated ESR or CRP and
at least one of the following: Anemia of chronic disease and/or a low albumin Positive rheumatoid factor and/or anti-CCP antibodies X-rays showing bony erosions and loss of cartilage Disease that extends beyond the joints such as vasculitis,
pericarditis, peripheral neuropathy, scleritis, etc
MILD RA
NSAIDS
PLAQUENIL
SULFASALAZINE
MINOCYCLINE
METHOTREXATE
MODERATELY
SEVERE RA
SINGLE OR COMBO
DMARDS including:
Methotrexate
Anti-TNF Agents
Anti-IL-1 Agents
Leflunomide
Azathioprine
Gold
Cyclosporine
Agents for Mild
RA
Page 5
Volume 22, Issue 1
SEVERE or
REFRACTORY RA
COMBINATION
DMARDS
ORAL STEROIDS
PROSORBA
COLUMN
CYTOXAN
TARGETED DMARDS
Tofacitinib (Xeljanz) is a targeted DMARD and is considered
as another class of drug therapy. It exerts its anti-inflammatory
effect by targeting the intracellular enzyme, Janus kinas
(JAK). It is generally reserved for moderately to severely ac-
tive RA, those who had inadequate responses to MTX or those
who could not tolerate MTX. It can be used in combination
with traditional DMARDS, but not biologic DMARDS. It also
has a black box warning for cancer, may increase cholesterol
and liver enzymes and decrease blood cell counts. Usual dos-
age is 5mg twice daily but it requires dose reduction if taking
liver enzyme inhibitors of CYP3A4 and CYP2C19.
BIOLOGIC DMARDS
Biologics work in specific areas of the immune system and are
divided into 2 classes based on their mechanism of action, anti
-tumor necrosis factor alpha agents (anti-TNF) and non-TNF
biologics. Because of their anti-inflammatory actions, these
medications are also used for other inflammatory diseases such
as psoriatic or juvenile arthritis, Crohn's or ulcerative colitis,
ankylosing spondylitis and psoriasis. Anti-TNF agents work
on TNF, a protein produced by white blood cells, which causes
inflammation. In healthy individuals, increased levels of TNF
are blocked naturally, but those with RA have higher than nor-
mal levels. Anti-TNF agents include etanercept, infliximab,
adalimumab, certolizumab and golimumab. Brand names and
maintenance doses are listed in the table below.
The non-TNF biologics act on other inflammatory processes
such as Interleukin-1 (IL-1), IL-6, and T-cells. These include
abatacept (Orencia), rituximab (Rituxan), and tocilizumab
(Actemra). Doses may vary depending on weight and admin-
istration is SQ or IV, although Rituxan is only available for IV
infusions.
Biologics, including both anti-TNF and non-TNF, are used
after inadequate response to monotherapy or combination ther-
apy with non-biologic DMARDS. Biologics may be used
with or without traditional DMARDS. They are generally
very expensive and require insurance approval. Most are given
as injections and the most common problem is injection site
reactions although allergic reactions may be severe. The caveat
of biologic DMARDS is that there is an increased risk for seri-
ous infections (including tuberculosis and fungal) as well as
increased cancer risk. Prior to start of therapy, patients should
have TB screens and receive recommended vaccinations as
infections may worsen during treatment. Live vaccines (i.e.
Zostavax or nasally administered FluMist) should not be given
to patients on biologics or Tofacitinib. Inactivated vaccines
(injectable flu, pneumococcal, etc) are recommended on RA
meds, even though they may not respond as well.
With long term use, there is possibly increased risk of
cancers such as lymphoma and skin cancer as well as
neurologic complications. Contraindications for TNF
-alpha blockers include patients with multiple sclero-
sis or moderate to severe heart disease.
Drug therapies are paramount to both pain relief and
quality of life for those with rheumatoid arthritis.
Current guidelines recommend more aggressive treat-
ment to stop the progression of the disease. Other non
-drug therapies that may help with joint pain include
heat/cold treatments, splints or orthotic devices or
joint protection techniques. Frequent rest periods be-
tween activities as well as 8-10 hours of sleep each
night are also recommended. Excess alcohol and
smoking should be avoided.
ANTI-TNF DRUGS BRAND NAMES MAINTENANCE DOSE
Infliximab Remicade® IV infusions every 4- 8
weeks at clinic
Etanercept Enbrel® 50mg SQ/week or 25mg
twice weekly
Adalimumab Humira® 40mg every other week SQ
Golimumab Simponi® 50mg SQ once a month
Golimumab Simponi Aria® IV infusions every 8 weeks at
clinic
Certolizumab pegol Cimzia® 200mg SQ every 2 weeks or
400mg every 4 weeks
Article by Melodie Seagle, Pharm D, BCGP
Adrenal Fatigue: A Real Disease?
Page 6
PHARM NOTES
Do you feel like you are tired all the time, even after getting a
full night of sleep? Do you feel as if you need multiple cups of
coffee to get you through the day? Do you ever wonder what
is wrong with your body? Adrenal fatigue is a possible expla-
nation, however, many medical professionals do not believe it
is a true medical condition.
The adrenal glands are composed of the outer adrenal cortex
and the inner adrenal medulla. Our body has 2 adrenal glands,
each sitting on top of a kidney. The adrenal cortex secretes
many hormones including glucocorticoids (ex. cortisol), min-
eralocorticoids (ex. aldosterone), and androgens (ex. DHEA).
Glucocorticoids help regulate carbohydrate, protein and fat
metabolism. Mineralocorticoids help regulate fluid volume
and sodium and potassium balance. The inner adrenal medulla
regulates the secretion of catecholamines (ex. epinephrine,
norepinephrine and dopamine).
Adrenal fatigue has been known by many other names
throughout the past century such as: non-Addison’s hypoadre-
nia, subclinical hypoadrenia, neurasthenia, adrenal neurasthe-
nia and adrenal apathy. Adrenal fatigue is the term used to
explain a group of symptoms that occur most commonly in
people who are under long-term mental, emotional or physical
stress. This includes those who have a stressful job, are a
working student, single parents or those with severe infec-
tions. The hallmark complaint is fatigue that is unrelieved by
sleep. Other symptoms are common and non-specific includ-
ing tiredness, trouble waking up in the morning, GI distress
and the need for stimulants such as caffeine to get you through
the day. When the body is under a high amount of stress, hor-
mones are released to regulate energy production and storage,
immune function, heart rate, muscle tone and other processes
that enable you to cope with the stress. In those that face long-
term stress, the body is unable to keep up with the demands
for hormone production by the adrenal glands. Overstimula-
tion of these glands results in a diminished output and occur-
rence of symptoms. In adrenal fatigue, the body is still able to
produce adrenal hormones, just to a lesser extent to satisfy the
body’s demands. Compared to Addison’s disease, also known
as adrenal insufficiency, the body is unable to produce any of
one or more of the adrenal hormones. This could be caused by
direct damage to the adrenal glands by an autoimmune disease
or excess use of exogenous steroids (ex. prednisone). Addi-
tional severe symptoms that are seen in Addison’s disease in-
clude: skin discoloration, weight loss, dehydration and loss of
body hair. Adrenal fatigue is essentially a minor form of ad-
renal insufficiency and hormone levels are still within normal
ranges.
Currently, adrenal fatigue is not accepted as a medical condi-
tion, which makes it difficult to diagnose because many physi-
cians do not believe this condition exists. There is no test that
detects adrenal fatigue, and diagnosis is most often based on
symptoms alone. Some medical doctors may test adrenal hor-
mone levels by collecting saliva but these tests are not based
on scientific evidence so the accuracy of these tests is ques-
tionable. Since stress is a key factor in the cause of adrenal
fatigue, recommendations for treatment includes reducing
triggers. Physicians who support the diagnosis of adrenal fa-
tigue may advise lifestyle improvements such as smoking ces-
sation, exercise, healthy diet, and routine sleep schedule to aid
in stress management. B vitamins as well as vitamins C and E
may be beneficial to aid in adrenal hormone production since
they are essential in the adrenal cascade. Magnesium before
bedtime may help promote sleep and relaxation. Other recom-
mended dietary supplements include Siberian ginseng
(Eleutherococcus senticosus), Ashwagandha (Withania som-
nifera), Maca (Lepidium meyenii), and Licorice (Glycyrrhiza
glabra) to promote calmness during the day and sleep at
night. Dosing recommendations for these dietary supplements
can be found in Table 1. Keep in mind that dietary supple-
ments are not regulated by the Food and Drug Administration
(FDA), which means that that is no guarantee that what is
written on the label is what is actually inside the bottle. The
dose being taken may have no active ingredients or the dose
may be too high. It is important that if dietary supplements are
taken that they have an United States Pharmacopeia (USP)
seal, which means the product was evaluated for quality. This
does not mean that the product was evaluated for safety or
efficacy. Even with treatment, it takes about 6 months to fully
recover from mild adrenal fatigue, 12-18 months for moderate
adrenal fatigue and up to 2 years for severe adrenal fatigue.
Adrenal fatigue can be very debilitating if symptoms are not
under control. It is important that if you or someone you know
is experiencing these symptoms that you talk with your doctor
right away. Adrenal fatigue may be a possibility, but because
the symptoms are non-specific, other serious health conditions
could be the cause such as adrenal insufficiency or depression,
which should both be managed under the supervision of a li-
censed healthcare provider.
Article by Kayla Barker, Pharm D Candidate
Wingate University School of Pharmacy
Page 7
Volume 22, Issue 1
Table 1: Dosing Recommendations for Dietary Supplements in Adrenal Fatigue
Dietary Supplement Dose
B Vitamins
Niacin (B3) 125-150 mg/day
Pyridoxine (B6) 50 mg/day
Pantothenic acid 1,200-1,500 mg/day
Vitamin C 2,500-4,000 mg/day
Magnesium citrate 400 mg before bedtime
Vitamin E 400-800 IU/day
Siberian ginseng 500 mg four times daily
Ashwagandha 300 mg twice daily
Maca 1.5 grams twice daily
PHARM NOTES
Kinston Pharmacy
2545 Jetport Road
Kinston, NC 28504
Phone 800 735-9111
Louisville Pharmacy
13040 East Gate Parkway
Suite 105
Louisville, KY 40223
Phone 866-601-2982
Mooresville Pharmacy
947 N. Main Street
Mooresville, NC 28115
Phone 800 578-6506
To all the Pharm Notes Family,
I read something recently that really gave me
cause to think. It is by Molly Fletcher, CEO of the Molly Fletcher Company as well as keynote
speaker and author. She has graciously allowed me to share it with you. (To read this Article in its entirety,
please go to: www.mollyfletcher.com)
10 Things that Require Zero Talent
How often do we equate success with talent? All the time. But the reality is, success isn’t created by talent
alone. Just like we might see immense talent squandered, we also see underdogs unexpectedly overachieve.
Here are 10 behaviors that we can always control that require zero talent, yet have a huge impact on our
success.
1. Being on time: Punctuality is a keystone habit.
2. Work ethic: The discipline of showing up consistently & making the best decisions that lead to
peak performance.
3. Effort: A mindset as much as a behavior.
4. Body language: Shapes how we are perceived by others.
5. Energy: Be conscious about where yours goes.
6. Attitude: Maximizes the talent that you do have and offsets what you lack.
7. Passion: The single most important way to suffocate the fear that keeps us from peak performance.
8. Being coachable: Become a better listener, learn from feedback, & embrace the success of others.
9. Doing extra: Go the extra mile.
10. Being prepared: Failing to prepare is preparing to fail.
Remember that talent is never enough. The best of the best don’t rest on
what they were born with—they dig down to get the most they can. Try
these 10 things (or just one!) and over time…. it will pay off.
Till next time……..
Cathy Fuquay
Pharm Notes Editor
Pharm Notes is a bimonthly publication by Neil
Medical Group Pharmacy Services Division.
Articles from all health care disciplines pertinent
to long-term care are welcome. References for
articles in Pharm Notes are available upon request.
Your comments and suggestions are appreciated.
Contact: Cathy Fuquay ([email protected])
1-800-735-9111 Ext 23489
...a note from the Editor
Thank you for allowing Neil Medical Group to partner with
you in the care of your residents!