I have always been fascinated with the female body and how it works. I am in awe of the thought that two tiny cells can come together and create human life. My first pharmaceutical passion was on fertility drugs. If the human body impressed me enough in its ability to make life, the fact that drugs can alter a person's body to change this ability was amazing to me. It is impressive that pharmacists have developed drugs that can help the heart beat right when it stops working, or drugs that can stop the production of cholesterol to lower the chances of a heart attack, or stop a runny nose during allergy season, but it is near incomprehensible that a drug can indirectly produce life.
There are not many pharmacists that focus solely on this topic. It is an emerging science, and there is not yet enough work to be done for a hospital or facility to have a pharmacist dedicated solely to this topic. For this reason, I began to look deeper to see if there was anything else related that I was interested in. Pregnancy was what brought me to my interest in fertility, so I began to study pregnancy. I am probably in the minority when I say that I loved being pregnant. At times it was uncomfortable, but the knowledge of what my body was accomplishing was enough to override any negative thoughts about the state in which my body was. Pregnancy is a very complicated topic when it comes to systemic drugs. The baby's and the mother's bodies are so intricately intertwined that it actually changes the structure and function of the mother's entire body. This is the only thing that can so drastically change the body's physical sense of meaning. It is incredible.
High risk OB was an area that caught my interest. There are certain medications that cannot be stopped during pregnancy for the sake of the mother's health, such as transplant medications and antiepileptics. If the mother would stop these medications, she would die, along with her baby. It is necessary to keep patients on these treatments but monitor them closely so that the baby is harmed in the least way possible. This is a very interesting concept in pharmacy. Which life is valued more, the mother's or the baby's? There is never an answer to that questions. Our job as health care professionals is to attempt to save both.
The last area of interest I found that will be featured in this blog is medication during lactation. Breastfeeding is yet another unique change in the human body that cannot be replicated. The mother's body still has the purpose of taking care of the baby even after it has left the uterus. The production of milk is still not completely understood, and it is very difficult to test for the presence of drugs in the milk. Even after the presence of drug is found in the milk, it's "back to the drawing board" with the pharmacokinetics. How much of this chemical will get to the baby's circulation? How will it effect the baby? What do the other nutrients in the breast milk do to the stability of the chemical? Is it's mechanism different when it is suspended in breast milk than when it is in tablet form? These are all perplexing questions that would need to be answered in order to tell if medications are safe during breastfeeding.
My favorite example is duloxetine (Cymbalta). Duloxetine is inactivated by the low pH of the stomach, so it is manufactured in a capsule that can withstand the hostile environment and pass into the intestines. In this higher pH, the capsule dissolves and the drug is released. It is then absorbed into the systemic circulation, where it can diffuse into the breast milk of a lactating woman. However, when the milk that contains the duloxetine reaches the stomach of a term infant with a mature digestive system, the drug is inactivated before it is able to be absorbed into the circulation. I am specific in describing the infant because a preterm neonate with an immature digestive tract houses a much higher stomach pH than other babies. It is not known if duloxetine tainted breast milk would be harmless in these infants. The topic is entertaining, however, there is not much data. It is hard to get test subjects for a study when the premise is, "We're not sure if this will harm your baby not." Most mothers will refuse.
With these topics in mind, I began speaking with other pharmacists and doctors on their opinions on how a pharmacist would be able to help. Across the board, everyone agrees that having an expert on medications would be an excellent addition to the team. Unfortunately, life is not that easy. That are not any studies published on how a pharmacist would impact the clinic in this area. Research and studies need to be done to see how a pharmacist in the Women's Health Clinic would be able to reduce costs, reduce hospitalizations, improve patient safety and outcomes, and improve patient satisfactions. My goal is to conduct this study and become the first pharmacist dedicated clinically to an ambulatory care Women's Health Clinic.
In this blog, I aim to educate myself as well as my readers on pharmacists that already practice at least part time in the areas stated above, any new and relevant research done on the topics listed above, and to analyze the material available to the general public on the world wide web. I hope that through this blog, I will become a more able pharmacist in this area, and my readers will be more properly and credibly educated on the topics of interest here.
Thank you for your time. Look forward to a blog in the next couple weeks on my research on human milk banks in North America and their policies on accepting milk from donor mothers who routinely take medications.
Alexis Ireland, PharmD Candidate 2014
