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Why Do DMARDs Take Time to Work for RA?

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Why Do DMARDs Take Time to Work for RA?


How long do you need to take a disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis before it’s fully effective? It depends on which one you use. But they all take a while, says Eric M. Ruderman, MD, a rheumatologist at Northwestern Medicine Rheumatology in Chicago. In fact, he says, DMARDs used to be called SARDs, slow-acting antirheumatic drugs.

When you take DMARDs, it usually takes 6-12 weeks to see a response, according to Ruderman. Why so long? Well, to explain that, it helps to understand what DMARDs do.

How Do DMARDs Work for RA?

Once, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen were the main treatment for rheumatoid arthritis (RA). They treat joint pain and inflammation. They do not prevent joint damage. If these didn’t do the trick, your rheumatologist might consider giving you a DMARD, which was a newer type of medication.

That’s changed in the last 15-20 years, says Ruderman. Now, DMARDs are prescribed as soon as you’re diagnosed with RA. Why? “We recognize that just treating symptoms really doesn’t cover it. You have to treat the underlying disease. That’s what gives you the best long-term outcomes,” he says.

Each type of DMARD works differently. But they all go beyond treating symptoms to block inflammation and slow the disease process. This minimizes the joint damage and complications that inflammation from RA can cause, such as heart problems, says Ruderman.

“People really belong on a disease-modifying drug right out of the gate because our goal these days is not just to manage the symptoms, but to put people in remission if we can. And we can most of the time,” Ruderman says.

NSAIDs and corticosteroids are an important part of an RA treatment plan, too, but they only improve symptoms caused by inflammation. DMARDs are the foundation because they work with your immune system to slow down or even stop the disease

.

Why Do DMARDs Take So Long to Work?

Because a DMARD medication treats underlying inflammation, “it’s not going to work overnight,” Ruderman says.” People often see some benefit right away, but it usually takes longer to ease symptoms like swollen, painful joints and morning stiffness, he says.

“The other complicating factor is that, particularly for methotrexate, there are dose issues,”  Ruderman says.

Your rheumatologist will probably start you on a low dose for about a month. If that doesn’t help enough, your doctor may bump up the amount. It usually takes about 3 months to get to a point where you and your doctor can decide whether the medicine is working. With some kinds of DMARDs, it takes up to 6 months for the maximum benefit, he says.

What Are the Different Types of DMARDs?

Your doctor can choose from among conventional DMARDS, which fight inflammation by working on your immune system as a whole, and biologic DMARDs, which target certain proteins involved in the immune response.   

DMARD drugs used for RA include:

  • Azathioprine
  • Hydroxychloroquine
  • Leflunomide (Arava)
  • Methotrexate (Rheumatrex, Trexall)
  • Sulfasalazine
  • Biologic DMARDs known as tumor necrosis factor inhibitors, such as adalimumab (Humira), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), and infliximab (Avsola, Inflectra, Remicade, Renflexis,)
  • Biologics called B-cell inhibitors, including rituximab (Rituxan, Ruxience, Truxima)
  • Biologics called selective costimulation modulators, such as abatacept (Orencia)
  • Janus kinase inhibitors, such as baricitinib (Olumiant), tofacitinib (Xeljanz), and upadacitinib (Rinvoq)

Methotrexate is usually the first DMARD doctors prescribe for people with RA. Hydroxychloroquine, leflunomide, and sulfasalazine are also common treatments.

Ruderman says leflunomide and methotrexate usually take the longest to reach full effectiveness.

Biologic DMARD drugs are quicker. “We often expect to see some meaningful benefit by about 6 weeks, sometimes sooner,” says Ruderman.

The newer kinase inhibitors, which include tofacitinib and upadacitinib, work fastest, he says. “I typically expect to see a benefit within about a month,” he says.

What Does Successful Treatment Look Like?

The ideal outcome is that you end up in remission.

“That’s our goal, especially if we treat people early,” Ruderman says. “It’s hard to know exactly, but somewhere between 60% and 75% of the time, we can actually get people into remission.” This may take several tries with different medications.

Ruderman defines remission as no swollen, painful, or tender joints. You might have a day every week or two where you don’t feel great or are achy in the morning, but this improves quickly. “For the most part, you just don’t feel like the disease is an issue in your life,” he says.

Unfortunately, if you’ve had RA for years, you probably already have a lot of damage, Ruderman says. That’s because the older treatments weren’t as effective. DMARDs can’t undo past damage from RA. But they can slow down the disease and may prevent further harm to your joints.

How Do You Know Which Drug Is Best for You?

While RA treatments have come a long way, there’s no way to predict which medication will work best for you. You may have to try three or four medicines to find one that gets results.

“It’s great that we have so many good drugs, and they all work really well,” says Ruderman. “We just don’t have a good way to choose between them.”

How Long Do You Need to Take DMARDs?

“The answer is pretty much forever,” Ruderman says. “RA is a lifelong disease and none of the medicines we have cure it. They control it.”

Once you find something that works, you should be able to use it for up to 15-20 years before you need to try something else. So far, research has shown that stopping your medicine altogether, even when you’re in remission, causes symptom flare-ups.

“It’s just not worth it,” says Ruderman. But your rheumatologist may be able to taper your dose a bit or let you go longer between doses once you’re in remission.



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Taking part in the Mediterranean Woven work of art: Best Recipes for a Splendid and Sound Excursion

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Taking part in the Mediterranean Woven work of art: Best Recipes for a Splendid and Sound Excursion

The Mediterranean eating regimen, which is known for its heart-solid rules and rich, various flavors, has turned into a general portrayal of sound and magnificent eating. Drawing inspiration from the waterfront areas of Greece, Italy, and Spain, this diet supplements new ordinary things, vegetables, whole grains, lean proteins, and the liberal utilization of olive oil. In this article, we will investigate presumably the best Mediterranean eating routine recipes that not simply highlight the culinary gathering of the area yet moreover add to, if all else fails.

  1. ** Greek serving of mixed greens with olives, feta, and verdant greens:**
  • Ingredients:
    • Cost peppers, tomatoes, cucumbers, red onions, Kalamata olives, Feta cheddar, olive oil, oregano, and red wine vinegar – Why it’s a favorite:
      With new vegetables, tart feta, strong olive assortments, and olive oil, this incredible serving of mixed greens catches the pith of the Mediterranean.
  1. ** Mediterranean Grilled Chicken:**
  • Ingredients:
    • Chicken chest – Olive oil, lemon juice, garlic, oregano, cherry tomatoes, and red onion – Why it’s a favorite:
    • The marinade blends the chicken in with a release of Mediterranean punch, making a delectable and splendid dish. Grilling adds a smoky part.
  1. ** Mediterranean Stuffed Peppers:**
  • Components:
    • Ringer peppers – feta, quinoa, chickpeas, cherry tomatoes – olive oil, lemon press, and flavors – Why it’s a favorite:
    • These spilling over peppers are stacked up with a liberal mix of quinoa, chickpeas, and feta, giving a splendid and supplement rich supper.
  1. ** With Eggplant Parmesan, Melanzane alla Parmigiana:**
  • Ingredients:
    • Eggplant cuts
    • Pureed tomatoes, mozzarella, Parmesan
    • Olive oil, basil
  • Why it’s a favorite:
    This Italian show-stopper, which is impeccably organized, underlines the adaptability of eggplant and the lovely flavor blend.
  1. ** Mediterranean Fish Tacos:**
  • “Components”
    • White fish filets
    • Whole grain tortillas
    • Greek yogurt, cucumber, dill sauce
    • Annihilated lettuce, tomatoes, red onion
  • Why it’s a favorite:
    A Mediterranean comprehension of a striking dish, these tacos integrate flaky fish finished with a reinforcing yogurt sauce.
  1. ** Mediterranean Quinoa Salad:**
  • Ingredients:
    • Quinoa, red onion, cucumber, and cherry tomatoes – Kalamata olives, feta, olive oil, oregano, and lemon juice – Why it’s a favorite:
      This superb plate of mixed greens is worked on by the novelty of the vegetables and the advantage of the feta, which go about as a protein-rich base.
  1. ** Mediterranean Chickpea Stew (Revithia):**
  • Ingredients:
    • Chickpeas, garlic, onions, olive oil, oregano, and lemon juice – Why it’s a favorite:
      Revithia is a straightforward however delightful stew that spotlights on the unobtrusive chickpea and utilizations strong Mediterranean olive oils and flavors.
  1. ** Shrimp Scampi with Whole Wheat Pasta:**
  • Components:
    • Shrimp, whole wheat spaghetti
    • Garlic, lemon juice, white wine
    • Parsley, red pepper pieces
  • Why it’s a favorite:
    • Flavorful shrimp are featured in a garlic and lemon-pervaded sauce in this light and smoky dish, which is served over whole wheat pasta for added fiber.

Conclusion:

These best Mediterranean eating routine recipes address the culinary overabundance and bracing portrayal of Mediterranean food. Every recipe grandstands the unique tones and serious flavors that make the Mediterranean eating schedule a proposed way of life, from delightful stews and barbecued dishes to new mixed greens. Embrace these recipes for a delightful excursion that spellbinds your taste buds as well as adds to your overall thriving.

Five Things To Know About Beta-Lactam Therapeutic Drug Monitoring (TDM)

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Five Things To Know About Beta-Lactam Therapeutic Drug Monitoring (TDM)


In this article 4 clinical pharmacists provide insights, pulling from their advanced experience with beta-lactam therapeutic drug monitoring (TDM).

Authored By: Kathryn DeSear, PharmD, BCIDP, AAHIVP, FIDSA; Barbara Santevecchi, PharmD, BCPS, BCIDP; Veena Venugopalan, PharmD, BCIDP; Lisa Vuong, PharmD

Article Posted 28 November 2023

Beta-lactam antibiotics are time-dependent antibiotics, which means that by increasing the time the free drug concentration remains above the minimum inhibitory concentration (%fT>MIC) of the pathogen at the site of infection, bactericidal activity will be maximized.1  For this reason, use of extended infusion over 3 to 4 hours or continuous infusion strategies can be ideal.

Historically, therapeutic drug monitoring (TDM) has been widely utilized for vancomycin and aminoglycosides given the narrow therapeutic index. Conversely, TDM has not been performed for beta-lactams because they were generally thought to be safe and well tolerated due to a wide therapeutic window. Furthermore, lack of availability of assays has limited the use of beta-lactam-TDM in clinical practice in the United States as well as in most parts of the world.

Beta-lactams such as piperacillin-tazobactam, cefepime, and meropenem form the backbone of antibiotic regimens in the sickest, most vulnerable hospitalized patients. This reinforces the need to focus efforts on optimizing beta-lactam dosing because suboptimal serum concentrations may impact therapeutic outcomes and result in the amplification of resistant bacteria.2  

Beta-lactam-TDM enables individualized antibiotic dosing, thereby challenging the “one size fits all” approach of standard dosing regimens. Beta-lactam-TDM is particularly useful in critical illness because pharmacokinetic (PK) variability increases the risk of over or under exposure of beta-lactams.3  PK refers to the movement of drug through the body over time as influenced by the processes of absorption, distribution, metabolism, and excretion (i.e., “how the body affects the drug”).

In this article we will highlight five things to know about beta-lactam therapeutic drug monitoring by discussing key questions on each point. We will use a case to emphasize some points. Let us begin!

PATIENT CASE

An elderly, frail nursing home resident presents to the emergency department (ED) with a three-day history of shortness of breath, altered mental status, and night sweats.  In the ED, she is febrile and subsequently received several fluid boluses and was started on vasopressors for blood pressure support.  A chest CT shows multilobar pneumonia.

Weight: 35kg

Estimated creatinine clearance: 75 ml/min.

Serum creatinine on admission: 0.42 mg/dL

Question 1: Why perform beta-lactam TDM?

A systematic review revealed a 30-day mortality rate of 35% from septic shock and 24% from sepsis.4 Given the negative clinical outcomes related to these illnesses and the high PK variability among critically ill patients, an individualized dosing approach with TDM should be considered.5

The updated surviving sepsis guidelines recommend optimizing the dosing of antimicrobials based on accepted pharmacokinetic/pharmacodynamic (PK/PD) principles and specific drug properties.6 PD  is the study of effect (efficacy and toxicity) once the drug has reached a specified site of action (i.e., “how the drug affects the body”).

A study of unbound beta-lactam concentrations in an ICU revealed that 33% and 63% of doses needed to be increased to attain PK/PD targets of 100%fT > MIC and 100%fT > 4xMIC, respectively.7  An evaluation of beta-lactam-TDM practices from the University of Florida Health hospital revealed that 1 of every 4 beta-lactam doses required modification following beta-lactam-TDM.8   

Beta-lactam TDM has the potential to impact clinical outcomes by optimizing PK/PD.

Question 2: Which patients should have beta-lactam TDM performed?

Institutions considering implementation of a beta-lactam-TDM program should focus initial efforts on patients who are expected to have derangements in PK/PD.  Patient characteristics that may be associated with alterations in beta-lactam PK/PD include critical illness, extremes of age or weight, organ dysfunction (e.g., renal impairment or augmented renal clearance), and hypermetabolic disease states such as cystic fibrosis (see Figure 1). These factors increase the potential for over or under exposure of beta-lactams, which may in turn predispose patients to toxicities or a suboptimal response to therapy.

Critically ill patients make up a unique population with several elements that may alter beta-lactam exposure, some of which include hypoalbuminemia (associated with an increase in unbound drug for highly protein bound drugs, such as ertapenem or ceftriaxone, along with potential for increased renal clearance), increased volume of distribution (Vd) for beta-lactams which are hydrophilic drugs, and requirement for organ support (e.g., continuous renal replacement therapy, extracorporeal membrane oxygenation, and molecular adsorbent recirculating system).8,9

Pathogen level characteristics that support beta-lactam TDM include organisms with minimum inhibitory concentrations (MIC) at or above the susceptibility breakpoint, multidrug resistant organisms with few alternative treatment options, and severe or deep-seated infections, such as CNS infections. 8,10  In addition, patients who require several weeks or more of beta-lactam therapy may benefit from TDM for dose optimization and to limit risk of toxicities and resultant alterations in therapy. 

Beta-lactam TDM may be the missing piece certain special populations need to have a positive clinical outcome.

PATIENT CASE CONTINUED I

The patient described in the case above has several factors that produce PK/PD variability and support beta-lactam TDM; these include advanced age, critical illness, and low body weight. 

Figure 1: Factors producing PK/PD variability

(MIC: Minimum inhibitory concentration; ARC: Augmented renal clearance; RRT: Renal replacement therapy; ECMO: Extracorporeal membrane oxygenation)

Question 3: When should beta-lactam concentrations be ordered? 

TDM is generally defined as the clinical laboratory measurement of a chemical parameter that, with appropriate medical interpretation, will impact drug dosing.11 TDM also refers to the individualization of drug dosage by maintaining plasma or blood drug concentrations within a targeted therapeutic range or window at the site of infection.11

Many clinicians have adopted model-informed precision dosing (MIPD) for monitoring of vancomycin. Dosing software which incorporate Bayesian forecasting, predicts an optimal initial dose using population PK models (PK data used to recommend a dose to achieve a predefined PK/PD target) and data from an individual patient (covariates).12-13  When measured drug concentrations become available, these data together with existing population PK data can be used to derive patient specific PK using Bayesian estimation to individualize dosing regimens.13

MIPD for beta-lactams is far less commonly used when compared to vancomycin. A more simplistic approach with a linear regression model can be utilized to estimate patient-specific PK parameters. Sampling of the antimicrobials is traditionally performed at the end of each dosing interval to obtain a trough or Cmin (concentration at the end of the dosing interval). Cmin provides information about the drug concentration at one snapshot in time. However, to accurately ascertain the clearance or volume of distribution (other key PK data points), additional samples earlier in the dosing interval are required.

In a one-compartment model, the patient’s PK parameters are calculated from at least two measured serum concentrations. This is depicted in Figure 2. These PK parameters are then inserted into first order kinetic equations to estimate exposure with various dosing regimens. 

Figure 2. First-order kinetics to estimate patient-specific PK

Question 4: How are beta-lactam concentrations interpreted and what is the process for dose adjustment?

We will continue the patient case here to discuss this.

Vancomycin and cefepime 2 grams every 8 hours were started soon after blood cultures were collected. A cefepime peak and trough were collected, as shown here:

Similar to vancomycin, beta-lactam concentrations are interpreted under the context of a patient’s renal function and timing of the concentrations drawn relative to when the dose was given. Given the clinical status of the patient and as there are no positive cultures at this time, it is reasonable to use the Clinical and Laboratory Standards Institute (CLSI) susceptibility breakpoint for cefepime vs. Pseudomonas aeruginosa as a surrogate for MIC target (i.e., 8 mcg/mL).

Sample Total concentration (mcg/mL) Estimated free concentration (mcg/mL) = total concentration x 80%
Peak, C1 181.8 145.4
Trough, C2 63.4 50.7

The free concentration is estimated from the total concentration based on published estimates for protein binding. Estimating unbound drug is an essential step if the lab performing the assay only performs total concentrations since it is the unbound (free) drug that is able to exert its antibacterial effects (Figure 3). For cefepime, estimated protein binding is ~20%.14 A visual representation of bound versus unbound beta-lactam drug is shown in Figure 3.

Figure 3. Unbound vs. bound beta-lactam

For our patient we will assume that drug elimination follows first-order kinetics (see Figure 2). The elimination rate constant (ke) and half-life (t1/2) can be calculated using the following equations:

unknown.jpg and assess the half-life. Typically, half-life for cefepime is about 2-3 hours. Therefore, given prolonged half-life, extending the dosing interval may be considered.

unknown.jpgand assess PK/PD target attainment.  Currently fCmin is ~5.8 times above the MIC target of 8 mcg/mL for the pathogen (e.g., empiric coverage vs. P. aeruginosa).

A PK/PD target of 100%fT>1-4x above MIC is recommended at our institution for deep seated infections, critically ill patients, and minimizing the selection of resistance.14,15,16  The data around optimal PK/PD targets continue to evolve. There are several excellent anti-infective dosing consensus papers and review articles which discuss this topic in greater detail.14,15,17,18  The current PK/PD target exceeds the desired range and further justifies extending the dosing interval.

DOSING ADJUSTMENT BASED ON BETA-LACTAM-TDM: Switch to cefepime 2 grams every 12 hours

Question 5: Which laboratories perform beta-lactam concentration analysis?

There are a number of labs that perform beta-lactam level analysis. Table 1 provides a list, which is not all-inclusive.

Table 1. Labs performing beta-lactam-TDM9

(RUO: Research use only; LC MS MS: Liquid chromatography-mass spectrometry)

Closing Comments

Beta-lactam TDM offers an opportunity to individualize dosing to the patient and pathogen, with the goals of optimizing therapy and minimizing toxicities. A recent meta-analysis showed that TDM-guided beta-lactam dosing in critically ill patients was associated with improved PK/PD target attainment, clinical cure, and microbiological cure.10  No associations were identified with regard to mortality and length of stay.

Beta-lactam TDM may be best viewed as a tool to individualize dosing and further alter the dogma of one size fits all dosing of beta-lactams.

References

  1. Turnidge JD. The pharmacodynamics of beta-lactams. Clin Infect Dis. 1998;27(1):10-22.
  2. Barreto EF, Webb AJ, Pais GM et al. Setting the beta-lactam therapeutic range for critically ill patients: Is there a floor or even a ceiling? Crit Care Explor. 2021;396):e0446.
  3. Martinez MN, Papich MG, Drusano GL. Dosing regimen matters: the importance of early intervention and rapid attainment of the pharmacokinetic/pharmacodynamic target. Antimicrob Agents Chemother. 2012;56(6):2795-805.
  4. Bauer M, Gerlach H, Vogelmann T et al. Mortality in sepsis and septic shock in Europe, North America and Australia between 2009 and 2019- results from a systematic review and meta-analysis. Crit Care. 2020;24(1):239.
  5. Legg A, Carmichael S, Chai MG, Roberts JA, Cotta MO. Beta-Lactam Dose Optimisation in the Intensive Care Unit: Targets, Therapeutic Drug Monitoring and Toxicity. Antibiotics (Basel). 2023;12(5):870.
  6. Evans L, Rhodes A, Alhazzani W et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247.
  7. Wong G, Briscoe S, McWhinney B, Ally M, Ungerer J, Lipman J, Roberts JA. Therapeutic drug monitoring of β-lactam antibiotics in the critically ill: direct measurement of unbound drug concentrations to achieve appropriate drug exposures. J Antimicrob Chemother. 2018;73(11):3087-3094.
  8. Venugopalan V, Hamza M, Santevecchi B, DeSear K, Cherabuddi K, Peloquin CA, Alshaer MH. Implementation of a β-lactam therapeutic drug monitoring program: Experience from a large academic medical center. Am J Health Syst Pharm. 2022;79(18):1586-1591. 
  9. Fratoni AJ, Nicolau DP, Kuti JL. A guide to therapeutic drug monitoring of β-lactam antibiotics. Pharmacotherapy. 2021;41:220-33. 
  10. Pai Mangalore R, Ashok A, Lee SJ et al. Beta-Lactam Antibiotic Therapeutic Drug Monitoring in Critically Ill Patients: A Systematic Review and Meta-Analysis. Clin Infect Dis. 2022;75(10):1848-1860.
  11. Kang JS, Lee MH. Overview of therapeutic drug monitoring. Korean J Intern Med. 2009;24(1):1-10.
  12. Wicha SG, Märtson AG, Nielsen EI et al. From Therapeutic Drug Monitoring to Model-Informed Precision Dosing for Antibiotics. Clin Pharmacol Ther. 2021;109(4):928-941.
  13. Novy E, Martinière H, Roger C. The Current Status and Future Perspectives of Beta-Lactam Therapeutic Drug Monitoring in Critically Ill Patients. Antibiotics (Basel). 2023;12(4):681.
  14. Guilhaumou R, Benaboud S, Bennis Y et al. Optimization of the treatment with beta-lactam antibiotics in critically ill patients-guidelines from the French Society of Pharmacology and Therapeutics (Société Française de Pharmacologie et Thérapeutique-SFPT) and the French Society of Anaesthesia and Intensive Care Medicine (Société Française d’Anesthésie et Réanimation-SFAR).  Crit Care 2019;23(1):104.
  15. Abdul-Aziz MH, Alffenaar JC, Bassetti M et al. Antimicrobial therapeutic drug monitoring in critically ill adult patients: a Position Paper. Intensive Care Med. 2020;46(6):1127-1153.
  16. Sumi CD, Heffernan AJ, Lipman J, et al.  What antibiotic exposures are required to suppress the emergence of resistance for gram-negative bacteria? A systematic review. Clin Pharmacokinet. 2019;58(11):1407-1443.
  17. Berry AV, Kuti JL. Pharmacodynamic Thresholds for Beta-Lactam Antibiotics: A Story of Mouse Versus Man. Front Pharmacol. 2022;13:833189.
  18. Onufrak NJ, Forrest A, and Gonzalez D. Pharmacokinetic and Pharmacodynamic Principles of AntiInfective Dosing. Clin Ther. 2016; 38 (9): 1930-1947

ABOUT THE AUTHORS

Kathryn DeSear, PharmD, BCIDP, AAHIVP, FIDSA

Kate DeSear, PharmD, BCIDP, AAHIVP, FIDSA is a clinical specialist in infectious diseases at University of Florida (UF) Health Shands Hospital, an 1,162 bed academic medical center, and co-leads the antimicrobial stewardship program with the program’s physician director. She serves as the residency program director of the Infectious Diseases PGY-2 residency. She is also a clinical assistant professor at the UF College of Pharmacy (COP).

She received her Doctor of Pharmacy from UF COP. She completed her pharmacy practice residency at Bay Pines Veterans Affairs Hospital and a specialty residency in infectious diseases at the UF Shands Hospital. Her areas of interest include antimicrobial stewardship, novel stewardship measures relating antimicrobial use to clinical or process outcomes, and rapid diagnostics.

Barbara Santevecchi, PharmD, BCPS, BCIDP

Barbara Santevecchi, PharmD, BCPS, BCIDP is a Clinical Assistant Professor at the UF COP and practices as an Infectious Diseases Clinical Pharmacy Specialist at the UF Health Shands Hospital.

She received her Doctor of Pharmacy from Wingate University and completed pharmacy practice and infectious diseases specialty residency training at the Medical University of South Carolina in Charleston, SC. Her interest areas include antimicrobial resistance, HIV, antimicrobial and diagnostic stewardship, and therapeutic drug monitoring.

Veena Venugopalan, PharmD

Veena Venugopalan, PharmD, BCIDP received her Doctor of Pharmacy degree from the University of Kentucky, College of Pharmacy and thereafter completed an Infectious Diseases residency at the University of Kentucky Medical Center.

She is currently a Clinical Associate Professor at the UF COP and serves as one of the Infectious Diseases clinical specialists at the UF Health Shands Hospital.  In addition to her research and clinical interest in antimicrobial resistance, beta-lactam TDM, and antimicrobial stewardship, she is also passionate about global health.

Lisa Vuong, PharmD

Lisa Vuong, PharmD is a clinical specialist in infectious diseases at UF Health Shands Hospital.

She received her Doctor of Pharmacy from the University of California, San Francisco. She completed her pharmacy practice residency and infectious diseases specialty residency at Henry Ford Hospital in Detroit, Michigan. Her areas of interest include implementation science, transitions of care, and antimicrobial stewardship.

RECOMMENDED TO YOU

 



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A Growing Concern About Gonorrhea’s Resistance to Antibiotics

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A Growing Concern About Gonorrhea’s Resistance to Antibiotics


A recent study documented by The Lancet highlights that treatment failures for gonorrhea have been uncommon in the United States. Still, there is growing concern about the emergence of antibiotic resistance in Neisseria gonorrhoeae, particularly non-susceptibility to cephalosporins. This concern is underscored by the identification of the penA 60.001 allele in Neisseria gonorrhoeae, a specific genetic variation that contributes to this type of antibiotic resistance. The penA 60.001 allele alters the bacterial response to cephalosporins, a key class of antibiotics for treating gonorrhea.

Investigators presented 2 cases in the USA where the penA 60.001 allele was identified. The first case was a patient with urethritis whose Neisseria gonorrhoeae isolate showed non-susceptibility to cephalosporins and other antibiotics. The second case was identified retrospectively with a similar pattern of resistance. The methods used to diagnose and treat the patients include antimicrobial susceptibility testing, nucleic acid amplification test (NAAT), and whole-genome sequencing. These methods revealed the specific antibiotic resistance patterns and the presence of the penA 60.001 allele. This discovery signals a worrying trend in the fight against this common sexually transmitted infection.

“Due to high rates of gonorrhea, rapid evolution of N gonorrhoeae resistance, and increasing case reports of penA 60.001 allele associated with treatment failures, US patients with failed treatment for gonorrhea might be anticipated in the near future,” according to the investigators. “Although ceftriaxone was still effective, these primary care cases are a warning to clinicians and public health officials to scale up clinical awareness, surveillance, and laboratory detection, including culture and gradient strip antimicrobial susceptibility tests and advanced molecular diagnostics, to delay the arrival of extremely drug-resistant gonorrhea until new treatments or vaccines are developed.”

3 Key Takeaways

  1. The study highlights the growing concern about the emergence of antibiotic-resistant strains of Neisseria gonorrhoeae in the US, particularly those showing non-susceptibility to cephalosporins.
  2. The study presents 2 cases where the penA 60.001 allele was identified. These cases showed non-susceptibility to cephalosporins and other antibiotics, raising concerns about the potential for treatment failures.
  3. The importance of increasing clinical awareness, surveillance, and laboratory detection methods to manage and prevent the spread of drug-resistant gonorrhea strains.

This study exhibits limitations by constraining a small sample size of 2 cases, which may not provide a comprehensive view of the relevance of the penA 60.001 allele. Also, the study’s insights are geographically limited to its geographic focus on Massachusetts, which may not represent wider trends. Additionally, the follow-up period for infection clearance might be insufficient to gauge long-term treatment effectiveness or recurrence risk. The lack of comprehensive contact tracing in one of the cases and a focus primarily on the penA 60.001 allele, while neglecting other possible resistance mechanisms, further restricts the study’s scope. Lastly, in 1 case, the assumption of infection clearance without direct microbiological confirmation could affect the accuracy of the results.

The investigators emphasize the need for increased clinical awareness, surveillance, and laboratory detection to manage and prevent the spread of these drug-resistant strains. This includes scaling up culture and gradient strip antimicrobial susceptibility tests, as well as advanced molecular diagnostics, to delay the arrival of extremely drug-resistant gonorrhea until new treatments or vaccines are developed. The study uncovers a concerning trend of cephalosporin-resistant gonorrhea in the US, underlining the urgency for enhanced detection methods and public health initiatives.

Reference

1. Reimche JL, Pham CD, Joseph SJ, et al. Novel strain of multidrug non-susceptible Neisseria gonorrhoeae in the USA. The Lancet Infectious Diseases. Published January 9, 2024. Accessed January 25, 2024. doi:S1473309923007855.



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The Let’s Talk Micro Podcast

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The Let’s Talk Micro Podcast


In this article the host of the Let’s Talk Micro Podcast (Luis Plaza Rios) is interviewed about his experience and learning clinical microbiology using podcasting via the Let’s Talk Micro podcast. 

Interviewee: Luis Plaza

Interviewer: Timothy P. Gauthier, Pharm.D., BCPS, BCIDP

Article Posted 1 December 2023

Podcasting has emerged as an incredible way to reach a global audience and discuss scientific information. Some great podcasts in the area of infectious diseases include the Society of Infectious Diseases Pharmacists’ Breakpoints Podcast, the American Society for Microbiology Podcasts, ID:IOTS, the Febrile Podcast, and ID Podcast, amongst others.

In the area of clinical microbiology, the podcast called “Let’s Talk Micro” provides discussions with experts on a variety of related topics. Clinical microbiology is a rapidly advancing field as new rapid diagnostic technologies enable faster organism identification along with more rapid susceptibility testing. It is an incredibly important field for the advancement of patient care today.

As folks seek out podcasting resources to learn about clinical microbiology, they may be interested to learn more about the Let’s Talk Micro Podcast, which is hosted by Luis Plaza, who is the Lead Medical Laboratory Scientist in Microbiology at a Hospital system in Orlando, Florida as well as a microbiology instructor for the Medical Laboratory Sciences program at the University of Central Florida. I had the pleasure to meet Luis in person and after exchanging some emails we were able to compose this article.

In this interview we will dive into learning microbiology through your ears, discussing his journey and all about the Let’s Talk Micro Podcast. If you are interested in learning more about the podcast beyond the interview, the points of contact listed below may also be of interest to you. I catch the podcast on Amazon music, but there are many ways to find it and learn about what is new on social media.

Here are the questions and answers from our interview…

1. How did you get interested in microbiology and what path did you take to reach where you are today?

Triggering curiosity

My interest in microbiology came while I was in the service. I joined the Navy many years ago and I was looking for a career or occupation that I could also work on after my time in the service was done, something that I could do on the outside as a civilian.

I have always enjoyed science especially biology and even prior  to joining the service I was studying it in college. Long story short it did not work out, I joined the service, and while I was looking for an occupation, I saw they offered an associate’s degree in medical laboratory science. I looked into it and learned about what they do, which is something that most of us prior to studying this have very little knowledge of.

Sure, we go to the lab growing up and have some sort of testing performed like a glucose test, or a CBC, but we don’t understand what’s going on behind the scenes. This degree seemed interesting, so I went ahead and enrolled in it while in the service and then one of the classes of course was microbiology and it was like love at first sight.

There was something, I don’t know how to explain it but like first of all it is so visually stimulating. Take some of the colors  the organisms produce. Some of them have pigmentation. Also the colors of the agar like the green in Hektoen or the red on blood agar. Then  learning about these organisms and their biochemical reactions and how they cause disease and some of them are part of our normal flora they just live there and learning about this whole process it was so fascinating and I felt like very drawn to it. There I knew that that’s what I wanted to do I wanted to become proficient at that and learn more about these organisms and what they do. Also learning about  a profession where you can help so many patients but it’s outside of what we normally grow up knowing, was something that appealed to me.

Training

We grow up knowing that there are doctors and nurses and then you have scientists, for which when you think about them, you picture someone in the laboratory with beakers performing some sort of experiment. However, most people do not know that this is an occupation which can make a big impact on patient care.

Once my time in the service was complete, I decided to go to the University of Central Florida where I applied to their Medical Laboratory Sciences bachelor’s degree.  I got accepted and while going through it, my passion for microbiology was still very strong. I can still remember how much I was looking forward to my microbiology rotation during clinicals. I finished my degree and then I actually started working in microbiology. At the time due to some personal situations I ended up rotating through other areas of the lab like and chemistry, but microbiology kept drawing me in. I think that is where I do my best work I. think it comes very natural to me understanding these organisms and these reactions and that is where I have  been working all these years.  In 2021 I enrolled in a Master’s for Microbiology and cell science at the University of Florida and I am  expecting to complete it in December of 2024. 

A personal story

It is very exciting work and so rewarding when we can provide that identification to the physician, when we can provide that susceptibility profile and I have a great story for you that comes to mind which one time we had a culture where there was Pseudomonas aeruginosa growing and then via MALDI-TOF besides the P. aeruginosa, an identification of Stenotrophomonas maltophilia was produced. We were unable to isolate it and those of you that work in the laboratory know that it is normal practice when you are having trouble isolating an organism to try to pick a colony that resembles the organism in question and attempt to isolate it, or perhaps use additional media.  What I love about this field is putting all these concepts together to solve a problem.  I looked at the susceptibility profile of P. aeruginosa and saw that it  was susceptible to meropenem so I suggested to sweep the colonies and place a meropenem disc since S. maltophilia is  resistant to meropenem so it should be able to grow. We did that and we actually managed to recover S. maltophilia since it was growing close to the disc. It was such a great feeling. 

2. What are your thoughts on the value of using podcasts for medical education?

The Value of Podcasting

I believe that podcasts are a great tool for learning not only for microbiology and Laboratory Medicine, but science and other topics in general as well. They are very valuable because they provide information in a way that is readily accessible. You can be doing anything while listening to a podcast – driving your car, riding a train, doing house chores – and you can be learning at the same time!

Just like everyone, people in the laboratory have families, busy lives where there is work and then after work there is something else to attend to such as  picking up the kids, homework,  dinner, etc. Podcasts bring that information to a place where you can access it while you’re doing any of these tasks. You can pause it, you can listen to it as many times as you want and then if you want to do your research beyond the podcast, you can go ahead and do so but it’s a great starting point to learn about topics. For these reasons, I believe it is valuable for people to have access to them.

Listening to podcasts, not only can you learn, but you can also find out what people from other parts of the world are doing  and how that relates to what you are doing. You can connect with people as well which is something that a lot of times we do not think about. We are so busy with our lives and we are in the lab and we are working let’s say 8 hours, a lot of times you do not have room for much else. With podcasts you can really find out what is going on in the laboratory and beyond. For example connecting with pharmacists and infection preventionists, it can help connect all the pieces together. It is  always great to learn what happens beyond the laboratory. 

Getting Into Podcasting

There are mainly two reasons why I got into podcasts: (1) I have always like to learn and (2) I like to share information.

When I am working on a bench in the microbiology lab, I always want to learn the “why” behind  things like why we make certain decisions such as working up a particular organism, selecting appropriate antimicrobials for susceptibility testing, or performing those tests. I have found out at least in my experience in the laboratory that at times learning the “why” is difficult because in our line of work the pace is tends to be fast, so there is not  a lot of time to ask questions right. You work your organisms, you put your results out there and then if you get stuck you ask your supervisor and that is it. Otherwise if you  stop every single time to ask questions or look at things or find the answer, you will consume a lot of your day.

I think a good analogy to explain this is like a kitchen and a recipe. You want to learn how to make a dish and then people just give you a recipe. I want to learn how to validate an instrument and I want to learn the steps you take and where that information is obtained from. However at times in the laboratory what you encounter is that someone just gives you an evaluation plan (i.e., recipe) and that’s it: validate the instrument and move on.

It’s difficult to learn in the lab and a lot of times there’s also a lack of mentoring and maybe they choose one person to teach things to and that is it. Then there is the sharing information part which is something that I have always loved to do and currently I am a laboratory instructor and I enjoy it immensely. I was always the technologist training someone, giving information about package inserts about the behind the scenes , talking about why do we do this or why do we do that and that’s the way that I am.

I enjoy teaching, and like I said, because podcasts are so accessible and such a convenient tool that is why I chose podcasts.  I decided to share information about organisms and reactions and I also want to make sure that people do not encounter the same barriers that I have encountered in my career where it seems that wanting to learn a lot of times is not seen as a good thing. If I have learned something I am going to share it and I am going to make sure that microbiologists out there they are arming themselves with many tools and they know where their resources are and they know what the information is so they can get comfortable enough where they can do an amazing job.

This is what I do in the podcast in addition to talking about organisms and biochemical reactions and things like that, I also talk about the things that I have learned from my experience in the bench and I point to the resources and where the information is so we can so people can continue building their knowledge which at the end translate into being a better microbiologist.

3. What is the focus of the Let’s Talk Micro Podcast?

Let’s Talk Micro focuses heavily on clinical microbiology, especially on information that is part of working on a bench with cultures. I provide information on different organisms: morphology, how they look on media, and what type of testing is there. I go over diseases and I also go over biochemical reactions . I talk about susceptibility testing too. This is a lot of material so it is going to take a while to go over all the different microorganisms, but as of right now I am currently going mainly over bacteria and then eventually I will move on to other groups of microorganisms.

The goal of the Let’s Talk Micro podcast is for it to be used as an educational tool. This is a lot of material and unfortunately because it is so much material it is very difficult to go over it in Microbiology training programs, especially those for medical laboratory sciences which are the ones that perform the majority of the testing and have to be licensed as such to work in a clinical microbiology laboratory.  I want this podcast to be used as an educational tool where people can find out more about what they do and at the very least know what the resources are and what kind of information they contain so if they ever need to access them, they know what and where they are.

In addition to reaching out to medical laboratory scientists I want to reach out to microbiologists in general starting of course with clinical microbiologists.  If you are a graduate student in microbiology or an undergrad student or if you are taking some sort of microbiology class, I want to provide information that can help you learn about this material and I want to do it in a way that a student and a professional alike can understand the material. I try to explain it in simple terms. So my goal is to put enough material in the podcast and bring awareness about it where hopefully institutions in the US and maybe around the world can access it and it can be shared with students and it can be recommended as a tool to learn.

Besides going over organisms and reactions and things like that I also bring guests that either they have worked on a project or have some sort of publication that I think that it pertains to our work like a validation of an instrument or a talk about a certain organisms. When I see articles like that or if I see a topic I go ahead and reach out to the guests and invite them to the podcast and they come in and they talk about a specific topic.

Going beyond the above, I also want to bring information about other areas of microbiology besides clinical and what can you do as far as what kind of work you can do in microbiology (e.g., marine microbiology or environmental microbiology) . I want people to know what the options are out there.

4. What has been your favorite Let’s Talk Micro Podcast episode?

Episode 88

While I have enjoyed many episodes either doing the research or talking to guests there are two that come to mind: one is episode 88 from season 2 which is the Clinical Microbiology Procedures Handbook where I got to talk with the editors of the 5th edition of that particular book and they explain what information is in there, how they choose that information, and  how it helps with our work in clinical microbiology. I like that episode in particular because this is such a great resource and I even use it to prepare for my episodes. It just it felt great to talk to the to the editors and being able to shine a light on this resource that helps us so much on the work that we do. I really wanted to bring this out to light so microbiologists out there know that this is available. The episode includes  information on molecular testing, media, and bioterror procedures. It is such a wonderful and complete resource, being able to provide that to the audience is something that I enjoyed very much.

Episode 98

The second episode that I enjoy a lot is the episode 98 which is the start of an antimicrobial resistance sub-series. I have Dr. Andrea Prinzi on it, who is a microbiologist and medical science liaison, co-hosting with me. This episode is dear to me, because going back to what I said about there being a lot of information in microbiology, this is true core of susceptibility testing and antimicrobials.

When we go to school, we learn a little bit about this topic but most of our knowledge comes from on the job experience. It can be daunting and a little intimidating when you are sitting there and you are performing testing and accepting susceptibilities so I wanted to really break down antimicrobials. The episode goes all the way from mechanisms of action to  talking about intrinsic resistance to what kind of organisms a particular drug or class of drugs intended for.

I wanted to put all this information in a podcast format so people can listen to it at their own pace. This is such an important part of our work as clinical microbiologists and we need to be comfortable with all this material but that can take a long time to learn and even when you start working in a microbiology laboratory you train for maybe 3-4 weeks and that is not enough time to learn most of this material. So bringing that information to the audience making it accessible is something that I am enjoying a lot.

Overall I enjoy episodes a lot when I have guests because it just it seems like they shared the same passion for the information as I do and talking to people like them, it is very rewarding and fulfilling.

5. How do you measure success for the podcasts you have released?

Downloads

There are several ways to measure the success of the Let’s Talk Micro podcast. The first one is the metrics which are measured by downloads. The podcast is getting a lot of downloads and the number has increased exponentially over time. I think there is still a lot of room to improve and it comes from a place that there is still a lack of awareness about it and that’s a challenge that I have with it. However, I am working hard on social media to promote it and reaching out to fellow microbiologists and laboratorians so they can share it with others. That’s one hurdle that I think I have to go over which is bringing awareness about it, but overall this has been very successful and as more people learn about it more people are downloading it and the difference in numbers from year one to now is amazing. I’m still very grateful.

Personal Benefit

And then there’s the personal metric.  Even if there were no downloads at all I measure the success in the amount of information that I have learned and how much I have grown as a professional. One of the things that I enjoy about this podcast is the process about it, which is doing the research. I enjoy that process and bringing a guest while reading about a publication. So overall research is fun. That is a process that I enjoy and in that process I have learned so much because I have to go back and read the information and my professional knowledge has increased tremendously. I have also met so many wonderful people that in all probability without the podcast I would not have met. That goes back to us been so busy in the lab that lot of times we do not have time for what is out there for like exploring other things: we do our job and go home.

For me it is a huge amount of success how much I have grown as a professional and the wonderful people that I have met. There’s a whole world beyond the lab and there are so many great microbiologists,  pharmacists, and physicians out there working in this profession  and sharing their information and  knowledge. Getting to meet them or talk to them and learn from them it’s an amazing experience so that alone it’s great success.

The success of learning and gaining knowledge and meeting people coupled with the fact that I do want to bring information out there to my fellow microbiologists and help them out as much as I can, that is what drives me to do the podcasts. It is all the steps. If you put them alone, they are great, and once combined they are even better.

6. What are some things you have learned from your experience doing the Let’s Talk Micro Podcast?

Editing

I have learned many things from doing the podcast and I think one of them is that it is challenging listening to your own voice because in my case I do my own editing. I sit there and I listen to my episodes and while I am doing the editing and then I listen to the edited version to make sure that no mistakes were made and that is something that is challenging. I have learned that for this you have to be committed and you have to be organized making sure that you set up a schedule where you are either doing research or you are recording depending on the frequency that that you are publishing episodes. I also think that it is always good to stay in touch with the audience and keep them updated. For example, if you cannot produce an episode, let people know that you are not able to publish one that particular week.

Expanding Knowledge

Something else that I have learned is just that there are so many incredibly knowledgeable and talented people out there who are sharing information, want others to learn, and they are willing to take the time to speak about it. Sometimes all you have to do is ask.

I have been wonderfully surprised about how nice the guests are and most people if you ask them about a topic and you extend an invitation, most times people will say yes. Every now and then you might get a no but a lot of times it is because people are busy with their jobs and they might not have time for it but if you wait long enough then they might be able to come on the podcast .

A lot of people out there are willing to share their information and they are so nice about it.

7. What do you think the future holds for medical podcasting and the Let’s Talk Micro Podcast?

I think the future looks great for podcasts. They are growing in numbers and you see a lot of people from artists to actors doing podcasts. It is a great way to share information and it is very convenient, so I feel podcasts have a very stable future. Since the years that I have been doing this, I have seen more podcasts come out and hopefully more do come out because it is it is a great format.

As far as Let’s Talk Micro Podcast, I plan on doing this for a long time.  I enjoy the process and it is valuable to me. I love the fact that I am helping out people and helping them learn more and that is something that I am very committed to. I do not get compensated for it in any way, but I think in the future if I could potentially get some sort of sponsorship where at the very least, I am able to attend let’s say different conferences where I can meet more people, connect with more people find more topics I think that will be very beneficial.

When I go to conferences, I try to bring awareness of the podcast. I talk to people presenting posters, reach out to speakers, and I give things like stickers with the podcast logo and QR code. Those conferences can be expensive when you combine the conference hotel and travel, so having some sort of sponsorship that cost can be off-set, which will help the podcast greatly. Like I said bringing awareness about it has been a hurdle. I am definitely planning on doing this for a long time.

Final Thoughts

If you listen to the podcast, please share it with others. If  you are a director, please share it with your staff. If you are a teacher, please share it with your students or just share it with your coworkers, but let them know that this is a resource that they can use. I am always looking for topics and looking for guests so if you have any potential topics, you can always reach out via social media or via e-mail but definitely share the podcast and let them know that it is out there (information above).

With social media being so huge as it is right now it is a great time to learn and use it for science.  I have found a lot of my guests through social media. For example, I see them on a on a platform sharing an article they have published and I reach out to them. Not being afraid to communicate with people has been important to my success.

It is a great experience once again but what I do tell everyone that’s looking to start a podcast it’s just make sure that you are responsible with the information you’re putting out there. That means doing the proper research and making sure that what you are placing out there is accurate but by all means go for it. Creating and following a schedule is also important for being consistent. The audience also appreciates consistency, so staying on a routine cadence for publishing episodes also helps.

Finally, I will share it is a great feeling when you are out in the world, someone approaches you, they recognize you from the podcast, and they say they listen and say that it has helped them. That is an amazing feeling that is something that I enjoy very much.

ABOUT THE INTERVIEWEE

Luis Plaza is a Lead Medical Laboratory Scientist in Microbiology at a Hospital system in Orlando, Florida. He is also  a Microbiology instructor for the Medical Laboratory Sciences program at the University of Central Florida. Microbiology has been a huge passion of his. Having a desire to learn and share information, he created the Let’s Talk Micro podcast. In there he explains clinical microbiology in simple terms. He goes over organisms, reactions, and brings guests relevant to the field of Microbiology. In his spare time he enjoys traveling, movies, and great coffee. 

Editors Note: I would like to sincerely thank Luis for taking the time out of his busy schedule and sharing his journey and experience podcasting. Check out Let’s Talk Micro and follow the social media profiles too!

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Making Sense of Influenza and COVID-19 This Year

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Making Sense of Influenza and COVID-19 This Year


During this time of year in the northern hemisphere, influenza and COVID-19 are in full effect. As the season is hitting or near its peak, the general public will once again need to be aware of the viruses and will want to find strategies to avoid them.

Anecdotally, people are saying the current COVID-19 variant is not as significant or severe as previous strains. However, there is great variability in what the experience of being sick is depending on people’s ages, existing comorbidities, and overall health profile. So, COVID-19 can look different to different people. Whereas, a young person who is in good health may see symptoms that mirror a cold; but a middle-aged person or a senior might see more severe symptoms that feel like influenza.

Still, this does not downplay the need for preventative care for everyone, especially in the form of vaccines, explained Robert H. Hopkins Jr, MD, medical director, NFID; professor of Internal Medicine and Pediatrics and chief, Division of General Internal Medicine, University of Arkansas for Medical Sciences.

“For those who still haven’t gotten their COVID-19 [vaccine], their influenza vaccine, and those eligible to get RSV vaccination, please do that. It is not too late,” Hopkins said. “It does take a little time for you to develop vaccine protection. But, I would encourage people to get that done because we don’t have a good way of predicting, even if you’ve had COVID-19 or flu earlier in the season, that you’re not going to get it again.”

Additionally, Hopkins discusses hygiene and risk mitigation as nonspecific interventions for prevention. These are things we may be aware of in some capacity but serve as good reminders.

“Washing your hands is important. Second, if you’re going to be out in in crowded situations, I would encourage people to wear a mask…a mask is not perfect, but if you’re wearing a mask over your nose and mouth, you’re reducing the number of particulates,” stated Hopkins.

He also reminds people to cough and sneeze into the sleeves of their shirts as opposed to their hands. This can prevent transmission of germs. And lastly, Hopkins talks about going out into crowds.

“If you have an opportunity to get out in a crowded setting, think a little bit about what your risk tolerance is for that setting. If you’re somebody that’s immune compromised, if you have significant health conditions, maybe this is not the time to be going to a concert, or to a basketball game, or to a crowded event where we may be more likely to catch one of these illnesses.

For those who might be vaccine averse, and do not like the idea of getting 2 vaccines at the start of every seasonal virus year, there are influenza/COVID-19 combination vaccines in development. Moderna has previously stated it was targeting a potential regulatory approval for their combination vaccine in 2025.

Contagion spoke to Hopkins who offered some insights on this year’s COVID and influenza seasons, combination vaccines, and isolation considerations for those who have the flu or COVID-19.



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Five Ways Preceptors May Integrate Generative Artificial Intelligence Programs Into Pharmacy Education Learning Experiences

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Five Ways Preceptors May Integrate Generative Artificial Intelligence Programs Into Pharmacy Education Learning Experiences


In this article a clinical pharmacist discusses ways that preceptors may integrate generative artificial intelligence programs into pharmacy education for student and resident learning experiences.

Authored By: Timothy P. Gauthier, Pharm.D., BCPS, BCIDP

Generative artificial intelligence was NOT used to create this text. Although, maybe it would be better if I had used it!

Article posted 13 December 2023

Artificial intelligence (AI) is a hot topic today. At all of the major conferences lately there seems to be well-attended lectures on AI and often it will be a focus or mentioned item in keynote speeches. In this article I will discuss the topic, provide some resources, and propose five ways that preceptors may integrate generative artificial intelligence programs into pharmacy education for student and resident learning experiences.

Let’s start with some definitions:

  • Artificial Intelligence (AI): the simulation of human intelligence processes by machines
  • Machine Learning (ML): a branch of artificial intelligence and computer science, focusing on the use of data and algorithms to imitate the way that humans learn, gradually improving accuracy
    • All ML is AI, but not all AI is ML
  • Generative Artificial Intelligence (GenAI): artificial intelligence capable of generating text, images, or other media, using generative models. Generative AI models learn the patterns and structure of their input training data and then generate new data that has similar characteristics.
    • GenAI is focused on creating new data that resembles training data, while ML is focused on analyzing data to find patterns and make accurate predictions.
    • GenAI is good for learning from itself to solve problems in succession, while ML is good for solving one problem at a time.
    • Chat GPT from OpenAI is an example of GenAI
  • Deep learning: a type of ML based on artificial neural networks in which multiple layers of processing are used to extract progressively higher level features from data

As I was researching this topic, I came across an article by Dr. Jeff Cain and colleagues published in AJPE that discusses the role of AI in the future of pharmacy education. Two of their quotes resinated with me. The first was: “AI will not replace you. Someone using AI will.” This point is well taken and indicates future and current pharmacists need to become educated about how to use AI, including the benefits and dangers it may offer. The second quote was “pharmacies have diligently transitioned from apothecaries into problem solvers, educators, and communicators.” This resonates with me on the topic, as pharmacy preceptors should consider how they can employ AI to help their learners become better problem solvers, educators, and communicators.

In terms of pharmacy education research on the topic of AI, there is not a lot out there. A scoping review on this topic published by Abdel Aziz and colleagues in October of 2023 identified only 7 studies on the topic. There is a great opportunity for scholars to engage in academic work on this topic, which is likely to rapidly emerge in the coming months/years.

The risks of AI are not going to be discussed in detail here, but it should be noted that pharmacists should beware policies of their employer(s) and avoid sharing any patient health information, trade secrets, private academic information, or other protected content onto AI platforms such as ChatGPT. As a word to the wise which I recently heard, if you would not want the information posted on a billboard with your name next to it, you probably should not be sharing it on an AI platform.

Now that we are a bit oriented to the topic, I will attempt to suggest 5 ways that preceptors may integrate generative artificial intelligence programs into pharmacy education for student and resident learning experiences.

1. Have your learner use generative artificial intelligence like a first-stop wikipedia resource

Learners are being introduced to new concepts all the time. While repurposing AI answers to provide information for direct patient care is highly questionable, using it as a starting point (like wikipedia) is fairly reasonable. In this context the outputs should be taken with a proverbial grain of salt.

The amazing speed at which the learner can interact with the GenAI programs is a major benefit. For the learner that is not using GenAI, this simple task may be a simple way to get them started. Of course, make sure to ask your learner about their experience so you can use their feedback to improve your ability to precept future learners.

2. As a preceptor use an artificial intelligence program to evaluate your learner’s work

GenAI programs can evaluate text for various elements. It can be as simple as getting a word count or the number of verbs in the text. It can be as advanced as having GenAI re-write the content in a different style (e.g., by prompting the program to write a more scientific sounding text).

It may also be fun to use GenAI to manipulate learner-submitted work in order to demonstrate a point. If using it as a way that is intended to overlap humor and learning, beware some students may be more sensitive than others. Even if the intent is to make it fun, not all learning strategies are a good fit for all learners.

3. Task your learner to to use a generative artificial intelligence program to learn something then teach you about it

Having a learner teach you can be a fantastic way to explore GenAI technology at a macro or micro level, while enhancing their awareness simultaneously. It is like that famous teaching philosophy – Learn one, do one, teach one!

Anyone who wants to understand GenAI will need to have an understanding of how to prompt GenAI to produce the intended results. Students may be able to assist preceptors to this end. This is an example that could be used for text, image, or video generators.

4. Assign your learner to compare a drug information question they have completed to the responses they are able to obtain from a generative artificial intelligence program

Once a pharmacy student or resident is aware of the principles on a given topic, they may be able to interact with GenAI to investigate strengths, weaknesses, and accuracy of the responses it is able to generate. This is a more advance level of Blooms Taxonomy, moving from define/identify as it is used more like a wikipedia, into the assess/evaluate realm.

A potential benefit of GenAI is for it to enable personalized learning. This can be particularly helpful when learners are in the more advanced domains of Bloom’s Taxonomy. Although, in my opinion, the risk for confusion and error is more likely within these domains, as compared to more fundamental areas.

 5. Have your leaner explore the ethical concerns of generative artificial intelligence… through interacting with generative artificial intelligence!

Learners are not likely to fully grasp the implications of how interacting with generative artificial intelligence may put them or their organization at risk. You could have your learner use recent examples in the news media (of which there are many) to explore this topic.

The topics of ethics and GenAI is going to be important for pharmacists now and for the foreseeable future, helping your learners become more aware of it may help set them up to avoid potential future pitfalls.

Closing Comments

Preceptors of pharmacy students and residents have the opportunity to integrate innovation with GenAI into the scholarship of teaching and learning. Potential GenAI applications are vast and rapidly emerging. The cross roads of GenAI and pharmacy education may be ripe for pharmacist researchers seeking a niche field.

The future of integration with GenAI into the pharmacy profession is sure to be an interesting one. This is just the tip of the iceberg, there is still a lot to learn, keeping pace with changes is sure to be a challenge, and we need to proceed with caution as we go. One thing is for sure, ignoring GenAI is not going to make it go away, so we might as well start to explore it now.

REFERENCES & READINGS

  1. The Role of Artificial Intelligence in the Future of Pharmacy Education
  2. Demystifying artificial intelligence in pharmacy
  3. A Scoping Review of Artificial Intelligence within Pharmacy Education
  4. Understanding the Distinctions Between Artificial Intelligence, Machine Learning and Generative AI
  5. Deep Learning: A Comprehensive Overview on Techniques, Taxonomy, Applications and Research Directions

DISCLAIMER: The views and opinions in this article represent those of the author and do not necessarily reflect the policy or position of any previous, current, or potential future employer.

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Natural Ways to Improve Memory

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Natural Ways to Improve Memory


Have you ever rushed through the morning getting ready to go somewhere only to discover you can’t find the car keys? Our ability to remember, recall, and learn new information is important for daily life. Unfortunately, we may start noticing little changes as we get older. But thankfully there are plenty of ways to keep our memory sharp as we age!

Some people maintain a sharp memory and quick wit well into their 90s. This article covers ways to naturally improve your memory and brain health at any age. 

What Causes Memory Decline? 

Neurological and cognitive health simply indicate overall wellness. While often associated with older adults, memory problems can affect people of all ages. 

Jim Kwik is a well-known memory and brain performance coach I’ve interviewed on my podcast. His story begins with a childhood head injury that caused issues with his ability to focus, learn, and retain information. That experience inspired him to learn everything he could about improving his brain. 

A head injury is one thing that can lead to cognitive decline, but it’s not the only cause. Other potential factors include:

  • Brain infections
  • Tumors 
  • Strokes
  • Toxins
  • Oxygen deprivation
  • Nutrient deficiencies 
  • Certain medications 
  • Gut dysbiosis
  • Sleep quality 
  • Stress and trauma

Anything that creates inflammation in the gut can create inflammation in the brain. Chronic brain inflammation may lead to cognitive decline and memory loss.

Symptoms of Memory Decline

Memory decline can manifest in a variety of ways depending on the person. However, common symptoms include:

  • Forgetfulness 
  • Difficulty learning new information
  • Repetitive questions or statements
  • Misplacing things
  • Poor judgment
  • Difficulty problem-solving
  • Confusion about time or places
  • Difficulty recognizing faces
  • Social withdrawal
  • Changes in mood or personality
  • Trouble finding the right words
  • Difficulty completing familiar tasks

Those with persistent or worsening memory issues should see a healthcare professional. The severity could be a red flag for conditions like mild cognitive impairment, Lyme disease, or Alzheimer’s. That said, healthy brain habits can help you avoid neurodegeneration.

Healthy Brain Habits

Adopting healthy brain habits can support cognitive well-being and long-term brain health. In fact, the memory area of the brain, the hippocampus, is known to regenerate. It can even grow new brain cells (neurons) into your 90s if given the right environment.

Here are some habits that may positively impact the brain over time:

Avoid Sugar and Processed Foods

Diets high in sugar and processed foods may harm cognitive function and particularly, memory. A high-sugar diet can actually shrink the brain. That’s particularly true of the hippocampus, the part of the brain responsible for short-term memory.

In a 2017 study, researchers wanted to find out how sugar might lead to dementia. They found that higher sugar intake was associated with a lower total brain volume in those with preclinical Alzheimer’s disease.

Sugar and processed foods are linked to chronic inflammation, insulin resistance, oxidative stress, and more. They can also lead to obesity, another risk factor for mild cognitive impairment (MCI).

Get Sufficient Sleep! 

We know quality sleep is essential for cognitive function and memory consolidation. Aim for 7-9 hours of quality sleep each night. If you don’t get enough sleep, you could be causing your memory to weaken over time. As an active mom, I aim for at least 9 hours every night.  

Consider Medication Side Effects

Certain medications can also lead to memory loss. For example, anticholinergic drugs (used for overactive bladder and Parkinson’s disease), seizure drugs, and certain sedatives are all associated with memory problems. However, the memory may improve when the patient discontinues the medication. 

Be Proactive in Stress Management

Chronic stress can lead to chronically high blood pressure, which is linked to brain issues. Taking some time to chill out with things like meditation, deep breathing, or yoga can be really helpful. Try something fun you enjoy, like watercolor painting or another creative outlet.

Get Regular Exercise 

Getting physical activity most days of the week is crucial for a healthy brain. Aerobic exercise increases blood flow to the brain and increases the size of the hippocampus, improving memory. Activities like walking, running, swimming, or cycling may lower the risk of cognitive decline.

Seek Mental Stimulation 

Never stop learning! Those who continue to challenge themselves have a lower risk of dementia. Even volunteering can help. Engage in activities that challenge your brain, such as puzzles, games, learning a new skill, or reading. When we stimulate our brain it helps with neuroplasticity or “rewiring” in the brain. 

Use Memory Techniques

There are also some techniques you can use to improve your memory. Here are a few tips and tricks:

  • Chunking – Chunking is a common memorization technique. It involves breaking down information into smaller, manageable parts or “chunks.” It’s especially used for phone numbers and to-do lists. You may even have your credit card number memorized due to this technique!
  • Mnemonic devices – Mnemonic devices are memory techniques that can help us remember information. They often involve associating information with a pattern, image, or acronym. Most of us used these in school. Remember ROY G. BIV for the colors of the rainbow?
  • Crossword puzzles – Crossword puzzles challenge your working memory, the system responsible for temporarily holding and manipulating information. Strengthening your working memory can have positive effects on your overall cognitive abilities. 
  • Don’t Give in To AI! – If you’re using GPS every time you drive, you’re doing your memory a disservice. A 2013 study found that using GPS or similar apps for navigation shrinks your hippocampus! A shrinking hippocampus is associated with declining memory function.

Be Social 

We need friends and connections. Loneliness is associated with an increased risk of dementia, including Alzheimer’s disease. On the other hand, regular social engagement is associated with better cognitive function. It also improves mental health. Maintain relationships with family and friends to support your emotional well-being.

Limit Alcohol

Too much alcohol can have detrimental effects on the brain. In fact, it can even change brain structure, leading to cognitive decline. Overindulging increases the risk of all kinds of dementia. Make sure to limit alcohol consumption to no more than one drink a day for women and no more than two drinks a day for men.

Remember, adopting these habits can significantly impact your overall brain health. 

Foods to Support a Sharp Memory 

Food is medicine! Inflammation in the gut leads to inflammation in the brain. So, eat with your microbiome in mind. Here are some foods scientifically shown to support a sharp memory throughout life:  

Fatty Fish 

Fish like salmon, trout, and sardines are rich in omega-3 fatty acids, particularly DHA, which is crucial for brain health and memory. A 2023 review study found that omega-3s slowed cognitive decline. 

Researchers encouraged those with early memory issues to eat more omega-3-rich fish or supplement with omega-3s. My favorites are salmon and sardines!

Eggs

Packed with several nutrients, including vitamins B6 and B12, folate, and choline, eggs support brain health and memory. A 2023 Japanese trial studied the effects of choline from egg yolks on cognition in older adults. 

At the end of the study, those in the choline group had improved verbal memory. Researchers concluded that 300 mg of egg yolk choline daily was helpful for memory. If you have an allergy to chicken eggs, try duck eggs.

Blueberries 

Packed with antioxidants, blueberries can help improve communication between brain cells and memory. A 2011 study found that wild blueberry juice improved memory in older adults. After 12 weeks of drinking blueberry juice, those with age-related memory decline did better with recall testing. They even had a better mood!

Lion’s Mane Mushroom

Lion’s mane mushroom is an edible and medicinal mushroom studied for its potential cognitive benefits. It’s especially known for supporting memory and brain function.

A 2009 study found those with mild cognitive impairment improved with lion’s mane. It took 4 weeks to notice a difference.

Green Tea

Trading some of your coffee for green tea may help preserve memory over time. The synergistic effect of caffeine and L-theanine in green tea may enhance brain function and improve alertness. 

A review of 21 studies found green tea improved cognition and brain function. The research showed green tea had benefits for memory and attention. It also improved working memory, which showed up on MRI films.

Nuts

Tree nuts like walnuts, almonds, and hazelnuts are rich in nutrients beneficial for brain health. Some of these include omega-3 fatty acids, antioxidants, and vitamin E. A whole walnut even looks much like the brain! 

Tree nuts may protect the memory in several ways. They provide important nutrients, but they also lower inflammation and support the growth of new brain cells.

Dark Chocolate 

If you need an excuse to eat chocolate, here it is! Dark chocolate has flavonoids, caffeine, and antioxidants, which may improve memory, focus, and mood. It turns out that dark chocolate increases nerve growth factor (NGF) in the brain. As a result, it may support cognitive performance, including memory.

Of course, no single food can miraculously boost memory. Including these foods within the context of a healthy diet and lifestyle makes a massive difference. 

Supplements to Improve Memory

Supplements can also help supply nutrients our brains need.  Natural Stacks is one of the supplements I use and they have nootropics and other supplements that support a sharper memory. Here are a few more ideas:

Fish Oil 

As mentioned, omega-3 fatty acids, particularly EPA and DHA, are essential for brain health. They play a crucial role in the structure and function of the brain. Supplementing with a high-quality fish oil may help. 

Bacopa Monnieri 

An herb used in traditional Ayurvedic medicine, Bacopa monnieri has been studied for its brain-boosting effects, including memory improvement. The research shows benefits for cognitive performance, including word recall and the ability to create new memories. I love Four Sigmatic’s mushroom-powered drinks and their Focus Mushroom Blend features memory-boosting herbs, including bacopa.

Ginkgo Biloba 

Ginkgo Biloba herb has a long history of use when it comes to improving memory. Studies show it can improve blood flow to the brain and has antioxidant properties. Other research suggests it may have memory-enhancing effects. It’s also been used for decades to help those with dementia.

Curcumin (Turmeric) 

Curcumin, the active ingredient in turmeric, has been linked to improved memory and overall brain health. These benefits are likely due to its anti-inflammatory and antioxidant effects. Some research suggests it may have cognitive benefits, including memory improvement.

A 2018 clinical trial used 90 mg of curcumin twice daily in healthy adults. After 18 months, the participants had improved their memories. Researchers believe it might be due to curcumin’s ability to reduce brain inflammation. Some turmeric powders have lead mixed in, but I get this high-quality turmeric here.

Resveratrol

Found in red wine, grapes, and some berries, resveratrol is an antioxidant studied for its potential for memory enhancement. A 2017 clinical trial studied 119 patients for a year and found resveratrol decreased brain inflammation. It also activated certain proteins that help prevent brain degeneration.

Vitamin B12

Vitamin B12 deficiencies are linked with cognitive decline, including Alzheimer’s Disease. It’s important to get enough vitamin B12 for overall brain health. Clams, liver, fish, and beef are some of the top food sources. 

Final Thoughts on How to Improve Memory

Memory decline isn’t inevitable as you age. However, it’s best to adopt good brain habits early on. Whatever your age, start now. Eat a brain-healthy, anti-inflammatory diet with plenty of healthy fats. Stay active, both physically and cognitively. Stay connected and try new things. 

A sharp mind is like anything else; use it or lose it. Be a lifelong learner who isn’t afraid to try new things – You’ll have a richer life as a result!

How’s your memory? Do you do specific things to keep your memory sharp or take nootropics? Share with us below!



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Stop Using the Medicine Cabinet. Oh, and Now Clean It Out

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Stop Using the Medicine Cabinet. Oh, and Now Clean It Out


Jan. 24, 2024 – If old bottles of prescription medicines and over-the-counter pain relievers are gathering dust behind your bathroom mirror, you’re not alone. But it’s important to take stock of what medications you have, what you can get rid of, and figure out how to store and discard your pills with care. 

Let’s start with the basics: Despite its name, you shouldn’t keep your pills in the bathroom medicine cabinet. There are two major reasons why, experts say. 

The first is that medicine cabinets are usually in bathrooms. That comes with a lot of humidity and high temperatures. According to the CDC, storing medications in places were temperatures often change and humidity is high has been shown to make medicines degrade more quickly. 

The second reason to move your pills is that often, anyone you share your home with can easily get to your medicine cabinet. If you’re trying to keep medications out of the hands of young children, people struggling with substance use, or teens with mental health issues, even a kitchen cabinet may not be the best place to keep pills. And studiesshow that most household medications aren’t stored properly. 

When Suzanne Robotti was a child, her younger sister loved to climb. One day, she walked into the kitchen to see that her then-5-year-old sister had climbed on top of the counter and found the baby aspirin. 

Robotti, founder of the MedShadow Foundation, a drug safety organization, and the consumer representative appointed to the FDA’s Drug Safety and Risk Management Committee, tattled, and her mother rushed her sister to the hospital. 

“They had to pump her stomach because she had indeed eaten an entire bottle of baby aspirin, which could have seriously damaged her kidneys and liver,” she said. 

“It sounds crazy, but there are people who keep their medicines under lock and key, the same way you would a gun. They’re just as dangerous as a gun in the wrong hands.” 

When Do Medicines Actually Expire? 

Most pill bottles have an expiration or “use-by” date of about a year after you receive them. This isn’t the case across the board, especially not for all prescription medications. 

“It’s kind of like that milk that you get; it’s probably good a little past the expiration date,” said Maryann Amirshahi, MD, a toxicologist, emergency medicine doctor, and co-director of the National Capital Poison Center. 

“There’s nothing magical about the day that it expires. But that being said, you don’t want to let it sit there for much longer than that,” she said.

Whether or not the medication is past its prime by the date on the packaging has a lot to do with how it has been stored. It also depends on what type of situation you find yourself in, said Joe Graedon, a pharmacologist and co-host of “The People’s Pharmacy” national call-in radio show. 

“If you’re in a situation that is not that critical – maybe you need a sleeping aid or an allergy medication – and you’ve got a medicine that is a week, month, or even a couple of months out of date, it probably didn’t go bad,” he said. 

But if you find yourself in a situation where the medication absolutely has to work – for example, if you have an infection and need an antibiotic, or someone needs an EpiPen – then you shouldn’t risk it. 

There’s a scenario that Amirshahi sees a lot on the job, both at Poison Control and in the emergency room. Patients will say that they had an antibiotic lying around the house from a previous infection, so they decided to take it for their current ailment. 

Here’s why that’s a problem: When you are prescribed an antibiotic, you’re supposed to finish it to make sure you completely get rid of the infection and avoid resistance, Amirshahi said. There are also different antibiotics used for different infections; a prescription you previously had for a urinary tract infection is not the same one you would get for a sinus infection. Lastly, the old antibiotic might be well past its expiration date, making it far less effective. 

What Do I Do With My Old Meds? 

For many medications, simply tossing the bottle in the garbage isn’t the best course of action. The best way to dispose of old prescriptions is to take advantage of take-back programs offered across the country. The FDA has a resource that helps you find local Drug Enforcement Administration-registered take-back locations. Many pharmacies will also take old drugs and dispose of them safely. 

If that doesn’t work for you, Amirshahi has another solution. 

“With most medications, you can actually put them in cat litter or coffee grounds before throwing them away – something gross – so that people won’t be tempted to take them,” she said. “You want to make them completely unpalatable.” 

Whatever you do, don’t flush medications down the toilet. Research has shown that doing this leads to an increased concentration of drugs in the water supply and damages aquatic wildlife. 



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Healthy Homemade Chocolate Recipe | Wellness Mama

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Healthy Homemade Chocolate Recipe | Wellness Mama


If there’s one guilty pleasure all moms enjoy, it’s chocolate! Thankfully there’s a way to justify indulging a little because chocolate (like wine) has some fantastic health benefits. The key is to choose quality chocolate from the right sources … or make your own homemade chocolate recipe.

It’s quick and easy and you have total control over the ingredients (and maybe even get to lick the spoon!). This recipe takes just a few ingredients. Melt over the stove, pour into molds, and … there you have it! The best chocolate that’s also healthy.

Why a Homemade Chocolate Recipe is the Best

It turns out that there are biological reasons why women crave chocolate. It may be for the magnesium boost (yes, chocolate contains magnesium). Or it could be for the feel-good serotonin and dopamine release that helps mood and sleep.

All chocolate is not created equal and most store-bought chocolate brands contain a lot more than cocoa powder. High fructose corn syrup, hydrogenated oils, soy lecithin, artificial flavoring, and carrageenan make the list of objectionable ingredients in many commercial brands.

Then there’s the sugar content, which is a problem … just 1/3 of a Cadbury chocolate bar has 22 grams of sugar. That’s not to mention white chocolate which is made with milk powder, cacao butter, and lots and lots of sugar.

Thankfully more brands are making healthy chocolate options with less sugar and quality ingredients. One of my favorites is Spring and Mulberry. It’s sweetened only with dates (no refined sugars!) and they have delicious flavors like lavender rose, pear and ginger, and mixed berry.

Making your own is cheaper though, and you can easily control the ingredients.

You can stock up on the few ingredients needed to make chocolate (as well as a few silicone candy molds to make fun shapes). It’s a delicious way to whip up a batch of healthy chocolate!

How to Make Chocolate at Home

In search of a GAPS friendly (and gluten-free, dairy-free, etc.) healthy chocolate, I realized I wanted to make my own. This homemade version is smooth and delicious. You can avoid the artificial ingredients when you make your own chocolate from scratch.

Some recipes just involve melting semisweet chocolate chips, but then you’ll still need to search for a healthy chocolate to start with. Instead, I opted for unsweetened cocoa powder as the base.

If it’s your first time making chocolate, here’s how to do it step by step.

Making chocolate at home involves melting cocoa butter, cocoa powder, honey, and vanilla on the stove. I use a double boiler (or heat-safe bowl set over a pan with water). Next, you’ll pour the chocolate recipe into molds for it to set.

Choosing a Shape

I used these silicone heart molds to make fun bite-size chocolates (great gift idea!). This mini loaf pan is great for bar sizes. You can even find silicone molds in a chocolate bar shape if you want to be really authentic!

I’m gifting little jars of homemade heart chocolates for Easter this year. They’re great for Christmas, St. Nicholas Day, and other holiday gifts too! You can easily find silicone molds that match any holiday theme (or just make bars).

Different Flavor Options For Homemade Chocolate

Our family prefers the taste of dark chocolate over milk chocolate so the chocolate recipe isn’t overly sweet. If you prefer a bittersweet bar then reduce the honey to 1/4 cup for a more intense chocolate flavor. It’s easy to add a variety of different flavors and mix-ins to create a specialty taste.

Here are some flavor options to try!

  • Mix in dried fruit
  • Add a pinch of salt to the chocolate mix for a sweet and salty taste
  • Add chopped-up marshmallows to the molds before pouring the chocolate in
  • Try some healthy trail mix sprinkled on top
  • Add coconut flakes or chopped nuts
  • Use herbs like lavender or rose petals
  • Flavor it with peppermint, orange, lemon, almond, or vanilla extract
  • Add a teaspoon of brewed espresso for a mocha bar
chocolate recipe

Healthy Homemade Chocolate Recipe

A simple and delicious homemade chocolate that’s GAPS, paleo, and kid-approved! Customize the recipe to make your favorite flavor.

  • In a double boiler on the stovetop, melt the cocoa butter over medium-low heat. You can also use a glass bowl on top of a small pan with a few inches of water in the bottom. Be sure the boiling water doesn’t get into the bowl!

  • Once the cocoa butter is melted, remove from heat and add cocoa powder, vanilla, and other flavor extracts.

  • Allow the mixture to cool slightly. When it’s the same thickness as the honey you’re using, stir in the honey. If using a solid raw honey, melt with the cocoa butter.

  • Make sure all the ingredients are well incorporated and smooth. Be careful not to get any water or moisture in the chocolate recipe or it will get grainy!

  • Pour the chocolate into silicone molds or a glass pan to harden. You can also pour it onto a baking sheet lined with parchment paper.

  • Let chocolate harden for several hours at room temperature until firm and remove from the molds. You can also stick it in the refrigerator to harden more quickly.

Nutrition Facts

Healthy Homemade Chocolate Recipe

Amount Per Serving (1 serving)

Calories 529
Calories from Fat 18

% Daily Value*

Fat 2g3%

Saturated Fat 27g169%

Polyunsaturated Fat 1.4g

Monounsaturated Fat 15.4g

Sodium 5mg0%

Potassium 280mg8%

Carbohydrates 38g13%

Fiber 6g25%

Sugar 28g31%

Protein 3g6%

Vitamin C 0.2mg0%

Calcium 24mg2%

Iron 3mg17%

* Percent Daily Values are based on a 2000 calorie diet.

  • These chocolates will stay fresh for over a week at room temperature or in the refrigerator for longer. They can also be frozen.
  • The nutrition data is for 1 chocolate bar but will depend on the size mold you use and how much of the bar you eat. 

More Chocolate Recipe Tips

You can use coconut oil instead of cocoa butter. This makes a really healthy chocolate, but it won’t be as thick or creamy (but it’s still very good!). If you use coconut oil, I recommend hardening and storing them in the fridge. This is one easy way to add coconut oil and magnesium to your daily diet!

I’ve melted the mixture in a small pan on very low heat and haven’t had a problem, but it’s not as reliable as the double boiler method. 

Looking for More Homemade Chocolate Recipes? Try:

Have you ever made chocolate at home? What are your favorite flavors? Share below!



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