For Clinicians | What Is Plague? One Bacterium, Three Diseases

By Dr. Jamie Wilkey, PharmD, Director of Clinical Education
Medically reviewed and edited by Aaron Asay, PA-C, DMSc, FIBODM, FAWM

Well, the plague is back in the news. Reports out of Russia in early October said a worker at an anti-plague institute died of pneumonic plague after a purported lab accident.¹ Russian officials deny it, and the regional governor calls it pneumonia of unknown cause.²

As a pharmacist, I may not be your breaking news source. But, I remember the stories from history class of millions dying from the plague back in the Middle Ages.  It’s a great reminder of how little most of us know about plague since it has dropped out of everyday conversation for the last 200 years. That’s what this clinical refresher is about: one bacterium, that causes three types of illness

Why does one bacterium cause three diseases?

Yersinia pestis is the one bacterium, and where it takes hold in the body (skin, blood or lungs) decides which of three main clinical patterns you’re looking at.³ 

A flea bite drops it into the skin. It travels to the nearest lymph node and multiplies there, usually in the groin, armpit, or neck, and that node swells into a bubo.⁴ That’s bubonic plague, and it’s more than 8 in 10 US cases.⁵

When it takes hold in the bloodstream, it causes septicemic plague: fever, chills, extreme weakness, and shock characterize this variant.⁶ It can follow an untreated bubo, or it can come first, without the telltale node and with prominent nausea, vomiting, diarrhea, and abdominal pain.⁴ Yep, it can look like a stomach bug with a fever.

When it takes hold in the lungs, it’s called pneumonic plague, a pneumonia that gets bad fast, with cough, chest pain, and sometimes bloody sputum. Patients can become infected by breathingin droplets or particles from a person or animal with plague pneumonia, orby an untreated bubonic or septicemic infection which spreads there.⁶,⁷

Left untreated, plague can move from node to blood to lungs. The lung form is the only type  that can spread from person to person.⁶

When a patient has a sudden fever and a painful, swollen lymph node within about a week of flea or animal exposure, and lives in or recently visited the rural West, that’s the time to start thinking plague.⁴,⁶ Ask where they’ve been and what animals they’ve touched, including the family cat and anything they hunted or skinned.³,⁷ It is prime hunting season out here in Utah/Wyoming right now so this is particularly on my mind as I walk around neighborhoods and see every third house processing  their successful hunts in their driveway. 

Why doesn’t the lung form spread like the flu?

Pneumonic plague does spread from person to person. Like flu, it travels in respiratory droplets and exposure within about 6 feet can be catching.⁸,⁹ The difference is timing.

Flu is most contagious in the first few days of illness.⁸ Plague, like aging cheese, gets stronger with time. Transmission risk is minimal early, before the cough fully develops, and highest in the mid-to-late stages, when the patient is coughing up sputum loaded with bacteria.⁹,¹⁰ By then, the patient is usually too sick to be out and about, so the people at risk are the ones close enough to care for them.

Colorado saw this in 2014. A dog with pneumonic plague infected its owner and two veterinary staff. A fourth person, who handled the dog’s body and later spent extended close time with the owner while he coughed up bloody sputum, may have caught it from him. That was the first possible human-to-human spread in the US since Los Angeles nearly 100 years before in 1924.¹¹

Masks and distance stopped pneumonic plague outbreaks even before antibiotics were available,¹⁰ and they still protect you and your staff today. CDC doesn’t consider prophylaxis necessary for clinicians caring for these patients as long as standard and droplet precautions are upheld.¹² Prophylaxis is for people with close, sustained contact with a patient or animal with pneumonic plague who weren’t wearing adequate protective equipment, or with direct contact with infected fluids or tissue. The regimens are in CDC’s 2021 plague recommendations in MMWR.⁹,¹²

Why does timing decide survival?

Since plague is bacterial, antibiotics can be effective when treatment starts early. Before antibiotics, about 2 of every 3 US cases were fatal. Since then, it’s about 1 in 6.³

Untreated, plague keeps moving, from node to blood to lungs, and the odds get worse at each stop in the body. Even in the antibiotic era, septicemic and pneumonic plague kill more often than bubonic.³

At the pharmacy counter, if a patient presents with fever plus a painful node and describes  that exposure history, refer them to a prescriber immediately. Don’t give them acetaminophen for the fever and tell them to wait-and-see. In the office, call your local or state health department as soon as you suspect plague, and start treatment without waiting on test results.⁴,¹² Tell the lab you suspect plague because automated systems can misidentify Y. pestis, and in Colorado one called it a different bacterium for a week.⁴,¹¹

Who actually gets plague in the US?

Plague lives in wild rodents and their fleas across parts of the West, including prairie dogs, ground squirrels, chipmunks, and wood rats.⁷ People get it when they cross into that cycle: an infected flea bites a rodent, a cat that ate the infected rodent passes it to its owner, or someone handles or skins an infected animal.³,⁷ Wyoming’s 2021 pneumonic plague case likely traced to contact with sick pet cats.¹³ The US sees about 7 cases a year, mostly in rural New Mexico, Arizona, Colorado, and California.³,⁵

Even the worst case here, a traveler arriving with pneumonic plague, has a known response. Health officials trace close contacts, those contacts get prophylaxis or fever monitoring, and the care team uses droplet precautions.⁹,¹² That’s what happened in Colorado in 2014: officials traced 114 close contacts, recommended prophylaxis for 88, and no further cases turned up.¹¹

When a patient asks about the Russia story, in the office or at the pharmacy, here’s a short reply you can use: plague is a bacterial infection, it’s curable when treated early, and it’s rare here.

Then the prevention list:¹⁴

• Keep fleas off pets, get a sick pet to the vet quickly, and don’t let pets that roam outside sleep in the bed.
• Use insect repellent with DEET while outdoors.
• Wear gloves to handle or skin animals.
• Clear brush, rock piles, and woodpiles near the house, where rodents like to live.

If a sudden fever and a painful, swollen node show up, get seen fast and report where you’ve been.

The bottom line

Plague is very unlikely to touch your patients. It’s still a good reminder that illness doesn’t wait for a convenient time, and that a plan made ahead of time beats a scramble. That’s the work we do at Jase: helping people prepare for the times primary care isn’t available, in no way as a replacement for it. A licensed provider reviews every request before anything is prescribed, and our emergency kit medications are for use only in an emergency, after first seeking help from a qualified healthcare provider.

Sources

1. Meduza. Hospital in Russia’s Irkutsk region quarantined amid reports that a patient died of pneumonic plague. October 2, 2026. https://meduza.io/en/news/2026/10/02/hospital-in-russia-s-irkutsk-region-quarantined-amid-reports-that-a-patient-died-of-pneumonic-plague
2. Doubine S, Euronews Russian. Russia denies lab worker died of plague as quarantine in Siberia stays in place. Euronews. October 5, 2026. https://www.euronews.com/2026/10/05/situation-under-control-russian-authorities-reassure-public-after-plague-reports-in-siberi
3. Kugeler KJ, Staples JE, Hinckley AF, Gage KL, Mead PS. Epidemiology of human plague in the United States, 1900-2012. Emerg Infect Dis. 2015;21(1):16-22. https://wwwnc.cdc.gov/eid/article/21/1/14-0564_article
4. Centers for Disease Control and Prevention. Clinical Testing and Diagnosis for Plague. https://www.cdc.gov/plague/hcp/diagnosis-testing/index.html
5. Centers for Disease Control and Prevention. Plague: Maps and Statistics. https://www.cdc.gov/plague/maps-statistics/index.html
6. Centers for Disease Control and Prevention. Signs and Symptoms of Plague. https://www.cdc.gov/plague/signs-symptoms/index.html
7. Centers for Disease Control and Prevention. How Plague Spreads. https://www.cdc.gov/plague/causes/index.html
8. Centers for Disease Control and Prevention. How Flu Spreads. https://www.cdc.gov/flu/spread/index.html
9. Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS. Antimicrobial treatment and prophylaxis of plague: recommendations for naturally acquired infections and bioterrorism response. MMWR Recomm Rep. 2021;70(3):1-27. https://www.cdc.gov/mmwr/volumes/70/rr/rr7003a1.htm
10. Kool JL. Risk of person-to-person transmission of pneumonic plague. Clin Infect Dis. 2005;40(8):1166-1172. https://pubmed.ncbi.nlm.nih.gov/15791518/
11. Runfola JK, House J, Miller L, et al. Outbreak of human pneumonic plague with dog-to-human and possible human-to-human transmission, Colorado, June-July 2014. MMWR Morb Mortal Wkly Rep. 2015;64(16):429-434. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6416a1.htm
12. Centers for Disease Control and Prevention. Clinical Care of Plague. https://www.cdc.gov/plague/hcp/clinical-care/index.html
13. Wyoming Department of Health. Wyoming Detects Rare Human Case of Pneumonic Plague. September 15, 2021. https://health.wyo.gov/wyoming-detects-rare-human-case-of-pneumonic-plague/
14. Centers for Disease Control and Prevention. Preventing Plague. https://www.cdc.gov/plague/prevention/index.html

For Clinicians | Medication List Accuracy: Nobody Has the Whole Picture Anymore

By Dr. Jamie Wilkey, PharmD, Director of Clinical Education
Medically reviewed and edited by Kristen Carpenter, PA-C

We’re closing out National Preparedness Month with the one step that costs nothing and that almost no patient has actually done: a medication record that’s correct.

As a pharmacist working in retail for many years, it became really clear to me that patients have a hard time keeping track of what they take. Especially polypharmacy patients, the ones on five or more medications. They don’t know all the drugs, the doses, who wrote those prescriptions, and sometimes even where they got it filled.

That’s not just a mess for the pharmacist trying to get a refill on the right medication. Deep down it’s a core problem for preparation and for healthcare in general. If there’s no one true source of what a patient is taking, in one place they can get to, it creates a ripple effect.

We are going to tackle this topic that seems simple, but is harder for your patients than you think. I’ll cover what patients actually bring us in the pharmacy, why no single record exists anymore, and how to work with a patient to start fixing it to get all of their medications in a record in one place.

What patients actually bring us

Ask a patient what they take and you’ll usually get the purpose, not the name. The blood pressure one. The thyroid one. The night blood sugar medicine. Not many know the full name, let alone the strength and the frequency. They get it from the pharmacist, put it in the organizer, and that’s the system.

When they do bring their medications in, it’s what we call brown bagging. A grocery bag on the counter, and we go through it vial by vial. They’re usually from different pharmacies and different doctors, and some aren’t being taken anymore. Just old vials still sitting in the house. Those vials are the only record that exists.

Then someone needs a transfer. They evacuated, or they’re traveling and out of refills. They hand me the bag as the pharmacist, or the handwritten note that says what everything is for but not what it is.It’s really hard to transfer a prescription I can’t identify (“your patient said they are taking a few medications for blood pressure and they need the one that is a red tablet sent over to us“), and I can’t call a prescriber about a medication I can’t name (“your patient said you gave them a pill last year for their mood. They need that refilled“).

How accurate are the lists patients do keep?

You might be thinking the patients who keep a list are fine. They aren’t.

In 138 patients at an urban emergency department in Australia, 75% of self-administered medication history forms had at least one discrepancy against a pharmacist-taken history, and 20% had at least one the authors judged high-risk ¹. In a US preoperative clinic, of 82 lists patients brought in themselves, 94% had at least one discrepancy against the clinic record, with a median of four per list ².

Both studies enrolled patients who produced a list at all. That’s the organized minority, the people who already did the thing we keep telling everyone to do. These numbers are the best case scenario. Yikes!

Nobody has the whole picture anymore

There used to be one record that tied it all together, and it was the insurance company because everything billed through them. Whatever pharmacy filled it, whichever doctor wrote it, all claims routed through the same company. That made the payer’s file the most comprehensive picture of what a patient was taking.

Now that behemoth that held everyone’s Rx history is coming apart. Patients frequently pay cash or use a discount card when it’s cheaper. They fill somewhere else because it’s faster. Some don’t want one company holding a list of everything they take and they intentionally fill for cash. Others don’t have insurance at all. And to add complexity to this, prescriptions start in more places now that there are so many new healthcare vertical companies with menopause from one service, weight loss from another, and mental health from a third. All on top of a primary care provider a patient already sees. 

So there’s no entity with the throughline anymore, and the patient became the record by default. We weren’t trained for this. Pharmacy school taught me a closed loop: one prescriber, one chart, one pharmacy that knew about both. That system is evaporating like a puddle on a hot summer day.

And before you assume your own office chart is the good copy: when researchers compared patient, GP, and community pharmacist records for 751 older patients in the Netherlands on an average of eight medications, the three sources disagreed for 71.9% of patients ³. There’s no correct copy for a patient to use or reference. Yikes!

The forms aren’t built to be patient-facing

So the patient is the walking medication record now. Nobody ever taught them how to do this, and the forms we hand them don’t help much.

Pull up any medication list template, the free federal one or whatever your clinic prints. They all start the same way: the name of the drug, and the strength. That’s what most just don’t know (especially those polypharmacy patients on 5+ medications). What they can tell you is that it’s the little white one for blood pressure.

So we hand someone a form that starts with the part they can’t do, and then we’re surprised when what comes back is wrong or half empty.

Here’s one thing you can use though. In that Australian study, the patients who left the pharmacy line blank had more than double the discrepancy rate, worse than patients on a long list of medications ¹. Tread carefully here…it predicts trouble, it doesn’t cause it. Filling the line in doesn’t make the rest of the list right. But a blank there tells you to slow down and ask more questions.

And to make matters worse, these patient-led records go stale fast. A patient fills one out in March, a specialist changes a dose in June, and nobody goes back to update it.

What actually works

Start with the one that already exists. Keep it simple!

If your patient is on Medicare Part D and meets the targeting criteria, their plan has to offer them a comprehensive medication review (CMR) every year, done by a pharmacist, at no cost to them ⁴. They walk out with a written summary in a standardized federal format, and that summary includes a personal medication list ⁵. I’ve done hundreds of these and they are fun. Most patients have never heard of them or think it is spam when a pharmacist calls them and offers to do one. 

When they don’t qualify for a CMR, or you want to do something today, print what you have. Have your MA pull the medication list off the chart and hand it over as a starting draft. Not a record. A draft. Make that clear it is just a springboard to start from because the minute a patient decides the office list is the authoritative one, they stop adding to it. And what’s missing from your chart is the whole point: the other prescribers, the cash fills, the online services, the supplements.

What the printout does is solve the naming of those medications. Your patient can’t write atorvastatin 40 milligrams from memory. They can absolutely correct a page that already says it and add “for cholesterol.” So they’re clear on how the name matches up with the indication

Then send them to their pharmacist with the bag. Brown bagging is helpful. In a randomized trial across three teaching hospitals in Colombia, a pharmacist-acquired history dropped the share of patients with at least one discrepancy from 93.6% to 60.7%⁶. A third better, and still wrong in six patients out of ten. That’s the ceiling, and it’s still the best we’ve got.

It’s also the only way an interaction check means anything, which we wrote about separately in The Drug Interactions You Create in an Emergency.

If you want a template to point them at, AHRQ’s is free, in English and Spanish, and it’s fine ⁷. No need to build your own.

This is what appropriate medical preparation looks like

Even in the best of times, when everything is working, it’s hard to help a patient nobody has a complete record for. In a disaster it compounds and makes everything worse.

The preparation that matters here is information, not inventory. A record the patient can actually get to, that says enough for someone else to act on it. None of this replaces primary care. Primary care is the bedrock for a patient building their Rx profile appropriately and accurately. 

That’s the work we do at Jase. We’re a team of physicians, physician assistants, and pharmacists, and we handle the clinical side ahead of time so a patient isn’t starting from zero when they can’t reach anyone. For the medications, patients complete an online intake for evaluation by a board-certified physician, which may include a live synchronous consult depending on their state. This record is a page your patient makes, and it’s the half of preparation we can’t do for them.

The bottom line

My grandma had this figured out on her own. She was on warfarin and knew how tricky that medication was with drug and food interactions. So she didn’t leave anything to chance. She typed her medications out on one page: the name, what it was for, the strength, the doctor who wrote it, and the pharmacy that filled it. Then she printed it and kept it in the kitchen, where someone (like an emergency responder) could easily and clearly find it.

Follow her great example! A simple Word document or the notes app works great. What it needs is to travel with the patient, to be findable by somebody else, and to have a date on it. Then update it once a year at the physical (at a minimum, and ideally whenever anything changes with their medications or supplements). It won’t be perfect. Even a pharmacist taking a full history doesn’t get it perfect. But a dated, mostly-right list that a stranger can find beats a grocery bag every time.

Sources

1. Wai A, Salib M, Aran S, Edwards J, Patanwala AE. Accuracy of patient self-administered medication history forms in the emergency department. American Journal of Emergency Medicine. 2020;38(1):50-54. Cross-sectional study, urban emergency department, Australia, 138 patients. https://pubmed.ncbi.nlm.nih.gov/31005394/
2. Lee KP, Nishimura K, Ngu B, Tieu L, Auerbach AD. Predictors of Completeness of Patients’ Self-reported Personal Medication Lists and Discrepancies With Clinic Medication Lists. Annals of Pharmacotherapy. 2014;48(2):168-177. Academic hospital preoperative clinic, 82 patient-brought lists, data collected January to October 2010. https://doi.org/10.1177/1060028013512109
3. Bosch-Lenders D, Stoffers HEJH, Winkens B, Twellaar M, Hufen WJM, et al. Discrepancies in prescribed medications as reported by patients, general practitioners, and community pharmacists in older patients with polypharmacy in primary care. BMC Primary Care. 2026. 751 patients across 24 general practices and 17 community pharmacies, the Netherlands. https://doi.org/10.1186/s12875-026-03332-3
4. Centers for Medicare and Medicaid Services. Medication Therapy Management. Part D sponsors must establish an MTM program, and programs may be delivered by pharmacists or other qualified providers. Contract year 2026 targeting criteria are described in the CY 2026 Medicare Advantage and Part D final rule fact sheet. https://www.cms.gov/medicare/coverage/prescription-drug-coverage-contracting/medication-therapy-management
5. Centers for Medicare and Medicaid Services. Medicare Part D Medication Therapy Management Program Standardized Format, frequently asked questions. Sponsors must at a minimum offer a comprehensive medication review annually to targeted beneficiaries, and the written summary provided to the beneficiary includes a Personal Medication List and a Medication Action Plan. https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovcontra/downloads/mtm-program-standardized-format-faqs-v08-1512-.pdf
6. Becerra-Camargo J, Martinez-Martinez F, Garcia-Jimenez E. A multicentre, double-blind, randomised, controlled, parallel-group study of the effectiveness of a pharmacist-acquired medication history in an emergency department. BMC Health Services Research. 2013;13:337. Three teaching hospitals in Bogota, Colombia, 242 patients completed. https://pmc.ncbi.nlm.nih.gov/articles/PMC3844415/

For Clinicians | Why Patients Run Out of Medication: The Ordinary Disruptions, Not the Disaster

By Dr. Jamie Wilkey, PharmD, Director of Clinical Education
Medically reviewed and edited by Kristen Carpenter, PA-C

As a pharmacist, I’ve helped patients keep access to their medications through real disasters (especially wildfires out here in Utah). Much much more commonly, I spent my time behind the counter helping patients get access to their medications during ‘normal life.‘ No epic natural or structural disaster caused the disruption, but it was still a giant pain for my patients to deal with.

Some of what got in their way, patients could do something about: whether they had a ride that week, or whether they could pay for their medications when they got to the counter.

The rest was totally out of their hands. 

• A manufacturer stops making a product and the shortage runs for months (and we covered how long those actually last here). 
• The pharmacy that filled their prescriptions for twenty years just closed.
• Their prescriber leaves the practice and the refill request sits in a queue nobody is watching. 
• The insurance plan changes its coverage rules on January 1 and nobody clearly loops in the patient on that
• The local chain pharmacy keeps temporarily closing due to staff shortages

Today we’re walking through both: what patients can stay ahead of, and what is out of their control. Most of the practical tips sit in that second group, because that’s where patients have the least wiggle room. It’s not quite as exciting as a full-scale disaster, but it’s a part of daily life I believe you should be prepared for because I dealt with it in some form daily with my patients for over a decade.

What patients can get ahead of

Cost is a big factor. 

• About 8% of US adults taking a prescription didn’t take it as prescribed in order to save money¹. Patients are getting better about raising the issue of medication cost with you in the appointment. GoodRx is the best tool we have here, especially for anyone with a high copay or anyone choosing not to run it through insurance. It’s a good, simple way to eyeball the cash cost of an Rx ahead of time. 

Travel is the one that arrives as an emergency. 

• Someone flies out Thursday and realizes Wednesday afternoon they don’t have enough medications for the trip. Their home pharmacy already has the prescriptions on file and can usually put together a vacation supply, but that takes lead time and sometimes a call to the plan. A pharmacy at their destination has none of their history and far less to work with. Tell patients to start working on their medications weeks before the departure date, not the night before (especially for overseas travel!). The more warning we in the pharmacy get, the more we can do, and their emergency doesn’t have to become ours.

For patients who depend on someone else for a ride, the best fix is usually removing the trip entirely. 

• I worked for a big chain for years, and it was clear that delivery there is a low priority and gets missed very often. A locally owned pharmacy that delivers is a different experience: you get to work with the same humans every time, and they have a stake in it going right. Mail order can work as well, depending on how easy the company is to work with. Some are atrocious and others are the easiest thing in the world. 

And finally, theft. 

• Theft as a loss for medications is more infrequent, and almost always a controlled substance and almost always someone living in the house with the patient. There isn’t much a pharmacy can do with it. The patient needs a police report, and for a Schedule II they need a new prescription from the prescriber, because those can’t be refilled at all.

What’s out of their hands:

• The drug is on shortage: ASHP was tracking 227 active drug shortages as of mid-2026, the third straight quarterly increase². Even so, the pharmacy has more room here than patients expect. We can usually work with whatever we have of it in stock, and at a chain we can see which nearby stores are holding it and send the prescription over so it’s in process within minutes. Patients can call around themselves, and once they find a pharmacy that has it, that pharmacy can pull it across. When it’s really gone gone everywhere, that’s when we need a new prescription from you. 
• Their pharmacy closed for good: Nearly one in three US retail pharmacies closed between 2010 and 2021, and roughly a third of counties ended that period with fewer pharmacies than they started with³. When a pharmacy closes, whoever bought the files now has the prescriptions, so nothing vanishes. Patients will feel friction on the first few fills, because pulling another location’s information into our system takes longer than it looks. They should have gotten a letter, but profile addresses are almost always outdated, so there’s no guarantee the patient heard anything ahead of time. Tell them to expect a few extra days and start the refill process early with a new pharmacy.
• Their pharmacy is closed today: We’ve had a pharmacist shortage across Utah for a while, so stores that should be open Saturday aren’t, and some close mid-day when nobody can cover a shift. It’s not just Utah, but all across the US. Patients find out by driving there and seeing a handwritten sign: ‘closed due to pharmacist/staff shortage, will reopen on X date/time.’ Chains are more exposed to staffing shortages, and also easier to recover from, because any store in the chain can see the profile and patch around the closed one.
• The refill request never reached you: This is usually a routing problem. Pharmacy systems grab the first address on file for a prescriber rather than the clinic the prescription came from, which breaks constantly for urgent care and for anyone practicing at several sites. If you’ve wondered where those requests go, that’s where.
• It’s January: Formularies change, and the bigger shock is the deductible resetting. The patient who paid nothing in December pays full price until they clear it, up to $615 on Part D this year⁴. The year has a shape now: expensive at the start, copays through the middle, then nothing once they hit the $2,100 cap⁴. Insurance doesn’t explain any of that. We do, at the counter, and we hate it too. We don’t set the prices. We just charge what insurance tells us to charge. 
• You don’t know whether the plan will cover it: Plan policies vary wildly, so don’t guess. Pharmacy billing is live, so as soon as we get the Rx we can tell you on the spot whether the plan will cover a vacation supply, an early refill, or a replacement. It isn’t a medical claim and it doesn’t take days. 

Two things from the pharmacy side prevent most of what’s in this article.

Write for 90 days at a time wherever the clinical picture allows it. I know most of you are doing that already. Keep it up! More insurers are covering 90 days supplies and it really does help a lot. 

This feels obvious, but make sure the right office phone number is on the prescription when you eRx it over. I’ve lost a lot of time calling the number on file and finding out the prescriber is somewhere else that day.

Last Thought

We’re a medical preparation company, and most of what we publish is about disasters. This is the other half of the same work. Appropriate medical preparation fits in daily life as well, not just big behemoth disasters. The same habits carry a patient through a wildfire, and they’ll use them far more often on an ordinary Tuesday. None of it replaces primary care. It’s the layer underneath, that keeps everything humming along.

Patients who are prepared are easier to take care of. They call before they’re out, they know what they take and who prescribes it, and the care goes better on both sides of the counter.

Sources

1. Mykyta L, Cohen RA. Characteristics of Adults Aged 18–64 Who Did Not Take Medication as Prescribed to Reduce Costs: United States, 2021. NCHS Data Brief No. 470. National Center for Health Statistics, June 2023. Cost-saving measures included skipping doses, taking less medication than prescribed, or delaying filling a prescription. https://www.cdc.gov/nchs/data/databriefs/db470.pdf
2. American Journal of Managed Care. Active US Drug Shortages Rise for Third Straight Quarter. 227 active shortages as of Q2 2026, reporting ASHP tracking data. https://www.ajmc.com/view/active-us-drug-shortages-rise-for-third-straight-quarter
3. Health Affairs, December 3, 2024. DOI 10.1377/hlthaff.2024.00192. Nearly one in three US retail pharmacies closed between 2010 and 2021; roughly one-third of counties saw a net decline in pharmacies. Summary: https://schaeffer.usc.edu/research/pharmacy-closures-united-states-health-affairs/
4. Centers for Medicare & Medicaid Services. Final CY 2026 Part D Redesign Program Instructions. Annual deductible $615; annual out-of-pocket threshold $2,100. https://www.cms.gov/newsroom/fact-sheets/final-cy-2026-part-d-redesign-program-instructions

For Clinicians | Drug Interactions in a Disaster: The Combinations a Bad Week Creates

By Dr. Jamie Wilkey, PharmD, Director of Clinical Education
Medically reviewed and edited by Kristen Carpenter, PA-C

When we think about prescription medicine in a disaster, we most often think about supply. Does the patient have enough of what they’re already taking? Can we get them something for the wound or the infection that happened because of the disaster?

I’m a pharmacist, so I also think about another way that disasters mess with our medications and that is drug interactions. Drug interactions are what happens when one thing changes what another thing does inside the body. Two prescriptions can do it. So can a prescription and something off a shelf, an ibuprofen, an antihistamine, a supplement nobody thinks to mention. And so can a prescription and the shape the patient is in, which is the version a disaster is good at making. Most of the year a computer catches these. In a disaster people take more medication and newer medication with less prescriber and pharmacist oversight, because we aren’t as easily reached.

Adverse drug events send about 4 of every 1,000 Americans to an emergency department each year, and the top two classes are anticoagulants and antibiotics.¹ A disaster does three things at once. It puts new drugs in people’s hands. It also can lead to dehydration. And lastly, it takes away convenient lab work. Today I’ll walk through the three dangerous drug interaction combinations that can result from a disaster, a few smaller traps, and how to keep an eye out for your patients ahead of time. 

Few New Medications

It’s easy to picture a disaster putting everybody on a pile of new medication. That isn’t what happens. Most people are taking what they were taking a week ago. A smaller group picks up something new, and it lands in three classes: an antibiotic, an NSAID, and an antihistamine.

As far as medications go those drug classes are generally basic and largely benign. What I want to talk with you about is that these are three drug classes you’d hand someone without a second thought because two of them produce all three of the cases below. Ordinary is what makes them dangerous, because nobody stops to check an ordinary drug.

The antihistamine is the odd duck here, because it doesn’t need a collision with another drug or new health condition to cause a problem. Diphenhydramine sits on the Beers list as highly anticholinergic, and clearance falls with age, so confusion, dry mouth and constipation all get more likely in an older patient, and cumulative anticholinergic exposure carries its own risk of falls and delirium.² Beers still says it may be appropriate for acute treatment of a severe allergic reaction, which is the disaster presentation, so here is a tricky medication that should be used in an emergency, but also watched very carefully for anyone over 65 years old.

 The Kidney Triple Whammy from Dehydration

A patient on a diuretic and an ACE inhibitor or ARB has been fine on that combination for years. Then comes three days of hauling debris in the heat, less water than they should be drinking, maybe some diarrhea. Their back hurts, so they take an ibuprofen.

Those three together have a name, the triple whammy, and the kidney is what gets walloped. A kidney filters by holding pressure across the filter, and when blood volume drops it protects that pressure two ways: it widens the vessel coming in and tightens the one going out. The NSAID blocks the widening. The ACE inhibitor or ARB blocks the tightening. Both of the kidney’s own defenses are gone at the same moment the diuretic and the dehydration are sending it less blood to work with. A 2025 meta-analysis of four studies and 42,367 patients put the odds of acute kidney injury at about double, OR 2.01 (95% CI 1.30 to 3.10).³ One study inside that review found the three-drug combination carried 1.64 times the risk of the two-drug version,³ so the ibuprofen really is what tips the scales here.

Nothing about their prescription changed. The dehydration and the extra NSAID broke a smooth-running system. 

Warfarin Plus an Antibiotic, With No Lab Draw

The second case here is the same story, but mixing it up with a different organ. This interaction will surprise nobody because it is warfarin–the medication that is ultra sensitive and seems to interact with everything. Warfarin plus a handful of common antibiotics pushes the INR up, partly because the antibiotic slows the enzyme that clears warfarin, partly because it kills off the gut bacteria that make vitamin K. The high-risk list is pretty short: TMP-SMX, ciprofloxacin, levofloxacin, metronidazole, fluconazole, azithromycin and clarithromycin.⁴

Disasters make blood draws a lot harder to get and they aren’t particularly top of mind in an event like that. In a cohort of 22,272 warfarin patients, TMP-SMX carried a hazard ratio of 2.09 for serious bleeding and ciprofloxacin 1.87, and 9.7% of the patients given fluconazole ended up with an INR above 6.⁴ Then the part that matters for a storm: patients who got an INR within 3 to 14 days of starting the antibiotic had a lower risk of serious bleeding, HR 0.61 (95% CI 0.42 to 0.88).⁴

The interaction was always there. The lab is what disappeared in a disaster.

Bactrim +  Spironolactone

This third and final big interaction is kind of the opposite because nobody expects it. Bactrim for a UTI, in a patient on spironolactone for heart failure, and both drugs are holding onto potassium like it is going out of style. Trimethoprim blocks the same channel in the kidney that amiloride does, so it behaves like a potassium-sparing diuretic stacked on top of the one the patient is already taking.

In a population study of Ontario patients 66 and older who were taking spironolactone, sudden death within 14 days of an antibiotic prescription was more than twice as likely with TMP-SMX as with amoxicillin, adjusted OR 2.46 (95% CI 1.55 to 3.90).⁵ Ciprofloxacin came in elevated too, at 1.55.

Here’s why it belongs in a disaster article. This is the combination you’d normally check a potassium on, and in a really bad week nobody is checking anything. The good news is that the fix is so easy: just picking a different antibiotic. Amoxicillin is the drug everything else in that study was measured against.

A Few Smaller Traps

These don’t each need their own section, but they come up every time.

• Know the acetaminophen ceiling. FDA’s over-the-counter limit is 4,000 mg in 24 hours for adults,⁶ Tylenol’s own Extra Strength label lowered it to 3,000, and the label warns separately about 3 or more alcoholic drinks a day.⁷ Prescription combination products have been capped at 325 mg per unit since 2014, but over-the-counter cold, flu and sleep products never were, which is how somebody stacks two products and blows past the ceiling without exceeding a single label.⁶
• Know which way to swap between ibuprofen and acetaminophen. For the patient who is dehydrated, on a diuretic with an ACE inhibitor or ARB, or on warfarin, acetaminophen is the safer analgesic. Use ibuprofen when the liver is the bigger worry: heavy alcohol use, liver disease, or a patient already getting acetaminophen from a combination product.
• Don’t let thirst be the cue. CDC lists diuretics, ACE inhibitors and ARBs as reducing thirst sensation, so the patients who most need to drink are the least likely to feel like it.⁸ Tell them to drink on a clock whether they feel thirsty or not.
• Watch what may bind with the antibiotic. Antacids, calcium and iron cut absorption of both doxycycline and the fluoroquinolones,⁹ and bismuth subsalicylate, the Pepto in the cabinet, is on doxycycline’s list too.¹⁰
• Address the sun! Doxycycline causes an exaggerated sunburn reaction and the and the fluoroquinolones carry their own photosensitivity warning.⁹ The doxycycline label says to stop the doxycycline at the first sign of skin redness,¹⁰ which is a hard instruction in a week with nothing else on the shelf, so make sure they know to cover up and stay out of direct sun for the whole course.

Where This Fits

We want everyone looking at the whole picture of a patient’s medications in a disaster. We’re a team of pharmacists, physicians and PAs, and we catch these same interactions in ordinary clinic weeks: the ibuprofen on top of the ACE inhibitor, the Bactrim in the spironolactone patient. The chemistry doesn’t change in a disaster. What changes is that the catching stops. The screen, the lab and the pharmacist who would have caught it all get harder to reach in an emergency.

So, Jase does the clinical work early. A licensed provider reviews the request and writes the prescription ahead of time, for a short list of predictable problems, for emergency use only and after the patient has tried to reach a qualified provider. That’s what we mean by appropriate medical preparation. We also mean helping patients know, before a disaster, which items on their own medication list are most likely to cause trouble.

The drugs a disaster adds are boring. What makes them dangerous is the patient’s existing medication list. 

Sources

1. Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US emergency department visits for outpatient adverse drug events, 2013-2014. JAMA. 2016;316(20):2115-2125. https://pmc.ncbi.nlm.nih.gov/articles/PMC6490178/
2. 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. https://doi.org/10.1111/jgs.18372
3. Calvo DM, Saiz LC, Leache L, Celaya MC, Gutiérrez-Valencia M. Acute kidney injury and morbi-mortality associated with “triple whammy” combination: systematic review and meta-analysis. Br J Clin Pharmacol. 2025;91(11):3031-3041. https://pmc.ncbi.nlm.nih.gov/articles/PMC12569550/
4. Lane MA, Zeringue A, McDonald JR. Serious bleeding events due to warfarin and antibiotic co-prescription in a cohort of veterans. Am J Med. 2014;127(7):657-663.e2. https://pmc.ncbi.nlm.nih.gov/articles/PMC4116816/
5. Antoniou T, Hollands S, Macdonald EM, Gomes T, Mamdani MM, Juurlink DN. Trimethoprim-sulfamethoxazole and risk of sudden death among patients taking spironolactone. CMAJ. 2015;187(4):E138-E143. https://pmc.ncbi.nlm.nih.gov/articles/PMC4347789/
6. US Food and Drug Administration. Acetaminophen. Safe Use of Over-the-Counter Pain Relievers and Fever Reducers. https://www.fda.gov/drugs/safe-use-over-counter-pain-relievers-and-fever-reducers/acetaminophen
7. Tylenol Extra Strength (acetaminophen) Drug Facts label. DailyMed, US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=59773893-09a8-47a2-943a-e9ea9da4458a
8. Centers for Disease Control and Prevention. Heat and Medications: Guidance for Clinicians. https://www.cdc.gov/heat-health/hcp/clinical-guidance/heat-and-medications-guidance-for-clinicians.html
9. CIPRO (ciprofloxacin hydrochloride) tablets, prescribing information. US Food and Drug Administration, 2024. https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/019537s095,020780s050lbl.pdf
10. Doxycycline hyclate tablets and capsules, prescribing information. DailyMed, US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=fad03768-f1d2-459f-965e-0ec29f189f1f

For Clinicians | Animal Sting Reactions: Large Local Reaction vs Cellulitis, and When It’s Anaphylaxis

By Dr. Jamie Wilkey, PharmD, Director of Clinical Education
Medically reviewed and edited by Kristen Carpenter, PA-C

This is part two of our Animals + Disaster series. Part one was all about which bites actually need antibiotics. Today we are talking about stings. And stings get a sharper answer (gotta love that pun, right!): almost none of them. The drug that matters in stings isn’t an antibiotic at all. Today we’re sorting all of this out, plus what fire ant pustules are doing and the two stings that need something other than an antibiotic.

What a sting does to the body

A sting is venom, injected on purpose, by an animal defending itself. A bite is a wound with mouth bacteria in it. A sting inoculates almost nothing, so infection isn’t really that likely.

Almost everything that stings you is female because stingers are modified ovipositors. The 3 bugs that are most likely to sting you in the US are honeybees and bumblebees, the vespids (yellowjackets, hornets and paper wasps), and imported fire ants. Honeybees leave the stinger behind still pumping venom, so get it out fast. Speed is what matters and technique doesn’t. ¹ Vespids keep theirs and can sting over and over, which is how one disturbed nest becomes a multiple-sting patient. Fire ants bite to hold on, then pivot and sting in an arc, and that’s where the ring of pustules comes from. ²

Bee and vespid venom is mostly protein, and protein is what IgE recognizes, so those are the stings that turn allergic. Fire ant venom doesn’t have much protein and is mostly piperidine alkaloids which are directly cytotoxic. That’s the pustule, and it’s why no Rx you prescribe changes it. ²

So what you’re looking at comes down to which insect, how many stings, and whether that patient has already made IgE. Scorpions and spiders aren’t going to be covered today (hang tight for that article coming up soon!), and scorpion envenomation is neurotoxic rather than allergic anyway. 

Is a hot, swollen sting site cellulitis?

Usually not. The clock tells you more than the exam does. A large local reaction is a late-phase IgE response, not an infection. A typical sting will progress normally as swelling over 10 cm that’s still there past 24 hours,³ peaking somewhere in that 24 to 48 hour window, then taking 3 to 10 days to fully settle.⁴ Patients will tell you their whole arm is swollen, and they’re often right. Cellulitis runs on a different clock. It shows up later, and instead of peaking and receding it keeps spreading past the sting site. So check out which direction the site has been moving, not how angry it looks on the day you see it. A site still spreading after 48 hours is the one to treat.

You’re probably wondering how an anaphylactic reaction plays in here, and whether it relates to these exaggerated sting sites. They might relate a little. The guideline puts the risk of a systemic reaction under 10%, and anaphylaxis under 5%. It also says these patients usually just get another big local reaction.⁴ So the swollen arm by itself isn’t what makes you refer or write for epinephrine. A systemic reaction is.

Fire ant pustules are supposed to look like that

Leave them alone. That’s the whole intervention. Easy, huh!?

Fire ants create their own community raft on floodwater, with thousands locked together, and they sting on contact when somebody wades into one.⁵ So stings climb after heavy rain and flooding across the Southeast and Gulf. Dozens of stings on the feet and ankles, in rings, is fire ants and nothing else.⁶ 

24 to 48 hours post-sting the sting sites become sterile pustules. ² They really are sterile! They look exactly like infection and nothing reverses them, because the alkaloid already killed the cells. ² The skin over a pustule is protecting the tissue underneath. Lancing one creates a wound that may need an antibiotic.  Therefore, just good ‘ol soap and water plus an antibiotic cream if a pustule opens on its own. ² Fire ant anaphylaxis does happen, but is pretty uncommon. Serious systemic reactions run around 2% of fire ant stings in people who seek care. ² 

When is a sting an emergency, and how long do you watch?

There’s really only one sting emergency, and it’s anaphylaxis. You recognize it one of two ways: either two+ organ systems are involved, or the blood pressure drops (a systolic < 90 in an adult or a fall of more than 30% from their own baseline). Hives plus vomiting counts, and so does hives plus wheezing. A drop in blood pressure after a sting is enough on its own, without a second system getting involved at all. ⁷

When you see these symptoms give epinephrine. Must be epinephrine! An antihistamine and a steroid aren’t a substitute here and they don’t keep the reaction from coming back a few hours later, which is the thing we all hope they’ll do. ⁷ 

How long do you watch? We all learned 4 to 6 hours for everybody. Well, the 2023 practice parameter cut that down. If the reaction wasn’t severe, one hour with no symptoms after it resolves is enough, because nearly every biphasic reaction has declared itself by then. ⁷ Only a severe reaction, or one that took more than one dose, needs longer.

And just keep in mind a second epinephrine dose may be needed. In a 2021 systematic review, 17% of venom-triggered reactions needed one when a health care professional was there to give it.⁸ That’s more than most of us would guess, so don’t discount it.

When it’s the venom, not the allergy

A patient with 50 or more stings is a different problem entirely. There’s enough venom on board at that point to do direct damage, so what you’re watching for is rhabdomyolysis, acute kidney injury and hemolysis rather than an allergic reaction.⁹ Tolerance runs about 22 stings per kilo, which means roughly 500 can kill a child.¹⁰ Management of being a human sting pin cushion is aggressive fluids with an eye on urine output, and plenty of people add bicarbonate, though it has never been shown to beat saline alone.¹²  Either way it needs a hospital and not an autoinjector. All of it comes from case reports, though. There’s no guideline here.

The referral almost nobody makes

Anyone who has had a systemic reaction to a sting should be referred for venom immunotherapy. Untreated, about 40% of those patients have another systemic reaction the next time they’re stung. On immunotherapy it’s under 3%. ¹¹ Patients know this as allergy shots for bee stings, and that’s the phrase to use at the counter, because “venom immunotherapy” means nothing to them. After a disaster sting the referral almost never gets made, and it’s the only thing on this list that changes what the next sting does to them.

Where this fits

Nearly everything in this article is a decision rather than a prescription. Is the arm swelling or spreading? Is the pustule intact or opened? Those calls are all or none right now. Either a patient reaches a clinician who reads the clock, or they’re home staring at a hot red arm with a search bar and a leftover antibiotic.

Jase works the layer in between, and for stings that mostly isn’t a drug. It’s the thinking done in advance: which reaction is expected, which one is spreading, and which one means the epinephrine comes out. Where a prescription is part of it, a licensed provider reviews the request and writes it, for emergency use only and after first trying to reach a qualified provider. That’s what we mean by appropriate medical preparation, and it’s in no way a replacement for primary care. It’s for the days primary care isn’t reachable.

Part one of this series was about bites, and how few of them actually need an antibiotic. And as you’ll see in part two, stings need one even less often. We’ll keep publishing how we make these calls for appropriate medical preparation.

The bottom line

Antibiotics really don’t help with stings. The hot swollen arm that looks infected almost never is, and the sting that actually needs a drug needs epinephrine.

So read the clock instead of the redness. Leave the pustules alone from those fire ants. When two systems are involved or the pressure drops, give epinephrine and watch the hour. And when a patient has already had a systemic reaction, make the referral, because it’s the only thing you’ll do that changes what the next sting does.

Sources

1. Visscher PK, Vetter RS, Camazine S. Removing bee stings. Lancet. 1996. PMID 8709689.
   https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(96)01367-0/abstract
2. Kruse B, Anderson J, Simon LV. Fire Ant Bites. StatPearls. Treasure Island (FL): StatPearls Publishing. Updated August 7, 2023. Venom is 95% water-insoluble alkaloid with a 5% aqueous protein fraction. Vesicles form within 4 hours and become sterile pustules by 24 hours. Serious systemic reactions occur in about 2% of fire ant stings among patients who seek care.
   https://www.ncbi.nlm.nih.gov/books/NBK470576/
3. Tripolt P, Arzt-Gradwohl L, Čerpes U, Laipold K, Binder B, Sturm GJ. Large local reactions and systemic reactions to insect stings: similarities and differences. PLoS One. 2020;15(4):e0231747. Large local reaction defined as swelling exceeding 10 cm lasting more than 24 hours. Median duration 7 days, range 1 to 21 days, in 310 patients.
   https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0231747
4. Golden DBK, Demain J, Freeman T, et al. Stinging insect hypersensitivity: a practice parameter update 2016. Ann Allergy Asthma Immunol. 2017;118(1):28-54. Large local reactions increase in size for 24 to 48 hours, exceed 10 cm contiguous to the sting site, and take 3 to 10 days to resolve. Patients with large local reactions have less than 10% chance of a systemic reaction and less than 5% chance of anaphylaxis, and usually have large local reactions again on subsequent stings.
   https://www.aaaai.org/Aaaai/media/Media-Library-PDFs/Allergist%20Resources/Statements%20and%20Practice%20Parameters/Stinging-insect-hypersensitivity-2016.pdf
5. NIOSH. Hurricane and Flood Key Messages for Employers, Workers, and Volunteers, Third Edition. Atlanta, GA: US Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2025-106; 2025. Fire ants “can cling together and float along in floodwaters,” sting aggressively when disturbed, and red bumps “within a day or two become white fluid-filled pustules.”
   https://www.cdc.gov/niosh/docs/2025-106/pdfs/2025-106.pdf
6. Diaz JH. The impact of hurricanes and flooding disasters on hymenopterid-inflicted injuries. Am J Disaster Med. 2007;2(5):257-269. PMID 18491841.
   https://doi.org/10.5055/ajdm.2007.0034
7. Golden DBK, Wang J, Waserman S, et al. Anaphylaxis: a 2023 practice parameter update. Ann Allergy Asthma Immunol. 2024;132(2):124-176. PMID 38108678. Reduced blood pressure defined as systolic below 90 mm Hg in adults or a decrease greater than 30% from that person’s baseline. Biphasic anaphylaxis is unlikely when the reaction is not severe and the patient remains symptom-free for one hour after resolution, a 95% negative predictive value (95% CI 90.9%-97.3%), and is likelier with increasing severity and in patients given more than one epinephrine dose.
   https://www.aaaai.org/Aaaai/media/Media-Library-PDFs/Allergist%20Resources/Statements%20and%20Practice%20Parameters/Anaphylaxis-Practice-Paramaters-2023.pdf
8. Patel N, Chong KW, Yip AYG, et al. Use of multiple epinephrine doses in anaphylaxis: a systematic review and meta-analysis. J Allergy Clin Immunol. 2021. PMID 33862009. Across 86 studies and 36,557 events, 7.7% of anaphylaxis events from any cause required more than one dose. Among venom-induced reactions in which a health care professional administered the subsequent dose, 17.1% (95% CI 11.3-25.0).
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8588837/
9. Osman UMA, Turfan S, Mohamud MFY. Multi-organ dysfunction due to envenoming syndrome following a massive bee attack: a fatal case study and comprehensive literature review. Int Med Case Rep J. 2024;17:353-357. PMID 38646457. More than 50 stings is categorized as massive envenomation, with rhabdomyolysis, acute kidney injury, hemolysis, DIC and myocardial injury described. Case report with literature review.
   https://doi.org/10.2147/IMCRJ.S456777
10. Insect Stings. Merck Manual Professional Version. The average unsensitized person tolerates 22 stings/kg body weight, so an adult can withstand more than 1,000 stings whereas 500 stings can kill a child.
    https://www.merckmanuals.com/professional/injuries-poisoning/bites-and-stings/insect-stings
11. Boyle RJ, Elremeli M, Hockenhull J, et al. Venom immunotherapy for preventing allergic reactions to insect stings. Cochrane Database Syst Rev. 2012;CD008838. PMID 23076950. Subsequent systemic sting reaction in 3 of 113 treated patients (2.7%) versus 37 of 93 untreated (39.8%). Risk ratio 0.10, 95% CI 0.03-0.28.
    https://doi.org/10.1002/14651858.CD008838.pub2