For Clinicians | Which Medications Can’t Be Missed

How to Help Patients Rank their Medication List Before a Disruption

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

September is National Preparedness Month and that’s a big deal for us over here at Jase. When it comes to medications, your patients get the same advice they get every year: keep some extra medication on hand. But between all the prescription medications they take and the OTC products and supplements, that one line of advice quickly grows confusing and unmanageable. Nobody has ever published a ranking of which medications matter most, so patients sort it themselves.

Why there isn’t a ranking

One team went through 186 academic articles and 252 web pages of preparedness guidance for chronically ill patients, spanning cancer, cardiovascular disease, diabetes, chronic respiratory disease, and kidney disease. Recommended amounts on hand for the medications that treat these conditions ran anywhere from having a cushion of 3 days to a full month depending on which source you opened. Most of the recommendations traced back to expert opinion rather than evidence. None of it answers which medications actually tolerate an interruption. The review catalogues how much to have and never asks which one matters most.¹

To make matters more opaque, the literature it covered ends in 2014. The gap is still open today. So when a patient asks us how much to keep on hand, we don’t have anything more than generalities to give them.

How to rank a list

Here’s the 4 questions we use: 

1. How sick does this patient get without this drug?
2. How fast does that happen?
3. How likely is this one to be short when everyone needs it?
4. Can this particular patient actually get to a pharmacy in a bad week? 

Run a list through those and the order falls out. It’s not always what the patient expects. The table below answers the first two for the most common classes. Those are drug properties. The last two are yours, because only you know this patient.

Three exceptions

The table above is great for a quick scan. Steroids, clonidine and seizure meds need more context than the table can hold.

Ask every patient on long-term steroids what they do when they get sick. If they don’t have an answer, that’s your time to shine in educating them. Physiologic stress raises the requirement, so the sick-day rule is to double the oral dose at a fever above 100.4F and triple it above 102.2F.12 Omission during stress is what precipitates adrenal crisis. A patient rationing their bottle is under stress and cutting the dose at the same time. Something to watch for sure.

Check whether your clonidine patients are also on a beta-blocker. Stopping clonidine suddenly can push blood pressure higher than it was before treatment, and being on a beta-blocker too makes that worse.4 That’s why an elective taper stops the beta-blocker several days first. Patients on both would need top priority attention if access to those medications were disrupted.

And now for epilepsy. Sustained nonadherence tracks with worse seizure control and higher mortality.¹⁰  But a prospective study published this year in drug-resistant epilepsy found that occasional missed doses did not acutely raise seizure risk.11 So they sit in the middle of the ranking, not at the top. A missed dose is not the emergency. Multiple missed doses are. 

You intuitively know which of these goes first. The patient doesn’t, not off the top of their head. So the next time their list is in front of you, help them sort it into what’s critical and what has some flexibility.

Where we sit, and what to take away

This is where Jase specializes: the undefined middle of appropriate medical preparation. We help patients get ahead of a disruption before it throws off a critical regimen, with a licensed provider reviewing every request. Disasters hit chronic conditions unevenly, and we help sort out what comes first. A complement to primary care, never a replacement for it.

The ranking is the thing to walk away with, and it’s an order rather than an amount. Every list has one drug that is most critical, and most patients aren’t clear exactly what that one is.

And now before you go you should know we still have one class that is so important that it needs its own article: psychiatric medications. Stopping them is one hazard and restarting them is another. So our next article will be a deep dive on mental health medications in a disaster.

Sources

1. Tomio J, Sato H. Emergency and disaster preparedness for chronically ill patients: a review of recommendations. Open Access Emergency Medicine, 2014. 186 academic articles and 252 web pages screened; recommended supply ranged from 3 days to 1 month; the authors state that most of the recommendations have not been validated scientifically and that a large number rest on anecdotal evidence or expert opinion. https://pmc.ncbi.nlm.nih.gov/articles/PMC4753992/
2. Administration and Pharmacokinetics of Levothyroxine, in 70 Years of Levothyroxine. NCBI Bookshelf. Elimination half-life averages roughly 6 to 7 days in euthyroid adults and about 7.5 days in treated hypothyroid patients, which is what supports once-daily dosing. https://www.ncbi.nlm.nih.gov/books/NBK585644/
3. Amlodipine besylate (NORVASC). FDA prescribing information via DailyMed. Terminal elimination half-life of about 30 to 50 hours, from which a return toward baseline over several days follows. The label separately notes that amlodipine gives no protection against the dangers of abrupt beta-blocker withdrawal, which is the distinction this row turns on. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b00570ff-4081-4514-b45b-eb6f753450f5
4. Clonidine. StatPearls, NCBI Bookshelf: abrupt discontinuation may result in rebound hypertension, the risk is higher with concurrent beta-blockade through unopposed alpha-adrenergic activity, and beta-blockers are withdrawn several days before tapering clonidine. https://www.ncbi.nlm.nih.gov/books/NBK459124/ Catapres (clonidine hydrochloride) FDA label: sudden cessation has produced nervousness, agitation, headache and tremor with a rapid rise in blood pressure and elevated plasma catecholamines, and rare instances of hypertensive encephalopathy, cerebrovascular accident and death have been reported after withdrawal. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/017407s037lbl.pdf
5. Asthma: Rank MA, et al. The risk of asthma exacerbation after stopping low-dose inhaled corticosteroids: a systematic review and meta-analysis of randomized controlled trials. Journal of Allergy and Clinical Immunology, 2013. Patients with well-controlled asthma who stop regular low-dose inhaled corticosteroids have increased exacerbation risk compared with those who continue. https://pubmed.ncbi.nlm.nih.gov/23321206/ COPD: Magnussen H, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. New England Journal of Medicine, 2014;371(14):1285-1294. 2,485 patients with a history of COPD exacerbation on triple therapy; stepwise fluticasone withdrawal over 12 weeks was noninferior for moderate or severe exacerbations, with a greater decline in lung function during the final withdrawal step. https://pubmed.ncbi.nlm.nih.gov/25196117/
6. Burge MR, Schmitz-Fiorentino K, Fischette C, Qualls CR, Schade DS. A prospective trial of risk factors for sulfonylurea-induced hypoglycemia in type 2 diabetes mellitus. JAMA, 1998. No hypoglycemia occurred across 156 fasting studies in elderly patients receiving maximum sulfonylurea doses. The retrospective literature reaches the opposite conclusion, with omission of one or more meals implicated in 80% of severe drug-induced hypoglycemia admissions; risk concentrates in renal or hepatic impairment, alcohol use, and polypharmacy rather than in fasting alone. https://jamanetwork.com/journals/jama/fullarticle/1150338
7. Reimer C, Sondergaard B, Hilsted L, Bytzer P. Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology, 2009;137(1):80-87. Randomized double-blind placebo-controlled trial in 120 healthy volunteers given 8 weeks of esomeprazole 40 mg followed by 4 weeks of placebo; clinically relevant heartburn, acid regurgitation, and dyspepsia appeared after withdrawal and persisted at least 2 weeks. Conducted in healthy volunteers, not chronic PPI patients. https://pubmed.ncbi.nlm.nih.gov/19362552/
8. Ketones and Insulin Pumps. UCSF Diabetes Teaching Center. Pump therapy carries higher ketone risk because long-acting insulins are not used and rapid-acting insulin is delivered in very small amounts; check glucose and ketones if basal delivery is interrupted for more than an hour. https://diabetesteachingcenter.ucsf.edu/content/ketones-and-insulin-pumps
9. Ferri N, Colombo E, Tenconi M, Baldessin L, Corsini A. Drug-Drug Interactions of Direct Oral Anticoagulants (DOACs): From Pharmacological to Clinical Practice. Pharmaceutics, 2022;14(6):1120. Elimination half-lives: rivaroxaban 5 to 9 hours in healthy adults, edoxaban 8 to 11 hours, apixaban 8 to 15 hours, dabigatran 12 to 17 hours. https://pmc.ncbi.nlm.nih.gov/articles/PMC9229376/
10. Faught E, et al. Nonadherence to antiepileptic drugs and increased mortality: findings from the RANSOM Study. Neurology, 2008. Medicaid claims analysis of 33,658 adults with epilepsy across 388,564 treated quarters, 26% of them nonadherent; nonadherence was associated with more than a threefold increase in mortality, hazard ratio 3.32 (95% CI 3.11 to 3.54). https://pubmed.ncbi.nlm.nih.gov/18565827/
11. Goldenholz DM, et al. Does Missing Medication Acutely Change Seizure Risk? A Prospective Study. Annals of Neurology, 2026. Prospective community-based cohort of 27 adults with drug-resistant epilepsy, defined as three or more seizures per month, followed 10 months each across 7,853 person-days with 93% average adherence; occasional missed doses did not measurably raise immediate seizure risk, while prior seizure history did predict future seizures. https://pmc.ncbi.nlm.nih.gov/articles/PMC12782288/
12. Adrenal Crisis. StatPearls, NCBI Bookshelf. Sick day rules: doubling the oral corticosteroid dose for fever exceeding 100.4°F (38°C) and tripling it for fever exceeding 102.2°F (39°C). https://www.ncbi.nlm.nih.gov/books/NBK499968/

For Clinicians | Purulent vs. Nonpurulent Cellulitis

What an Antibiotic Can’t Do for a Wound

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

Most of what goes wrong with a wound isn’t fixed by an antibiotic. Your patients are working that out on day three, alone, with something left over in the closet. Today we’re covering antibiotic prescribing basics, the things a pill can’t touch, and the presentations that get seen rather than treated.

Purulent and nonpurulent: two kinds of wound trouble

Almost everything that goes wrong with a wound is one of two problems, and they behave nothing alike.

Purulent is a pocket. Pus collects in one place, the body walls it off, and pressure builds inside. You can feel it: a tender lump that gets firmer, then squishy in the middle. Abscess, furuncle, carbuncle, all the same problem at different sizes. It doesn’t spread so much as it grows and tightens, and it keeps going until something opens it, either a blade or the skin giving way on its own. 

Nonpurulent is a spread. There’s no pocket to find. Infection moves outward through the tissue, so the red edge sits somewhere different tomorrow than it did today. That’s cellulitis, and the border is the thing to watch. 

An antibiotic travels in the blood, and blood is the one thing that doesn’t reach the middle of a walled-off pocket. Therefore, a pocket has to get opened for treatment. A spread gets a drug to heal because that drug will actually reach the infection site. Draining an abscess is the treatment, not the prep work before the real treatment.

Which drug does which job

Purulent, once it’s drained, often needs nothing at all. That surprises people, so here it is straight from the guideline: for a simple abscess that’s been opened, systemic antibiotics are unnecessary, even when the organism is MRSA.¹ The drainage did the work. A drug gets added when the patient meets SIRS criteria or has genuinely impaired host defenses, not because a scary name came back on the culture.¹

Nonpurulent is the one that actually needs a drug. There’s nothing to open, so the treatment is systemic and it aims at strep: penicillin VK or cephalexin.¹ Cephalexin is 500 mg every six hours. The twice-a-day scripts that come through for a red leg are underdosed for it. The article reviewer, Kristen, has a family member who is an infectious disease doctor and she always says so many people underdose cephalexin and that is the reason it fails, not because it was “resistant”.

So of the two problems in front of you, the pill is the primary treatment in exactly one. The other one needs a blade.

When MRSA actually enters the picture

Pus means staph, and staph in the community is frequently MRSA. No pus usually means strep, and strep is never MRSA. So MRSA lives in the abscess, and the abscess, once it’s drained, usually needs no antibiotic at all.

This leaves our MRSA treatment reflex pointed at the wrong wound. The red leg with no pocket is where doxycycline gets added in practice, and it’s the presentation where MRSA is least likely to be.

The pair itself isn’t wrong. Cephalexin covers strep and misses MRSA. Doxycycline and trimethoprim-sulfamethoxazole cover MRSA and are shakier on strep. When you truly need both, IDSA’s oral answer is clindamycin alone or a beta-lactam paired with one of those two.¹ A real regimen, but used inappropriately at times when only strep needed covering.

So somebody ran that trial. Five hundred patients with uncomplicated cellulitis, cephalexin plus Bactrim against cephalexin plus placebo. Cure rates came back two points apart, with cephalexin alone on the higher end.² Cephalexin plus Bactrim isn’t a better treatment than cephalexin alone, and the trial’s own authors couldn’t rule out a small benefit they’d want tested again.

Nobody gets to say cephalexin alone wins. But it isn’t the no-brainer it feels like either, and that’s enough to make the next red leg worth a “why are we still doing this?”

MRSA coverage (Bactrim or doxycycline by mouth) belongs in two places: a drained abscess in someone with systemic signs or impaired host defenses, and cellulitis where there’s a real reason to suspect it, like penetrating trauma, known MRSA, or injection drug use.¹

What a pill can’t touch

Tetanus is the big one here. The ten-year vaccine interval is for clean, minor wounds. For a dirty one, and that means a puncture, a crush, a burn, or anything carrying soil or saliva, the interval is five years.³ Somebody eight years out from their last booster who steps on a nail in the garden is due, even though the ten-year rule will tell them they’re fine. Either Td or Tdap works for wound prophylaxis.³

Diabetes and peripheral vascular disease change the math, in two different ways that get collapsed into one. Poor perfusion means the wound closes slowly and infection is harder to clear. Neuropathy is the other problem, and it sits upstream of all of it: an injury goes unnoticed because the pain that normally makes a person look never arrives. By the time the wound is seen, it’s older than the patient’s story suggests.⁴

Then the one that isn’t an antibiotic decision at all. Pain out of proportion to what the skin shows, a border moving while you watch it, systemic toxicity, crepitus or bullae. That’s a necrotizing infection until proven otherwise, and IDSA’s line is prompt surgical consultation:¹ a surgeon tonight rather than a prescription and a recheck in the morning.

The guideline is twelve years old

The guideline I keep quoting is from 2014, and it’s still the current US document. Two randomized trials since then complicate what I told you about drained abscesses. Talan found Bactrim after drainage raised cure from roughly 74% to 80%.⁵ Daum found the same direction in abscesses under 5 cm.⁶ Both landed within three years of the guideline, and the guideline still says what it said.

None of it answers what the patient is actually asking, which is what to do about their own leg on day three.

The missing middle

Right now this is all or none. Either the patient gets to you and you look at the leg, or they’re navigating this on their own (offgrid, trapped by a natural disaster, or in a foreign country to name a few scenarios). Nothing sits in between, where somebody has already told them which version of this kind of infection needs a healthcare professional’s eyes on it.

That in-between is our work, and it has a name: appropriate medical preparation. It isn’t a replacement for primary care, and this article is the argument for why. Half of what we’ve covered is something only a clinician can do.

We’re medical doctors, PAs, and pharmacists, and we spend our time charting the parts of this that the guidelines leave grey. If a patient is pressing you for something to keep on hand and you don’t have the bandwidth for it, send them to us at Jase.com. A licensed provider reviews the request and writes the prescription, and we’ll keep publishing where we draw the lines.

The bottom line

Most of what goes wrong with a wound isn’t fixed by an antibiotic. Some of it gets opened, some of it is a tetanus shot, some of it needs a surgeon tonight, and a good share of it was never an infection at all.

When specialists re-examined patients who’d been diagnosed with cellulitis, 41% had something else, usually stasis dermatitis, eczema, or lymphedema.⁷ That’s trained clinicians, examining the patient in person, getting it wrong four times out of ten. Your patient, looking at their own leg and typing symptoms into a phone, is not going to do better.

Sources

1. Stevens DL, Bisno AL, Chambers HF, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-e52. https://academic.oup.com/cid/article/59/2/e10/2895845 
2. Moran GJ, Krishnadasan A, Mower WR, et al. Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A Randomized Clinical Trial. JAMA. 2017;317(20):2088-2096. https://pmc.ncbi.nlm.nih.gov/articles/PMC5815038/ 
3. Centers for Disease Control and Prevention. Tetanus. Epidemiology and Prevention of Vaccine-Preventable Diseases (Pink Book), chapter 21. https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-21-tetanus.html 
4. Senneville É, Albalawi Z, van Asten SA, et al. IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023). Clin Infect Dis. 2023. https://pubmed.ncbi.nlm.nih.gov/37779323/ 
5. Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N Engl J Med. 2016;374(9):823-832. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4851110/ 
6. Daum RS, Miller LG, Immergluck L, et al. A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N Engl J Med. 2017;376(26):2545-2555. https://pmc.ncbi.nlm.nih.gov/articles/PMC6886470/ 
7. Nightingale R, et al. Misdiagnosis of Uncomplicated Cellulitis: a Systematic Review and Meta-analysis. J Gen Intern Med. 2023;38(10):2396-2404. https://link.springer.com/article/10.1007/s11606-023-08229-w 

For Clinicians | What Diseases Spread After a Hurricane, Flood or Fire

Ranked by the Surveillance Data

By Dr. Jamie Wilkey, PharmD — Director of Clinical Strategy, Jase

Natural disasters that displace a lot of people (hurricane, flood or wildfire) can lead to sickness. I don’t know about you, but I always pictured something specific to the natural disaster; for example in a hurricane it would be something waterborne and making those in contact with the floodwater itself sick.

What truly makes people sick after a storm has less to do with the disaster itself than with what happens next: a few hundred people evacuated into one building, sharing air and bathrooms for a week. The disaster displaces people. The crowding is what spreads the post-disaster disease. Crowding is something we as clinicians can help our patients be ready for ahead of time.

Today we’re busting some myths: what really spreads after a natural disaster, and in what order.

Can you get sick at a hurricane or wildfire evacuation shelter?

Yes, and it’s the most likely way you get sick after a disaster.

The two best data sets we have on this are both wildfire shelters. In January 2025, the Pasadena Convention Center opened as an evacuation shelter for the Eaton fire and held about 1,700 people by the second night. Over six weeks of operations, enhanced surveillance counted 104 cases of norovirus, 56 of COVID-19, 29 of influenza, and 30 of nonspecified respiratory illness.¹ Every category on that list is viral. Nine of the norovirus patients and six of the COVID-19 patients were hospitalized.¹

In November 2018, norovirus moved through eight of the nine Camp Fire evacuation shelters in Butte and Glenn counties: 292 cases among roughly 1,100 evacuees, an estimated 27% attack rate, median patient age 63.² Twenty-one of them, 7%, needed evaluation at a hospital or urgent care.²

Not a drop of floodwater in either one. What those two events shared was several hundred people in one building sharing bathrooms and air for weeks, which is exactly what a hurricane evacuation also produces.

Pasadena had written its shelter infection control protocols partly off the 2018 Camp Fire outbreak, and a site visit on day six still found no adequate isolation area, inadequate hand hygiene and PPE use, and cleaning products that don’t kill norovirus.¹ 

What the two responses came down to:

• Screening arriving evacuees for GI symptoms at registration, which is where Camp Fire caught cases²
• A real isolation area for people who were sick, with their own toileting and handwashing
• Handwashing with soap and water rather than hand sanitizer, because alcohol does little to norovirus²
• Around-the-clock cleaning with a disinfectant that works on norovirus, meaning an EPA List G product¹

There is no medication anywhere in either response. At Eaton, COVID-19 and influenza antivirals weren’t even available on site.¹ Both reports are observational, so infection control is temporally associated with cases falling rather than proven to have caused it.¹ 

Reports fell sharply nine days after the first site visit.

What infections actually go up after a flood?

The waterborne part of the story isn’t wrong, it’s just smaller than it looks, and it’s a different list than most people picture. This tier belongs to water. Wildfire evacuation carries the shelter risk above, not this one.

Lynch and Shaman ran 23 years of national surveillance data against tropical cyclone exposure in the United States, 1996 through 2018, and tested six waterborne diseases. Three went up:

1. Cryptosporidiosis, up 52% during storm weeks³
2. Shiga toxin-producing E. coli, up 48% the week after a storm³
3. Legionnaires’ disease, up 42% two weeks after a storm³

The other three didn’t. Salmonellosis and giardiasis weren’t greatly associated with storm exposure, and shigellosis rates dipped slightly.³

The two GI infections on that list are managed with fluids and rest, not antibiotics. With STEC that isn’t a preference: the IDSA guideline says to avoid antibiotics when Shiga toxin is involved, because of the risk of hemolytic uremic syndrome.⁴ Legionnaires’ does need an antibiotic, but it’s pneumonia, so it needs a diagnosis and usually a hospital first. It also isn’t coming from the floodwater. It comes from the building’s own plumbing after the power goes out and the water sits warm and still.

Quick reference: what actually spreads, and what stops it

WHO laid out the pattern in 2007: outbreak risk after a disaster tracks population displacement, water and sanitation, crowding, the baseline health of the population, and access to care, rather than the disaster itself.⁵ The tiers below run roughly in the order the surveillance data supports, though no single source ranks them head to head.

Tier 1: viral illness in shelters. Norovirus, COVID-19, influenza, and the respiratory illness that never gets a name. It moves person to person in crowded congregate housing, and what holds it down is the infection control above.

Where a prescription fits: no antiviral touches norovirus, and for influenza and COVID-19 the gate is the clock and the prescriber, not the test.⁹ That gap is what preparation closes. Oseltamivir and nirmatrelvir-ritonavir are both JaseCase add-ons, and ondansetron is in the base kit for the vomiting norovirus causes. All of it is reviewed and prescribed by a licensed provider ahead of time, for emergency use only after trying to reach care.

Tier 2: skin and soft tissue infection. Cuts and punctures during cleanup, contaminated by debris and standing water. Gloves and boots prevent most of it, irrigating early with clean water prevents more, and tetanus vaccination should already be current before anyone starts hauling drywall.⁶

Where a prescription fits: here, and only here. A wound that has become infected with spreading cellulitis, in a patient who can’t reach care, for emergency use only after trying. Not an abscess, which needs drainage rather than a pill.

Tier 3: the water-ecology infections. Leptospirosis comes from skin or wound contact with fresh water carrying animal urine. Vibrio vulnificus comes from an open wound meeting warm brackish or coastal water.

Where a prescription fits: not at home. Vibrio needs IV antibiotics and usually an operating room.⁸ Leptospirosis does have an oral answer in doxycycline, but the symptoms are indistinguishable from flu and dengue without testing, and 10% of the post-Fiona cases were dengue-positive too.⁷

Tier 4: the rare ones.Mucormycosis is a fungal wound infection, melioidosis a soil bacterium. Both are real, both are documented after disasters, and both are hospital-level care every time.

Where a prescription fits: it doesn’t. Both need hospital care.

One myth to put the kabosh on once and for all while we’re here. CDC states that floodwater exposure by itself does not create tetanus risk, and post-flood tetanus vaccination campaigns aren’t indicated.⁶ The risk rides on the puncture wound, not the water, which is why the people who need current vaccination are the ones going in to clean up.

Where preparation really helps

Three of the four bacterial infections above need something no cupboard holds. Vibrio is surgical before it’s medical: pain out of proportion to the wound, erythema spreading while you watch it, bullae, or crepitus means an emergency department now, not a call in the morning, because early debridement is what changes the outcome.⁸ Legionnaires’ is pneumonia and needs the workup. Severe leptospirosis is Weil’s disease: jaundice, renal failure, hemorrhage.

What’s left is pretty narrow.

The influenza antiviral is the strongest case. Oseltamivir is approved for treatment within two days of symptom onset, and CDC is explicit that treatment shouldn’t wait for laboratory confirmation, because testing delays it and a negative rapid test doesn’t rule flu out.⁹ The barrier was never the test. It’s the clock and the prescriber, and after a hurricane those are the same problem.

The antiemetic matches the volume. Tier 1 is mostly norovirus, and norovirus sends people looking for care because of what they can’t keep down. Ondansetron doesn’t touch the virus and doesn’t need to.

The antibiotic is the narrowest. A wound that has become infected with spreading cellulitis, in a person who can’t reach care, with roads out and clinics closed. Not the abscess, which needs drainage rather than a pill.

All three are for emergency use only, after trying to reach a provider, and a patient has them at home because a licensed provider reviewed the request and wrote the prescription.

What appropriate medical preparation actually covers

Look at what worked in this article and it sorts into two piles. One is free and behavioral: gloves and boots, soap and water over sanitizer, a separate room for the person who’s vomiting, current tetanus before anyone hauls drywall. The other is out of reach: an IV, an operating room, a prescriber who can see you today.

Almost nothing sits between them. Three things do, and all three only work if they were in the house before the storm, which means someone prescribed them before the storm.

That band is the category, and it has a name: appropriate medical preparation. The clinical work happens ahead of time, by a licensed provider who reviews the request and writes the prescription, for bounded indications, for emergency use only after the patient has tried to reach care. It is in no way a replacement for primary care or an emergency department. It exists for the stretch when neither one is reachable, which after a hurricane runs days.

We’re a family company of medical doctors, physician assistants, and pharmacists, and we’d rather publish where the line falls than sell past it. If a patient asks what they should have at home before a storm and you’d rather not work through it in a visit that’s already full, you can send them to us at jase.com, where a licensed provider reviews every request and writes every prescription. We’ll keep publishing the criteria as we work them out.

The bottom line

The infections that actually follow a hurricane, flood, or wildfire come out ranked almost backward from the way preparedness content lists them. The top of the list is viral, it spreads because people are packed into one building, and it’s stopped by gloves, soap, separation, and cleaning with the right product. Three of the four bacterial infections in this article need a clinician, an IV, or an operating room.

The next time a patient asks what to have on hand before a storm, the first half of the answer is prevention, and it’s free. The second half is three prescriptions for three situations, and that’s a conversation to have before the season rather than during it.

Sources

1. Patrick R, Lee K, Kuan M, et al. Norovirus, COVID-19, and Influenza Outbreaks Among Residents and Staff Members at the Eaton Wildfire Evacuation Shelter, Pasadena, California, January-February 2025. MMWR Morb Mortal Wkly Rep 2026;75(26):337-342. https://www.cdc.gov/mmwr/volumes/75/wr/mm7526a2.htm 
2. Outbreak of Norovirus Illness Among Wildfire Evacuation Shelter Populations, Butte and Glenn Counties, California, November 2018. MMWR Morb Mortal Wkly Rep 2020;69(20). https://www.cdc.gov/mmwr/volumes/69/wr/mm6920a1.htm 
3. Lynch VD, Shaman J. Waterborne Infectious Diseases Associated with Exposure to Tropical Cyclonic Storms, United States, 1996-2018. Emerg Infect Dis 2023;29(8):1548-1558. Cryptosporidiosis 52% increase during storm weeks (95% CI 42%-62%); STEC 48% increase at lag week 1 (95% CI 27%-69%); Legionnaires’ disease 42% increase at lag week 2 (95% CI 22%-62%). https://wwwnc.cdc.gov/eid/article/29/8/22-1906_article 
4. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis 2017;65(12):e45-e80. https://academic.oup.com/cid/article/65/12/e45/4557073 
5. Watson JT, Gayer M, Connolly MA. Epidemics after Natural Disasters. Emerg Infect Dis 2007;13(1):1-5. https://wwwnc.cdc.gov/eid/article/13/1/06-0779_article 
6. CDC. Safety Guidelines: Floodwater. https://www.cdc.gov/floods/safety/floodwater-after-a-disaster-or-emergency-safety.html 
7. Leptospirosis Outbreak in Aftermath of Hurricane Fiona, Puerto Rico, 2022. MMWR Morb Mortal Wkly Rep 2024;73(35). Mean weekly cases 10.4 during the 15 weeks after the storm versus 2.9 during the prior 37 weeks. https://pmc.ncbi.nlm.nih.gov/articles/PMC11376507/ 
8. Vibrio vulnificus in Taiwan. Emerg Infect Dis 2004;10(8). Overall case fatality approximately 30%; 86% of patients with cutaneous lesions received surgical treatment. https://wwwnc.cdc.gov/eid/article/10/8/04-0047_article 
9. CDC. Influenza Antiviral Medications: Summary for Clinicians. https://www.cdc.gov/flu/hcp/antivirals/summary-clinicians.html

For Clinicians | Medication Exposed to Flood Water

The FDA Rule and Its One Exception

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

Today we are covering three things: what FDA actually recommends for water-exposed medication, the one exception and why two of your patients will quote you different rules about it, and what to do at the counter while the determination is still open.

This is not only a coastal question. The National Flood Insurance Program reports that 29% of its flood claims between 2014 and 2024 came from outside high-risk flood areas.¹ Add burst pipes and a creek that came up over a road, and it reaches practices nowhere near a hurricane track.

Does medication that touched floodwater have to be discarded?

Yep. All of it. FDA recommends discarding any drug that came into contact with flood or contaminated water, including drugs in their original containers with screw-top caps, snap lids, or droppers.² The same goes for medication kept somewhere other than its original bottle: a pill organizer, a baggie, a daily-dose box.

A consumer closure (like child-proof cap) is not a water barrier. It keeps out a curious 4-year-old. It was never built to exclude contaminated water, and FDA is explicit that a tight cap does not change the answer. CDC spells out the dosage forms FDA doesn’t: pills, pill organizers, liquids, drugs for injection, inhalers, and skin drugs.³ 

This is a discard rule rather than a stability calculation because of what was in the water. CDC’s position is that we don’t know exactly what is in floodwater at any given point in time.5 It can carry human and livestock waste, whatever was under the sink, whatever came out of the garage, and medical and industrial hazardous waste. These are pills someone swallows, and CDC ties eating or drinking anything floodwater touched to E. coli and Salmonella.5 FDA’s trigger is flood or unsafe municipal water, which is broader than flooding alone.

When can a flood-exposed medication still be used?

There is one exception. FDA writes it as a scenario rather than a rule, which is why it reads oddly:

“A drug may be needed to treat a life-threatening condition, but a replacement may not be readily available. Drugs exposed to fire or unsafe water should be replaced as soon as possible. If the drug looks unchanged – for example, pills in a wet container appear dry – the drugs can be used until a replacement is available. If the pills are wet, then they are contaminated and need to be discarded.”²

Read as a rule, all three have to be true:

1. The indication is life-threatening.
2. A replacement is not readily available.
3. The product looks unchanged.

FDA never calls the drug safe. It says exposed drugs may be contaminated, then says a life-sustaining one can be used anyway until a replacement arrives. That’s bridge therapy: once the replacement is in hand, the exposed product gets discarded.

Cost is not one of the three. It’s a real access barrier and it should change how fast you move on a replacement. It doesn’t change whether a contaminated bottle stays in use.

Why the same guidance reaches patients two ways

CDC’s full guidance lines up with FDA’s, and on the stop rule it’s much clearer: take the lifesaving drug if it looks normal and dry, and “stop taking them as soon as replacement medication becomes available.”4

What reaches the public isn’t that page. CDC writes the same guidance as a text-message blast and a television news crawl, and at that length it becomes: “You can use lifesaving drugs stored clean and safe if they look normal and dry.”3 One sentence. Nothing about whether a replacement is available, nothing about when to stop.

So you get two patients working from the same agency. One saw the crawl during storm coverage and figures dry pills settle it. The other read the full page article and knows appearance is the last thing you check, after the drug is life-sustaining and after there is nothing available to replace it. Both got federal guidance.

Appearance is the only condition a patient can check without us. It is also the one that matters the least.

What to do at the counter or clinic

Quarantine rather than discard while the determination is open. Label it clearly as “NOT FOR USE” and keep it separate from everything else. That protects in both directions: you are not throwing out products the patient may have real trouble replacing, and you are not leaving a questionable bottle within reach while the question is still open.

Then give an interim instruction, because “set it aside” is not an instruction until the patient knows what to do about tonight’s dose. Working as a pharmacist I’d say, “Don’t take anything out of that bottle. I’m working on a replacement today and I’ll call you before your next dose is due.“

Document the exposure, what you consulted, the determination you reached, the interim instruction, and when a pending determination closes. An undocumented determination didn’t happen.

For emergency medication replacement when it is hard to reach the provider, check whether your board has issued an emergency dispensing notification. Texas issued one on July 7, 2025 for the Hill Country flooding, authorizing pharmacists to dispense up to a 30-day supply of non-Schedule-II drugs without prescriber authorization for patients in the declared counties.6

The authorization carries conditions. Tell the patient the refill is going out without prescriber authorization and that future refills need it, notify the prescriber at the earliest reasonable time, and keep a record. If the prescription was originally filled somewhere else, the patient needs the container, label, receipt, or other documentation, and you need to have tried to transfer it first.⁶

Mixing a suspension under a boil-water notice

This one’s interesting because no flooding is required. Any time there’s a boil-water notice, medication that needs to be reconstituted gets purified or bottled water only.² And you’re thinking, “The water’s boiled, that was the entire point of the notice! It should be fine…” Maybe. The FDA names purified and bottled and stops there. Boiled tap isn’t on the list, and the guidance never says whether it counts, so the instruction that holds up is FDA’s own: bottled or purified. A simple way to communicate this to patients is: “Don’t mix it with tap water, even boiled. Bottled water only until the notice lifts.”

The powder is a separate question from the water. Sealed and dry, it’s fine, and what you add is the only thing to sort out. If the bottle or the powder itself was in contact with flood or unsafe water, we’re back to the discard rule at the top.

The middle step nobody has built

After water reaches the cabinet, our patients have 2 options and both are bad. Throw everything out and go without until somebody can be reached, or keep it and hope. There is no sanctioned step in between, and that step is the part that needs a clinician: an actual determination, made by someone who knows which of the 3 conditions apply.

That determination is what appropriate medical preparation looks like here. It is not a supply question. Two things that cost a patient nothing before any water shows up, and both sit in FDA’s own guidance: a written list of every prescription with drug, dose, prescriber, and pharmacy, and the bottles kept inside a water-tight container with a lid.² That written list isn’t only for you. A displaced patient seeking an emergency refill at a pharmacy that didn’t fill the original needs exactly that documentation to get one.⁶ Then the determination itself, made with us instead of guessed at off whatever version of the guidance reached them first.

This complements primary care rather than replacing it. We are here for the stretch when primary care is not reachable, which after a flood runs days.

For the acute problems a flood actually produces, the wound care and the infections, we keep contingency medication available for patients whose providers would rather refer than build that conversation from scratch. A licensed provider reviews every request and writes every prescription, and that medication is for emergency use only, after first seeking help from a qualified provider.

We will keep publishing the frameworks as we work them out, including the ones where the full guidance and the short version patients actually see don’t line up.

The bottom line

If it touched flood or unsafe water, discard it. That includes the bottle with the tight cap and the tablets that look perfect. The only route to keeping it is a life-threatening indication, no replacement available, and no visible change, and the exposed product gets discarded once the replacement is in hand. Quarantine while you sort it out, write down what you decided, and reconstitute with bottled water only.

The patient in front of you may have already made this call without us. Ask what got wet and where it was, not how it looks.

Sources

1. Federal Emergency Management Agency, National Flood Insurance Program. What is My Flood Risk. https://www.floodsmart.gov/flood-zones-and-maps/what-is-my-flood-risk. Retrieved August 17, 2026.
2. U.S. Food and Drug Administration. Safe Drug Use After a Natural Disaster. https://www.fda.gov/drugs/emergency-preparedness-drugs/safe-drug-use-after-natural-disaster. Content current as of August 28, 2019. Retrieved August 17, 2026.
3. Centers for Disease Control and Prevention. Drugs Exposed to Water. Natural Disasters public service announcement toolkit. Quoted line appears under Text Messages for Mobile Devices and Related Television Crawls for News Media. https://www.cdc.gov/natural-disasters/psa-toolkit/drugs-exposed-to-water.html. Last updated February 7, 2024. Retrieved August 17, 2026.
4. Centers for Disease Control and Prevention. Lifesaving Drugs. Natural Disasters public service announcement toolkit. https://www.cdc.gov/natural-disasters/psa-toolkit/lifesaving-drugs.html. Last updated February 6, 2024. Retrieved August 17, 2026.
5. Centers for Disease Control and Prevention. Safety Guidelines: Floodwater. https://www.cdc.gov/floods/safety/floodwater-after-a-disaster-or-emergency-safety.html. Last updated February 6, 2024. Retrieved August 17, 2026.
6. Texas State Board of Pharmacy. Hill Country Flooding: Emergency Dispensing of Prescription Medications. Issued July 7, 2025. Authorized under Texas Pharmacy Act Sec. 562.054 and Board rule 291.34(b)(8)(E). https://www.pharmacy.texas.gov/files_pdf/2025-Flood-Notification.pdf. Retrieved August 17, 2026.

For Clinicians | 2024 First Aid Guidelines

What Changed, and What Your Patients’ Kits Still Get Wrong

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

Your patient bought their first aid kit off an endcap, or from whichever online checklist looked credible. Nobody clinical was standing beside them when they did it. Pharmacists, go look at the kit on your own shelves this week. There’s a good chance it has hydrogen peroxide in it.

Patients tend to assume that buying a first aid kit means they are covered. “Well, it’s better than nothing!” They read a list, buy the box, put it under a truck seat or in a closet, and do not open it again until something goes wrong.

In 2024, the American Heart Association and the American Red Cross published the first comprehensive revision of first aid treatment recommendations since 2010¹. Yet some retail kits still ship to the previous standard and online search results still describe the outdated items.

For a quick real life example, take good ol’ baby aspirin. Many patients still have an 81- mg bottle in the cabinet, and that may be the bottle they’ll grab when a family member’s chest starts hurting. But one 81 mg tablet is below the dose the guidelines recommend in suspected cardiac chest pain. Fixing that takes fifteen seconds in the office or at the counter.

This article covers several changes in the 2024 guidelines, a few common beliefs patients’ kits continue to reinforce, and the larger preparedness gap that first aid guidelines were never designed to fill.

What changed in the 2024 first aid guidelines?

The 2024 document is the first comprehensive revision since 2010, following focused updates in 2015, 2019, and 2020.¹ The writing group identified several new or substantially revised topics: opioid overdose, bleeding control, open chest wounds, spinal motion restriction, hypothermia, frostbite, presyncope, anaphylaxis, snakebite, oxygen administration, and pulse oximetry, with pediatric guidance where it applies.¹ Earlier recommendations remain in effect unless the 2024 document specifically updates them.

Two of those changes reach into the box your patients already own.

Bleeding control: One manufactured windlass tourniquet is now a line item in the Red Cross minimum contents table for a first aid kit.² Not a tactical upgrade. The minimum. But putting one in the kit is only useful if the patient knows when and how to apply it.

Opioid overdose: When a person with a suspected opioid overdose is unresponsive and not breathing normally, the guidelines call for activation of EMS, high-quality CPR with compressions and ventilation, and naloxone.¹ Those actions may overlap. Naloxone is not in the minimum contents table.²

Nobody owns the seam

Those updates reveal a larger problem. Patients do not separate first aid, disaster preparedness, and medication planning. They expect one kit to cover all three. Four quick corrections can make the kit more useful, but they also show where its limits begin.

Two separate bodies of guidance address different parts of the same household emergency plan.

• On the injury side, the first aid guidelines and Stop the Bleed address immediate care: direct pressure, wound packing, and tourniquet use.³ No mention of prescriptions.
• On the disaster side, the federal preparedness guidance tells families to keep a written medication list with diagnosis, dosage, frequency, supply needs and allergies, plus a cooler for anything requiring refrigeration.⁴ It says little about how to effectively irrigate a wound or control severe bleeding.

Nobody at home is sorting injury guidance from disaster guidance. There’s one box on hand, and they expect it to cover whatever comes up. 

Patients ask what’s reasonable to keep at home, and neither body of guidance tells you as the provider or pharmacist what’s reasonable to authorize in advance, or where the boundary sits between preparing a patient and writing an inappropriate prescription.

Quick reference: four corrections

Four points cover much of what patients need to know when this subject comes up in the clinic or at the pharmacy counter.

Three involve time-sensitive emergencies in which the right response can save a life. The peroxide correction is less dramatic, but it can prevent avoidable tissue injury and delayed healing.

The layer the kit was never built to hold

This next part is not strictly a first aid question, which is why no first aid guideline answers it.

Some families have the pill bottles and nothing useful for a wound. Others have gauze for days and no plan for the medications they take every morning.

Household medical preparedness has at least three layers. The first is immediate first aid: the supplies and skills used for bleeding, burns, wounds, sprains, and other acute problems. The second is continuity: current chronic prescriptions, an updated medication and allergy list, and a plan for storage or refrigeration.⁴ The third is individualized contingency planning for predictable problems when timely care is unavailable. In selected cases, that may include short-course medication prescribed in advance after a licensed clinician reviews the patient and provides condition-specific instructions.

That third layer is not part of the AHA/Red Cross first aid guidelines. It is a separate clinical decision, and stored medication should be used only under the instructions provided and when qualified medical assistance cannot be reached promptly.

The missing clinical layer

Underneath all four corrections is a structural problem. A household gets one of two things: they reach a clinician, or they work with whatever is in a box assembled to someone else’s checklist. Little formal guidance addresses the space between those options, which is how an endcap product ends up deciding what a family has on hand when something goes wrong.

That clinical layer has a name: individualized medical preparation. It is work completed before an emergency for a limited set of circumstances that may not wait for business hours.A tourniquet and naloxone illustrate the broader principle that useful emergency interventions must often be obtained—and understood—before they are needed. The first aid guidelines do not extend that principle to advance prescribing, but they demonstrate why preparation matters.

This is not a replacement for primary care. Complex diagnoses, ongoing conditions, and clinical uncertainty belong in the exam room. The appropriate role of advance planning is narrower: a defined set of circumstances, a patient screened in advance, clear instructions, and a plan for what requires direct care.

If you’d rather refer

Some of you would rather not write for this at all, which is a reasonable place to land. When a patient asks and you don’t want to be the one deciding what’s appropriate to keep on hand, send them to us at Jase.com. A licensed provider reviews every request and determines if a prescription is appropriate, so the referral is a clinical handoff and not a way around a visit.

We’ll keep publishing where we draw lines, what evidence we’re using, and the criteria behind a no. If we’re going to name a clinical category, the framework should be public enough for other clinicians to scrutinize and argue with.

The bottom line

The guidelines moved in 2024, but many patients’ kits did not move with them. An emergency is the wrong time to discover that the aspirin instructions are incomplete, the tourniquet is missing or unfamiliar, or the only wound cleaner in the box is peroxide.

Tell your patients to spend fifteen minutes with the kit they already own. Check the dates, replace what’s expired, take out what doesn’t belong in a wound, and make sure they know how to use what remains. They may not need a bigger kit. They need a current one and a plan they understand.

Sources

1.  Hewett Brumberg EK, Douma MJ, Alibertis K, et al; American Heart Association and American Red Cross. 2024 American Heart Association and American Red Cross Guidelines for First Aid. Circulation. 2024;150(24):e519-e579. 
2. Minimum Contents for American Red Cross First Aid Kit, Table 2, 2024 AHA and American Red Cross Guidelines for First Aid. cpr.heart.org 
3. Stop the Bleed. American College of Surgeons Committee on Trauma. stopthebleed.org 
4. Tips for Medication. Ready.gov, Federal Emergency Management Agency.
5. Wound Home Care. American College of Surgeons. facs.org 
6. FDA Approves First Over-the-Counter Naloxone Nasal Spray. US Food and Drug Administration, March 29, 2023.