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When inflammation persists, it no longer serves a helpful purpose. This type of inflammation, also referred to as chronic inflammation, occurs when your body consistently acts like it’s under attack, releasing white blood cells indefinitely. In the long term, an elevated white blood cell count can affect other organs such as your heart, lungs, and kidneys. Research has also found a connection between chronic inflammation and other chronic diseases including heart disease, diabetes, cancer, Alzheimer’s disease and Crohn’s disease.

Inflammation, Explained

Acute inflammation is the body’s natural way of fighting infections and injuries as part of the healing process. When you have an injury, blood flow increases as your body instinctively releases white blood cells, proteins, and other inflammatory chemicals to protect the wounded area. This leads to redness, swelling, and pain at the site of injury. The body reacts similarly when you have a virus or cold, but in these instances, the blood cells and inflammatory chemicals are released throughout the whole body rather than to one spot. This type of inflammation is good for you, as it allows your body to heal.

But when inflammation persists, it no longer serves a helpful purpose. This type of inflammation, also referred to as chronic inflammation, occurs when your body consistently acts like it’s under attack, releasing white blood cells indefinitely. In the long term, an elevated white blood cell count can affect other organs such as your heart, lungs, and kidneys. Research has also found a connection between chronic inflammation and other chronic diseases including heart disease, diabetes, cancer, Alzheimer’s disease and Crohn’s disease.

Read on for more information about the causes and symptoms of chronic inflammation and how to prevent or treat it.

Causes and symptoms of chronic inflammation

Several known factors can trigger chronic inflammation:

Lifestyle factors including obesity, diet, smoking, alcohol use, stress, and sleep disorders

Autoimmune diseases like type 1 diabetes or lupus, in which the body mistakenly attacks itself

Long-term exposure to pollution, industrial chemicals, or other toxins

Some individuals with this type of inflammation experience fatigue, fever, and joint and muscle pain. However, while there are clear physical signs of acute inflammation, chronic inflammation does not always have visible symptoms.

Your doctor can help determine if you have chronic inflammation. They will likely ask about your symptoms and perform a physical exam as a first step. They may then order additional tests to detect inflammation. These tests look for various indications of inflammation in your body, but they cannot formally diagnose inflammation or any other health condition. Rather, they provide a more comprehensive picture of your health so that your doctor can recommend the best next steps.

Potential tests your doctor may recommend during this process include a C-reactive protein (CRP) test and/or an erythrocyte sedimentation rate (ESR) test. A CRP test identifies your blood levels of CRP, a protein produced in your liver. Chronic and acute inflammation have both been linked to high levels of CRP.

An ESR test examines how quickly your red blood cells sink to the bottom of a test tube, with higher rates of settlement pointing toward more inflammation. Doctors often recommend this test when there is a possibility of high inflammation.

Sometimes these tests may help your doctor diagnose an inflammation-linked condition, such as rheumatoid arthritis or type 2 diabetes.

Chronic inflammation and other health conditions

There is a connection between chronic inflammation and many other health conditions. Inflammation can occur directly as the result of rheumatoid arthritis, which is both an autoimmune condition and an inflammatory disease. If you have rheumatoid arthritis, your immune system attacks your joints — often in your hands, writs, and knees — which leads to inflammation. There is also a direct link between inflammation and other inflammatory diseases, like ulcerative colitis and Crohn’s disease.

Inflammation has also been linked to heart disease and diabetes, but research into this connection is ongoing. While inflammation is more common in individuals with these health conditions, there is not yet definitive evidence that inflammation by itself directly increases your risk for these conditions.

Inflammation in the walls of your blood vessels has been linked to atherosclerosis, the accumulation of fats, cholesterol, and other substances in your arteries. In the long term, atherosclerosis increases your risk for a heart attack or stroke.

Since obesity, smoking, and physical activity are all risk factors for inflammation, heart disease, and diabetes, the overlap of these risk factors likely plays a role in the connection between the conditions. The good news is that a single healthy choice can lower your risk for all three diseases at once.

Your healthcare provider will recommend treatment based on the type of inflammation you have, however not all cases of chronic inflammation require medication.

Two types of medications are commonly used to lower both acute and chronic inflammation: nonsteroidal anti-inflammatory drugs (NSAIDs) including ibuprofen (Advil®), aspirin (Bayer®) or naproxen (Aleve®) and oral steroids including prednisone (Deltasone®, Prednicot®), methylprednisolone (Medrol®), and dexamethasone (Decadron®, Dexasone®). Steroid injections can reduce inflammation in a specific joint or muscle and are often used to treat rheumatoid arthritis.

If you have an inflammatory disease, your doctor may recommend medications specifically used to treat that disease. Medication classes commonly used to treat inflammatory diseases include:

Disease-modifying anti-rheumatic drugs (DMARDs) like methotrexate (Rheumatrex®), sulfasalazine (Azulfidine®), and leflunomide (Arava®). These medications can slow the progression of rheumatoid arthritis.

Statins, a type of medication commonly used to treat high cholesterol. They have anti-inflammatory effects and can lower CRP levels.

You can also fight inflammation simply by what you eat. An anti-inflammatory diet includes antioxidant-rich foods like the following: 

Cherries, blueberries, oranges, and other fruits

There are also some foods that have been linked to higher levels of inflammation. If you have chronic inflammation, your doctor may suggest limiting your intake of the foods below as part of your treatment plan:

White bread, pasta, pastries, and other refined carbohydrates

Soda, fruit juices with added sugar, energy drinks, and other beverages high in sugar

Red meat and processed meat like hot dogs and sausage

At Alto, we’re committed to making it as simple as possible to prioritize your health and well-being and stay on top of your medications.  We will work with your doctor, your insurance (if applicable), and any third party savings programs that you may qualify for to ensure your medications are as affordable as possible. And our team of pharmacists is available to chat whenever questions come up about side effects or how to take your medication properly.

Reach out any time through in-app secure messaging or by phone at 1-800-874-5881.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition.

All third party trademarks (including logos and icons) referenced by Alto Pharmacy remain the property of their respective owners. Unless specifically identified as such, Alto’s use of third party trademarks does not indicate any relationship, sponsorship or endorsement between Alto and the owners of these trademarks.

Working from home offers many benefits. The lack of commute to and from the office can mean more quality time with family, mid-day workouts, or a load of laundry over lunch. And with fewer distractions, the environment of a home office is a productivity boost for certain work styles.

How to Say Healthy While Working From Home

At the same time, some individuals may find it more difficult to concentrate outside of a physical office, and remote work can also impact your mental health. In a recent public opinion poll conducted by the American Psychiatric Association (APA), nearly two-thirds of the respondents reported feeling isolated or lonely at least sometimes as a result of working from home, while 17% said that they experience isolation and loneliness all the time. And a majority of the respondents who partially work from home said that they find it difficult to step away from work at the end of the day.

With remote work on the rise — the number of U.S. adults who work from home increased from 22% to 42% between 2019 and 2020 — it is important to prioritize your mental and physical well-being and create boundaries between work and social life. Here are steps you can take to stay sane and healthy while working from home.

A physical office space naturally incorporates structure into your day. Simply sitting down at your desk and seeing colleagues allows you to mentally shift into work mode. This is important for not only productivity, but also for work-life balance — just as you are able to jump right into your to-do list once you enter the office, the clear boundary between work and home means you’re less likely to revisit that list once the day is over. Plus, watching a coworker take a break may be a much needed reminder that it’s time to grab lunch or get some fresh air.

There are several ways to give yourself structure while working from home. First, mimic the experience of going to work. It may be tempting to stay in pajamas and check emails from bed, but many remote employees find it easier to concentrate — and to leave work behind at the end of the day — by creating a morning routine and using a designated workspace that’s not in your bedroom.

In addition, having a clear plan for the day can boost both productivity and mental health, as you will have carved out time for high-priority tasks and breaks. For some individuals, planning the day the night before makes it easier to jump into work the next morning, so consider incorporating this into your end of day routine if you find it helpful. There are a variety of ways to lay out what needs accomplishing, from organizing your day entirely on a calendar to using a task management tool. Increasing focus and productivity while working from home is all about finding the system that’s right for you.

It’s just as important to consider your personal preferences and work habits when planning breaks. The frequency of your breaks should correlate to how long you can maintain a state of deep focus. Taking breaks every 75 to 90 minutes may be realistic for some individuals, but others may find shorter bursts of work more helpful. The pomodoro method has become a common approach to time management. You will focus on a single task for 25 minutes then take a five minute break, repeating the pattern three more times before taking a 15 minute break.

Whichever system you choose for breaks, remember to use some of that time for physical activity. Exercise affects both your physical and mental health and may help reduce some of the stress and isolation that often comes with remote work.

Having a designated workspace can help you create boundaries between work and social life. Working from home can contribute to burnout, and using your bedroom as the office can often lead to a workday that stretches well past eight hours. If you can, make a workspace in another room. If you don’t have space to use as a designated home office, try the kitchen table or living room.

In addition to supporting your mental health, working in a space that’s set aside for work can help minimize distractions and maximize productivity, particularly if you live with family members or roommates. Young children or anyone who’s never worked from home themselves may not know to avoid interrupting you during your workday. You can set boundaries by informing everyone at home of your working hours and communicating your expectations.

The design of your workspace can also impact your emotional well-being and physiological health. Exposure to sunlight is linked to higher levels of serotonin, a hormone believed to regulate your mood and lower anxiety. If possible, use a workspace that gets a lot of natural light, and use part of your break time to soak up some sun. Add some greenery to your home office too — research has found that having plants nearby as you work can increase productivity.

Maintaining good posture while you work can prevent tightness in your neck or back pain. If working while seated, keep your feet flat on the ground beneath your knees. Avoid working from a chair that’s too tall and prevents your feet from reaching the ground. If you can, use an ergonomic office chair or a standing desk, which offers many health benefits. If using an office chair, remember that each person’s physiological needs are different, so take time searching for the right fit.

The repetitive motion of typing in a seated position has been linked to carpal tunnel syndrome — numbness and tingling in your hand, wrist, and/or arm caused by pressure on your median nerve. A hunched posture can put strain on your wrists and hands, so using an ergonomic chair or standing desk is already a step toward preventing carpal tunnel syndrome. Be mindful of your arm and wrist position as well. Work with your elbows bent by your side and keep your forearms stretched out in front of you parallel to the floor. Using an external computer monitor or keyboard can make it easier to maintain this position.

Working in silence by yourself can lead to greater concentration and productivity in some cases, but too much isolation and loneliness affects your mental health. An office environment allows for natural socialization and conversation throughout the day, and recreating this experience at home requires a bit more intention.

If you work on a team, use workplace messaging tools to maintain connections with coworkers. Take the initiative in setting up virtual or in-person events like happy hours. And if you’re located in the same area as your colleagues, schedule a coworking session in a local coffee shop. Remote work is also a great opportunity to expand your professional network by joining a coworking space.

It’s important to maintain other social connections, too. Schedule after-work plans with friends and family, and don’t forget to pause notifications and sign off for the day.

Let Alto support your health and wellness

Practicing good self-care while working from home involves prioritizing your physical health. Alto is here to support you with exceptional pharmacy care at every step of the way. We make it simple to stay on top of your medications with free, same-day delivery and medication management tools like reminders and auto refills in our mobile app.

How to Stay Healthy While Working From Home

Last year, we set out to tackle this technical debt by splitting the User model into separate concerns and refactoring the entire system into this new paradigm.

Tackling Technical Debt and Improving Security: How Alto Untangled an Overloaded User Model

At Alto, we have three types of users: customers, healthcare providers (nurses, doctors, etc), and operations users who run the pharmacy. For each type of user, we maintain a separate application (though they share a monolithic backend for now): our customer app; our Alto Connect app for providers; and our internal pharmacy management tool called Wunderbar, which powers the pharmacy experience from prescription intake to fulfillment.

Early on, we made the pragmatic choice to represent both customers and operations users with a single User model, distinguishing them with a “roles” attribute. This required repetitive checks that, over time, slowed down our engineering teams, presented substantial privacy risk, and posed difficult scaling challenges as we evolved our monolith into different microservices. 

The challenges of relying on a single User model for different types of users

The notion of a User is core to our concept of identity from which authentication and authorization proceeds. From a security perspective, it’s difficult to build an extensible and clean authentication and authorization system when you’re overloading one model for two very different populations of users. From a privacy perspective, this muddied customer records (which are subject to more restrictions because they’re healthcare records) with workforce records, hamstringing many analytics efforts.

Authentication: Alto employees who were also Alto customers were required to use their work emails for their customer accounts. Not only was this restriction frustrating for Alto employees, but it also posed a security risk: employees should only be able to access Wunderbar via corporate SSO, not their personal account passwords. 

Authorization: Engineering new authorization capabilities required intricate knowledge of the idiosyncrasies of our user structure. This both slowed down development and created tremendous risk that any mistake could easily escalate user permissions.

Privacy: Because they existed in the same table, both customer records and Alto operations user records were classified as Protected Health Information, or PHI, which severely limited what we were able to do with them.

Attribution: Our robust audit logs were significantly less useful when a user ID in the transaction log might refer to either an ops user or a customer.

State management: Some updates pertaining to admin identity lived on the customer model, some lived on the employee model, and others lived in other various models.

Architecture: Tight coupling would have prevented us from decoupling our monolithic system into smaller services.

Our backend is primarily a monorepo Rails application that shares a tremendous amount of functionality between our customer, provider, and ops user-specific domains. Generally we use JWTs to secure customer and ops user sessions. These JWTs are issued only once valid credentials have been present.

Ops users are required to log in via Okta SSO, enforcing both valid username/password as well as a two-factor authentication (2FA) prompt. We use Devise and Omniauth to wire up the OIDC flow with our upstream identity provider, and we use CanCan to expand a set of roles per-user into a set of capabilities that restrict what resources they can access/modify.

Ops users primarily work in our internal pharmacy management app. However, the state of these users was shared between several different tables: Users, which otherwise refer to customers, and Employees, which share some ops user-specific state tied to Users.

Large change sets of code being deployed at once are harder to code review, harder to unwind if something goes wrong, and are more likely to be more disruptive. For this project, we knew that such a large architectural change had to be broken up into many more-digestible pieces if we were to be successful. The plan:

1. Create a new dedicated model for our ops users

# == Schema Information
#
# Table name: wunderbar_users
#
#  id                        :bigint(8)        not null, primary key
#  user_id                   :bigint(8)        indexed
#  email                     :string           not null, indexed
#  first_name                :string           not null
#  last_name                 :string           not null
#  token_last_invalidated_at :datetime
#  roles_mask                :integer          default(0), not null
#  title                     :string           not null
#  team                      :string           not null, indexed
#  is_active                 :boolean          default(TRUE), not null
#  slack_user_id             :string
#  pod                       :string

This was the easy part: create the database structure for a properly isolated admin user type, which we called a WunderbarUser.

We now had our admin user state split between Employees and Users, with a new table that engineers and analysts wanted to use that was not yet populated, and we had to make progress while allowing new hires and new customers alike to onboard to our platform.

2. Synchronize state between the old tables and new table

Next, we created a WunderbarUser for any User who was, or ever had been, a Wunderbar user. This required some historical digging —we had a lot of people who were onboarded, and even some offboarded, before we even had the intermediate Employee record!

Two major choices at this stage really helped the project succeed. First, we ensured that the WunderbarUser records all had IDs matching the corresponding User records. This is because a lot of our legacy audit records (that we’re required to preserve and keep useful as a Covered Entity under HIPAA) referenced an `admin_user_id` column populated with the ID of the User. If we just created all new entries for WunderbarUsers, these old logs would require at least one level of indirection (e.g. querying back to User) to make useful.

     # Create with the same ID as the user that we're creating this from.
     wunderbar_user_attributes = {
       id: user.id,
       user_id: user.id,
       email: user.email,
       roles_mask: user.roles_mask,
       date_of_birth: user.date_of_birth,
       token_last_invalidated_at: user.token_last_invalidated_at,
       first_name: user.first_name,
       last_name: user.last_name,
       preferred_first_name: user.preferred_first_name,
       is_active: false,
     }

Second, we created a new WunderbarUser any time we created a new Employee record (e.g. when we onboarded a new employee) and synchronized any changes between Users, Employees, and WunderbarUsers tables. As a side note: we knew we’d have to protect this syncing logic to ensure that we only copied each change once — otherwise, our callbacks would fire forever!

3. Migrate functionality slowly to use the new ops user model

We migrated logic to reference WunderbarUsers where previously we’d referenced Users and/or Employees. Authentication, authorization, audit logs, and pharmacist licenses were all updated here — albeit painstakingly!

We then migrated all of the foreign keys our various Postgres database tables held to either the Users or Employees tables to instead reference the WunderbarUsers. This ended up being around a hundred foreign keys, but a constraint-only migration that fortunately didn’t involve any data changes.

In short: our goal was to do this change slowly and steadily enough that nobody would notice until, one day, we could announce to the team, “Hey, we did a big security-pertinent project, and now you can change your customer email to be anything.”

Authentication: While we use the same JWT format for each, our customer and operations user authentication systems are now totally separated.

Authorization: With separate user types, we have separate capabilities and domain-specific authorization checks for each area, enforced in code.

Experience: Onboarding as a new Altoid (somebody who works here; come join us!) is totally separate from the customer experience, and you no longer need to link your accounts together.

Privacy: Our ops users who choose to be customers enjoy the full privacy afforded to our customers without tying their account to their work identity in any way.

Attribution: Legacy audit logs are still index-able and query-able with the same IDs, just in a slightly different table.

State management: Customer state lives on the User table, and ops user state lives on the new WunderbarUsers table. Our callbacks on each have been dramatically pared down, and our intermediary Employee table is entirely gone, along with a number of other now-ancillary tables.

Architecture: We have a clear path to federate RBAC checks without shipping our entire customer database between services.

Bonus: Performance and code readability generally improved by removing complex joins and join tables and isolating concerns between the customer and ops user domains.

Another Bonus: Significant refactorings and increased test coverage along the way while we cleaned up some very old, very stale code.

Large architectural changes of legacy systems with heavy use are rarely 100% smooth. Here are a few learnings to keep in mind the next time you tackle a hefty piece of technical debt. 

1. Always validate your assumptions (e.g. the data your constraints are against) when foreign keys are concerned. Multiple times we assumed, “Hey, we’ve migrated a bunch of really big tables that are really old (insurance claims, prescriptions, and more), so there’s no way we could have another admin user that we haven’t created a commensurate WunderbarUser for, right?” Wrong! Your data can always have inconsistencies, but a simple SQL query (e.g. validate that all values of the column you’re migrating the foreign key to have a matching WunderbarUser) can save a lot of time and headaches.

2. When migrating foreign key constraints on tables with active reads in Postgres, ensure you break it into two steps. Migrate your foreign key with `{ validate: false }`

 def up
   remove_foreign_key :inventory_orders, to_table: :users, column: :created_by_id
   add_foreign_key :inventory_orders, :wunderbar_users, column: :created_by_id, validate: false
 
   validate_constraint
 end

Validate the named constraint of your foreign key separately

 def validate_constraint
   validate_constraint_statement = 'ALTER TABLE "inventory_orders" VALIDATE CONSTRAINT "fk_rails_abcd1234";'
   ActiveRecord::Base.connection.execute(validate_constraint_statement)
 end

3. When working with legacy tables, be mindful of legacy systems. Our Billing service used a very outdated golang ORM that panicked if a column specified by the `struct` in source no longer existed; this caused a late-night outage that made auto billing requests back up the next day.

4. Scoping projects is hard! This was a larger project than our team had ever scoped and delivered before. Once all the dust settled, this project took several months longer than our initial scoping estimates.This project was worth doing, but better estimates allow us to prioritize better. If we’d had a great scope of this immense project upfront, would we have chosen to do it first? Also, this was a tremendously difficult project to separate into material stages; all the benefit was really backloaded.

In the end, this was a very satisfying and important project to complete. We wouldn’t have been able to accomplish it without a lot of help from our colleagues on the Platform team, the Security team, and across many other functions atAlto. Very large projects that involve a lot of moving pieces and impact other teams are always scary — but we can’t let that fear prevent us from making the changes we know we need to do in order to be successful long-term.

The Engineering Team is hiring! Learn more about open positions here.

If you take insulin daily to manage type 1 or type 2 diabetes, it’s important to choose a method of insulin delivery that fits your lifestyle and diabetes management needs. Many individuals who are often on-the-go find insulin pens to be most convenient given their portable size, discrete nature, and quick administration time. 

What to Know About Insulin Pens

Read on for more information about these devices, including the different types of insulin pens and what to consider when choosing one.

An insulin pen combines insulin and a syringe into a single device, allowing for a faster and easier administration than syringes. When it is time to administer an insulin injection, all you have to do is attach a new needle and dial the correct dosage on the pen. If you take multiple types of insulin every day, many insulin pen manufacturers offer color-coded pens or different designs to help you quickly identify each pen’s type of insulin.

While insulin pens simplify insulin delivery and how you measure your doses, you will still need to self-administer injections throughout the day. This is in contrast to an insulin pump, which automatically delivers doses of insulin at specific times. If you require many insulin injections each day, you may want to ask your healthcare provider if an insulin pump would be a good fit for your diabetes management needs.

There are two main types of insulin pens: disposable and reusable.

A disposable insulin pen contains a prefilled cartridge used for multidosing. You will discard the pen once the cartridge is empty or when the insulin expires, depending on the type of insulin you are using. These devices are sometimes referred to as “flex pens” or “quick pens.” Common brands include Lantus®, Tresiba®, Humalog®, Novolog®, and Basaglar®.

A reusable pen contains cartridges of insulin that are discarded once empty or when the insulin expires. You will replace the empty or expired cartridge with a new one and reuse the pen. These are sometimes referred to as “smart pens.” Common brands include InPen® and NovoPen®.

Follow the steps below to safely administer your insulin injections with a disposable or reusable insulin pen. A diabetes educator or healthcare provider can answer any questions and help you become more comfortable using the device.

1. Verify the expiration date of your insulin and do a visual check to make sure it has no clumps — most pens have a visible insulin reservoir. If the insulin is cloudy, roll the pen for a minute. (If the insulin is clear, you do not have to roll the pen.) If you take multiple types of insulin, make sure you are using the correct type.

2. Remove the pen cover or cap and sterilize the pen tip with alcohol using a cotton swab or gauze pad.

3. Attach a new needle to the pen, and have a sharps container ready for the used equipment. (You will need to use a new needle for each injection.)

4. Prime the pen if using it for the first time. Dial the dosage knob to two units, hold the pen with the needle pointing up, and tap the pen gently to let any air bubbles rise to the top. Press and hold the knob and look for a drop of insulin. If you do not see any insulin, repeat these steps as needed until at least one drop appears. This removes air bubbles from the needle and ensures that the needle is properly functioning. 

5. Choose an injection site, typically your abdomen, thigh, or arm, and wipe it with an alcohol swab. Hold the needle at the angle instructed by your doctor, most often a 90-degree angle.

6. Insert the needle into the skin and push the button on your insulin pen to deliver the injection. Wait ten seconds to make sure all of the insulin has been absorbed into your skin.

Unused pens must be refrigerated. However, do not place them in the freezer. Once in use, you may keep your insulin pen at room temperature. It’s important to avoid extreme temperatures as much as possible, so do not leave them anywhere where they will get too hot, like a car, or too cold. In addition, check the product’s package insert for an expiration date or consult your doctor about when to discard a pen or cartridge with unused insulin.

What to consider when choosing an insulin pen

You should consult with your doctor before choosing an insulin pen. In addition, consider the following factors:

The type of insulin you take — some insulin pens are only compatible with specific types of insulin.

Your insulin dosing needs — each pen has a maximum dosage. In addition, different pens can deliver insulin in increments of a half unit, one unit, or two units.

Your insurance coverage — ask your insurance provider what coverage they offer of insulin pens, if any, and explore the costs of other insulin delivery methods to determine the best fit for your needs.

Most insurance plans have separate medical and pharmacy benefits. In most cases, professional services provided by your doctor will fall under medical benefits while prescription diabetes medications — including insulin — will fall under pharmacy benefits. 

Some diabetes supplies, including many reusable insulin pens, are covered under a third type of benefits: the Durable Medical Equipment (DME) section of your policy. There may be restrictions on the brands or suppliers that are available, and it’s important to check with your specific policy to understand what will be covered and under which sections.

Many disposable insulin pens are often covered with your pharmacy benefits, in which case Alto may be able to help you get started with using an insulin pen. We will work with your insurance (if applicable) and any third party savings programs so that you can get your insulin pen at the lowest possible price.

A diabetes pharmacy partner you can rely on

At Alto, we believe a pharmacy should be a partner in your diabetes care. We have a dedicated diabetes support team to ensure that you have everything you need to follow through on your individualized treatment plan. Reach out any time through in-app secure messaging or by phone at 1-800-874-5881.

At Alto, we strive to reduce the stress that comes with managing your diabetes however we can. As a pharmacy for all of your diabetes needs, we’re able to sync all of your medications and supplies into a single delivery every month. In fact, you might even be a little surprised by just how much is included in a diabetes delivery, so we put together a short overview of what’s inside the box.

What’s in Your Alto Pharmacy Diabetes Delivery

We recommend unpacking your full package upon delivery and making sure you have everything you need. Carefully check insulated wrappers or ice packs to make sure you don’t miss any medications or supplies, and promptly place any items marked “Refrigeration Needed” in your refrigerator.

A quick note on refrigeration: we understand how important it is that your medications and supplies arrive in good condition, and we use temperature controlled packaging to ensure that insulin is held at the right temperature while it’s on the way to you.

Depending on what your care team has prescribed, you’ll probably have many or all of the following in your Alto delivery:

Diabetes medications in the form of vials, pens, pills, tablets, or inhalation devices

Insulin pumps (small electronic devices that deliver doses of insulin at specific times - common brands include Omnipod®)

Blood glucose meters, test strips, and lancets (common brands include Accu-Chek® and OneTouch®)

Smart insulin pens (a method of insulin delivery that combines insulin and syringe into a single device - common brands include InPenTM)

Continuous glucose meters (CGMs) (a small electronic device that automatically collects glucose readings at regular intervals throughout the day - common brands include Dexcom® and Freestyle Libre®)

Supplies like needles or syringes will be packaged in their own bag with a label that explains their purpose.

Note: the specific medications and supplies you have for your injections and diabetes care may look different than what is displayed in these photos. If your physician has instructed you to use a specific device, supply or medication, always follow their instructions.

It’s important to practice safe disposal methods for your needles and other injection or testing supplies. 

Use your red sharps container to safely store your needles after use. Sharps should never be thrown loosely into the trash, in the toilet, or in the recycling bin. Sharps that retract after use or are very small should follow the same disposal method as all other sharps.

Alto does not accept returns of sharps containers - you can find a safe local disposal site here.

If you need a new sharps container, send us a message in the app, and we’ll add it to your next delivery.

We’re a one stop shop for all your diabetes management needs. In addition to auto refills and med syncing, we offer free, same-day delivery and automatic savings investigations. And our team of pharmacists is always here to answer your questions by phone or the Alto app. 

Reach out any time through in-app secure messaging or by phone at 1-800-874-5881 to learn how Alto can be a partner in your diabetes care.

Emphysema — which falls under the umbrella of chronic obstructive pulmonary disease (COPD), along with chronic bronchitis — is a lung disease that most often develops as the result of many years of heavy smoking. It affects more than 3 million people in the United States.

Emphysema: Causes, Symptoms and Treatments

As a progressive lung disease, symptoms of emphysema become more pronounced over time. While there is no cure, emphysema is both manageable and preventable. You can slow the progression of the disease by following the treatment plan your doctor recommends and maintaining a healthy lifestyle.

Read on to learn more about the causes and symptoms of emphysema and common treatment options.

Emphysema involves slow and gradual damage to the tiny air sacs in your lungs (alveoli). As these air sacs weaken over time, the surface area of the lungs is reduced, limiting how much oxygen can travel to your bloodstream.

Since emphysema progresses gradually, signs and symptoms may not appear until the lung tissue has already been significantly weakened. For many people, the first noticeable symptoms include shortness of breath and more frequent coughing, especially during physical activities. Other symptoms of emphysema include wheezing, exhaustion, and chest tightness, and producing greater amounts of mucus.

In some cases, the lack of oxygen can cause blue or gray lips or fingernails. If you experience this symptom, seek immediate medical attention.

The majority of emphysema cases occur as the result of cigarette smoking, with heavier smoking linked to a higher risk of developing emphysema. Additional risk factors for emphysema include the following:

Age — in many cases of smoking-related emphysema, symptoms first become noticeable between the ages of 40 and 60

Exposure to high pollution chemical fumes or lung irritants

Having a history of childhood respiratory infections

To determine if you have emphysema, your doctor will ask about your health history and the potential symptoms of emphysema that you are experiencing. They may ask you questions about your smoking history, your exposure to secondhand smoke or chemical fumes, and if you have a family history of lung health issues.

After taking your health history, they may order one or more of the following tests to confirm a diagnosis of emphysema:

Imaging tests, including chest X-rays and computerized tomography (CT) scans, which combines X-ray images taken from different angles.

An arterial blood gas test, which measures how well your lungs transfer oxygen to your bloodstream and remove carbon dioxide.

An electrocardiogram (ECG) to check your heart’s function and rule out a diagnosis of heart disease.

A pulse oximetry, which measures the oxygen level of your blood. This can show how well oxygen travels to the parts of your body furthest from your heart.

Lung function tests, which measure how much air your lungs can hold, how easy it is for them to empty air, and how well they deliver oxygen into your bloodstream.

Quitting smoking is the most important thing you can do to slow the progression of emphysema. If you are having trouble quitting, ask your doctor for smoking cessation resources like nicotine replacement therapy to help manage withdrawal symptoms and cravings. In addition, the treatment options below can slow the progression of emphysema and help you live an active lifestyle.

Several types of medications are used to manage and treat emphysema.

Bronchodilators like albuterol (Ventolin®, Proventil®, AccuNeb®), albuterol sulfate (ProAir® HFA®, ProAir RespiClick), and levalbuterol (Xopenex®) help relax your airway muscles and open your lungs to reduce discomfort. Although not common, potential side effects of bronchodilators include nervousness or shakiness, headache, throat or nasal irritation, and muscle aches. Your doctor can explain more about the risks and benefits of using a bronchodilator when building your treatment plan.

Inhaled corticosteroids reduce swelling in your lungs and open your airways so that more air can move in and out of your lungs. They may be taken via inhaler or nebulizer. Corticosteroids commonly prescribed to treat emphysema include beclomethasone dipropionate (branded options include Qvar Redihaler®), budesonide (Pulmicort®), ciclesonide (Alvesco®), flunisolide (Aerospan®), fluticasone propionate (Flovent®), and mometasone (Asmanex Twisthaler®). 

Inhaled corticosteroids typically do not cause long-term side effects, but mouth and throat irritation and oral yeast infections may occur. As a precaution, rinse your mouth with water after each dose to prevent infections.

Antibiotics may also be used to fight infections that can lead to emphysema-related complications like acute bronchitis or pneumonia.

Pulmonary rehabilitation is an outpatient educational program that provides the skills and knowledge needed to manage your emphysema and increase your level of physical strength and fitness. The classes are led by a team of healthcare professionals, physical therapists, and dietitians and taught in a group setting, giving you the opportunity to connect with other individuals living with emphysema and other lung diseases. Pulmonary rehabilitation is often a good fit for individuals who frequently experience shortness of breath when performing daily activities despite taking medication as prescribed.

Supplemental oxygen, or oxygen therapy, can relieve shortness of breath and increase your tolerance for physical activities. There are several devices used in oxygen therapy. Your doctor can guide you in choosing the right oxygen delivery system based on your health needs, lifestyle, and insurance benefits. You may be prescribed one oxygen device to use at home and one to use when you are on the go.

Be sure to follow all of your doctor’s instructions when using your oxygen device, including the flow rate setting (how much oxygen you’ll need per minute). In addition, you may find it helpful to explore the American Lung Association's resources on oxygen therapy.

We’re here to support your emphysema treatment

Sticking to the treatment your doctor has recommended is critical to managing emphysema. At Alto, we make that as easy as possible by offering free hand-delivery, automatic savings investigations, and easy medication management tools through our website and app. And our team of pharmacists is always here to answer your questions by phone or through the Alto app. 

Reach out any time through in-app secure messaging or by phone at 1-800-874-5881 to learn how Alto can support your emphysema treatment plan.

In our previous post, we discussed how we designed our biometric authentication system with both privacy and a better user experience in mind. In this post, we'll show you exactly how we did it.

Considerations and Approaches for Implementing Biometric Login: Part 2

In Part 1, we discussed how we designed our biometric authentication system with both privacy and a better user experience in mind. In this post, we'll show you exactly how we did it.

To build a new authentication mechanism, we opted to use the react-native-biometrics library. This library interfaces with the device's biometrics, generates a keypair, and stores the private key within the device's keystore. When logging in with biometrics, the library creates a signature using the stored private key, and the signature is then sent to the server for validation. (Note: this library is now unmaintained. At the time of writing, this implementation can instead be accomplished with the following maintained libraries: expo-local-authentication to access device biometrics, keypair to generate a keypair, react-native-keychain to access the device keystore.)

Check if biometrics are supported and configured by the user for this device.

const { available } = await ReactNativeBiometrics.isSensorAvailable();

If yes, prompt the user for a biometric scan.

const { success } = await ReactNativeBiometrics.simplePrompt({ promptMessage: 'Confirm ID' });

If the scan succeeds, generate a keypair. The react-native-biometrics library's createKeys method will automatically save the private key to the device's keystore, and return the public key counterpart. Send the public key to your server.

const { publicKey } = ReactNativeBiometrics.createKeys('Confirm biometrics');

// Save the public key to your database
post('/save_biometric_key', { key: publicKey, device_id: 'xyz' })

When the user tries to login with biometrics, scan their biometrics. This time, if the scan succeeds, create a signature using the stored private key. The react-native-biometrics library's createSignature method handles all of this.

// Prompts for scan
// On scan success, accesses private key and uses it to generate a signature, which is then returned
const signatureResponse = ReactNativeBiometrics.createSignature({
  promptMessage: 'Face or fingerprint ID for Alto Pharmacy',
  payload: BIOMETRIC_SIGNATURE_PAYLOAD,
});

Send the signature to the server to validate against the public key. If validation succeeds, the user has successfully authenticated with biometrics and can proceed into the app.

// Call your server API to validate the signature against the public key that you've stored in the database
const validationSuccess = await post(
  `/validate_biometric_signature`,
  {
    signature: signatureResponse.signature,
    payload: BIOMETRIC_SIGNATURE_PAYLOAD,
		device_id: 'xyz',
  },
);

if (validationSuccess) {
  // Login Success
} else {
  // Login failure
}

import ReactNativeBiometrics from 'react-native-biometrics';

const setUpBiometricLogin = async () => {
  // Check if biometrics are supported and configured on this device
  const { available } = await ReactNativeBiometrics.isSensorAvailable();

  if (available) {
    // Prompt user to scan biometrics
    const { success } = await ReactNativeBiometrics.simplePrompt({ promptMessage: 'Confirm ID' });
      
    if (success) {
      // If scan is successful, generate a keypair, then save the public key to the server
      const { publicKey } = await ReactNativeBiometrics.createKeys('Confirm biometrics');

      post('/save_biometric_key', { key: publicKey, device_id: 'xyz' })
    }
  }
}

const loginWithBiometrics = async () => {
  // Scan user's biometrics. On scan success, generate a signature
  const signatureResponse = await ReactNativeBiometrics.createSignature({
    promptMessage: 'Face or fingerprint ID for Alto Pharmacy',
    payload: BIOMETRIC_SIGNATURE_PAYLOAD,
  });

  // Validate the signature against the public key saved on the server
  const validationSuccess = await post(
    `/validate_biometric_signature`, 
    {
      signature: signatureResponse.signature,
      payload: BIOMETRIC_SIGNATURE_PAYLOAD,
      device_id: 'xyz',
    },
  );

  if (validationSuccess) {
    // Login Success
  } else {
    // Login failure
  }
}

1. build a way to store a public key associated with a device

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