The Georgia Pharmacy Journal: April 2011

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2011 VIP Day Your Day. Your Profession.

Your Voice.

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Celebrating 30 years of service to the Pharmacists of Georgia!

Let us be Your Insurance Resource Join us in celebrating 30 years of serving the members of the Georgia Pharmacy Association.

To learn more visit www.gpha.org.

Call or e-mail TODAY to schedule a time to discuss your health insurance needs.

Trevor Miller – Director of Insurance Services 404.419.8107 or email at tmiller@gpha.org Georgia Pharmacy Association Members Take Advantage of Premium Discounts Up to 30% on Individual Disability Insurance Have you protected your most valuable asset? Many people realize the need to insure personal belongings like cars and homes, but often they neglect to insure what provides their lifestyle and financial well-being - their income!

The risk of disability exists and the financial impact of a long-term disability (90 days or more) can have a devastating impact on individuals, families and businesses. During the course of your career, you are 3½ times more likely to be injured and need disability coverage than you are to die. (Health Insurance Association of America, 2000) As a member of the Georgia Pharmacy Association, you can help protect your most valuable asset and receive premium discounts up to 30% on high-quality Individual Disability Income Insurance from Principal Life Insurance Company.

For more information visit www.gpha.org. * Association Program subject to state approval.

Policy forms HH 750, HH 702, HH 703. This is a general summary only. Additional guidelines apply. Disability insurance has limitations and exclusions. For costs and details of coverage, contact your Principal Life financial representative.

The Georgia Pharmacy Journal

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April 2011

18

Departments

2011 VIP Day at the Capitol Your Day. Your Profession. Your Voice.

FEATURE ARTICLES

5 11 15 21 30

8 11 12 12 13 14 20

Pharm PAC 2010-2011 APhA Programs Information GPhA New Members BLS Program Information Convention Information Alumni Dinner Registration 12th Georgia Foundation Golf Tournament 31 GPhA Board of Directors

GPhA Moves to Online Voting Advertisers

Pharmacy Technician Registration Information March 2011 CORRECTION: CPE Quiz Continuing Education for Pharmacists: Update on Antiplatelets

2 2 6 9 9 9 10 16 17 32

The Insurance Trust Principal Financial Group 2010 Bowl of Hygeia Logix, Inc. Michael T. Tarrant Melvin Goldstein, P.C. Pharmacists Mutual Companies GPhA Workers Compensation AIP The Insurance Trust

2011 Spring Region Meetings Information

COLUMNS

4 7

President’s Message

For an up-to-date calendar of events, log onto

www.gpha.org.

Editorial

The Georgia Pharmacy Journal

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April 2011

PRESIDENT’S MESSAGE Dale M. Coker, R.Ph., FIACP GPhA President

Street Rx admit that I am way behind the times in certain areas, especially when it comes to street drug terminology, so I was glad that Eddie Madden forwarded an informative article from pharmacist e-link to help educate me. The author of the article was making his case about the need for tracking of the sale of pseudoephedrine. Gary Boggs, an agent at the DEA, was quoted as saying that a sub-criminal culture of so-called “pill brokers” has been created, going from retail store to retail store with their GPS units to buy the limit at each store, even clipping coupons to increase their margins. And by the way, the margins are already pretty good, selling a box of pseudoephedrine for $40 to $50 after purchasing for $7 or $8.

one solution, his own Senate Bill 36, Prescription Drug Monitoring Act. Dr. Jim Bartling, Pharm.D., Associate Dean for Student Affairs and Admissions of Mercer School of Pharmacy and Health Sciences, did an outstanding job of conveying the problems pharmacists face in dealing with the “pill mill” issue.

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In many ways, the drug summit was kind of like preaching to the choir, because most of the audience was very aware of the magnitude of the problems; however, there were some statistics that really stood out. One such example is that the number of people who died in one year in Georgia from overdoses of prescription drugs alone (508) is more than six times the number of people who died from overdoses of all other illegal drugs combined (86).

Before laws were passed that placed a strict limit on purchases, requiring buyers’ names, the process of “cooking” methamphetamine was mostly a one-person operation because the operator could buy as many pills as he needed to supply his demand. Enter the “pill brokers” and the process of “smurfing,” whereby producers recruit friends, neighbors, homeless and even their own children to buy the pills.

All who attended the drug summit agreed that something has to be done about the problems caused from methamphetamine and prescription drug abuse. Well, it just so happens that your association has been very influential in the introduction of legislation that will offer potential solutions to both problems: the previously mentioned SB 36, which passed overwhelmingly in the Senate and is at the time of this writing in House Committee awaiting a vote. We will also be working to make pseudoephedrine a Schedule V drug, which can only be dispensed by a pharmacist.

Another term I learned was “shake-and-bake.” This is the process of making meth in small quantities for personal use by mixing the ingredients in a two-liter bottle. And, by the way, if you have lost your formula, or if the drug has fried your brain to the point you don’t remember how to “cook” it, never fear, there are websites, such as Erowid, which will refresh your memory.

I learned about Erowid in the recently attended drug summit at Georgia State University entitled Prescribing our Future: A Summit on Prescription Drug Abuse in Georgia. Hosted by Sally Quillian Yates, U.S. Attorney General, Northern District of Georgia, this conference was prompted primarily from a call from one of her constituents whose child had died from a narcotic drug overdose. The event was attended by every facet of law enforcement and health care who have a stake in finding a solution to the problem of prescription drug abuse. Our profession was represented well by Rick Allen, director of the Georgia Drugs and Narcotics Agency, who spoke about the problem in Georgia and by Senator Buddy Carter, who offered

The Georgia Pharmacy Journal

There seems to be a growing consensus, as evidenced by the U.S. Attorney General Drug Summit, that the citizens of Georgia have had enough of the unnecessary deaths attributed to narcotic overdoses and the sub-criminal culture that has been created in association with the production and distribution of methamphetamine. It is our duty and responsibility as an association representing our profession to take a stand and offer solutions. We have done that, but can’t let up until the last vote is taken. Stay informed through the weekly Pharm-O-Gram and call your legislators when called upon to let them know that we have the prescriptions for the solutions.

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April 2011

GPHA NEWS

GPhA Changes its Election Process: Important Date Changes for 2011 Election post-marked no later than midnight June 10, 2011, in order to allow for pick up, ballot security and counting.

February 15, 2011 The Georgia Pharmacy Association Nominating Committee made up of the twelve Region Presidents and the GPhA President will meet to consider nominations from the membership.

March 20, 2011 The Georgia Pharmacy Association Nominating Committee will submit their selections for candidates for GPhA First Vice President and Second Vice President to the GPhA membership. Any GPhA member who would like to be a candidate for First or Second Vice President and is not among those presented by the GPhA Nominating Committee may petition to have their name included on the ballot or these offices. The petition requires the signature of at least twenty active members of the Georgia Pharmacy Association for the candidate to be certified by the GPhA Executive Vice President as a candidate via petition, and will allow candidates time to reach out to the membership during the Spring Region Meetings.

June 21, 2011 At noon on this date the electronic ballot via the internet will be closed and no other votes accepted. This will allow the candidates several days at the annual meeting to reach out to members who will be allowed to vote via the internet at the convention. An electronic tally will be provided to the Teller’s Committee at 3:00 p.m. on this day, and the results announced to the GPhA Board of Directors.

The newly elected officers of GPhA will installed at the President’s Inaugural Banquet.

We will be sending ballots via the email address we have on file at the GPhA office. If you do not wish to receive a digital ballot please call Tei Muhammad at 404-419-8115, and provide her with the mailing address at which you wish to receive your paper ballot. For those without email addresses on file with GPhA you will receive a paper ballot.

April 19, 2011 Noon on this date is the last time in which a candidate not presented by the GPhA Nominating Committee, can petition GPhA to be on the ballot as a candidate for office. Any member of GPhA not wishing to vote via the internet may request from GPhA via phone, mail or email a paper ballot for voting by April 19, 2011.

If you have any questions about the election process please contact Maggie Patterson at mpatterson@gpha.org or 404-4198120.

May 4, 2011 On this day voting via the internet will open. All paper ballots must be returned to the special GPhA post office box and be

GPhA Needs You and Your Pharmacy Knowledge We are looking for a few good writers to write CPE Articles for the GPhA Journal. If you are interested in building your resume and helping GPhA create the premier CPE program in the state of Georgia please contact Maggie Patterson, Director of Professional Development and Governance at mpatterson@gpha.org or 404-419-8120.

The Georgia Pharmacy Journal

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April 2011

2010 Recipients of the “Bowl of Hygeia” Award

James Walker Alabama

Robert Johnson Arizona

Ronald Norris Arkansas

Horace Williams California

Tim Mead Colorado

Jacqueline M. Murphy Connecticut

Kim Robbins Delaware

Eric Alvarez Florida

Flynn Warren Georgia

Elwin Goo Hawaii

Carl Hudson Jr. Illinois

Jeanne VanTyle Indiana

John Forbes Iowa

Steven Charles Kansas

Kimberly Croley Kentucky

John O. LeTard Louisiana

Douglas Kay Maine

David Fulton Jr. Maryland

Donna Horn Massachusetts

Michael Sanborn Michigan

Gregory W. Trumm Minnesota

William Wells Mississippi

Robert Piepho Missouri

Ernest Ratzburg Montana

Charles Moore Nebraska

Kathryn Craven Nevada

Robert Gooch New Hampshire

Richard Weiss New Jersey

L. Kirk Irby New Mexico

Stephen Giroux New York

Albert Lockamy Jr. North Carolina

Terry Kristensen North Dakota

Jeffrey Allison Ohio

Charles Braden Oklahoma

John Block Oregon

Michele Musheno Pennsylvania

Marisel Menchaca Puerto Rico

Kimberly McDonough Rhode Island

Lynn Connelly South Carolina

Mark Dady South Dakota

Sherry Hill Tennessee

Douglas Parker Texas

Derek Christensen Utah

Randy Pratico Vermont

Brenda Smith Virginia

The “Bowl of Hygeia”

Holly Henry Washington

Betsy Elswick West Virginia

Susan Sutter Wisconsin

Linda Martin Wyoming

The Bowl of Hygeia award program was originally developed by the A. H. Robins Company to recognize pharmacists across the nation for outstanding service to their communities. Selected through their respective professional pharmacy associations, each of these dedicated individuals has made uniquely personal contributions to a strong, healthy community which richly deserves both congratulations and our thanks for their high example. Over the years a number of companies have supported the continuation of this worthwhile program, including Wyeth and Pfizer.

The American Pharmacists Association Foundation, the National Alliance of State Pharmacy Associations and the state pharmacy associations have assumed responsibility from Pfizer for continuing this prestigious recognition program. The Bowl of Hygeia is on display in the APhA Awards Gallery located in Washington, DC.

EXECUTIVE VICE PRESIDENT’S EDITORIAL Jim Bracewell Executive Vice President / CEO

VIP Day - Advocating for the Future of Pharmacy ast month’s “March Madness,” which is a term associated with college teams fighting it out on basketball courts across the nation, could well have applied to the final weeks of the Georgia General Assembly.

6. PBM auditors would have no restrictions on their actions and no consequences.

7. PBMs would not be required to be licensed to do business in Georiga.

8. Dangerous drug lists would not be updated annually.

9. The Georgia Drugs and Narcotics agents would not be required to be licensed pharmacists.

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As I write this article, the legislature is still in session and therefore there is nothing that can be reported as the final outcome of legislation affecting pharmacy. One thing however that I can report with a great deal of certainty is that because of the hundreds of pharmacists and pharmacy students that attended VIP Day at the state capitopl, the outcome of pharmacy related legislation was positively affected for the pharmacy profession.

This list could go on for several pages and each item would validate even more the need for a strong advocacy effort by your profession. Are you content with the practice privileges of your license? I doubt but a limited few are satisfied. Do you believe pharmacy should evolve with the changes in healthcare? Or would you be content to count by five, lick, stick and pour as the profession was described just a short few years ago.

How important and how relevant is VIP Day to expanding and improving the practice of pharmacy in our state?

Rightfully the scope of practice of pharmacy and every other health profession is governed by the laws of our state. These laws are enacted by our elected officials who respond to the needs brought before them each year. If GPhA does not advocate for the profession of pharmacy, who should?

If you really do not know the answer to that question then you need to consider a few items about where the pharmacy profession would be today without the advocacy efforts of your association.

1. The dispensing of prescription drugs would be a privilege granted to a wide variety of mid level health care providers.

2. The mail delivery of prescriptions drugs in our state would have little or no oversight.

3. Pharmacists would not be allowed to provide immunizations under a protocol.

4. The value of pharmacists in the healthcare delivery would be diminished.

5. The availability of generic drugs for patients would be curtailed by carve out programs promoted by manufacturers of branded prescription drugs.

The Georgia Pharmacy Journal

Pharmacists can ill afford to abdicate the enactment of legislation that dictates the practice of pharmacy to the voice of non-pharmacists, and to special proprietary interests in healthcare. VIP Day this year was a huge success; it was a major demonstration of the collaboration of all practices of pharmacy in a unified voice.

A voice that is being heard at the state capitol as never before, if you were not there, you need to ask yourself what was more important to your career, to your future than for you to join your fellow pharmacists in a united voice for your profession.

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April 2011

Pharm PAC Enrollment Pledge Year 2010-2011

Titanium Level ($2400 minimum pledge) Michael E. Farmer, R.Ph. David Graves, R.Ph. Jeffrey L. Lurey, R.Ph. Robert A. Ledbetter, R.Ph. Marvin O. McCord, III, R.Ph. Judson L. Mullican, R.Ph. W.A. (Bill) Murray, R.Ph. Mark L. Parris, Pharm.D. Fred F. Sharpe, R.Ph. Jeff Sikes, R.Ph.

Platinum Level ($1200 minimum pledge) Robert Bowles, Jr., R.Ph., CDM, Cfts Jim Bracewell T.M. Bridges, R.Ph. Bruce L. Broadrick, Sr., R.Ph. Thomas E. Bryan, Jr., B.S. William G. Cagle, Jr., R.Ph. Keith Chapman, R.Ph. Hugh M. Chancy, R.Ph. Dale M. Coker, R.Ph., FIACP J. Ashley Dukes, R.Ph. Jack Dunn, R.Ph. Stewart Flanagin, Jr., R.Ph. Andy Freeman Ann Hansford, R.Ph. Robert M. Hatton, Pharm.D. Alan M. Jones, R.Ph. Ira Katz, R.Ph. Harold M. Kemp, Pharm.D. J.Thomas Lindsey, R.Ph. Brandall S. Lovvorn, Pharm.D. Eddie M. Madden, R.Ph. Jonathan Marquess, Pharm.D., CDE, CPT Pam S. Marquess, Pharm.D. Kenneth A McCarthy, R.Ph. Scott Meeks, R.Ph. Drew Miller, R.Ph., CDM

Laird Miller, R.Ph. Jay Mosley, R.Ph. Allen Partridge, Jr. Tim Short, R.Ph. Dean Stone, R.Ph., CDM Chris Thurmond, Pharm.D.

Edward Franklin Reynolds, R.Ph. James Thomas, R.Ph. Brandon Ullrich Alan M. Voges, Sr., R.Ph. Flynn W. Warren, M.S., R.Ph. Oliver C. Whipple, R.Ph. Walter Alan White, R.Ph.

Gold Level ($600 minimum pledge)

Bronze Level

James Bartling, Pharm.D., ADA, CAC II Liza G. Chapman, Pharm.D. Patrick M. Cook, Pharm.D. Mahlon Davidson, R.Ph., CDM Jim Elrod, R.Ph. H. Neal Florence, R.Ph. Ted Hunt, R.Ph. Robert B. Moody, III, R.Ph. Sherri S. Moody, Pharm.D. Sharon M. Sherrer, Pharm.D. Michael T. Tarrant Jeffrey Richardson, R.Ph. Houston L. Rogers, Jr., Pharm.D., CDM Robert Anderson Rogers, R.Ph. Daniel C. Royal, R.Ph. Dean Stone, R.Ph., CDM Thomas H. Whitworth, R.Ph., CDM

($150 minimum pledge)

Silver Level ($300 minimum pledge) Renee D. Adamson, Pharm.D. John L. Colvard, J. R.Ph. Chandler Conner, R.Ph. F. Al Dixon, R.Ph. Marshall L. Frost, Pharm.D. James Jordan, R.Ph. Michael O. Iteogu, Pharm.D. Willie O. Latch, R.Ph. William J. McLeer, Sr., R.Ph. Kalen Beauchamp Porter, Pharm.D. Sara Mandy Reece, Pharm.D.

Monica M. Ali-Warren, R.Ph. James R. Brown, R.Ph. Mark C. Cooper, R.Ph. Michael A. Crooks, Pharm.D. Charles Alan Earnest, R.Ph. Amanda R. Gaddy, R.Ph. Amy S. Galloway, R.Ph. Johnathan Hamrick, R.Ph. William E. Lee, R.Ph. Earl Marbut, R.Ph. Leslie Ponder, R.Ph. Richard Brian Smith, R.Ph. Marion Wainright, R.Ph. Steven Wilson, R.Ph. Sharon B. Zerillo, R.Ph. Jackie White John Kalvelage Carey B. Jones, R.Ph. Fred W. Barber, R.Ph. Jeffrey Richardson, Jr., R.Ph.

Members (no minimum pledge) Jill Augustine Claude W. Bates, B.S. Chad J. Brown, R.Ph. Max C. Brown, R.Ph. Lucinda F. Burroughs, R.Ph. Shobhna D. Butler Pharm.D. Waymon M. Cannon, R.Ph.

If you made a gift or pledge to Pharm PAC and your name does not appear above please, contact Kelly J. McLendon at kmclendon@gpha.org or 404-419-8116. Donations made Pharm PAC are not considered charitable donations and are not tax deductible.

The Georgia Pharmacy Journal

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April 2011

Pharm PAC Contributors’ List Continued Walter A. Clark, Jr., R.Ph. Jean N. Courson, R.Ph. Carleton C. Crabill, R.Ph. Alton D. Greenway, R.Ph. J. Clarence Jackson, Jr., R.Ph. Gina R. Johnson, Pharm.D., BCPS, CDE Joshua Kinsey, Pharm.D. Ashley S. London Charles Lott, R.Ph.

Tracie D. Lunde, Pharm.D. Randall Marett, R.Ph. Ralph K. Marett, M.S. Whitney B. Pickett, Pharm.D. Rose Ann Pinkstaff, R.Ph. Michael Reagan, R.Ph. Leonard Franklin Reynolds, III, R.Ph. James Riggs, R.Ph. Victor Serafy, R.Ph.

Harry A. Shurley, Jr., R.Ph. James Strickland, R.Ph. Leonard Templeton, R.Ph. Heatwole Thomas, R.Ph. James. E. Stowe, Jr., R.Ph. Erica Veasley, R.Ph. William D. Whitaker, R.Ph. Jonathon A. Williams, Pharm.D. Michael R. Williams, R.Ph.

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The Georgia Pharmacy Journal

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APhA Certification Course in Pharmaceutical Care for Patients With Diabetes Friday, June 17, 2011 (12:30 - 6:30 PM) For more details and to register online today visit www.gpha.org or call 404-231-5074.

If you plan to attend the GPhA Convention you must register for that event separately.

Cost: Member: $350 Potential Member: $450 Student: $175 The American Pharmacists Association and the Georgia Pharmacy Association are accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

If you have any questions about these events please call 404-231-5074.

Pharmacy Technician Registration Information In accordance with O.C.G.A. § 26-4-28, the Georgia Board of Pharmacy has adopted Rule 480-15-02 which requires pharmacy technicians to register with the Board of Pharmacy. Pharmacy Technicians may submit applications for registration online at www.sos.ga.gov/plb/pharmacy. The requirements for registration are as follows: • • • • • •

Submit the $100 application fee Attest that applicant is at least 17 years old Attest that applicant is currently enrolled in high school, has a high school diploma or has a GED Obtain a criminal history background check through the Cogent Systems/GAPS at a GAPS location If currently employed in a pharmacy, submit the license number of the pharmacy where the applicant is employed If certified, submit a copy of applicant's Pharmacy Technician Certification Board certificate

Once a registration is approved, the registration will be made available on the Professional Licensing Board's website at https://secure.sos.state.ga.us/myverification/. The deadline for registration is June 30, 2011.

Please visit the Board's website at www.sos.ga.gov/plb/pharmacy for more information including state laws, board rules and frequently asked questions.

The Georgia Pharmacy Journal

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April 2011

GPHA MEMBER NEWS

Welcome to GPhA! The following is a list of new members who have joined Georgia’s premier professional pharmacy association!

Pharmacy School Student Members Individual Pharmacist Members Albertine Agnes Kazmark, Lawrenceville Keevis Cooper, Union City Lien Kim Mac, Atlanta Kirbie Elise Guerin, Lawrenceville Ernie Luk, Lawrenceville

New Graduate Pharmacist Members Jeffrey W. Smith, Pharm.D., Marietta Richard Allen Brook, Pharm.D., Douglasville Mina Yun, Pharm.D., Atlanta Philip Tyler Mayotte, Pharm.D., Kennesaw Megan Leigh Sightler, Pharm.D., Madison

Denise Hawkins, Pharm.D., Hawkinsville Melanie Germany, Atlanta Patricia Knowles, R.Ph., Evans Hubert Bennett, Perry John Benjamin Rountree, Statesboro Jennifer Leavy, Pharm.D., St. Simons Island Becky Hamilton, R.Ph., Acworth Dana E. Strickland,R.Ph., Athens Deborah L. Gale,R.Ph., Demorest Denikka LaToya Hull, Pharm.D., Evans Dianne W. May, Pharm.D., North Augusta Paige D. Dawson, Pharm.D., Hawkinsville Karen Michele Long, R.Ph., Tunnel Hill Leigh Bolton, R.Ph., Ellijay Candace W. Boatright, Pharm.D., Patterson

Basic Life Support for Health Care Providers Course Monday, June 20, 2011 (1:00 PM - 5:00 PM) Amelia Island Plantation 6800 First Coast Highway Amelia Island, FL 32034 For more details and to register online today visit www.gpha.org or call 404-231-5074.

Cost: Member: $75 Potential Member: $100 Cancelation Policy: No refunds will be issued; however, timely notification of cancelation may allow another pharmacist to participate in this program.

The Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

The Georgia Pharmacy Journal

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April 2011

June 18-22, 2011: GPhA Convention, Amelia Island Plantation, Amelia Island, Florida Join us on the beaches of Amelia Island to learn about new trends in our ever-changing world of pharmacy.

Lock in the lowest rates when you register today!

The Plantation highlights include: • 249 luxurious oceanfront rooms with patios & balconies overlooking the Atlantic ocean • Indoor and outdoor pools and fully equipped fitness center • Luxurious full-service spa and salon on site • Golf & tennis shops on site and numerous activities available • Several fine and casual dining options • More than 49,000 square feet of state-of-the-art meeting space GPhA Registration Types: GPhA Member GPhA Potential Member GPhA Student Member

Early Bird $295 $470 $125

5/2 - 6/1 $320 $495 $150

6/1 - 6/17 $345 $520 $175

On site $400 $570 $175

To register for Convention go to www.gpha.org or call Kelly McLendon at 404-419-8116.

If your company would like to exhibit at the GPhA Convention please visit the Convention website or call Caroline Fields at 404-419-8126.

Registration Options: Spouse and Guest Registration (Does not include CPE) $265 Student Sponsorship $100 Convention Registration Fee includes: • Admittance to CPE Sessions (No CPE will be granted for Spouse and Guest Registrations.)

• All Refreshments • Exhibits • Entertainment • President's Reception (Students wishing to attend the Tuesday evening activities will purchase tickets at registration.)

• Awards Banquet • Coffee/Dessert Reception How to reserve a hotel room: For information regarding hotel reservations visit www.gpha.org or call 904-261-6161.

Cancelation Policy: All registration cancelations must be in writing and emailed to kmclendon@gpha.org. Cancelations received before June 1, 2011, will be refunded less a $50 cancelation fee. After June 1, 2011, all registration fees will be non-refundable.

The Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

The Georgia Pharmacy Journal

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April 2011

Mercer University College of Pharmacy and Health Sciences Alumni Dinner Monday, June 20, 2011, at 7:30 p.m.

Sandy Bottoms Beach Bar & Grill, 2910 Atlantic Ave., Main Beach, Fernandina Beach, FL Please make ______ reservations at $35.00 per person. _______ I would like to sponsor ______ student(s) for the alumni dinner at $35.00 each.

Name (on Credit Card): _______________________________________________________________ Name of spouse and/or guest(s): _________________________________________________________ Billing Address: _____________________________________________________________________ City: _______________________________ ST: ___________ Zip Code: ______________________ Cell: ____________________________ Work: ___________________________________________ E-mail: ___________________________________________________________________________ Circle One: Check Visa Master Card Amex Card Number: __________________________________ CVS#: __________ Exp.Date: ____________ Mail registration form to Sharon Lim Harle, Mercer University, 3001 Mercer University Drive, Atlanta, GA 30341.

Make check payable to Mercer University. For more information call (678) 547-6420 or e-mail to lim_s@mercer.edu.

University of Georgia College of Pharmacy Alumni Dinner Monday, June 20, 2011, at Slider’s Seaside Grill 1998 S. Fletcher Ave., Fernandina Beach, FL 7:30 p.m.

I will attend the Alumni Dinner for alumni spouses and friends of University of Georgia College of Pharmacy.

Please make ______ reservations at $35.00 per person. _______ Yes, I would like to sponsor ______ student(s) for the alumni dinner at $35.00 each.

Name: ______________________________________________ Name of spouse and/or guest(s): Address: City:

Class/Year:

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_____________________________________________________

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Work Phone: _________________________ Home Phone: __________________________ Mail registration form with check, payable to UGA Foundation, by June 17, 2011, to Sheila Roberson, College of Pharmacy Alumni Director, University of Georgia, College of Pharmacy, Athens, GA 30602. For more information please call 706.542.5303.

The Georgia Pharmacy Journal

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April 2011

March 2011 CORRECTION: Continuing Education for Pharmacists Quiz and Evaluation Due to an error in the March Journal CPE Quiz we are printing the corrected CPE quiz below.

If you want credit for the March CPE please complete this quiz and return it for credit with the coupon in the March Journal.

1. A 54 year-old male has a blood pressure reading in your pharmacy of 152/94 mg Hg. How would you classify this blood pressure reading?

A. Prehypertension.

B. Stage 1 hypertension.

C. Stage 2 hypertension.

D. Normal blood pressure.

6. Angiotensin converting enzyme inhibitors: A. Routinely increase heart rate by direct stimulation.

B. Exert selective action on Beta-2 nerves in the vascular smooth muscle.

C. Cannot be given concurrently with thiazide diuretics.

D. Can produce a chronic cough.

2. New data indicates: A. Diuretics are not effective in blood pressure control.

B. Single drug therapy to the maximum effective level is preferred.

C. Use of more than one medication with gradually increasing from small doses is effective.

D. All antihypertensives result in lowered potassium serum levels.

7. Calcium channel blocking agents can cause all but which of the following?

A. Peripheral edema.

B, Altered INR results in patients taking warfarin.

C. Stimulation of renin release.

D. Worsening of heart failure.

8. Alpha-1 blockers: A. Can induce a syncopal episode with the first dose of the medication.

B. Are effective for benign prostatic hypertrophy.

C. Cause lowered blood pressure through their effects of limiting norepinephrine action.

D. A and B. E. All of the above.

3. Renin is released secondary to: A. Decreased sodium and/or fluid in the distal convoluted tubule.

B. Increased potassium levels in the loop of Henle.

C. Increased sodium and/or fluid in the distal convoluted tubule.

D. Decreased sodium and/or fluid in the proximal convoluted tubule.

9. Which of the following is/are good patient teaching tips for methyldopa?

A. Take the medication at the same time each day if possible.

B. Report any new medications added to your regimen to your primary physician.

C. Take your methyldopa in the morning with your other medications, including iron if prescribed.

D. A and B. E. All of the above.

4. Thiazide diuretics lower blood pressure in patients with hypertension. The mechanism(s) for this action are: A. Reduce alpha adrenergic tone and decrease heart rate.

B. Reduce fluid levels through diuresis and additional activity on blood vessels.

C. Reduce fluid levels through diuresis and a central nervous system action to decrease alpha adrenergic action.

D. Reduce fluid levels through diuresis and reduce cardiac output by decreasing heart rate.

10. Which of the following is considered a cardiovascular risk factor?

A. Routine aerobic physical activity of 45 minutes per session five times a week.

B. Women aged 56 years old with no other cardiovascular event history.

C. Presence of microalbuminuria.

D. Body mass index of 26 Kg/m2.

5. Beta blockers actions: A. Can reduce hepatic glucose output.

B. Can directly cause bronchodilation.

C. Can increase LDL-cholesterol levels.

D. Can reduce renin release in the kidney.

The Georgia Pharmacy Journal

15

April 2011

Trevor Miller, Director of The Insurance Trust 404-419-8173 or tmiller@gpha.org

Do you want to work for an

Independent Pharmacy?

Do you want to own your own pharmacy?

Call Jeff Lurey, R.Ph. AIP Director 404Ǧ419Ǧ8103 jlurey@gpha.org

FEATURE ARTICLE

2011 VIP Day at the Capitol - Your Day. Your Profession. Your Voice.

Caroline Fields Director of Events & Conferences

including 25 members of both the House and Senate Health and Human Services Committee.

n February 23, 2011, the Freight Room at the Georgia Railroad Freight Depot was taken over by pharmacists from around the state, proving that pharmacy’s strength in numbers of committed professionals. Every year, GPhA hosts VIP Day to show legislators that pharmacists are interested in state politics and their profession. This year was no different, with one of the highest turnouts of pharmacists in GPhA history.

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GPhA is extremely appreciative to all the Legislators who took time out of their schedule to be at our event and converse with pharmacists about issues within the profession. Their presence and involvement at one of our

VIP Day also marks the time when the Association chooses to honor a legislator who has done his/her part for the pharmacy profession in the political arena. This year’s GPhA Legislator of the Year Award went to Representative Mickey Channell (House District 116).

Rep. Channell has been serving the state of Georgia since 1992 and has done his part to help fight for improved healthcare and the profession of pharmacy.

This year’s event also had one of the best legislator turnouts on record. The program had appearances and speeches from Governor Nathan Deal; House Speaker David Ralston; Attorney General Sam Olens; Insurance Commissioner Ralph Hudgens; and DCH Commissioner David Cook. Furthermore, approximately 50 legislators showed up to the event,

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18

April 2011

biggest political events of the year will give us great strides with our grassroots efforts. Incoming-President Jack Dunn, R.Ph., said, “Yesterday’s VIP Day will give a lot of momentum for the rest of year. This will hopefully be a stepping stone to further improve our advocacy and membership for the future of our organization.” The success of this event allows GPhA to be a continuous driving force behind important legislation that benefits the profession of pharmacy.

This year’s VIP Day Event was memorable and valuable. GPhA Member Jeff Sikes, R.Ph., said, “I’m very impressed. The meeting was very organized, effective, and worthwhile…

I’m very proud of our organization and extremely optimistic with respect to our future goals and objectives to ‘Take Pharmacy Back’ and have a seat at the table when policy is being discussed… from Gov. Deal to all the speakers, I sincerely believe they value pharmacists’ input.” With the help and guidance of our leadership, GPhA will continue to do its best and bring useful programming to its members.

If you were unable to attend VIP Day this year , we hope you will make plans to join us in 2012 for this very important and meaningful event. The success of our Government Advocacy program depends on the participation and involvement of every single GPhA member. We urge you to seek out your representatives and introduce yourself — talk about the profession and the important issues facing pharmacy, which in turn affect Georgia patients. It’s all about building relationships and the most important relationships begin with you.

The Georgia Pharmacy Journal

19

April 2011

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Continuing Education for Pharmacists Update on Antiplatelets Article Contributed by Meagan S. Barbee, Pharm.D. candidate, Mercer University College of Pharmacy and Health Sciences; Gina J. Ryan, Pharm.D., BCPS, Clinical Associate Professor, Mercer University College of Pharmacy and Health Sciences; and Lisa M. Lundquist, Pharm.D., BCPS, Clinical Associate Professor and Assistant Dean for Administration, Mercer University College of Pharmacy and Health Sciences.

bjectives: At the conclusion of this lesson, successful participants should be able to:

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1. Describe mechanisms of action, indications, dosing, adverse reactions and monitoring parameters for aspirin.

1a. Describe mechanisms for actions, indications, dosing, adverse reactions and monitoring parameters for thienopyridines.

2. Describe treatment guidelines for use of GP IIb/IIIa 1b. Describe drug interactions for antiplatelet agents.

3. State pertinent patient counseling and education information regarding antiplatelet agents.

Background Platelets normally function in the body to coagulate the blood and inhibit bleeding.

However, they can also adhere to vascular endothelium and precipitate thromboembolic events. Their function is dependent upon activation, aggregation and adherence. Platelets are activated by various receptor-mediated processes in which a ligand binds to a receptor on the platelet. Once the ligand binds to its respective platelet surface receptor, the glycoprotein (GP) IIb/IIIa receptor undergoes a conformational change to become active. The activated form of the GP IIb/IIIa receptor binds and adheres to fibrinogen on damaged vascular endothelium and other platelets.

Ligands that activate platelets include adenosine diphosphate (ADP), serotonin, collagen, thrombin, thromboxane, and platelet activating factor (PAF). Platelets may be inhibited by three primary mechanisms: 1)

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decreasing the amount of ligand available to activate platelets, 2) blocking the ligand receptors on the platelets, and 3) blocking the GP IIb/IIIa receptor. The class of antiplatelet medications can be divided by mechanism of action on the platelet.1,2 Platelet lifespan is approximately eight to

reduce the risk of experiencing subsequent thromboembolic events.

Also, antiplatelets are used in the acute treatment of some thromboembolic events. It is important for the pharmacist to differentiate between the types of antiplatelet medications and to know their labeled indications and recommended usages.

2

ten days. Some medications that are irreversible inhibitors of platelet function employ their effect throughout the lifespan of the platelet since platelets also lack nuclei to synthesize new receptors and mediators. Irreversible acting antiplatelet medications include aspirin, 3-6

clopidogrel, prasugrel, and ticlopidine.

Antiplatelet medications are used in treatment and in primary and secondary prophylaxis of several different acute and chronic thromboembolic conditions.

Namely, antiplatelets are used in cerebrovascular conditions such as transient ischemic attack (TIA) and ischemic stroke. Also, antiplatelets are used in patients with cardiovascular conditions such as atrial fibrillation, coronary artery disease, peripheral artery occlusive disease, and the acute coronary syndromes (ACS: unstable angina, STelevated myocardial infarction [STEMI] and non-ST elevated myocardial infarction [non-STEMI]) among others.

Antiplatelet medications are used in primary prophylaxis to prevent thromboembolic events. Patients who have experienced a thromboembolic event as described above are at higher risk of experiencing a second thromboembolic event compared to patients who have not had an event.

Antiplatelet medications are used in such patients as secondary prophylaxis to

21

Cyclooxygenase (COX) Inhibitors The most commonly used agent in this class is aspirin. Aspirin irreversibly acetylates and inhibits cyclooxygenase-1 on platelets. This results in decreased prostaglandin formation and decreased formation of the prostaglandin derivative, thromboxane A2, thus inhibiting platelet aggregation.3 Aspirin has many indications, but it is used as an antiplatelet in acute situations of ischemic stroke, non-cardioembolic stroke or TIA as well as STEMI and nonSTEMI.3,7-10 It is also recommended for long-term prophylaxis of stroke, vascular death and subsequent myocardial infarction (MI) in high-risk patients.

High-risk patients include those with chronic stable angina, unstable angina, peripheral artery occlusive disease, diabetes, coronary artery disease, those who have a history of MI, TIA or minor stroke.11-14 High-risk patients also include those with atrial fibrillation who have less than two of the following risk factors: hypertension, diabetes, age greater than 75, heart failure and moderately or severely impaired left ventricular systolic function.15 Unfortunately, the mechanism of action of aspirin is not specific to only platelet cyclooxygenase. Aspirin also inhibits the

April 2011

formation of the protective prostaglandins in the stomach, which is why the main adverse effect associated with aspirin is stomach irritation, ulcers, and in severe cases a gastrointestinal (GI) bleed. The enteric coated (EC) formulation of aspirin is designed to decrease the direct local irritation of aspirin and is suggested for use in maintenance dosing situations. Doses vary based on indication and treatment setting and are listed in Table 2. In rare cases, aspirin has been associated with tinnitus and hearing loss, especially at higher doses, and should be discontinued if this occurs.3 Aspirin should not be given to patients who have a salicylate allergy or those with active peptic ulcer disease.3 When dispensing or recommending aspirin, patients should be warned about the signs and symptoms of GI upset and GI bleed, specifically stomach pain, heartburn, nausea, vomiting and black or tarry stools.

Pause & Reflect: Describe mechanisms of action, indications, dosing, adverse reactions and monitoring parameters for aspirin.

Adenosine Diphosphate (ADP) P2Y12 Receptor Blockers (Thienopyridines) The next class of antiplatelet medications, known as the thienopyridines, includes three agents: clopidogrel (Plavix®), prasugrel (Effient®) and ticlopidine (Ticlid®). These medications exhibit their antiplatelet effect by irreversibly blocking the action of ADP on the P2Y12 component of ADP receptors on the surface of platelets.4-6 The activation of the GP IIb/IIIa receptor complex is thus inhibited and reduces platelet aggregation. The ADP receptors remain irreversibly blocked for the remainder of the platelet lifespan. Clopidogrel and prasugrel are prodrugs and must be converted to their active forms via cytochrome P450 (CYP450) enzymes.4,5 Specifically, clopidogrel is activated by CYP2C19, CYP3A4, CYP2B6 and CYP1A2.4 Prasugrel is primarily activated

by CYP3A4 and CYP2B6 with CYP2C9

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and CYP2C19 having less involvement.5 Both clopidogrel and prasugrel are indicated in the acute treatment of acute STEMI and non-STEMI in patients undergoing percutaneous coronary intervention (PCI).4,5 Clopidogrel is also indicated for the treatment of STEMI and non-STEMI in medically managed patients and for the prevention of MI, ischemic stroke and vascular death in patients with a recent history of MI, recent stroke, or established peripheral artery disease (PAD).4 Ticlopidine is indicated to reduce the risk of thrombotic stroke in patients who had a thrombotic stroke or stroke precursors (TIA, transient monocular blindness, reversible ischemic neurological deficit, or minor stroke). When administered with aspirin, ticlopidine is also indicated in patients who have received a stent to reduce the incidence of thromboembolic events.6 Dosing of thienopyridines is based on treatment setting (i.e. acute versus maintenance therapy) and is listed in Table 2.

More than the other agents, ticlopidine is associated with the risk of lifethreatening blood dyscrasias including thrombotic thrombocytopenic purpura (0.025-0.05%), neutropenia/agranulocytosis (2.4%), and aplastic anemia (0.0125-0.025%). Each of these adverse events are black box warnings in ticlopidine’s prescribing information.6 It is also associated with a high rate of GI side effects such as diarrhea (12.5%) and nausea (7%).6 Prasugrel prescribing information contains a black box warning for increased bleeding risk and is contraindicated in patients with active bleeding or who have a history of TIA or stroke.5 According to the TRITON-TIMI study, prasugrel is associated with a significantly higher incidence of bleeding when compared to clopidogrel.17 In the study, 4% of prasugrel patients bled significantly enough to require a transfusion compared to 3% of clopidogrel-treated patients.17

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Clopidogrel, on the other hand, is associated with interpatient genetic variability more than other thienopyridines.16 Some patients, classified as “poor metabolizers,” possess certain genetic variations in CYP2C19 and are not able to effectively convert the prodrug to the active metabolite.4 The frequency of poor metabolizers varies among different populations (2% in whites, 4% in blacks, 14% in Chinese).4 Patients who do not respond adequately to clopidogrel may be at approximately five-times greater risk of myocardial infarction, stent thrombosis and death.17,18 The clopidogrel labeling was revised to include a black box warning reflecting this genetic variability in March 2010.

In general, patients who are receiving a thienopyridine should be monitored for bleeding and blood dyscrasias. Patients receiving ticlopidine should have their liver function tests (aspartate aminotransferase [AST], alanine aminotransferase [ALT], gamma glutamyl transpeptidase [GGT], and alkaline phosphatase) monitored because it is contraindicated in patients with severe liver impairment and has been shown to increase these liver function tests. When dispensing prasugrel, clopidogrel, or ticlopidine, pharmacists should inform patients that they might bruise more easily and it will take longer for them to stop bleeding. Patients should also be educated about the signs and symptoms of excessive bleeding such as blood in the urine or black and/or tarry stools. Patients receiving ticlopidine should be told to report any yellowing of the skin or eyes to their physician.

Because thrombocytopenia is associated with all thienopyridines, patients should be informed to report any unexplained symptoms such as fever, weakness, extreme skin paleness, purple skin patches or petechiae to their physician or pharmacist.4-6 In the TRITON-TIMI trial, prasugrel showed superior efficacy over clopidogrel in the primary efficacy composite

April 2011

endpoint (death from cardiovascular causes, nonfatal MI or nonfatal stroke) in patients with diabetes and in patients who are “poor metabolizers.”17 The current 2009 Update to the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines does not explicitly recommend clopidogrel over prasugrel or vice versa for any specific group of patients.12 This is mainly due to uncertainties surrounding risk and benefits of one drug over another and how to select patients who may perform better on prasugrel.19 Previous guidelines, however, favor clopidogrel over ticlopidine in STEMI and non-STEMI patients mostly because of the adverse effects of ticlopidine.9,10 For peripheral artery occlusive disease, an aspirin-based regimen remains first line for patients with coronary or cerebrovascular disease, and clopidogrel is only recommended in patients who have adverse effects to aspirin.13 Pause & Reflect: Describe mechanisms for actions, indications, dosing, adverse reactions and monitoring parameters for thienopyridines.

Glycoprotein (GP) IIb/IIIa Receptor Blockers GP IIb/IIIa receptor blockers are another class of antiplatelet agents and include: abciximab (ReoPro®), tirofiban (Aggrastat®), and eptifibatide (Integrilin®). The GP IIb/IIIa receptor is the major platelet surface receptor involved in platelet aggregation. When this receptor is blocked, substrates such as fibrinogen and von Willebrand factor cannot bind and the result is inhibition of platelet aggregation.25-27 Abciximab is a chimeric monoclonal antibody and also binds to the vitronectin (αvβ3) receptor found on platelets, vessel wall endothelial, and smooth muscle cells blocking cell adhesion.25 Tirofiban and eptifibatide are both reversible antagonists.26,27 Of the three agents, tirofiban is the only non-peptide, and eptifibatide and abciximab are both associated with the formation of antibodies that contribute to allergic

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reactions.25-27 The GP lIb/lIla receptor blockers are only used in the hospital setting in patients with ACS to reduce the incidence of negative outcomes. All agents are indicated in patients undergoing PCI who have moderate risk for an ischemic event. Risk factors for an ischemic event include ongoing chest pain, hemodynamic instability, positive troponin, or dynamic electrocardiogram (ECG) changes.10 Eptifibatide and tirofiban are also indicated and recommended in patients with nonSTEMI who are to be medically managed and are of at least moderate risk for an ischemic event.10,26,27 The CHEST and ACC/AHA guidelines recommend the use abciximab in patients with STEMI only if PCI is planned.9,19 Abciximab should only be used in conjunction with aspirin and heparin, and tirofiban should only be used with heparin.9,10,25,26 The major side effects of these agents are thrombocytopenia (abciximab: 2.5-3%, eptifabtide:1.2%, and tirofiban: 1.5%) and bleeding. The incidence, type and severity of bleeding varied widely among all three agents across studies. The incidence of major thrombolysis in myocardial infarction (TIMI) bleeding was 1.3-10.8% for eptifibatide, 1.4-2.2% for tirofiban, and 0.8-3.8% for abciximab.

The incidence of minor TIMI bleeding was 3-14.2% for eptifibatide, 10.5-12% for tirofiban and 3.2-7.6% for abciximab.

The incidence of bleeding requiring a transfusion was 1.5-12.8% for eptifibatide, 4-4.3% for tirofiban and 0.52.4% for abciximab. Bleeding incidence in the eptifibatide trials correlated with dose, and bleeding incidence in the abciximab trials correlated with heparin dose during coadministration.25-27 Patients should be monitored for signs and symptoms of bleeding and thrombocytopenia as well as platelet, hemoglobin, and hematocrit levels. If platelet counts drop below 100,000/mm3, administration of GP lIb/lIla receptor blockers should be held

23

and possibly discontinued. The renal function of patients receiving eptifibatide should be monitored, and eptifibatide should not be administered to patients who are dependent on renal dialysis.27 Dosing for GP IIb/IIIa receptor blockers is weight-based. 25-27 This class of medications is contraindicated in patients who had major surgery in the previous 4-6 weeks and in patients with severe uncontrolled hypertension, active or recent bleeding, recent history of stroke, or any history of hemorrhagic stroke.25-27 Abciximab, furthermore, should not be administered to patients who received dextran or oral anticoagulants within seven days unless their international normalized ratio (INR) is ≤ 1.2, and it is also contraindicated in patients with a history of intracranial neoplasm, arteriovenous malformation, or aneurysm.25 Administration of abciximab may stimulate the production of human antichimeric antibodies, which could lead to an allergic hypersensitivity reaction, including anaphylaxis. In trials, 5.8% of patients tested positive for human antichimeric antibodies after the first dose of abciximab, and 6-27% of patients tested positive for human anti-chimeric antibodies after receiving subsequent doses. Patients who are human antichimeric antibody positive are at an increased risk of developing thrombocytopenia and may have hypersensitivity to other monoclonal antibodies.25 Pause & Reflect: Describe treatment guidelines for use of GP IIb/IIIa. Miscellaneous Agents The exact mechanisms of action and pharmacodynamic effects of cilostazol (Pletal®), dipyridamole (Persantine®), and pentoxifylline (Trental®) are not fully understood. Cilostazol is a phosphodiesterase III inhibitor.

Phosphodiesterase III normally functions to breakdown cyclic adenosine monophosphate (cAMP). Inhibiting

April 2011

phosphodiesterase III increases levels of cAMP which induces vasodilation and inhibits platelet aggregation.13,20 Several theories on the mechanism of action of dipyridamole have been reported including inhibition of phosphodiesterase, though this is thought to weakly contribute to its overall pharmacodynamic effect.12,22 It is mostly reported that dipyridamole inhibits the uptake of adenosine into platelets, endothelial cells, and erythrocytes. This inhibition results in an increase in the local concentration of adenosine which acts on the platelet A2receptor and stimulates adenylate cyclase to increase cAMP levels. Platelet aggregation is thus inhibited, and the adenosine also acts as a vasodilator.12,21,22 The mechanism of action of pentoxifylline is even less understood. It is known to decrease blood viscosity and improve erythrocyte flexibility.13,23 All three medications may cause gastrointestinal distress.20,21,23 In addition, the administration of cilostazol has been associated with headaches (27-34%, depending on dose).20 Patients given cilostazol should be told that the beneficial effect on walking distance may take 2-12 weeks, and they should take this medication on an empty stomach.20 Cilostazol is contraindicated in patients who have heart failure or have active bleeding.20 Pentoxifylline should not be used in patients with a recent history of cerebral or retinal hemorrhage or in those who are intolerant to methylxanthines (i.e. caffeine or theophylline).23 Patients should take dipyridamole while sitting or lying down as it causes temporary dizziness and headache. Patients should also monitor their own blood pressure and heart rate when taking dipyridamole.21 Cilostazol and pentoxifylline are indicated for the reduction of symptoms of intermittent claudication, a component of peripheral artery occlusive disease.20,23 With warfarin, dipyridamole is

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indicated for thromboembolic prophylaxis in patients who have had cardiac valve replacement.21 However, dipyridamole plus aspirin (Aggrenox®) is indicated in patients who have had a TIA or ischemic stroke to reduce the risk of stroke.24 The 2008 CHEST guidelines recommend the use of extended-release dipyridamole with aspirin or clopidogrel over aspirin alone in patients who have experienced a non-cardioembolic stroke or TIA for secondary stroke prevention.8,12 A phosphodiesterase inhibitor-based regimen is recommended as first-line therapy in patients who have intermittent claudication and peripheral artery occlusive disease.13 Cilostazol is recommended for patients with moderate-to-severe disabling intermittent claudication who do not respond to exercise therapy, and who are not candidates for surgical or catheterbased intervention.13 Further, the CHEST guidelines recommend against the use of pentoxifylline in such patients with intermittent claudication.13 Herbal Preparations and Natural Medicines Neither the 2008 CHEST guidelines nor the 2006 ACC/AHA guidelines recommend herbal products for the prevention or treatment of thromboembolic disorders. There is no conclusive evidence in the literature to suggest a positive effect of any herbal preparation on patient outcomes related to thromboembolic disorders. There have been reported uses of various herbal product and natural medicines for the prevention and treatment of various thromboembolic complications and risk factors associated with such complications. Specifically, ginger, ginkgo, turmeric, capsaicin alfalfa, anise, bilberry, mesoglycan, gotu kola, nattokinase, pycnogenol, fish oil, sweet orange, glycerol, alpha-GPC, Siberian ginseng, green tea, kudzu, and vinpocetin, among others, have been referenced as having variable effectiveness for thromboembolic disorders ranging from “possibly effective” to “likely ineffective.”28 It is

24

important for the pharmacist to know that herbal products do not undergo the same quality assurance testing procedures and clinical trials as do prescription medications, and the FDA currently has no regulation over the manufacturing of herbal preparations or quality control measures to ensure the presence and quantity of active ingredient.

Drug Interactions Drug interactions associated with antiplatelet medications are centered around an increased risk of bleeding. The use of these drugs with other antiplatelet agents, anticoagulants, or thrombolytics will increase the risk of bleeding.

Pharmacists should be aware of the recent controversy surrounding the drug interaction between clopidogrel and proton pump inhibitors. All proton pump inhibitors (PPIs) are reported to be substrates or inhibitors of CYP2C19, though some PPIs, such as omeprazole, inhibit the enzyme more than others.

The package insert for clopidogrel recommends avoiding concomitant omeprazole and clopidogrel administration and separating administration by 12 hours. Additionally, the package insert recommends considering using another acid reducing agent with less CYP2C19 inhibitory activity.4 To date, there has been no conclusive evidence to support or refute the claim that coadministration of proton pump inhibitors with clopidogrel effects outcomes. The pharmacist should, however, be cognizant of this interaction and advise caution to the patient and the prescriber especially since omeprazole and lansoprazole are available as over the counter medications. Pharmacists are in a position to identify patients who truly need proton pump inhibitors in the ambulatory and community settings and perform effective medication reconciliation on patients in the inpatient setting. Specific drug interactions for all antiplatelet medications can be found in Table 1. When coadministration is unavoidable, patients should be monitored for efficacy of individual

April 2011

medications and for side effects, such as bleeding.

Pause & Reflect: Describe drug interactions for antiplatelet agents.

Conclusion In addition to being knowledgeable about antiplatelet agents, their side effects, monitoring parameters and key patient counseling points, pharmacists should be able to recognize appropriate and inappropriate treatment regimens for the above motioned disease states as well as identify patients at high risk for thromboembolic complications.

Pharmacists can play a key role in screening and identifying patients for modifiable risk factors such as hypertension, smoking, obesity, and hyperlipidemia associated with the acute coronary syndromes, stroke, and peripheral artery occlusive disease.

Pharmacists can also help patients realize the seriousness of medication compliance in helping decrease these risk factors and in treating syndromes associated with thromboembolism.

Facilitating compliance through patient

counseling, encouraging timely refills and helping the patient monitor his/her modifiable risk factors is another important role for the pharmacist.

Additionally, pharmacists are provided with sufficient knowledge and access to patients to recognize the signs and symptoms of a TIA and stroke and refer patients to a medical facility for immediate care. Such screening and triaging skills could save patients lives, improve the outcomes of care and effectively identify patients in need of additional care.

Pause & Reflect: State pertinent patient counseling and education information regarding antiplatelet agents.

References 1. Davi G and Patrono C. Platelet Activation and Atherothrombosis. N Engl J Med. 2007;357(24):2482-2494.

2. Thijs T, Nuyttens BP, Deckmyn H and Broos K. Platelet physiology and antiplatelet agents. Clin Chem Lab Med. 2010;48:S3-S13.

3. Aspirin [package insert]. Morristown, NJ: Bayer Corporation; 1996.

4. Plavix® [package insert]. Bridgewater, NJ: Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership; 2010.

5. Effient® [package insert]. Indianapolis, IN: Daiichi Sankyo, Inc. and Eli Lilly and Company; 2009.

6. Ticlopidine [package insert]. Princeton, NJ: Sandoz Inc.; 2008.

7. Krumholz HM, Radford MJ, Ellerbeck EF, et al.

Aspirin in the treatment of acute myocardial infarction in elderly medicare beneficiaries.

Patterns of use and outcomes. Circulation.

1995;92(10):2841-2847.

8. Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P, American College of Chest Physicians.

Antithrombotic and thrombolytic therapy for ischemic stroke: American college of chest physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6 Suppl):630S-669S. 9. Goodman SG, Menon V, Cannon CP, et al.

Acute ST-segment elevation myocardial infarction: American college of chest physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6 Suppl):708S-775S. 10. Harrington RA, Becker RC, Cannon CP, et al.

Antithrombotic therapy for non-ST-segment elevation acute coronary syndromes: American college of chest physicians evidence-based clinical practice guidelines (8th edition). Chest.

Table 1. Clinically Significant Drug Interactions Medication

Clinically Significant Drug Interactions

Cyclooxygenase (COX) Inhibitors Coadministration with the following will increase the risk of stomach bleeding: anticoagulants, steroids, Aspirin (Bayer , others, other NSAIDs, and 3 or more alcoholic drinks per day.3 Other significant interactions include: valproic with dipyridamole: acid, phenytoin, methotrexate, acetazolamide, heparin, and warfarin24 Aggrenox ) Adenosine Diphosphate (ADP) P2Y12 Receptor Blockers (Thineopyridines) CYP2C19 inhibitors, NSAIDs, warfarin4 clopidogrel (Plavix ) warfarin, NSAIDs4 prasugrel (Effient ) aspirin, NSAIDs, cimetidine, digoxin, theophylline, phenobarbital, phenytoin, propranolol6 ticlopidine (Ticlid ) Glycoprotein (GP) IIb/IIIa Receptor Blockers Coadministration with anticoagulants, thrombolytics and other antiplatelet medications is associated abciximab (ReoPro ) with an increased risk of bleeding.25 heparin, aspirin, warfarin, levothyroxine, omeprazole26 tirofiban (Aggrastat ) Coadministration with thrombolytics, oral anticoagulants, NSAIDs, and dipyridamole could lead to an eptifibatide (Integrilin ) increased risk of bleeding. Eptifibatide should not be used with other GP IIb/IIIa receptor blockers.27 Miscellaneous Agents CYP3A4 and CYP2C19 inhibitors. Caution is advised when using with other antiplatelet medications cilostazol (Pletal ) in patients at risk for bleeding.20 21 24 dipyridamole (Persantine , adenosine, cholinesterase inhibitors with aspirin: Aggrenox ) anticoagulants, antiplatelets, theophylline, antihypertensive medications23 pentoxifylline (Trental )

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2008;133(6 Suppl):670S-707S. 11. Lewis HD, Jr, Davis JW, Archibald DG, et al.

Protective effects of aspirin against acute myocardial infarction and death in men with unstable angina. Results of a veterans administration cooperative study. N Engl J Med. 1983;309(7):396-403.

12. Patrono C, Baigent C, Hirsh J, Roth G, American College of Chest Physicians.

Antiplatelet drugs: American college of chest physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6 Suppl):199S-233S. 13. Sobel M, Verhaeghe R, American College of Chest Physicians, American College of Chest

Physicians. Antithrombotic therapy for peripheral artery occlusive disease: American college of chest physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6 Suppl):815S-843S. 14. Becker RC, Meade TW, Berger PB, et al. The primary and secondary prevention of coronary artery disease: American college of chest physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6 Suppl):776S-814S. 15. Singer DE, Albers GW, Dalen JE, et al.

Antithrombotic therapy in atrial fibrillation: American college of chest physicians evidencebased clinical practice guidelines (8th edition).

Chest. 2008;133(6 Suppl):546S-592S.

16. Mega JL, Close SL, Wiviott SD, et al.

Cytochrome P450 Genetic Polymorphisms and the Response to Prasugrel Relationship to Pharmacokinetic, Pharmacodynamic, and Clinical Outcomes. Circulation. 2009;119:2553-2560.

17. Wiviott SD, Braunwald E, McCabe CH, et al.

Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001-2015.

18. Buonamici P, Marcucci R, Migliorini A, et al.

Impact of platelet reactivity after clopidogrel administration on drug-eluting stent thrombosis. J Am Coll Cardiol. 2007;49(24):2312-2317.

19. Kushner FG, Hand M, Smith SC, Jr, et al. 2009

Table 2. Indication and Evidence-based Dosing Regimens Indication Acute treatment of STEMI in patients to be medically managed (no PCI) Acute treatment of STEMI in patients to have PCI

Acute treatment of non-STEMI in patients to be medically managed (no PCI) Acute treatment of non-STEMI in patients to have PCI

Prophylaxis after stent placement

Acute ischemic stroke (and not receiving thrombolytics) Prophylaxis for patients with a history of non-cardioembolic stroke or TIA Prophylaxis for patients with atrial fibrillation with less than two risk factors Prophylaxis in patients who have stable CAD or ACS and primary prevention in patients with moderate risk Peripheral artery occlusive disease without coronary or cerebrovascular disease Peripheral artery occlusive disease with moderate-to-severe disabling intermittent claudication not responding to exercise therapy, and not a candidate for surgical or catheter-based intervention

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Preferred Treatment and Dosing as per Guidelines aspirin 162-325mg orally, non-enteric formulation WITH oxygen, nitrogen, anticoagulant and morphine WITH 300-600mg oral loading dose clopidogrel +/thrombolytic (depending on timing of symptoms)9,14,19 aspirin 162-325mg orally, non-enteric formulation WITH oxygen, nitrogen, anticoagulant, morphine and abciximab 0.25mg/kg IV bolus followed by a 12-hour infusion at a rate of 10 mcg/min and WITH 300-600mg oral loading dose clopidogrel OR 60mg oral loading dose prasugrel9,14,19 aspirin 162-325mg orally, non-enteric formulation WITH oxygen, nitrogen, anticoagulant and morphine +/- eptifibatide or tirofiban WITH 300-600mg oral loading dose clopidogrel10,14 aspirin 162-325mg orally, non-enteric formulation WITH oxygen, nitrogen, anticoagulant, morphine and abciximab 0.25mg/kg IV bolus followed by a 12-hour infusion at a rate of 10 mcg/min and OR eptifibatide as a double IV bolus (each 180 mcg/kg, given 10 min apart) followed by an 18-hour infusion of 2 mcg/kg/min WITH 300-600mg oral loading dose clopidogrel OR 60mg oral loading dose prasugrel10,14 aspirin 325mg by mouth daily x 3 months then 81mg by mouth daily, indefinitely WITH clopidogrel 75mg by mouth daily OR prasugrel 10mg by mouth daily; thienopyridine duration for 9-12 months or indefinitely in patients who have adverse effects to aspirin9,10,14,19 aspirin 162-325mg by mouth, non-enteric formulation8 aspirin in combination with extended release dipyridamole 25/200mg by mouth twice daily OR clopidogrel 75mg by mouth daily8 aspirin 81-325mg by mouth daily15 aspirin 81mg by mouth daily, indefinitely14

aspirin 81mg by mouth daily, indefinitely OR clopidogrel 75mg by mouth daily, indefinitely in patients who have adverse effects to aspirin13 cilostazol 100mg by mouth twice daily13

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Table 3. Abbreviations Abbreviation ACS ADP ALT AST cAMP COX CYP450 EC ECG GGT GI GP HACA INR MI Non-STEMI PAD PAF PCI PPIs STEMI TIA TIMI

Definition Acute coronary syndromes Adenosine diphosphate Alanine aminotransferase Aspartate aminotransferase Cyclic adenosine monophosphate Cyclooxygenase Cytochrome P450 Enteric coated Electrocardiogram Gamma glutamyl transpeptidase Gastrointestinal Glycoprotein Human anti-chimeric antibodies International normalized ratio Myocardial infarction Non-ST elevated myocardial infarction Peripheral artery disease (also called peripheral artery occlusive disease) Platelet activating factor Percutaneous coronary intervention Proton pump inhibitors ST-elevated myocardial infarction Transient ischemic attack Thrombolysis in myocardial infarction

focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the american college of cardiology Foundation/American heart association task force on practice guidelines. J Am Coll Cardiol.

2009;54(23):2205-2241.

23. Pentoxifylline [package insert]. Sellersville, PA: TEVA Pharmaceuticals USA; 2006.

20. Cilostazol [package insert]. Boca Raton, FL: Breckenridge Pharmaceutical, Inc.; 2009.

24. Aggrenox速 [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; 2009.

21. Dipyridamole [package insert]. Princeton, NJ: Zydus Pharmaceuticals USA Inc.; 2009.

25. ReoPro速 [package insert]. Indianapolis, IN: Eli Lilly and Company; 2005.

22. Gamboa A, Abraham R, Diedrich A, et al. Role of adenosine and nitric oxide on the mechanisms of action of dipyridamole. Stroke.

2005;36(10):2170-2175.

26. Aggrastat速 [package insert]. Somerset, NJ: Medicure Pharma Inc.; 2007.

27. Integrilin速 [package insert]. Kenilworth, NJ: Schering-Plough; 2009.

28. Natural Medicines Comprehensive Database [Internet Database]. Stockton, CA: Therapeutic Research Faculty. Updated (periodically).

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Continuing Education for Pharmacists Quiz and Evaluation Update on Antiplatelets 1. ________ is/are indicated in the acute treatment of STEMI in patients who are not going to receive a PCI and will be medically managed. a. clopidogrel b. prasugrel c. ticlopidine d. clopidogrel and prasugrel

6. Clopidogrel is a _____ and is activated by _________.

This is the source of the main drug interaction with proton pump inhibitors associated with clopidogrel. a. prodrug, cytochrome P450 enzymes b. prodrug, plasma esterases c. P2Y12 ADP receptor blocker, the presence of adenosine diphosphate d. P2Y12 ADP receptor blocker, stomach acid

2. Overall, what is the main adverse effect of antiplatelet medications? a. gastrointestinal distress b. thrombocytopenia c. increased risk of bleeding d. increased risk of thromboembolic complications

7. Dosing for all GPIIb/IIIa receptor blockers: a. is renally adjusted b. does not require a bolus c. is adjusted for those with hepatic impairment d. is weight based 8. The correct acute treatment dose of aspirin for an ACS or an ischemic stroke is: a. 81mg by mouth b. 162mg by mouth c. 325mg EC by mouth d. All of the above are acceptable regimens.

3. Which of the following patients would be the best candidate for aspirin antiplatelet therapy? A patient who a. Has a standing history of atrial fibrillation with diabetes and hypertension b. Recently received a stent placement who is also on clopidogrel c. Has mild peripheral artery occlusive disease with a history of peptic ulcer disease d. Is having an acute ischemic stroke and is to receive thrombolytics

9. What is the preferred thromboembolic prophylaxis agent and duration of treatment in patients who have adverse effects to aspirin and who also have a history of ACS and PCI who received a stent? a. prasugrel 10mg or clopidogrel 75mg by mouth daily for 9-12 months b. prasugrel 10mg or clopidogrel 75mg by mouth daily, indefinitely c. cilostazol 100mg by mouth twice daily for 9-12 months d. aspirin 81mg EC by mouth daily, indefinitely

4. _________ is indicated and recommended according to the guidelines for the treatment of mild, asymptomatic peripheral artery occlusive disease in patients without coronary or cerebrovascular disease. a. a phosphodiesterase inhibitor b. a COX inhibitor c. a GP IIb/IIIa receptor blocker d. all of the above

10. Patients receiving aspirin should be counseled about the signs and symptoms of gastrointestinal bleed. These include: a. heartburn, nausea, vomiting, headache, tachycardia b. black or tarry stools, vomiting, heartburn, stomach pain, nausea c. nausea, headache, black or tarry stools, bradycardia, vision disturbances d. vomiting, heartburn, stomach pain, nausea, pallor

5. Patients who are dispensed cilostazol, pentoxifylline or dipyridamole should be counseled on adverse effects related to: a. hearing loss/tinnitus b. thrombocytopenia c. nephrotoxicity d. gastrointestinal distress

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Journal CPE Answer Sheet The Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. No financial support was received for this activity.

Update on Antiplatelets This lesson is a knowledge-based CPE activity and is targeted to pharmacists.

GPhA code: J11-4 ACPE#: 0142-0000-11-004-H01-P Contact Hours: 1.0 (0.10 CEU) Release Date: 04/01/2011 Expiration Date: 04/01/2013 1. Select one correct answer per question and circle the appropriate letter below using blue or black ink (no red ink or pencil.)

2. Members submit $4.00, Non-members must include $10.00 to cover the cost of grading and issuing statements of credit/ Please send check or money order only. Note: GPhA members will receive priority in processing CE. Statements of credit for GPhA members will be emailed or mailed within four weeks of receipt of the course quiz.

1. A B C D 2. A B C D 3. A B C D 4. A B C D 5. A B C D

6. A B C D 7. A B C D 8. A B C D 9. A B C D 10. A B C D

Activity Evaluation: must be completed for credit Please rate the following items on a scale from 1 (poor) to 5 (excellent)as to how well the activity: 1. Relates to pharmacy practice: 1 2 3 4 2. Met my educational needs: 1 2 3 4 3. Achieves the stated learning objectives: 1 2 3 4 4. Faculty presented the information: 1 2 3 4 5. Made use of the educational material (article): 1 2 3 4 6. Teaching methods conveyed information (tables, figures, boxes): 1 2 3 4 7. Post-test aided in assessing my grasp of the information: 1 2 3 4 8. Met my expectations: 1 2 3 4 9. Avoided any bias: 1 2 3 4 10. How long did it take to complete this activity? _______________________

5 5 5 5 5 5 5 5 5

A passing grade of 70% is required for each examination. A person who fails the exam may resubmit the quiz only once at no additional charge.

Please check here if you are indicating a change of address ___ Phone #: _______________________________ Name: ____________________________________________________________________________ License Number(s) and State(s): ___________________ Email Address: ___________________________ Address: __________________________________________________________________________ City: _________________ State: __________ Zip: __________ Remove this page from the Journal and mail this completed quiz and evaluation to: GPhA, 50 Lenox Pointe NE, Atlanta, GA 30324.

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2011 Spring Region Meetings: GPhA’s Legislative Update Program For more details about these events and to register please visit www.gpha.org or call 404-231-5074. If you have questions about an event and its time or location that is not listed, please contact the Region President.

Region 1: April 19, 2011 Carey Hilliards Banquet Room/Restaurant 6:30 p.m. Dinner & 7:30 p.m. CPE Heather DeBellis, Region President (865) 803-7833/hdebellis@southuniversity.edu Speakers: Dale Coker, GPhA President & Jim Bracewell, GPhA EVP/CEO

Region 7: April 19, 2011 Adairsville Inn Restaurant, Adairsville 6:00 p.m. Networking, 7:00 p.m. Dinner & 8:00 p.m. CPE Mike Crooks, Region President (404) 825-9042/mikecrooks.rx@gmail.com Speakers: Jack Dunn, GPhA Presiden Elect & Pam Marquess, GPhA Second Vice President

Region 2: April 21, 2011 Spring Hill Country Club, Tifton 7:00 p.m. Dinner & 8:00 p.m. CPE Members: $10 & Potential Members: $15 Fred Sharpe, Region President (229) 888-1210/fsharpe@u-save-it.com Speakers: Robert Hatton, GPhA First Vice President & Eddie Madden, GPhA Chairman of the Board

Region 8: April 12, 2011 Old Holiday Inn, Waycross 7:00 p.m. Networking, 8:00 p.m. Dinner & 9:00 p.m. CPE Members: $10 & Potential Members: $12 Larry Batten, Region President (912) 449-3201/battenrx@yahoo.com Speakers: Robert Hatton, GPhA First Vice President & Jim Bracewell, GPhA EVP/CEO

Region 3: April 12, 2011 Columbus Regional Health System Confernce Center 6:30 p.m. Dinner & 7:30 p.m. CPE John Drew, Region President (706) 323-5461/rxdrew@yahoo.com Speakers: Pam Marquess, GPhA Second Vice President & Jack Dunn, GPhA President-Elect

Region 9: April 12, 2011 Woodbridge Inn, Jasper 7:00 p.m. Dinner & 8:00 p.m. CPE Cost will be no more than $20 per person.

David Gamadanis, Region President (770) 926-3210/dgamadanis@yahoo.com Speakers: Dale Coker, GPhA President & Eddie Madden, GPhA Chairman of the Board

Region 4: April 26, 2011 Eagles Landing Country Club, Stockbridge 6:00 p.m. Networking, 6:30 p.m. Dinner & 7:00 p.m. CPE Amanda Gaddy, Region President (770) 389-1426/amandagaddy@charter.net Speakers: Pam Marquess, GPhA Second Vice President & Jim Bracewell, GPhA EVP/CEO

Region 10: April 26, 2011 Logan’s Roadhouse, Athens 6:30 p.m Networking, 7:00 p.m. Dinner & 8:00 p.m. CPE Chris Thurmond, Region President (706) 548-0205/vildrug@bellsouth.net Speakers: Jack Dunn, GPhA President Elect & Eddie Madden, GPhA Chairman of the Board

Region 5: April 21, 2011 Aldo’s Italian Restaurant, Tucker 6:00 p.m. Networking, 6:30 p.m. Dinner & 7:45 p.m. CPE Shobhna Butler, Region President (770) 317-8232/sdbutler@b-wellness.com Speakers: Dale Coker, GPhA President & Jack Dunn, GPhA President-Elect

Region 11: April 21, 2011 Bonefish Grill, Augusta 6:30 p.m. Networking, 7:00 p.m. Dinner & 8:00 p.m. CPE Marshall Frost, Region President (706) 678-5764/mfrost@longsrx.com Speakers: Pam Marquess, GPhA Second Vice President & Jim Bracewell, GPhA EVP/CEO

Region 6: April 26, 2011 Healy Point Country Club, Macon Networking 6:30 p.m., 7:00 p.m. Dinner & 8:00 p.m. CPE Ashley Faulk, Region President (706) 714-1620/ashleyfaulk@yahoo.com Speakers: Dale Coker, GPhA President & Jim Bracewell, GPhA EVP/CEO

Region 12: April 19, 2011 Deano’s Italian Restaurant, Dublin 6:30 p.m. Dinner & 7:30 p.m. CPE Ken Eiland, Region President (478) 275-8648/Kenton.eiland@va.gov Speakers: Robert Hatton, GPhA First Vice President & Eddie Madden, GPhA Chairman of the Board

The Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

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2010 - 2011 GPhA BOARD OF DIRECTORS

The Georgia Pharmacy Journal Editor:

Jim Bracewell jbracewell@gpha.org

Managing Editor & Designer:

Kelly McLendon kmclendon@gpha.org

The Georgia Pharmacy Journal® (GPJ) is the official publication of the Georgia Pharmacy Association, Inc. (GPhA). Copyright © 2011, Georgia Pharmacy Association, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including by photocopy, recording or information storage retrieval systems, without prior written permission from the publisher and managing editor.

All views expressed in bylined articles are the opinions of the author and do not necessarily express the views or policies of the editors, officers or members of the Georgia Pharmacy Association.

ARTICLES AND ARTWORK Those who are interested in writing for this publication are encouraged to request the official GPJ Guidelines for Writers. Artists or photographers wishing to submit artwork for use on the cover should call, write or e-mail the editorial offices as listed above.

SUBSCRIPTIONS AND CHANGE OF ADDRESS The Georgia Pharmacy Journal® (GPJ) (ISSN 1075-6965) is distributed as a regular membership service, paid for through allocation of membership dues. Subscription rate for non-members is $50.00 per year domestic and $10.00 per single copy; international rates $65.00 per year and $20.00 single copy. Subscriptions are not available for non-GPhA member pharmacists licensed and practicing in Georgia.

The Georgia Pharmacy Journal® (GPJ) (ISSN 1075-6965) is published monthly by the GPhA, 50 Lenox Pointe NE, Atlanta, GA 30324.

Periodicals postage paid at Atlanta, GA and additional offices.

POSTMASTER: Send address changes to The Georgia Pharmacy Journal®, 50 Lenox Pointe, NE, Atlanta, GA 30324.

ADVERTISING Advertising copy deadline and rates are available at www.gpha.org upon request. All advertising and production orders should be sent to the GPhA headquarters as listed above.

GPHA HEADQUARTERS 50 Lenox Pointe, NE Atlanta, Georgia 30324 Office: 404.231.5074 Fax: 404.237.8435

Position

Eddie Madden Dale Coker Jack Dunn Robert Hatton Pamala Marquess Jim Bracewell Hugh Chancy Robert Bowles Keith Herist Jonathan Marquess Sharon Sherrer Liza Chapman Mary Meredith Heather DeBellis Fred Sharpe John Drew Amanda Gaddy Shobhna Butler Ashley Faulk Mike Crooks Larry Batten David Gamadanis Chris Thurmond Marshall Frost Ken Eiland Renee Adamson Josh Kinsey Don Davis Ira Katz DeAnna Flores Lance Faglie John T. Sherrer Michael Farmer Steve Wilson

Chairman of the Board President President-Elect First Vice President Second Vice President Executive Vice President/CEO State-at-Large State-at-Large State-at-Large State-at-Large State-at-Large State-at-Large State-at-Large Region One President Region Two President Region Three President Region Four President Region Five President Region Six President Region Seven President Region Eight President Region Nine President Region Ten President Region Eleven President Region Twelve President ACP Chairman AEP Chairman AHP Chairman AIP Chairman APT Chairman ASA Chairman Foundation Chairman Insurance Trust Chairman Ex Officio - President, GA Board of Pharmacy Ex Officio - Chairman, GSHP Ex Officio Mercer Ex Officio Mercer ASP Ex Officio South Ex Officio South ASP Ex Officio UGA Ex Officio UGA ASP

Sonny Rader Gina Ryan Johnson Jill Augustine Rusty Fetterman Olivia Santoso Sukh Sarao David Bray

www.gpha.org

Print: Star Printing - 770.974.6195

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