7KH 2I¿FLDO 3XEOLFDWLRQ RI WKH *HRUJLD 3KDUPDF\ $VVRFLDWLRQ
0DUFK
GPhA 2011 Convention Omni Amelia Island Plantation June 18-22, 2011 9ROXPH 1XPEHU ZZZ JSKD RUJ
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
2
March 2011
13
Departments
GPhA 2011 Convention Omni Amelia Island Plantation June 18-22, 2011 FEATURE ARTICLES
5 14 19 30
6 8 11 12 31
GPhA Member News Pharm PAC 2010-2011 APhA Programs Information GPhA New Members GPhA Board of Directors
Advertisers
GPhA Moves to Online Voting Pharmacy Loses a Legal Advocate: Alvin Leroy Toliver Passes Away Continuing Education for Pharmacists: Hypertension Therapy Update
2 2 6 7 9 9 9 10 12 15 16 17 27 32
The Insurance Trust Principal Financial Group Pharmacy Quality Commitment PharmAssist Recovery Network Logix, Inc. Michael T. Tarrant Toliver & Gainer Pharmacists Mutual Companies Melvin Goldstein, P.C. GPhA Career Center GPhA Workers Compensation AIP Caribbean CPE Cruise 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
3
March 2011
PRESIDENT’S MESSAGE Dale M. Coker, R.Ph., FIACP GPhA President
The Art of Possibility dispenser of medications. Being proactive always points to possibility.
an you imagine going to your first day of class in Pharmacology and your professor assigns an “A” grade to you and everyone else in the class before taking your first note? I made a few “A” grades in pharmacy school, but don’t ever remember getting an “A” before earning it. Well, that is exactly what Boston Philharmonic Orchestra conductor Benjamin Zander does. Why would he do such a thing and what would this have to do with the pharmacy profession, anyway?
C
Zander also made reference to the “out of box thinking” buzz words. Everyone seems to want it, but how do you attain it? Zander’s response, “It’s very simple. You ask a question: What assumptions am I making that I don’t know I’m making?” He also went on to say that everyone in an organization, from top to bottom, should be able to speak about assumptions without fearing loss of any kind. There have to be watch dogs in every organization to voice those assumptions.
Jim Bracewell shared an article with the GPhA Executive Committee a few months ago concerning the aforementioned orchestra conductor. I read it and it made an impression, but as often happens in our fast paced world and self inflicted business, it got buried in a stack of papers. While searching for a topic to write about this month, I started sifting through the reams of materials Bracewell throws at us each month to see if he had given us anything worth sharing (just kidding, Jim), when I ran across the article again.
Now about getting an “A” grade before “deserving” it. It is all about expectations. With Zander’s students, he expects and assumes excellence. When his students make a mistake, his response: “How fantastic!” His point: every setback is an opportunity to learn. Every setback represents a world of possibility. You see, giving an “A” at the beginning sets a standard that every student will naturally strive to maintain, and even exceed. I think that too often we settle for mediocrity in our personal and professional lives simply because our own assumptions and expectations aren’t based on a standard of excellence.
To make a long story short, Zander conducted with a dictatorship style, as does every other orchestra conductor. That dictatorship style carried over in his personal life and cost him two marriages. When he separated from his second wife, a soul searching process began that led to a life changing shift. He and the second wife entered into a creative partnership and wrote a book together about strategies for attaining positive change, THE ART OF POSSIBILITY.
As my good friend, Robert C. Bowles Jr. R.Ph., CDM, CFts, has always reminded me, “You have to learn to ask the right questions.” When problems and challenges arise, the right question becomes, “What are you going to do now?” We can choose possibility or we can react with anger and resignation. Possibility always wins in the end. Under the direction of Jim Bracewell, this organization has been, and will continue, on the path of possibility. Keep our feet to the fire. Ask the right questions. Question the assumptions. Above all, stay involved, stay engaged, stay informed and keep your leadership accountable for leading your profession and your association in the right direction.
When it comes to problem solving and leadership, Zander emphasizes that everyone has options. “You can face problems with resignation, anger or possibility.” I remember when the notion of medication therapy management (MTM) was first introduced. For various reasons, many pharmacists, including yours truly, looked at this initiative with resignation. Contrast that with those pharmacists who had the courage to look at it as a possibility. Those pharmacists are the ones who are benefiting and exploring even more possibilities that help cement pharmacy’s role as a health care provider rather than a
The Georgia Pharmacy Journal
4
March 2011
GPHA NEWS
GPhA Changes its Election Process: Important Date Changes for 2011 Election
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.
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 post-marked no later than midnight June 10, 2011, in order to allow for pick up, ballot security and counting.
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 404-4198115, 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.
The Georgia Pharmacy Journal
If you have any questions about the election process please contact Maggie Patterson at mpatterson@gpha.org or 404-419-8120. 5
March 2011
GPhA MEMBER NEWS In August of 2010, Lee J. Dunn, Sr., R.Ph., Lee Jack Dunn, Jr., R.Ph., and Brent Dunn, were spotlighted in the Pickens County Progress for soon being able to boast of three generations of pharmacists. The senior Dunn bought Jasper Drugs & Gifts 60 years ago. Jack, his son and GPhA President-Elect, is now the owner of the pharmacy and in 2014 Brent Dunn will graduate from Mercer University with his pharmacy degree. In November 2010, Jasper Drugs & Gifts was named the Business of the Month for the Pickens County Chamber of Commerce. The pharmacy was also featured in the APPALACHIAN COUNTRY MAGAZINE. Melody C. Sheffield, B.S., Pharm.D., Public Service Associate at The University of Georgia College of Pharmacy, received the credential
Board Certified Pharmacotherapy Specialist (BCPS).
HIV Medicine in their credentialing program.
Deanna “Dee Dee” Whiten McEwen, Pharm.D., Public Service Assistant at The University of Georgia College of Pharmacy, received a mini-grant from the UGA Office of Service Learning to implement a smoking cessation program for UGA employees.
Drew A. Pyrz, R.Ph., owner of Cairo’s Center Drugs, was named the 2011 Young Professional of the Year for the Cairo-Grady County Chamber of Commerce.
Keith Nicholas Heristm, Pharm.D., AAHIVE, CPA, Clinical Associate Professor, authored “Financial Analysis in Pharmacy Practice,” which has been accepted for publication by the PHARMACEUTICAL PRESS in London to be released in the spring of 2011 in the U.S., co-authored with Matt Perrri and Brent Rollins. Herist also recently re-certified as an AAHIV Expert for another two-year period with the American Academy of
William A. “Tony” Moye, R.Ph., the founder of Moye’s Pharmacy, was appointed to the Georgia State Board of Pharmacy by former Governor Sonny Perdue on August 4, 2010. He is a University of West Georgia Foundation trustee and Mercer University trustee. He serves on the board of United Community Bank in Henry County. He is past chair of the Henry County Chamber of Commerce and past Henry County Citizen of the Year. Moye earned a bachelor’s degree from University of West Georgia and a pharmacy degree from Mercer University.
“We implemented PQC in our pharmacy four months ago – it was easy. I have noticed an enhanced effort from the staff to work together to avoid and eliminate quality-related events.” Pharmacy Quality Commitment® (PQC) is what you need! PQC is a continuous quality improvement (CQI) program that supports you in responding to issues with provider network contracts, Medicare Part D requirements under federal law, and mandates for CQI programs under state law. When PQC is implemented in your pharmacy, you will immediately improve your ability to assure quality and increase patient safety. Do you have a CQI program in place?
Call toll free (866) 365-7472 or go to www.pqc.net for more information. PQC is brought to you by your state pharmacy association.
EXECUTIVE VICE PRESIDENT’S EDITORIAL Jim Bracewell Executive Vice President / CEO
Improving Your Profession
f you could do one thing to improve the profession of pharmacy, would you?
runway? Where the roar of the engines of engaged professionals can take pharmacy to a new destination as the premier provider of managed medication therapy healthcare that we know is the critical answer to escalating costs and failed outcomes of treatment.
I
I bet each pharmacist reading that question immediately responded, “Yes, of course I would”…but would you?
If you could do one thing to improve the profession of pharmacy, would you? Then think about the possibility of pharmacists really engaged in the control of the profession of pharmacy and ask the very next pharmacist you see to join you in the creating the future for your profession at GPhA for less that the cost of a cup of coffee.
In Georgia, less than one pharmacist in five is a member of their professional association. So what is my point? Well, if an individual who spends several years in study, thousands of dollars for tuition, and hundreds hours to earn a degree in pharmacy will not spend $14.58 per month or less than 50 cents a day to belong to the state group whose sole purpose is to advocate to improve their profession, then would they really do just one thing to improve the profession of pharmacy?
PharmAssist Recovery Network The PharmAssist Network continues to provide advocacy, intervention and assistance to the impaired practitioners, students and technicians in the state. If you or anyone you know needs assistance, please call the hotline number:
Now that I have put a big load of guilt on all of the pharmacists who are taking a free ride on the profession, let me suggest, to the one in five who are members of the GPhA, that you ought to do one more thing. You should invite a colleague to join your association. What is the possibility that you could tow a Boeing 747 across a runway at Hartsfield-Jackson International Airport? Not much of a chance by yourself, but if you got a few friends to join you with each just pulling a little then it becomes a very easy task. Many charitable groups have done just that over and over raising funds for a worthy cause. Would you like to see the Boeing 747 of pharmacy move forward? What is the possibility that the profession of pharmacy could seize this new day in healthcare as our society and government come to grips with implementing broad new healthcare benefits and perhaps universal coverage?
PharmAssist Hotline Number (24 hours / 7 days a week)
Are you, the committed members of the profession, going to let our plane sit at the gate or are you going to reach out? Are you willing to ask one friend, or one colleague, with a sincere invitation to join us and move that pharmacy plane to the
The Georgia Pharmacy Journal
404-362-8185 (All calls are confidential) 7
March 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.
Alan M. Voges, Sr., R.Ph. Flynn W. Warren, M.S., R.Ph. Oliver C. Whipple, R.Ph. Walter Alan White, R.Ph.
Bronze Level ($150 minimum pledge)
Gold Level ($600 minimum pledge) 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. 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
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. Charles Lott, 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.
Members (no 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. Michael O. Iteogu, Pharm.D. Willie O. Latch, R.Ph. William J. McLeer, Sr., R.Ph. Kalen Beauchamp Porter, Pharm.D. Edward Franklin Reynolds, R.Ph. James Thomas, R.Ph. Brandon Ullrich
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. 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 Carey B. Jones, 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
8
March 2011
Pharm PAC Contributors’ List Continued Joshua Kinsey, Pharm.D. Ashley S. London 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.
Questioning the wisdom of your financial plan? If so, this ad entitles you to:
A cup of coffee, and a second opinion.
Lawyer and Pharmacist
You’re welcome to schedule a time to come in or talk via conference call about your financial goals and what your portfolio is intended to do for you and your family. I’ll review it with you and give you my opinion – without obligation.
Leroy Toliver, Pharm.D., R.Ph., J.D. • Professional Licensure Disciplinary Proceedings • Medicaid Recoupment Defense • Challenges in Medicaid Audits • OIG List Problems • SCX or Other Audits
Either way, the coffee is on me.
Michael T. Tarrant
Leroy Toliver has been a Georgia Registered Pharmacist for 38 years. He has been a practicing attorney for 29 years and has represented numerous pharmacists and pharmacies in all types of cases. Collectively, he has saved his clients millions of dollars.
Financial Network Associates 1117 Perimeter Center West, Suite N-307 Atlanta, GA 30338 • 770-350-2455 mike@fnaplanners.com www.fnaplanners.com i An Independent Financial Planner since 1992 Focusing on Pharmacy since 2002 i
Toliver and Gainer, LLP
Securities, certain advisory services and insurance products are offered through INVEST Financial Corporation (INVEST), member FINRA/SIPC, a federally registered Investment Adviser, and affiliated insurance agencies. INVEST is not affiliated with Financial Network Associates, Inc. Other advisory services may be offered through Financial Network Associates, Inc., a registered investment adviser.
The Georgia Pharmacy Journal
942 Green Street, SW Conyers, GA 30012-5310 altoliver@aol.com 770.929.3100
9
March 2011
Endorsed by:**
Guarantee a better
Q Quality y of Life ffor yyour fa family. family.
Life Ins Insurance surance can provide p for your your loved l d ones by: b
3URYLGLQJ FRYHUD DJH IRU ÀQDO PHGLF FDO DQG IXQHUDO H[S SHQVHV ͻ 3URYLGLQJ FRYHUDJH IRU ÀQDO PHGLFDO DQG IXQHUDO H[SHQVHV ͻ outstand ding debts ͻ ͻ Paying outstanding esta ate for those you care car c e about ͻ ͻ Creating an estate colleg ge funding ͻ ͻ Providing college
Life insu insurance urance solutio solutions ons fr from om Thee Pharmacistss Life Insurance Insuranc ce Company. Company. For F o r more more information, inf o r mat io n, contact co n tac t your yo ur local lo cal representative: re p re s e n t a t i v e :
Hutton H utton Madden Madden 800.247.5930 8 00.247.5930 eext. xt . 77149 149 678.714.9198 678.714.9198 www.phmic.com w w w.p h mi c. co m * This is not a claims ms reporting site. You cannot electronically electronica ally report a claim to us. To report a claim, call 800.247.5930. 247.5930. ** Compensated endorsement. e Not all products available a in every state. The Pharmacists Pharmacissts Life is licensed in the District of Columbia and al allll states except AK, FL, HI, MA, ME, NH, NJ, NY and VT. Check with your representative or the company for details on coverages and carriers. *
32 %R[ $OJRQD ,RZD 32 %R[ $OJRQD , RZD
APhA Certification Course in Pharmacy-Based Immunization Delivery Saturday, May 07, 2011 (8:00 AM - 6:00 PM) Hilton Garden Inn / Macon / Mercer University 1220 Stadium Drive Macon, GA 31204 For more details and to register online today visit www.gpha.org or call 404-231-5074. Deadline to register is April 15, 2011. The APhA training program requires participants to be certified in Basic Life Support for Health Care Providers. Cost: Member: $400 Potential Member: $495 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.
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.
The Georgia Pharmacy Journal
11
March 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 Simone E. Afamefuna, Lawrenceville Nicole E. Phipps, Winder Nelvin Daniel, Atlanta Shahrouz Dehgahi, Norcross Maryam Nourbakhsh, Dawsonville Mary Ann Bousquette, Douglasville Bhumika S. Dhanani, Lawrenceville Brittany R. Hearon, Lawrenceville Ashley M. Williams, Lilburn Natasha Guerrier, Lawrenceville Abdullah Katoot, Roswell Sharon Crowe, Lawrenceville David H. Jones, Statesboro Rich Crumpton, Athens Josh L. McCook, Statesboro Khanh Ta, Suwanee
.FMWJO . (PMETUFJO 1 $ " 5 5 0 3 / &@@@ : "5 - "8
New Graduate Pharmacist Members Courtney Mays, Atlanta Trey Williams, Norcross
3PTXFMM 4USFFU .BSJFUUB (FPSHJB 5FMFQIPOF 'BY XXX NFMWJONHPMETUFJO DPN
Individual Pharmacist Members
„ 1SJWBUF QSBDUJUJPOFS XJUI BO FNQIBTJT PO SFQSFTFOUJOH IFBMUIDBSF QSPGFTTJPOBMT JO BENJOJTUSBUJWF DBTFT BT XFMM BT PUIFS MFHBM NBUUFST
Wilburn W. Simpson, R.Ph., Kathleen Ronaldo Morales, Ellijay
Technician Membership
Associate Membership
„ 'PSNFS "TTJTUBOU "UUPSOFZ (FOFSBM GPS UIF 4UBUF PG (FPSHJB BOE $PVOTFM GPS QSPGFTTJPOBM MJDFOTJOH CPBSET JODMVEJOH UIF (FPSHJB #PBSE PG 1IBSNBDZ BOE UIF (FPSHJB %SVHT BOE /BSDPUJDT "HFODZ
Paula L. Coorlin, Dunwoody Robert A. Keiser, Marietta
„ 'PSNFS "ENJOJTUSBUJWF -BX +VEHF GPS UIF 0GGJDF PG 4UBUF "ENJOJTUSBUJWF )FBSJOHT
Amy Q. Flournoy, CPhT, Marietta Susan E. Hester, CPhT, Marietta
The Georgia Pharmacy Journal
12
March 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
13
March 2011
GPhA MEMBER NEWS
Pharmacy Loses a Legal Advocate: Alvin Leroy Toliver Passes Away
lvin Leroy Toliver (Bugsy), died early in the morning on February 5, 2011. A funeral service was held on Tuesday, February 8, 2011, at 11:00 a.m. at Sugarloaf United Methodist Church.
A
While his immediate family benefited most from his Christ-like love, enduring patience, and tireless work to provide not only love, guidance, and support but also countless and often lavish material gifts, all who knew him can attest to his kindness and generosity. He led by example showing his children what happiness and marriage can be through the constant love he showed his wife, Linda. He inspired his children not only to succeed in their education and chosen careers, but made sure they enjoyed the journey to its fullest by entertaining their friends, supplying inexhaustible funds, and giving incredible gifts all along the way - even when it meant forgoing those things himself. His family will always remember hugs and kisses warmly given, songs sung in perfect tune but with none of the right words, wise guidance carefully offered, patience eternally portrayed, and Christmas mornings ridiculously overdone. All who knew him can remember untold parties hosted, tenderloins roasted, and beverages poured. His law partners and co-workers at Toliver & Gainer, fellow GPhA pharmacists, professional colleagues and clients throughout the country, and fellow Mercer students - both those he taught and those he learned with - will remember his knowledge, skill and expertise in his chosen crafts of pharmacy and law, whether from late night phone calls to resolve a professional crisis, jury arguments seeking to right wrongs, or lectures to teach others similar skills and expertise. Leroy now joins his mother, Marie Toliver and brother, Michael Toliver. His dad Leroy, wife Linda, brother Rick, children Jamie, Adam, Buddy and Stacie, and grandchildren Ashlyn, Ella, Spencer, Seth, Tarin and Chase will carry his memory forward. Contributions can be made in Leroy's honor at Mercer University Pharmacy School Scholarship or Sugarloaf United Methodist Church.
The Georgia Pharmacy Journal
14
March 2011
SUPPORTING PHARMACISTS. ADVANCING CAREERS. Find the best jobs and highly qualified pharmacists Georgia has to offer.
Members Save 20% on Job Postings Use code MEMDIS001
Career Center
www.gpha.org/jobs
Trevor Miller, Director of The Insurance Trust 404-419-8173 or tmiller@gpha.org
&
! "#!$" % '( (
!
"" $ %
! $ ! 0
! $
#
$
!
&
'#()*" '(+ '
) ' ,-.
' ) ') ! 1 ! ././0.
! $ !
2
)#..-'
(" /"#+' '
!
1
1
)3+-. '#()*" '(+ '
4 5 6 676 879
#(.#; ), %.0'+ . " %%%
1
)
' ,-.
(" /"#+' '
0 : ! (" )
)
/) . +
) " -
. +'
" +)
Continuing Education for Pharmacists Hypertension Therapy Update “Hypertension Therapy Update� is the first in a series of continuing education articles authored and generously contributed to the Tennessee Pharmacists Association by: Condit F. Steil, Pharm.D., CDE; Professor and Chair, Pharmacy Practice Department, School of Pharmacy, Gordon E. Inman College of Health Sciences and Nursing, Belmont University Reprinted with permission of the authors and the Tennessee Pharmacists Association where this article originally appeared. This activity may appear in other state pharmacy association journals.
Goal The goal of this lesson is to discuss hypertension and its medical management.
Objectives At the conclusion of this lesson, successful participants should be able to: 1. list goals for hypertension control; 2. chart categories of drug therapy available for hypertension treatment; 3. describe the use of each agent, dosing, and monitoring guideline; and 4. forecast potential direction for future hypertension therapy plans. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7 Report) identifies evidence-based treatment steps for the management of hypertension. Blood pressure has been classified into 4 stages; normal (<120/80 mm Hg), prehypertension (120-139/80-89 mm Hg), stage 1 hypertension (140-159/90-99 mm Hg), and stage 2 hypertension (>160/>100 mm Hg). Diagnosis and classification of hypertension are determined from the average of 2 blood pressure readings obtained from 2 separate clinic visits; it is measured with the patient in a seated The Georgia Pharmacy Journal
position, after at least a 5 minute rest. According to JNC-7 guidelines, the blood pressure goal in hypertensive patients without diabetes or any additional compelling conditions is less than 140 mm Hg systolic and less than 90 mm Hg diastolic, or less than 130 mm Hg systolic and less than 80 mm Hg diastolic in patients with diabetes or chronic kidney disease. Depending on the presence of other comorbid conditions, the individualized goal may be lower. Treatment plans for hypertension have evolved to include combination therapy that targets different mechanisms to obtain optimal levels in blood pressure and possibly limit side effects. Although the JNC-7 is the most recent report of recommendations, it was released in 2003, and new products and clinical evidence indicate some change will occur with the next review, the JNC-8. The indication from the Joint National Committee website (www.nhlbi.nih.gov/guidelines /hypertension/) is that the JNC-8 will not be released until 2011. One possible direction for the next review may be to recommend combination antihypertensive therapies very early in the treatment plan for a patient with high blood pressure, rather than maximizing the dose of one drug at a 19
time. The role of diuresis, and thiazide diuretics specifically, continues to be a topic of debate with each set of new guidelines. Diuretics improve the efficacy of the other agents for hypertension by limiting fluid retention. Some evidence suggests long term diuretic use may not result in optimal outcomes when compared to other combinations. Another potential shift may be a change in the goal blood pressure levels. The recent ACCORD blood pressure study demonstrated that tight management of blood pressure did not result in improved outcomes in patients with type 2 diabetes. The study design called for the intensively treated group to achieve a systolic blood pressure of <120 mm Hg, and the control group to achieve a systolic blood pressure of <140 mm Hg. A review of the data shows that the average systolic blood pressure achieved in the intensive treatment group was 119 mm Hg and 133 mm Hg in the control group. These results translate into positive outcomes in diabetic patients, due to their systolic blood pressure goal of less than 130 mm Hg. Blood pressure is the product of cardiac output and total peripheral resistance (TPR). Cardiac output is the product of the stroke volume and heart rate. Pathophysiologic changes March 2011
that result in hypertension are usually not limited to one abnormality; rather, several changes in the normal function of body systems contribute to the hypertensive condition. Two important systems that work to maintain normal blood pressure are the autonomic nervous system and the renin-angiotensin-aldosterone system. The autonomic nervous system maintains regulatory action for the vascular system. Abnormal sympathetic/adrenergic tone contributes to increased peripheral resistance. As a patient challenges his or her vascular system with increased fluid and sodium, renin activity in the kidney, a primary component of compensation, adjusts to the increased volume. Inhibition of renin reduces blood pressure and can reverse albuminuria. The renin-angiotensin-aldosterone system regulates the balance of fluid volume, electrolytes, and blood volume in the body. Altered/decreased levels of fluid or sodium in the distal tubule of the nephron in the kidney stimulate the release of renin, which activates angiotensinogen to form angiotensinI (AT-I). Angiotensin-converting enzyme (ACE), in the pulmonary and vascular endothelium, then converts AT-I to angiotensin-II (AT-II). Aldosterone is released from the adrenal gland to induce retention of sodium and water with the goal of maintaining proper fluid and electrolyte balance. However, this renin activity also produces vasoconstriction, sodium retention, smooth muscle proliferation, and increased antidiuretic hormone in the vasculature. The real concern is that abnormally high renin activity is required to maintain balance. While some diseases can cause high renin The Georgia Pharmacy Journal
activity, no specific cause other than poor health habits (high caloric and sodium intake, stressful lifestyle, tobacco use) can be identified in the majority of patients. Abnormally high release of renin over time can result in intraglomerular hypertension, with resulting proteinuria. These changes are chronic in nature and result in endothelial dysfunction and microalbuminuria. Insulin resistance is also a by-product of this long term assault on the kidney.
Therapy of Hypertension Lifestyle modification should be the initial step of hypertension therapy for all patients. This treatment includes a meal plan such as the DASH (Dietary Approaches to Stop Hypertension) diet that limits sodium intake and facilitates healthy eating. Regular physical activity, according to each individual patientâ&#x20AC;&#x2122;s tolerance level and comorbid conditions, should be included, as should possible weight reduction and stress relief. Smoking cessation, if needed, is also a valuable addition to the treatment plan. All healthcare providers should be prepared to assist and reinforce the message about these health habits. Several different categories of antihypertensive medications with varying mechanisms are marketed. Today, the clinician can choose from a variety of products that may provide enhanced effects for the specific patient while limiting the side effect of the treatment. Table 1 provides a listing of the medication categories, products, and their dosing.
Types of Anti-hypertensive Medications The diuretics clinically used for hypertension include thiazide-type, 20
loop, and potassium-sparing agents, and the decision of which to use is based on their mechanism and/or site of action. Baseline renal function and serum potassium are important factors in determining the initial choice of diuretic. Thiazide diuretics are usually the initial or second agent used for hypertension. Combination therapy with other preferred antihypertensive agents work synergistically to minimize the fluid retention of other therapies. The JNC-7 report recommends thiazidetype diuretics as first-line therapy for uncomplicated hypertensive patients. Hydrochlorothiazide (HCTZ) is the most frequently prescribed diuretic for the treatment of hypertension alone, though not effective in patients with significant decline in renal function. Loop diuretics are the choice diuretic when the patientâ&#x20AC;&#x2122;s glomerular filtration rate (GFR) falls below 30 mL/min, or in a situation where greater diuresis is needed, specifically in a volume overloaded patient with symptomatic heart failure. Potassium-sparing diuretics are the only diuretics that may increase serum potassium; loop and thiazide diuretics typically lower serum potassium based on their site of action. Clinically, potassiumsparing diuretics are combined with a thiazide-type diuretic to balance serum potassium. Alone, these medications have minimal effect on reducing blood pressure. The various types of diuretics work in different areas of the kidney. Thiazide-type diuretics inhibit the Na+/Cl- channel in the distal convoluted tubule of the nephron, whereas loop diuretics inhibit the Na+/K+/2Cl- action in the ascending limb of the loop of Henle. Potassium sparing agents, amiloride and March 2011
triamterene inhibit the luminal Na+ channels, while spironolactone and eplerenone are aldosterone antagonists. Initially, the drop in blood pressure from diuretics is due to a decreased cardiac output as a result of decreased blood volume. Chronically, the blood pressure reduction is not a result of diuresis. Diuretics are generally taken once daily in the morning to limit sleep disruption from frequent urination, which can be caused by dosing diuretics in the evening. Low doses are used for the initial therapy and can be titrated up if necessary. For example, when treating hypertension alone, doses >25mg of HCTZ show no additional decrease in blood pressure. Patients with preexisting gout or uric acid stone disease, severe renal impairment, hepatic dysfunction, and/or electrolyte imbalances require close monitoring, as diuretics can induce flare-ups/worsening of these disorders. Thiazide-type diuretics (except metolazone) are contraindicated in patients with a known hypersensitivity to sulfonamides, though the risk of cross-sensitivity is not well defined. Adverse effects associated with diuretics can include changes in serum electrolytes, such as hypokalemia, hypomagnesemia, hyperuricemia, hyperglycemia, hyperlipidemia, hypercalcemia (thiazides), and hypocalcemia (loop). Photosensitivity has been reported. Some drug interactions of significance include nonsteroidal antiinflammatory drugs (NSAIDs), which can decrease the antihypertensive effect of diuretics. Diuretics can substantially increase lithium levels by inhibiting lithiumâ&#x20AC;&#x2122;s elimination; The Georgia Pharmacy Journal
therefore, lithium levels should be monitored 5 to 7 days after starting or discontinuing a diuretic. Thiazide diuretics are known to inhibit the release of insulin from the beta cells of the pancreas, resulting in hyperglycemia. Baseline blood pressure, serum electrolytes, uric acid, glucose, and lipids should be measured prior to initiating therapy, after 1-2 months, and every 6-12 months thereafter. An angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) is recognized as a step one or a step two drug following a diuretic treatment. This staging is dependent on the patientâ&#x20AC;&#x2122;s other compelling indications for therapy, such as chronic kidney disease, diabetes mellitus, heart failure, post-MI, or recurrent stroke prevention. ACE inhibitors can delay the progression of microalbuminuria to macroalbuminuria. ACE inhibitors inhibit the formation of angiotensin-II by blocking the conversion of angiotensin-I to angiotensin-II. These agents increase bradykinin, which stimulates release of nitric oxide, a vasodilator. ACE inhibitors cause dilation of the efferent arteriole in the renal circulation, which aids in the lowering of blood pressure and long term renoprotective action but can also reduce GFR and induce acute renal failure. ARBs are traditionally prescribed when ACE inhibitor therapies are not tolerated due to side effects such as cough. ARBs inhibit angiotensin-II release by blocking the Angiotensin-I receptor. This leads to a reduction in aldosterone secretion, vasoconstriction, and sympathetic activity. ACE inhibitors are often less effective at lowering blood pressure 21
and may increase the risk of angioedema in African-Americans. ACE inhibitors and ARBs are generally administered 1 to 3 times daily with or without food. Oncedaily dosing can be in the morning or evening, based on patient preference and adverse effects, such as drowsiness. Taking the medication at the same time every day is important. Concurrent food intake may affect the absorption of captopril and moexipril, so dosing prior to a meal is warranted. The effects of blood pressure lowering can be seen within 1 hour of administration, with maximum effects after 6 to 8 hours. ACE inhibitors and ARBs are contraindicated during pregnancy. Use in the second or third trimesters can lead to fetal injury or death. Overall, ACE inhibitors are well tolerated with few side effects, especially if monitored appropriately. The most notorious adverse effect, often the reason for discontinuation of ACE inhibitors, is cough. This adverse effect is primarily due to the increase in bradykinin activity. Other adverse effects commonly associated with ACE inhibitors include fatigue, headache, dizziness, hyperkalemia, acute hypotension, and gastrointestinal problems. Hematologic effects, such as neutropenia and agranulocytosis, have also been reported. Concurrent use of NSAIDs, potassium-sparing diuretics, and potassium supplements may increase potassium levels. ACE inhibitors can increase lithium levels, due to decreased fluid volume and loss of sodium ions; therefore, close monitoring of lithium levels is recommended. Blood pressure, serum electrolytes, and renal function should be measured at baseline, in the first month, and every 6 months March 2011
throughout treatment. ARBs are listed as category C for the first trimester of pregnancy and category D for the second and third trimesters, so ARBs should be avoided in pregnancy. ARBs are contraindicated in patients with significant disease of a single, functional kidney. ARBs are generally well tolerated, with more common adverse effects including dizziness, diarrhea, dyspepsia, hyperkalemia, headache, and upper respiratory complaints. The frequency of cough associated with ARBs is less than with ACE inhibitors. Concurrent use of potassium-sparing diuretics, potassium supplements, or salt substitutes may increase serum potassium levels significantly. Use of ACE inhibitors and/or beta-blockers with ARBs should be avoided in patients with heart failure. ARBs can increase lithium levels due to decreased fluid volume and loss of sodium ions; therefore, close monitoring of lithium levels is recommended. Blood pressure, serum electrolytes, and renal function should be measured at baseline and periodically throughout treatment. Potassium levels should be monitored within the first month of initial therapy and every 4-6 months, due to the potential onset of hyperkalemia. Direct renin inhibitors (DRIs) are a relatively new category of agents for hypertension. They work within the renin-angiotensin-aldosterone system. This category is not included in the JNC-7, as it was introduced after the release of JNC-7. DRIs directly inhibit renin, which means that little or no contribution will result from the renin-angiotensinaldosterone-system. Aliskiren is taken once daily and can be taken with or without food. Starting therapy begins The Georgia Pharmacy Journal
with a low dose and is adjusted to goal. Adding an ARB or diuretic to aliskiren can be helpful in lowering blood pressure. DRIs are contraindicated in pregnancy. They have a low adverse effect profile that includes a cough, though the incidence is less than with ACE inhibitors. Diarrhea, dizziness, headache, rash, edema, increased uric acid, and low blood pressure can occur. Aliskiren is metabolized in the liver by the cytochrome P-450 3A4 system, and patientsâ&#x20AC;&#x2122; blood pressure, electrolytes, and renal function should be monitored while on aliskiren. Beta-blockers are commonly prescribed as an addition to an existing hypertension treatment plan. Beta-blockers are beneficial for patients with concurrent cardiac problems and are indicated for patients with high risk for coronary disease, as well as secondary prevention of MI and heart failure. There are 2 main types of betaadrenergic receptors in human physiology, beta1 and beta2. Beta1 receptors are located on the heart, where activation causes an increase in heart rate, contractility, and conduction velocity. Blockade of these receptors reduces cardiac output. The agents with combined alpha and beta blockade will be considered here with their improved lipid profile. Beta-receptors have a wide range of functions in the body. Activation of beta1-receptors located in the juxtoglomerular cells of the kidney stimulate the release of renin. Beta2receptors in the liver increase hepaticmediated glucose output when stimulated. Beta2-receptors in the lungs induce bronchodilation. Some 22
beta blockers are selective for beta1 effect while others are nonselective and inhibit both the beta1 and beta2 receptors equally. When higher doses of a beta1-selective blocker are given, selectivity diminishes. Highly lipidsoluble beta1-receptor blockers cross the blood brain barrier readily and increase the risk of central nervous system adverse effects. Some betablockers also have intrinsic sympathomimetic activity (ISA). Beta-blockers are administered once to twice daily and should be taken at a consistent time. Atenolol is classified as pregnancy category D and crosses the placental barrier, producing a reduced weight of infants. Beta-blockers are contraindicated in patients with sinus bradycardia. Nonselective betablockers are contraindicated in patients with asthma. Beta-blockers can inhibit the release of insulin from the pancreas, resulting in increased blood glucose levels in patients with type 2 diabetes. Conversely, they can also mask hypoglycemic-induced tachycardia, as it can decrease the individualâ&#x20AC;&#x2122;s awareness of hypoglycemia, which typically presents as dizziness and sweating but may not be visible when a patient is on beta-blocker therapy. Common adverse effects with betablockers are CNS-related, such as sedation, dizziness, drowsiness, lightheadedness, fatigue, and headache. Other notable adverse effects include bradycardia, hypotension, depression, and sexual dysfunction, especially in older adults. Gastrointestinal effects of constipation, diarrhea, and nausea have been reported but occur less frequently. Beta-blockers have March 2011
additive effects on heart muscle contractility with nondihydropyridine calcium channel blockers (Diltiazem and Verapamil), amiodarone, and digoxin. Typically, patients taking beta-blockers should be tapered down when they are discontinued and not stopped suddenly. Baseline blood pressure, heart rate, lipid profile, and blood glucose levels should be conducted. Beta-blockers can increase total cholesterol, LDL-cholesterol, and triglycerides and decrease HDLcholesterol. Calcium channel blockers (CCBs) are an additional group of agents for hypertension control. Typically, they are a second or third option, and have less of an impact on cardiovascular disease when compared to other antihypertensive agents. Nondihydropyridine CCBs can be considered for patients who have not tolerated ACE inhibitor or ARB therapy. Nondihydropyridine CCBs may reduce proteinuria. CCBs are structurally classified as nondihydropyridine and dihydropyridine. CCBs block the Ltype calcium channel, which results in vasodilation. Nondihydropyridine CCBs primarily cause vasodilation within coronary vessels and have a more depressive effect on cardiac conduction, while dihydropyridine CCBs primarily cause vasodilation in the vascular smooth muscle. CCBs are dosed 1 to 3 times daily and can be taken with food to minimize adverse effects. Low initial dosage is adjusted every 2 weeks to patient tolerance, blood pressure, and heart rate. An immediate-release dosage form is rarely used for the treatment of hypertension. Typically, once-daily calcium channel blocker formulations are dosed in the morning, except for verapamil extended-release products, The Georgia Pharmacy Journal
which are given at bedtime. CCBs are also contraindicated in patients with sick sinus syndrome or a heart block without a pacemaker. Verapamil is contraindicated in patients with congestive heart failure. CCBs can induce headache, dizziness, nausea, dyspepsia, flushing, and constipation. Nondihydropyridine CCBs are associated with cardiac adverse effects including cardiac conduction abnormalities and bradycardia. Dihydropyridine CCBs have adverse effects related to their relaxing of vascular tone. Dihydropyridine CCBs cause peripheral edema more significantly than the other CCBs. Most CCB drug interactions stem from the cytochrome P-450 enzyme system. Concurrent medications and foods (such as grapefruit juice) that are also metabolized through this system should be used cautiously. Diltiazem and verapamil can inhibit other CYP3A4 substrates, such as statins and theophylline. CCBs inhibit platelet function, resulting in an increased risk for bleeding if used concurrently with anticoagulants, such as warfarin or aspirin. Although indicated for the treatment of hypertension, alpha1-receptor blockers are rarely prescribed for this indication. They are most beneficial in patients with benign prostatic hyperplasia (BPH). Alpha1-receptor blockers can be a treatment option for patients with both diabetes and BPH. The alpha1-receptor blockers inhibit the effect of norepinephrine on vascular alpha1-receptors. Activation of the alpha1-receptor by norepinephrine leads to vasoconstriction, resulting in an
23
increase in TPR. The alpha1-receptor blockers are preferably dosed at bedtime to minimize the risk of postural hypertension often observed within hours after administration. Initial therapy often starts with a lower dose and can be adjusted to goal. The alpha1-receptor blockers also cause a mild decrease in neutrophils and white blood cell counts, which is generally not significant. Adverse effects commonly associated with alpha1-receptor blockers include fatigue, malaise, dizziness, shortness of breath, hypotension, edema, and weight gain; palpitations, blurred vision and sexual dysfunction have also been noted. Blood pressure and heart rate should be monitored at baseline and at each visit after initiating treatment. If antihypertensive agents are added, the patient should be assessed for first-dose syncope and postural hypotension. Interruptions in therapy increase the risk; thus, nonadherent patients are not good candidates for this drug. Syncope is managed by having the patient lie down, rest, and receive supportive care as necessary. Vasodilators induce their action by direct vasodilation of the vascular smooth muscle, producing a significant reduction in peripheral resistance. A reflex action from the baroreceptors to this action is an increase in heart rate, cardiac output and renin release. Candidates for vasodilators should receive diuretics and an agent that reduces adrenergic tone, perhaps a beta-blocker. Side effects include an increased heart rate, water retention, and dermatitis, and some cases report a peripheral neuropathy. Hydralazine may induce March 2011
a dose-related, reversible lupus-like syndrome. Minoxidil can cause a hypertrichosis reaction. While indicated for the treatment of hypertension, central-acting alphaadrenergic agonists are rarely prescribed for this indication. Central-acting alpha-adrenergic agonists stimulate alpha2-receptors in the brain to inhibit the production of serotonin, dopamine, norepinephrine, and epinephrine. This inhibition produces decreased heart rate and TPR. Central-acting alpha-adrenergic agonists are available in tablets and a transdermal patch (Catapres速). Tablets are taken in daily divided doses, preferably at consistent times. Transdermal patches are applied once weekly. Clonidine is classified as pregnancy category C and should be avoided. Methyldopa is pregnancy category B and can be used in pregnancy. It is converted to alphamethylnorepinephrine, a natural byproduct of catecholamine breakdown, which may also limit its use in gestation. The use of a monoamine oxidase inhibitor (MAOI) is contraindicated in patients taking methyldopa as hypertensive crisis
reactions have been reported. Central-acting alpha-adrenergic agonists are contraindicated in patients with severe coronary insufficiency, recent MI, cerebrovascular disease, and renal or hepatic dysfunction. Side effects can include nausea, vomiting, constipation, dry mouth, and CNSrelated effects, such as sedation, weakness, nervousness, dizziness, and drowsiness. Hypotension, sexual dysfunction, and hair thinning/loss have been reported. Iron can decrease the absorption of methyldopa up to 66%. Therefore, iron should be separated by at least 2 hours from methyldopa administration. Methyldopa also increases the risk of lithium toxicity, even in the presence of normal lithium levels. Signs and symptoms of lithium toxicity, such as lethargy and muscle weakness, should be monitored. Over-the-counter drug products containing pseudoephedrine and ma huang (ephedra, ephedrine) can increase blood pressure. This is greatly enhanced for patients takingmethyldopa and clonidine. Tricyclic antidepressants, e.g., amitriptyline
and imipramine, may antagonize central alpha2-receptors. Clonidine and methyldopa should also be used cautiously with beta-blockers, since withdrawal of these agents in patients concurrently on beta-blockers has led to life-threatening increases in blood pressure. Patients should be monitored for signs of depression at clinician visits. When stopping the drug, gradual tapering of the drug should occur over several days to prevent withdrawal.
Summary Several agents are now marketed to control blood pressure to the desired range. However, little improvement in overall control has been noted, and further efforts are needed to encourage patients to continue to follow proper meal plans, engage in regular physical activity, and take their medications. Continual patient instruction about emerging techniques is vital. The future changes and updated recommendations brought forth by the JNC-8 will be interesting to observe.
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
24
March 2011
The Georgia Pharmacy Journal
25
March 2011
The Georgia Pharmacy Journal
26
March 2011
n a e b b Cari OASIS of the SEAS
September 17 - 24, 2011 12 Hours of Continuing Education
Day
Port
Arrive
Depart
Sat
Ft Lauderdale
Sun
At Sea
Mon
Labadee
8:00 am
5:00 pm
Tue
Falmouth, Jamaica
10:00 am
6:00 pm
Wed
At Sea
Thur
Cozumel, Mexico
8:00 am
7:00 pm
Fri
At Sea
Sat
Ft. Lauderdale
5:00 pm
INSIDE STATEROOM: $759* pp OCEAN VIEW STATEROOM: $879* pp BALCONY STATEROOM: $979* pp CENTRAL PARK BALCONY : $1009* pp BOARDWALK BALCONY : $1079* pp CE Registration Fee: $135 CE Registration Non-Member Fee: $175
Call to book your CE Cruise!
(800) 805-7245 Go to www.funseas.com/FPA for more information
*rates are per person, double occupancy. Airfare, govâ&#x20AC;&#x2122;t fees and transfers are extra
CE is provided by the Florida Pharmacy Association which is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. These activities are eligible for ACPE credit.
Continuing Education for Pharmacists Quiz and Evaluation Hypertension Therapy Update 1. Heart failure affects approximately how many Americans? A. 5 million B. 10 million C. 5 billion D. 10 billion
6. Which of the following should be avoided in a patient diagnosed with heart failure? A. Diltiazem B. Hydrochlorothiazide C. Eplerenone D. A and B
2. True or False: Heart failure involves structural changes to the heart. A. True B. False
7. Angiotensin II plays a role in the cardiac remodeling process by: A. increasing vasoconstriction. B. increasing aldosterone. C. increasing parasympathetic response. D. A and B.
3. The ACC/AHA Staging system is different from the NYHA Functional Classification because: A. it denotes the different stages using roman numerals. B. patients can only move in one direction on the continuum. C. it is only used to distinguish different scenarios of patients in Class IV. D. different stages are distinguished based on the patientâ&#x20AC;&#x2122;s exercise tolerance.
8. Norepinephrine: A. increases heart rate. B. decreases heart rate. C. decreases heart contractility. D. Activates the renin-angiotensin-aldosterone system. 9. Which of the following ARBs are commonly prescribed for heart failure? A. Candesartan B. Olmesartan C. Eprosartan D. A and B
4. Most symptomatic patients with Stage C heart failure should be on a regimen that includes: A. ACEI and BB. B. ACEI, BB, digoxin. C. ACEI, BB, and a diuretic. D. ACEI, BB, Spironolactone, and digoxin.
10. Which group below represents the three BBs that are appropriate to use in HF management? A. Bisoprolol, carvedilol, sustained release metoprolol succinate about 30 minutes prior to a dose of nicotinic acid B. Bisoprolol, labetalol, propranolol C. Carvedilol, metoprolol tartrate, timolol D. None of the above
5. The new section in the 2009 HF Guidelines update addresses: A. home healthcare. B. the hospitalized patient. C. pharmacoeconomic issues. D. none of the above.
The Georgia Pharmacy Journal
28
March 2011
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.
Hypertension Therapy Update This lesson is a knowledge-based CPE activity and is targeted to pharmacists. GPhA code: J11-3 ACPE#: 0142-0000-11-002-H01-P Contact Hours: 1.5 (0.15 CEU) Release Date: 03/01/2011 Expiration Date: 03/01/2013 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. 2. 3. 4. 5.
A A A A A
B B B B B
C D C D C D 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 7. Avoided any bias: 1 2 3 4 8. 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. The Georgia Pharmacy Journal
29
March 2011
2011 Spring Region Meetings: GPhA’s Legislative For more details about these events and to register please visit www.gpha.org or Update Program call 404-231-5074. If you have question about the event and its times or locations that are not listed please contact the Region President. 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 President Elect & Pam Marquess, GPhA Second Vice President
Region 1: April 19, 2011 Heather DeBellis, Region President (865) 803-7833/hdebellis@southuniversity.edu Speakers: Dale Coker, GPhA President & Jim Bracewell, GPhA EVP/CEO Region 2: April 21, 2011 Spring Hill County 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 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 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 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 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 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
Region 7: April 19, 2011 Adairsville Inn Restaurant, Adairsville 6:00 p.m. Networking
The Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
The Georgia Pharmacy Journal
30
March 2011
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
The Georgia Pharmacy Journal
Name
31
March 2011