The Official Publication of the Georgia Pharmacy Association
March 2009
Preserving the Triad GPhA Convention June 20-24, 2009
Sawgrass Golf Resort and Spa, Ponte Vedra Beach, Florida Volume 31, Number 3
www.gpha.org
NEW PLANS – BETTER RATES – MORE BENEFITS in 2009
Look what’s NEW in 2009... Reduced Rates Prescription Drug Coverage Dental and Orthodontic Benefits Guaranteed Issue Term Life Insurance... up to $150,000 with no underwriting requirements
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 e-mail 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.gphainsurance.com. * 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.
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Departments
GPhA Convention Registration Information June 2024, 2009 Ponte Vedra Beach, FL Sawgrass Golf Resort and Spa, A Marriott Resort FEATURE
12 16 18 20 21
ARTICLES
Together Rx Access Improves Prescription Access for Eligible Uninsured Georgians Seeing Clearly Legislative Update
7 10 11 14 22 24 30
2009 Spring Region Meetings New Members GPhA Members in the News GPhF Information Pharmacy Schools in the News Journal CE GPhA Board of Directors
Advertisers 2 2 4 5 8 9 13 18 21 22 29 31 32
The Insurance Trust Principal Financial Group Pharm PAC PQC Pharmacists Mutual Companies AIP Meeting Announcement Toliver and Gainer GoodSense Michael T. Tarrant GPhA Career Center PharmStaff PACE Alliance The Insurance Trust
Philadelphia College of Osteopathic Medicine to Open School of Pharmacy in Georgia Technician News: PTCB Unveils New Testing Features
COLUMNS
4
President’s Message
6
Editorial
For an uptodate calendar of events, log onto
www.gpha.org. The Georgia Pharmacy Journal
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March 2009
PRESIDENT’S
MESSAGE Robert Bowles, Jr. , R.Ph., CDM, CFts GPhA President
You should do something... s we enter March we find this country in the middle of trying and troubling times. The economy is in the tank, the unemployment rate is high, and we as individuals have a rather small role to play in the choices that are being made to benefit us. While these challenges have hit us all hard we must continue to press forward.
Region Meetings or some other professionally advantageous event, you should choose to attend something. Whether you choose to contribute to the Georgia Pharmacy Foundation, PharmPAC, or some other worthy cause, you should contribute something.
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We have united under the title of the Georgia Pharmacy Association , 2,800 plus strong, and we should be proud that we pharmacists in our diverse practice areas have stayed in tune with the practice of pharmacy and the patients we serve. In these trying times this vision will be what brings us through to a bright future both as professionals and as an Association.
Our profession is still here and there is still work to be done. In these pages you will find news about changes in our profession and opportunities to contribute to the advancement of pharmacy. Review your choices carefully. Whether you choose to attend Convention, the Spring
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safety net? Do you have a
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EXECUTIVE
VICE
PRESIDENT’S
EDITORIAL
Jim Bracewell Executive Vice President / CEO
Live Breaking News s watch your favorite television program you have all become accustommed to seeing a message track across the bottom of the screen alerting you to breaking news. You have also become accustommed to the notation in the upper right corner the screen, the word LIVE if the broadcast is taking place as you are viewing it.
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Your GPhA leadership took that same lesson to heart and realized that while it takes time and costs quite a bit of money, the successful outcomes of communication with members across the state pay huge dividends on the investment of time and resources.
Next month – April 2009 – you, as a member of GPhA, and guests have the opportunity to hear the latest breaking news about the profession of pharmacy in Georgia in a live format from the elected leadership of your professional association.
Many of your patients opt out or decline counsel, feeling they have all the information they need to optimize the benefit of their medications. You as a pharmacist know how foolish that patient’s behavior is for their health, but do you as a pharmacy professional realize how the success of your career and your future are determined so much by the exchange of information at your profession’s region meeting each spring and fall?
Why does GPhA invest so much of your precious membership resources in providing twelve region meeting each fall and spring across the state? Why do your elected leaders take eight to twelve days away from their pharmacy practice each year to present at these region meetings?
Please indicate your choice by visiting the GPhA website calendar and signing up to attend the 2009 GPhA Spring Region Meeting of your choice.
You know from your own practice how important it is to counsel in person with a patient that has undertaken a new powerful drug regiment. Nothing is more powerful or is as meaningful to the patient and will produce the most successful outcome like an in person meeting with the patient. The Georgia Pharmacy Journal
Being an informed practicing professional is your decision. I hope to see many of you at a Region Meeting listed on the adjoining page next month.
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GPhA 2009 Spring Region Meetings State Pharmacy Law 2009 Update
Sharon Sherrer, Pharm.D., CDM, Chairman, 2008-2009 Robert Bowles, R.Ph., CDM, President, 2008-2009 Eddie Madden, R.Ph., President-Elect, 2008-2009 Dale Coker, R.Ph., First Vice President, 2008-2009 Jack Dunn, Second Vice President, 2008-2009 Jim Bracewell, Executive Vice President
Schedule of Spring 2009 Region Meetings For additional information and to RSVP go to www.gpha.org April 21, 2009 - 7:00-9:00 p.m. April 21, 2009 - 6:00-9:00 p.m. April 21, 2009 - 6:30-9:00 p.m. April 23, 2009 - 6:30-9:00 p.m. April 23, 2009 - 6:00-9:00 p.m. April 23, 2009 - 7:00-9:00 p.m. April 28, 2009 - 6:30-9:00 p.m. April 28, 2009 - 6:00-9:00 p.m. April 28, 2009 - 6:30-9:00 p.m. April 30, 2009 - 6:30-9:00 p.m. April 30, 2009 - 6:30-9:00 p.m. April 30, 2009 - 6:30-9:00 p.m.
Holiday Inn Tellus NWGA Sci. Museum Columbus Reg. Med. Center The Village at Moore Village Griffin Country Club Carey Hilliard’s Restaurant TBA Bonefish Grill TBA Stonebridge Country Club Mercer University TBA
Region 8 - Waycross Region 7 - White Region 3 - Columbus Region 12 - Dublin Region 4 - Griffin Region 1 - Savannah Region 10 - TBD Region 11 - Augusta Region 6 - TBD Region 2 - Albany Region 5 - Atlanta Region 9 - TBD
Larry Batten Pam Marquess Renee Adamson Ken Eiland Bill McLeer Alex Tucker Chris Thurmond Marshall Frost Bobby Moody Alex Tucker Shobhna Butler Alissa Rich
For details about the Continuing Education Program at the Spring Region Meetings please visit www.gpha.org or call GPhA at 404.231.5074. The Georgia Pharmacy Association is accredited by the Accreditation Council of Pharmacy eduction as a provider of continuing pharmacy education. These activities are eligible for ACPE credit; see final CPE activity announcement for specific details.
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AIP Spring Meeting April 25-26, 2009
Sea Palms Resort, St. Simons Island, GA Come relax in the lush oasis that is Sea Palms Resort. Take a walk under ancient live oaks, where the ocean air mixes with a soft marsh breeze. Bike on the beach, play golf, tennis or just relax on your balcony overlooking the island's natural beauty. Sea Palms Resort offers the perfect setting for our AIP Spring Meeting. Our spring meeting will offer continuing education, time to meet with our vendors, an AIP Business Session to discuss issues impacting independent pharmacy, time to network with other AIP Pharmacies and catch up with old friends. Plan on attending and bring your family for a weekend to be remembered. AIP has negotiated a special room rate of $139 (Deluxe) and special pricing on other accommodations (accommodation choices include hotel-style deluxe guest rooms, executive studios with kitchenette and fully furnished one to three bedroom suites with scenic sun deck or screened porch). To guarantee that you receive this special rate and to ensure you get a room please make your reservation as soon as possible. Sea Palms has more amenities than any other property on St. Simons Island and is just minutes from the beach. With twenty seven holes of golf, three swimming pools, three rubico clay tennis courts, a fitness center and sauna, sandpit volleyball court, bike rentals and horseshoes, the recreational opportunities are boundless. We are very excited about this year’s AIP Spring Meeting. We will give you more details as the time nears. Make your plans now to attend.
Please call 1.800.841.6268 for reservations (Ask for the AIP room block) Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
• CE opportunities • AIP Business Meeting • Social and Cocktails with our Partners Registration: (For Planning Purposes Please Fill Out and Return) Member’s Name: __________________________Nickname (for badge): __________________________ GA R.Ph. License No:___________ Pharmacy Name: _________________________________________ Address: _____________________________________________________________________________ Phone:(____)____________ Fax:(____)_____________ E-mail Address: __________________________ Please circle the following: Academy Member? Yes No GPhA™ Member? Yes No **If Spouse/Guest is attending please print his/her name: ______________________________________ Nickname (for badge): ___________________ Is the above guest a member of GPhA? Yes____ No ____
Please Fax Registration to 404.237.8435 The Georgia Pharmacy Journal
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Welcome to GPhA! The following is a list of new members who have joined Georgia’s premier professional pharmacy association! Ginger Adams, Athens Rjena Azad, Stone Mountain Bishakha Bandyopadhyay, Martinez Lynn T. Barrett, Pharm.D., Carrollton Richard Bettis, Athens Hilary Boretz, Athens Kylee Bowen, Athens David Boyd, Blythe Jennifer Boykin, Athens Matthew Bridges, Evans Laura Briscoe, Athens Jayme Bristow, Athens John Bullard, Hahira Kyle Burcher, Athens Benjamin Butts, Crawfordville Annette M. Butty, CPhT, Kennesaw Lana C. Carter, R.Ph., Townsend Jordan Chambers, Douglasville Jessica Chandler, Madison Sarah Chen, Alpharetta Vanessa L. Clark, Dublin Jenny Cribb, Stockbridge Lydia Cronic, Athens Danielle Cronin, Athens Amanda J. Crowe, B.S., Grayson John E. Crowe, Jr., B.S., Statesboro Tran Danh, Rome Mindy Daniel, Jackson Sarah Daniel, Athens Sali Deo, Athens Kremena Dimitrova, Marietta Vinh Do, Athens Amy Ellis, Ellaville Claire Elrod, Colbert Meghan Federman, Evans Rafael Felippi, Athens John Galdo, Marietta Dominque Gardner, Athens Hannah Gilmore, Leesburg Sametria Glass, Bonaire Meredith Goodson, Athens Courtney Gorham, Evans
Laura Guillebeau, Athens Brett Hall, Athens Ashley Hamby, Stockbridge Katherine Haney, Athens Justin Hildreth, Thomson Kimberly Hill, Athens Quynh-Nhu Ho, Gainesville Susan L. Holmes, B.S., Silver Creek Anna Hudson, Athens Amber Jenkins, Athens Molly Keaton, Athens Khalil Khlifi, Athens Kristen Kinmon, Flowery Branch Bradley Kirk, Danielsville Parag Kumar, Valdosta Alina Kuo, Douglasville Ginger Lancaster, Athens Esther Lannu, Athens Zachary Lapaquette, Augusta Christie Lee, Athens Bin Lin, Lilburn Jade Lott, Athens Jenna Luedtke, Lilburn Robert Luschen, Athens Matthew Mack, Athens Sabra L. Maddox, R.Ph., Woodbine Melissa Mahoney, Bethlehem John C. Martin, III, Blackshear Regina Pauline Maxey, Athens Emilee McDonald, Athens Kathleen McManus, Gainesville Melissa Medders, Savannah Julianna Murphy, Rincon Steven Nakajima, Athens Dorris Ottens, Athens Shuang Ouyang, Athens Christine Owens, Athens Annie Oyanontaruk, Alpharetta Sean Park, Canton Jaina Patel, Augusta Manisha Patel, Athens Quynh Diem Phan, Conyers
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Zachary Phillips, Gainesville Allison Povlak, Lawrenceville Erin Powell, Jackson Kelly Pritchett, Athens Sarah Rath, Athens Elizabeth A. Riggle, Athens Paun Rimtepathip, Marietta Jetta Sartwell, Athens Abbie Scarborough, Jesup Brandy Schley, Athens Carly Schmitt, Newnan John Joseph Small, Atlanta Joshua Smith, Helena Ashley Summers, Canton Jennifer Sutherland, Athens Michael Thiman, Buford Kelly Thornburg, Warner Robins Benjamin Timms, Calhoun Adam Toenes, Chamblee Thao Tran, Augusta Morgan Trepte, Roswell Kimberly Trinidad, Duluth Drew Vaughn, Lawrenceville Iraida Vega, Athens LeAnn Walton, Lincolnton Kimberly Ward, Senoia David Warren, Macon Melissa Weaver, Athens Lucyna Webb, Athens Misty West, Athens Bryan White, Athens Murriel M. Williamson, R.Ph., Dublin Carolyn D. Winney, CPhT, Roswell Corey Witenko, Athens Allison Young, Bogart
March 2009
GPhA
MEMBERS
IN
Azza El-Remessy, R.Ph., Assistant Professor at the University of Georgia, published a review article in the Journal of Pharmacotherapy entitled, “Diabetic Retinopathy: Current Management and Experimental Therapeutic Targets.” Kalen Porter, Pharm.D., Assistant Professor at the University of Georgia, presented student posters, “Evaluation of Completeness of Medication Reconciliation in Compliance with the Joint Commission’s Requirements” and “Evaluation of Antimicrobial Surgical Prophylaxis in a Children’s Medical Center” at the American Society of Health-System Pharmacists meeting. Ken Couch, R.Ph., president of Smith Drug Company in Spartanburg, SC, was the recipient of the Healthcare Distribution Management Achievement. HDMA’s Center for Healthcare Supply Chain Research and Wyeth Pharmaceuticals honored Couch during the association’s Annual Leadership Forum Awards Banquet in National Harbor, MD. James W. Fetterman, Jr., Pharm.D., associate professor and experimental coordinator for South University, H.W. “Ted” Matthews, Ph.D., R.Ph., dean of the College of Pharmacy and Health Sciences at Mercer University, Bradley G. Phillips, Pharm.D., BCPS, FCCP, professor and head of the department of clinical and administrative pharmacy at the University of Georgia, Kremena Dimistrova and Matthew Mack, University of Georgia pharmacy school students were all featured in the Atlanta Journal Constitution on January 18, 2009, in the article entitled “The Future of Pharmacy”, The article discusses the growing role of pharmacists in the healthcare system.
THE
NEWS
William Prather, R.Ph., member of the Georgia State Board of Pharmacy is a member of the National Association of Boards of Pharmacy’s Task Force to Examine the Feasibility of Standard Prescription Label Requirements. He attended a meeting of this group on December 6-7, 2008, in Tucson, AZ, to evaluate current state and federal laws and regulations addressing prescription label format and content. Janice Hatcher, a student at Mercer University’s College of Pharmacy and Health Sciences received the National Association of Chain Drug Stores (NACDS) Foundation Pharmacy Student Scholarship. Milton “Butch” Bowling, R.Ph., and Jim Bracewell, Executive Vice President and CEO of GPhA, were featured in the February 5, 2009 issue of the Gainesville Times as part of the article “Bill Would Let Pharmacies Give Flu Shots.” This article was about pharmacy legislation on the dispensing of flu shots.
Laird Miller, R.Ph., was selected to serve as a member of the Steering Committee on National Legislation and Government Affairs for the National Community Pharmacists Association. Fred Barber, R.Ph.,was named president of the Georgia State Board of Pharmacy on January 1, 2009. Robert “Bobby” Ledbetter, R.Ph., was featured in The Dahlonega Nugget. His granddaughter is a part of The Learning Channel’s series Toddlers and Tiaras. If you have an item that you would like included in the GPhA Members in the News section of The Georgia Pharmacy Journal please email the item to Kelly McLendon at kmclendon@gpha.org or fax it to her attention at 404.237.8435.
Steve Purvis, R.Ph., owner of Huff’s Pharmacy in Ellijay opened the first Mini Clinic in an AIP member pharmacy on February 2, 2009. The clinic attaches to the pharmacy from both the outside and the pharmacy.
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Feature
Article
Together Rx Access Improves Prescription Access for Eligible Uninsured Georgians mong those most in need today are the more than 45 million * people without insurance, those who, in this economy, are finding it harder than ever to take care of what’s most important…their health. In Georgia, nearly 1.7 million individuals† do not healthcare coverage, which may make it difficult for these individuals to pay for the prescription medicines they need to stay healthy and to treat many common conditions, such as asthma, high cholesterol and diabetes. In fact, sixty percent of people with chronic conditions skip taking their medicines if they are uninsured. ‡
cholesterol, diabetes, depression, asthma, and many other common conditions. The Card is free to get and free to use. Individuals may be eligible for the Together Rx Access Card if they do not qualify for Medicare, do not have public or private prescription drug coverage, have a household income of up to $30,000 for a single person or $60,000 for a family of four (income eligibility is adjusted for family size), and are legal residents of the United States or Puerto Rico.
Pharmacists play a critical role – both as healthcare provider and educator – in helping their uninsured customers gain access to prescription medicines. Because individuals often seek medical advice and counsel from their pharmacist, it is important for these healthcare providers to be aware of and familiar with relevant medication assistance programs and services. This knowledge enables pharmacists to educate customers about these programs and helps uninsured people to better afford the prescriptions they need to live healthier lives.
Together Rx Access uses cardholder and prescription information to administer the program, communicate with cardholders, and for market research and analysis by its member companies. Together Rx Access and its business partners do not contact cardholders to market other products or services or for market research unless the cardholders affirmatively agree to such contacts.
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Cardholders simply bring the Card to their neighborhood pharmacist along with their prescription, and the savings are calculated right at the pharmacy counter. More than 2,000 pharmacies accept the Card in Georgia.
In August 2008, the Governor of Georgia and Together Rx Access announced the launch of the Together Rx Access FOR GEORGIA Card, the first state specific Together Rx Rx Help for Uninsured Individuals Access Card. As part of this effort, the State is using existing One free program, Together Rx Access, which is sponsored resources to identify residents who may benefit from the by many of the nation’s leading pharmaceutical companies, Program. Nearly 68,000 Georgians have enrolled in the provides eligible individuals and families with immediate Program. Those in Georgia who have used their Card have and meaningful savings on prescription products right at collectively saved $4 million on their prescription their neighborhood pharmacy. With the Together Rx medicines. Access® Card, most cardholders save 25 to 40 percent§ on brand-name prescription products. More than 300 brandname prescription products are included in the Program.** Savings are also available on a wide range of generics. Medicines in the Program include those used to treat high The Georgia Pharmacy Journal
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Quick and Easy Enrollment There are three easy ways to enroll in the Program. And, no documentation is required. • Visit TogetherRxAccess.com to instantly enroll online. • Call the toll-free phone number 1-800-250-2839. • Complete a short paper application and return it by mail. A Together Rx Access quick start savings card is also available. Potential enrollees simply detach the Card, and call the toll-free number listed on the brochure to find out if they are eligible, enroll, and instantly activate their Card. To receive a supply of quick start savings cards, or other enrollment materials, visit www.togetherrxaccessonline.com/order/.
Sources: *State Health Facts. www.statehealthfacts.org. Accessed January 30, 2009. †State Health Facts. www.statehealthfacts.org. Accessed January 30, 2009. ‡Collins S. et all. Gaps in Health Insurance: An All-American Problem. The Commonwealth Fund. 2006. Available at www.commonwealthfund.org/usr_doc/Collins_gapshltins_920.pdf. §Each cardholder's savings depend on such factors as the particular drug purchased, amount purchased, and the pharmacy where purchased. Participating companies independently set the level of savings offered and the products included in the program. Those decisions are subject to change. **Visit TogetherRxAccess.com for the most current list of brand-name medicines and products.
How Pharmacists Can Help Listed below are few a simple ways that pharmacists can help educate uninsured individuals and families about Together Rx Access: • Determine eligibility by reviewing the Together Rx Access Card qualifications together. • Direct eligible individuals to TogetherRxAccess.com to enroll online. • Provide the Together Rx Access toll-free number 1-800-250-2839. • Request and distribute quick start savings cards to eligible individuals. • Display and distribute materials in the pharmacy. • Inform other healthcare professionals about TogetherRxAccess.com. In addition, one-on-one communications is an effective way to engage individuals and families who are uninsured. For this very reason, pharmacists are well suited to inform potential enrollees about the Program as they engage in personal conversations with uninsured Georgians on a regular basis.
Lawyer and Pharmacist 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 Leroy Toliver has been a Georgia Registered Pharmacist for 34 years. He has been a practicing attorney for 25 years and has represented numerous pharmacists and pharmacies in all types of cases. Collectively, he has saved his clients millions of dollars.
For more information, visit TogetherRxAccess.com or call 1-800-250-2839.
The Georgia Pharmacy Journal
Toliver and Gainer, LLP 942 Green Street, SW Conyers, GA 30012-5310 altoliver@aol.com 770.929.3100
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Pharmacy
News
Seeing Clearly... by Trevor Miller, Director of Insurance Services - tmiller@gpha.org arch is Save Your Vision Month which educates the public about the importance of getting comprehensive eye examinations regularly in order to preserve the vision. Not only can taking the time to protect the health of your eyes reduce the risk of vision loss, but going for a routine eye exam can help detect systemic and chronic diseases like diabetes.
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Save Your Vision Month is definitely not about eating immense amounts of carrots and avoiding sun light! This health month even goes beyond optometrists telling their clients to get their annual eye exam. Your business can help build momentum around eye health for your employees, patients and consumers throughout this month-long observance. Did you know that the UV radiation from the sunlight can be extremely damaging to the eyes, potentially causing long term problems like cataracts? Research has shown that long hours in the sun without protecting your eyes increases your chances of developing eye disease. UVblocking sunglasses can help protect your eyes from sun damage.
Darker glasses are not necessarily better because UV protection comes from an invisible chemical applied to the lenses, not from the color or darkness of the lenses. Look for an ANSI label. Save Your Vision Month does not only target at-risk groups; everyone at any age can benefit from regular comprehensive eye exams in order to promote healthy eyes! March will also begin a new partnership between The Insurance Trust and the Georgia Optometric Association (GOA), where The Trust health, life and dental benefits will begin to be offered to all GOA members, their staff and families. We are excited to begin this relationship and encourage all of our GPhA members to make an appointment with an optometrist, get a routine eye examination and say hello to our new affiliated friends from GOA. So how are you going to promote Save Your Vision Month?
The ideal sunglasses do not have to be expensive, but they should block 99% to 100% of UVA and UVB radiation. Check the label to be sure they do. Some labels may say, "UV absorption up to 400 nm." This is the same as 100% UV absorption. Also, labels that say "Meets ANSI UV Requirements" mean the glasses block at least 99% of UV rays. Those labeled "cosmetic" block about 70% of the UV rays. If there is no label, don't assume the sunglasses provide any protection.
Source - The America Optemetric Association The Georgia Pharmacy Journal
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GPhA Convention June 20-24, 2009 Sawgrass Golf Resort and Spa, Ponte Vedra Beach, Florida Register Online Today for...
Preserving the Triad GPhA’s 2009 Convention will be held at the Sawgrass Golf Resort and Spa in June. This is a favorite venue of GPhA members. With quick access to the gorgeous beach, a spacious and luxurious hotel and spa, and delicious food, we are assured a relaxing and educational convention. GPhA offers an “early bird” convention rate through the end of April. Hotel rooms fill quickly so make your reservations now and plan to attend the 2009 Convention. Register online at www.gpha.org. GPhA Registration Type GPhA Member GPhA Member with Spouse or Guest and Student Sponsorship GPhA Member with Spouse or Guest GPhA Member with Student Sponsorship Spouse or Guest Only Registration (Does Not Include CE) GPhA Non-Member GPhA Non-Member with Spouse or Guest and Student Sponsorship GPhA Non-Member with Spouse or Guest GPhA Non-Member with Student Sponsorship
Early Bird $295 $660 $535 $420 $240 $470 $835 $710 $595
Sawgrass Golf Resort and Spa, A Marriott Resort www.sawgrassmarriott.com For Resort Reservations call: 1.800.457.4653 Room Block Expires 5/15/2009 so make your reservations today! Single or Double Room $179 Island Green Villa Suite (1 Bedroom and Full Kitchen) $254
5/1-6/1 $320 $710 $585 $445 $265 $495 $885 $760 $620
After 6/1 $345 $735 $610 $470 $265 $520 $910 $645 $645
Convention Registration Fee: includes admittance to CE Sessions, Sunday Opening Dinner, All Refreshments, Exhibits and Entertainment, President’s Reception, Awards Banquet, Coffee/Dessert Reception.
Tentative GPhA Annual Convention Programming HIV/AIDS: The Pharmacists Perspective New Drug Update 2009 Medication Errors Pharmacy Law Update Managing and Monitoring Diabetes *APhA Pharmacy-Based Immunization Delivery Program *additional fee applies Additional details on the tentative programs will be posted to www.gpha.org as they become available. The Georgia Pharmacy Association is accredited by the Accreditation Council of Pharmacy eduction as a provider of continuing pharmacy education. These activities are eligible for ACPE credit; see final CPE activity announcement for specific details.
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GPhA’s February Legislative Update by Stuart Griffin, Director of Governmental Affairs - sgriffin@gpha.org
House Bill 273 – Prescription Drug Monitoring
Senate Bill 123 – Pharmacy Benefits Manager (License and regulate PBMs under the Department of Insurance) Committee Assignment: Insurance and Labor Sponsor: Senator Lee Hawkins (R-Gainesville)
(Creates a database of controlled substances) Committee Assignment: Health and Human Services Sponsor: Representative Ron Stephens (R-Savannah)
SB123 will have its first committee hearing on Tuesday, February 17. Last year we had trouble with a similar licensure bill in the Senate. We have worked hard to iron out the issues and we are confident we have done so. SB123 will provide for the following:
HB273 sets up a central automated database of all controlled substances dispensed in Georgia. This information is presently collected by pharmacists and legally available to Georgia Drugs and Narcotics Agents. The purpose of this bill is to curtail the diversion of controlled substances. No cost to the pharmacist is associated with this program and the database will be accessible to pharmacists and physicians in Georgia.
• License and regulate PBMs under the Department of Insurance • Enforcement of the ‘Pharmacy Audit Bill of Rights’ • Penalize those PBMs involved in the ‘practice of medicine’ GPhA members have done an amazing job of contacting and educating their legislators on the importance of a PBM bill. Please continue reaching out to your elected officials so they will realize how important this type of legislation is to the future of the pharmacy industry.
House Bill 217 – Immunization (Creates protocol of influenza vaccine) Committee Assignment: Health and Human Services Sponsor: Representative Jimmy Pruett (R-Eastman)
Thank You to GoodSense • 2/5/2009, Passed House Health and Human Services Committee • 2/12/ 2009, Passed House Rules Committee
In December, GoodSense gave the Association, free of charge, 350 bottles of 200mg tablets of ibuprofen. Our government affairs department placed a sticker on these bottles that read, “For all of your Legislative Session headaches” and distributed them to all of the Georgia state legislators and their assistants. Compliments have been pouring in from these actions and it looks like we have started a good thing.
HB217 provides for influenza vaccine protocol between a physician and a pharmacist. This bill allows a physician to give protocol to 10 pharmacists located within a bordering county of the signing physician.
GPhA provides weekly updates to the GPhA membership via email. If you would like to receive these updates please email Kelly Mclendon at kmclendon@gpha.org.
It is important for the association to continue these types of activities so legislators can be aware of our presence at the capitol. Please patronize GoodSense for their help in these matters and thank them when you have the opportunity. The Georgia Pharmacy Journal
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GA S PV hE A T UH PE D ADTAET E
Become a part of GPhA’s grassroots team and support your profession!
May 12, 2009 Eggs and Issues Breakfast Washington, D.C. Sign up online at www.gpha.org.
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March 2009
Feature
Story
Philadelphia College of Osteopathic Medicine to Open School of Pharmacy in Georgia
Postsecondary E d u c a t i o n Commission, recruiting of students will commence. The first class of 75 is Mark P. Okamoto, PharmD, has been named dean, chief students academic officer and professor of pharmacy for the expected to begin proposed school. Dr. Okamoto was formerly professor and study in August 2010. Chair at the College of Pharmacy Practice at the University “As with our Georgia-based School of Osteopathic of Hawaii at Hilo. Medicine and graduate biomedical sciences programs, we A native of southern California, Dr. Okamoto also will recruit from Georgia and from southern states, and previously served in a number of academic and leadership establish clinical training sites in the south,” according to positions at Western University in Pomona, California, Okamoto. “Our hope is to retain our graduates for the including Associate Dean for Assessment and Teaching practice of pharmacy in Georgia and in the South.” Effectiveness & Chair of Social & Administrative Sciences. His experience at Western University, home of the College Additional information about admission to the School of of Osteopathic Medicine of the Pacific, gives Dr. Okamoto Pharmacy will be available on the College’s web site a unique perspective on integrating a school of pharmacy (www.pcom.edu) after July 1. within an osteopathic college campus. Dr. Okamoto received his BS degree from the University of California at Georgia Campus - Philadelphia College of Osteopathic Los Angeles and Pharm.D. degree from the University of Medicine is a branch campus of the private, not-for-profit Southern California and has completed 2 post-doctoral Philadelphia College of Osteopathic Medicine, an fellowships in pharmacokinetics and pharmacoeconomics osteopathic medical school built on an over one-hundredat USC. He has a distinguished academic history of year tradition of educational excellence. GA-PCOM offers teaching, administration and research, and comes to both the doctor of osteopathic medicine degree and a PCOM with a most impressive list of peer-reviewed certificate and master’s degree in biomedical science. Doctors of osteopathic medicine take a "whole person" publications and grants. approach to health care, treating patients, not just Should pre-candidate status be received from the ACPE, symptoms." and initial approvals have been received from The Middle States Commission on Higher Education, the Pennsylvania Department of Education and the Georgia Nonpublic he Board of Trustees of Philadelphia College of Osteopathic Medicine has authorized the College to apply to the American Council of Pharmacy Education (ACPE) for approval to begin a four-year School of Pharmacy at the College’s Suwanee, Georgia, campus.
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Technician
News
Pharmacy Technician Certification Board (PTCB) Unveils New Testing Features for 2009 he Pharmacy Technician Certification Board (PTCB) – the pioneer in the certification of pharmacy technicians - announced today that on April 1, 2009, the PTCB Examination will be available in continuous testing format at Pearson Professional Centers nationwide. PTCB also announced that exam candidates will receive an official pass or fail result at the test center after the completion of the exam, effective immediately.
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The PTCB certification program is the only certification endorsed by the American Pharmacists Association (APhA), the American Society of Health-System Pharmacists (ASHP), the National Association of Boards of Pharmacy (NABP) and other professional pharmacy
Financial Planning for Georgia’s Pharmacists
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organizations. The PTCB examination is administered in all 50 states, DANTES testing centers worldwide, and in Guam and Puerto Rico, and is included in the regulations of 30 states. The transition to on-demand, year round exam availability is designed to meet increasing demand from educators, employers and pharmacy technicians. PTCB candidate demographics and numbers have expanded steadily over PTCB’s 14 years as the industry leader in certifying pharmacy technicians. In 2008, PTCB tested over 50,000 pharmacy technicians and has certified 330,425 CPhTs since inception in 1995, through the examination and transfer process. "As industry demand continues to grow and more states like Texas require pharmacy technicians to be PTCB certified as part of the registration process, we recognized the need to evolve our program," said Melissa Murer Corrigan, RPh, Executive Director and CEO of PTCB. "Similar to NAPLEX (the pharmacist licensure exam), pharmacy technicians soon will be able to take the test ondemand and learn their pass/fail status immediately. These new features will support patient safety and enhance customer service." The current quarterly administration of the PTCB examination will conclude on March 31, 2009. Eligible exam candidates applying after April 1, 2009, will be authorized to test immediately, and may schedule an exam appointment in the 90 days following approval. Candidates will continue to schedule examination appointments at any of the over 200 Pearson Professional Centers nationwide and internationally at DANTES testing centers in the continuous testing format. The PTCB national Pharmacy Technician Certification Examination (PTCE) certification program is accredited by the National Commission for Certifying Agencies (NCCA).
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GEORGIA
PHARMACY
SCHOOLS’
NEWS
Mercer University College of Pharmacy and Health Sciences News n January 16, 2009, the Women’s Health Committee of Mercer’s chapter of APhA-ASP held an on-campus event to promote awareness of human papillomavirus (HPV) and cervical cancer. We chose to hold the event on-campus since much of Mercer’s Atlanta campus consists of younger females and the target age group for the Gardasil vaccine is up to age twenty-six. After gathering brochures on cervical cancer and Merck’s vaccine, Gardasil, we were able to prepare information packets to distribute to students on-campus. When students came by, we answered any questions they had about cervical cancer and Gardasil, along with handing out information packages. Our main focus was to tell students that early vaccination and regular Pap tests can make
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cervical cancer one of the most preventable types of cancer. We also put up posters from the National Cervical Cancer Coalition in the pharmacy building to remind students that January is Cervical Health Awareness Month. Surpassing our goal, we were able to reach about 100 students at this event! Cassie Joyce & Neely Cline Women’s Health Committee Co-chairs
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March 2009
GEORGIA
PHARMACY
SCHOOLS’
NEWS
University of Georgia College of Pharmacy News UGA Professors Honored
UGA Professors Present
Marjorie Shaw Phillips, Clinical Professor and Pharmacist Coordinator for Medical College of Georgia Health, was practitioner surveyor for the American Society of Health System Pharmacists-reaccreditation survey of the PGY1 Pharmacy Residency at Riverside Methodist (Ohio Health) in Columbus, Ohio.
James Cooper, Professor Emeritus, presented “Asthma and COPD in the Older Adult” to the Geriatric Education Conference for health care professionals.
Trina von Waldner, Director of Postgraduate Continuing Education, was invited to serve on the Northeast Georgia Mountains Medical Reserve Corps Advisory Board. The mission of the Medical Reserve Corps (MRC) is to improve the health and safety of communities across the country by organizing and utilizing public health, medical and other volunteers. The Gainesville-based MRC as 258 members, including six pharmacists.
Merrill Norton, Clinical Associate Professor, presented the following: “Psychopharmacology Update 2009,” at the Georgia Addictions Counselors Association Pharmacology Symposium, Talbott Recovery Campus, Atlanta; “ What Is the Student Pharmacist Addiction Probability Scale?” at Mercer University College of Pharmacy and Health Sciences, Atlanta; “The Addiction Pharmacy Series: Pain and the Addicted Patient,” at the UGA Mental Health Pharmacotherapy Symposium.
South University School of Pharmacy News outh University’s GPhA chapter has had a few projects over the past month. We had six students attend the GPhA Standing Committee at Lake Lanier in Buford, Georgia. Here, members discussed public relations, academic affairs, government affairs issues, and continuing education. Guest speaker Andy Rogers came to South University to speak to us about Legislative Day (Very Involved Pharmacists Day) which will be on February 18. The Class of 2011 officers were elected early so they can learn more about their roles from the current officers.
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affected by diabetes. Here, people could access up to date information about diabetes while our volunteers provided them with blood pressure readings, BMI screenings, and diabetic foot exams. On January 27, we held our chapter officer elections. We also teamed up our school’s ASHP for health screenings at Parent University on January 31. February looks like it will be just as eventful. This past week, on February 5, we held sushi making class that was open to all South University Pharmacy students. This served as a great social event as well as a successful fundraiser.
On the philanthropic side, The American Diabetes Association hosted Diabetes University on Saturday, January 19, 2008, at The Armstrong Center for all people The Georgia Pharmacy Journal
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March 2009
Thomas A. Gossel, R.Ph., Ph.D. Professor Emeritus Ohio Northern University Ada, Ohio
J. Richard Wuest, R.Ph., Pharm.D. Professor Emeritus University of Cincinnati Cincinnati, Ohio
Gossel
Wuest
Ischemic Stroke: Prevention and Treatment Goals. The goal of this lesson is to
discuss ischemic stroke (cerebrovascular accident) with focus on its clinical characteristics and treatment.
Objectives. At the conclusion of this lesson, successful participants should be able to: 1. recognize epidemiologic information and clinical characteristics relevant to ischemic stroke; 2. identify symptomatology that characterizes ischemic stroke and the principles that govern clinical confirmation and management; and 3. select from a list specific therapeutic measures that are reported to modify signs and symptoms of ischemic stroke. Background
Worldwide, 5.5 million people die each year as a result of stroke. Another 15 million survive, but are disabled. In the United States, the incidence is at pandemic proportions; 700,000 individuals will be stricken annually, with 200,000 of these events being a recurrent event. Each year, about 46,000 more women than men in the United States experience a stroke. When considered separately from other cardiovascular disease, stroke ranks
third among all causes of death in this country, behind heart disease and cancer. The mean lifetime direct cost of ischemic stroke per individual in the United States is estimated to be $140,048.
Pathogenesis of Stroke
Stroke can be caused by localized obstruction of the blood supply into an area of the brain due to its mechanical blockage in an artery (ischemic stroke), or by blood escaping from an artery within the brain (hemorrhagic stroke). It encompasses pathology in both the cerebrovascular and the cardiovascular circulations. Cerebral ischemia resulting from large-vessel atherosclerosis (the most common cause of ischemic stroke) and coronary ischemia share common mechanisms including plaque accumulation within vessel walls, erosion and rupture, inflammation, apoptosis (natural or programmed cell death) and thrombus (clot) formation. Advancing age is a risk factor. Stroke prevalence varies by gender and race (Table 1). Studies have noted relationships between initial stroke, vascular risk factors (e.g., hypertension, diabetes, hyperlipidemia), and lifestyle risk
(e.g., smoking, alcohol use, obesity, lack of physical activity). Factors correlating with recurrent stroke include large artery atherosclerosis, previous multiple strokes, disability after stroke and diabetes mellitus. Ischemic strokes are reported in American Heart Association statistics to account for 87 percent of all strokes. Following ischemia-induced oxygen deprivation, some neurons die within minutes to cause irreversible brain injury. Surrounding the area of necrosis (the infarct) is tissue called the penumbra in which the blood supply is marginally sufficient to maintain minimal cellular activity. In the absence of sufficient blood supplied from adjacent arterioles (reperfusion) or with additional injury, a time-related death occurs to the penumbra and it will be incorporated into the infarct. Hypertension. In humans, changes in blood pressure follow a reproducible pattern over 24 hours that includes a rapid early-morning surge associated with awakening. This response coincides with increased risk for stroke. In a metaanalysis of 31 published reports describing the circadian timing of 11,816 strokes, most events occurred
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Table 1 Prevalence and annual incidence of stroke by gender and race in the United States Population Total Total men Total women White men White women African-American men African-American women Mexican-American men Mexican-American women Hispanic or Latino Asian American Indian/ Alaskan Native
Prevalence (%) 2.6 2.5 2.6 2.3 2.6 4.0 3.9 2.6 1.8 2.2 1.8 3.1
Incidence* 700,000 327,000 373,000 277,000 312,000 50,000 61,000 ---------------------
*Includes new and recurrent strokes Adapted from Dickerson LM, Carek PJ, Quattlebaum RG. Am Fam Physician. 2007;76:282. between 6:00 a.m. and 12:00 noon. A similar variation was noted for different subtypes of stroke: ischemic (n=8,250), hemorrhagic (n=1,801) and transient ischemic attack (TIA) (n=405). It is logical to reason that antihypertensive agents and their dosing schedules should be selected that provide adequate blood pressure control during the early morning hours. The Role of Cholesterol. The linear relationship between serum cholesterol concentration and cardiovascular disease is more clear than that between serum cholesterol concentration and stroke. Most large epidemiologic studies have not separated the various types of stroke in terms of etiology, but have grouped heterogeneous mechanisms into the single category of ischemic stroke, weakening the likelihood of finding a clear association. One investigation reported that serum cholesterol levels higher than 280 mg/dL were associated with increased risk for death from ischemic stroke while
concentrations less than 160 mg/dL were associated with increased risk for hemorrhagic stroke. Other studies demonstrated that cholesterol levels greater than 300 mg/dL were associated with increased risk for non-hemorrhagic stroke. The correlation between cholesterol level and stroke, while hazy, nevertheless associates lipid disorders to the pathogenesis of atherosclerosis in both cardiovascular and cerebrovascular disease and, as mentioned earlier, is noted as the primary cause of ischemic stroke.
Transient Ischemic Attack
Transient ischemic attack (TIA) is common with 300,000 events occurring annually in the United States. A TIA (“mini-stroke,” “smallstroke”) is experienced as a temporary focal (localized) neurologic deficit. The most common symptom is sudden onset of muscular weakness affecting one side of the body (hemiparesis). A sensation of numbness on one side of the body (hemiparesthesia), inability to speak
clearly and/or imbalance, along with blurred vision or blindness in one eye and double vision (diplopia) are others. The focal and temporary nature of symptoms differentiates TIA from ischemic stroke. Lack of clear distinction between these afflictions with regard to other symptoms has led to the emphasis of a single criterion: TIA symptoms last less than 24 hours, typically only a few minutes. This short duration, followed by complete recovery and absence of neurologic deficit on examination, makes TIA particularly challenging. Numerous prospective, observational studies have shown that following TIA, patients are at extremely high risk for a full-blown stroke. In one study of more than 1,700 patients who appeared in an emergency department with TIA, the 90-day risk of stroke was 10.5 percent. This was a 50-fold greater risk than expected for an age-matched cohort of persons without TIA. The risk of stroke was front-ended with over half of the secondary events appearing within the first two days. Twenty-one percent of the stroke victims died and another 64 percent were disabled. From these data it was concluded that for every 100 patients with TIA, 2.2 would die and 6.7 would be disabled within three months as a result of stroke. The most urgent need for a patient with symptoms suggesting TIA or stroke is to identify the nature of the event, whether ischemic or hemorrhagic. Even though symptoms of TIA may have abated before initial consultation, a thorough history and examination can illuminate whether the patient has experienced similar events previously. It can also yield a preliminary assessment of risk factors and possible etiology. Since symptoms are transient and may have nonischemic causes such as seizure and syncope, and since physicians rarely actually observe a patient during a TIA, it is often difficult if not impossible to confirm a
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diagnosis on the spot. Agreement between independent observers on TIA diagnosis is reported to be poor even among neurologists.
Atrial Fibrillation
Atrial fibrillation is a signature disorder of aging, with a prevalence of about 5 percent in persons aged 65 years and older and approximately 10 percent of those over the age of 80. With prevalence increasing, partly because of an aging population, it is projected that by year 2050 there will be an estimated 5.6 million people in the United States with atrial fibrillation, about half of them being over 80 years of age. Atrial fibrillation increases the risk of ischemic stroke by approximately five-fold and is the cause of an estimated 15 percent of all ischemic strokes in the United States. This proportion is even higher, approxmately 24 percent, in persons aged 80 to 89 years. The prevention of atrial fibrillation-related stroke is an important public health concern since strokes occurring from atrial fibrillation result in higher mortality and disability. Warfarin is highly effective in preventing atrial fibrillation-related stroke, reducing stroke risk by about 68 percent and mortality by 33 percent, and it also appears to prevent the most severe type of ischemic stroke. However, because elderly patients have both the highest risk for stroke without warfarin and the highest risk for hemorrhage with it, maximizing anticoagulation therapy while minimizing toxicity is a central challenge for its use in these persons. The drug’s narrow therapeutic window and associated hemorrhagic toxicity can make anticoagulation management difficult. Optimal anticoagulation intensity, measured by the International Normalized Ratio (INR), is between 2.0 and 3.0. Low fixed-dose warfarin is ineffective in preventing strokes, although clinicians may settle for lower INRs in older patients. INR values under 2.0 significantly increase the risk for stroke. Older patients are less likely than younger ones to receive
anticoagulation therapy and more likely to receive insufficient doses. Aspirin provides some protection from stroke in persons for whom warfarin is contraindicated. Although aspirin reduces stroke risk by about 21 percent and has fewer hemorrhagic complications than warfarin, a randomized trial comparing the two treatments in persons between the ages of 80 and 90 years showed that more patients discontinued aspirin therapy compared with warfarin, mostly due to gastrointestinal side effects. The warfarin arm of the Atrial Fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE-W) study showed warfarin to be superior to combined clopidogrel (Plavix) plus aspirin with similar rates of hemorrhagic complications. Investigations into other antithrombotic agents continue; for now however, warfarin remains the most effective drug to prevent stroke in patients with atrial fibrillation.
Symptoms and Confirmation of Acute Ischemic Stroke
Acute stroke is characterized by the sudden onset of a focal neurologic deficit, although some patients experience a stepwise or gradual progression of symptoms. Common deficits include impaired speech (dysphasia), defective vision or blindness in half of the visual field (hemianopia), weakness, ataxia and sensory loss. Signs and symptoms are typically unilateral, and consciousness is generally normal or only slightly impaired. Persistence of any neurological deficit beyond two hours, even if the patient subsequently recovers, nearly always is accompanied by some degree of tissue destruction. Ischemic stroke cannot be distinguished with certainty from intracerebral hemorrhage on the basis of signs and symptoms alone. In all patients with suspected stroke, computed
tomography (CT, CAT scan) or magnetic resonance imaging (MRI) of the brain is necessary. Both CT and MRI have a high sensitivity for acute intra-cranial hemorrhage, but MRI has a much higher sensitivity than CT for acute ischemic changes, especially in the first hours after an ischemic stroke.
Prevention and Treatment
Patients with a history of ischemic stroke and/or TIA are high risk for subsequent cerebrovascular and cardiovascular events. Current guidelines for prevention support the aggressive modification of risk factors, including smoking cessation, reduction in alcohol consumption for heavy drinkers, weight reduction, antihypertensive therapy and rigorous control of blood glucose. Four antiplatelet agents have been shown to reduce the risk for recurrent ischemic stroke: aspirin, ticlopidine, clopidogrel, and dipyridamole. These are discussed subsequently. Treatment of Acute Ischemic Stroke. Responses from numerous clinical trials are in agreement that patients who receive care in a primary stroke center are more likely to survive, regain independence and return home than are those who do not receive such specialized care. Once ischemic stroke has been confirmed, the next step is to determine whether the patient might be a candidate for thrombolysis therapy. Acute thrombolysis is the most promising approach to treat acute stroke. Intravenous Thrombolysis with a Recombinant Tissue Plasminogen Activator (rt-PA). Despite FDA approval more than a decade ago and the fact that alteplase (Activase) is currently the only approved rt-PA treatment for this condition, alteplase reportedly remains underused in the United States. In one study, 69 percent of hospitals did not use thrombolysis at all. In hospitals that did (mostly those with a high volume of stroke patients), only 1 percent of stroke patients received
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thrombolysis. Other estimates are that 6 to 8 percent of ischemic stroke patients are potentially eligible for rtPA based on published criteria, but only 3 to 4 percent receive it. The National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator (NINDS rt-PA) Stroke Study was a multicenter, randomized trial that demonstrated efficacy of treatment with intravenous alteplase started within three hours after onset of symptoms. Thirty-one to 50 percent of 624 patients receiving alteplase at a dose of 0.9 mg/kg of body weight, 10 percent of the dose given as a bolus and the remainder infused over one hour at a maximum total dose of 90 mg, had a favorable neurologic or functional outcome at three months, compared with 20 to 38 percent of patients given placebo. Symptomatic intracerebral hemorrhage occurred in 6.5 percent of patients receiving intravenous 4 rtPA and in 0.6 percent of controls. Intracerebral hemorrhage following thrombolysis is higher in patients with increased age and those with more severe strokes. Similar concerns have been voiced about the efficacy and safety of routinely using rt-PA in patients with early ischemic changes on CT. Further analysis of data from the NINDS rt-PA Stroke Study showed that in the first three hours after onset of symptoms, the appearance of ischemic changes on CT was not an independent predictor of increased risk of symptomatic intracerebral hemorrhage or other adverse outcomes following treatment with rt-PA. Several studies have concluded that intravenous thrombolysis with rt-PA can be used in the community hospital setting with efficacy and safety similar to that found in the randomized trials. The effect of aspirin in combination with rt-PA is unknown, so it is recommended that aspirin be withheld for 24 hours in patients treated with intravenous thrombolysis. Neither dipyridamole nor clopidogrel have been tested in
randomized trials in the acute phase of ischemic stroke. Anticoagulants. A meta-analysis of six randomized trials involving 21,966 patients found no evidence that anticoagulants (unfractionated heparin, low-molecular-weight heparins, heparinoids, thrombin inhibitors, or oral anticoagulants) administered during the acute phase of stroke improve functional outcomes. While their use does not improve overall functional outcomes, subcutaneously administered lowdose unfractionated heparin or lowmolecular-weight heparin has been recommended in patients at high risk for deep venous thrombosis, such as those who are immobile. The use of heparin in patients with ischemic stroke, even progressing stroke, remains controversial. HMG-Co A Reductase Inhibitors. These drugs (also called “statins�) reduce stroke risk in persons with hyperlipidemia and are a powerful tool in stroke prevention. Non-statin lipid-lowering agents are not associated with decreased risk. The mechanism for statins is probably multifactorial. Reducing LDLcholesterol levels is a benefit, but other actions may also be at play. These include effects on endothelial function, cell proliferation, inflammatory response, immunologic reactions, platelet function, and lipid oxidation. Statins have also been shown to prevent atrial fibrillation in patients in a number of different circumstances. One possible explanation may be that they reduce inflammation since markers such as C-reactive protein, which is increased in atrial fibrillation, are reduced by high doses of statins. Statins may also have independent neuroprotective effects since their use is associated with improved outcomes and functional capacity in patients who have experienced ischemic strokes.
Secondary Stroke Prevention
Recurrent stroke prevention is a high
public health priority due to resultant morbidity and mortality, as well as the healthcare costs associated with disability. The majority of strokes in the United States are noncardioembolic ischemic events, so antiplatelet agents are the recommended first-line therapy for secondary stroke prevention. Aspirin. Patients with a history of ischemic stroke treated with aspirin have a lower risk of stroke and death, compared with placebo. Both lowdose (50 to 166 mg/day) and highdose (325 mg/day) regimens are similarly effective in preventing vascular events. Higher doses are associated with more gastrointestinal side effects and bleeding episodes. Specifically, patients receiving more than 200 mg/day for at least one month have more gastrointestinal bleeding, fatal or life-threatening bleeding and total bleeding episodes compared with persons receiving less than 100 mg/day. The overall risk for major bleeding associated with aspirin (75 to 500 mg/day) is small. Clopidogrel. Clopidogrel (Plavix) is approved for prevention of recurrent vascular events (MI, stroke, vascular death). In one randomized controlled trial, persons with recent ischemic stroke, MI or symptomatic peripheral arterial disease received clopidogrel (75 mg) or aspirin (325 mg) daily for two years. There was a statistically significant difference in effectiveness (although of borderline clinical significance) with clopidogrel compared with aspirin (5.32 vs. 5.83 percent risk of ischemic events). Clopidogrel has been studied in combination with aspirin for prevention of recurrent stroke; however, the combination therapy is not recommended in patients with a history of stroke. In one trial, more than 7,000 patients with previous stroke received clopidogrel (75 mg) plus aspirin (325 mg) or clopidogrel alone for 18 months. Combination therapy was not superior to clopidogrel monotherapy in preventing secondary ischemic
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stroke, MI, vascular death or rehospitalization for ischemic events. The combination regimen did increase the risk of life-threatening bleeding and major bleeding. Dipyridamole and Aspirin. Extended-release dipyridamole and aspirin are available in a combination product (Aggrenox) approved for prevention of recurrent stroke. In one trial, 6,602 patients receiving dipyridamole (200 mg twice daily) plus aspirin (25 mg twice daily) experienced a lower risk of ischemic stroke and TIA over the two-year period compared with aspirin alone. Combination therapy did not increase the risk of major or minor bleeding. Ticlopidine. In various studies comparing ticlopidine (Ticlid) with aspirin, the antiplatelet has shown both greater and lesser activity than aspirin in reduction of risk for secondary stroke. Ticlopidine is not typically chosen for first-line use because it carries a small risk for severe neutropenia and is associated with a risk of thrombotic thrombocytopenia purpura. This is a rapidly fatal or occasionally protracted disease due 5
to formation of fibrin or platelet clots considered. For weight reduction to a in arterioles and capillaries of many goal body mass index under 25 kg/m2 organs. and waist circumference less than 35 inches for women and less than 40 Risk Factor Reduction in Persons inches for men, patients should be with Cerebrovascular Disease. The encouraged to engage in physical Seventh Report of the Joint National activity for at least 30 minutes most Committee on Prevention, Detection, days of the week. Evaluation and Treatment of High Blood Pressure (JNC 7) recommends Summary and Conclusions maintaining a blood pressure goal of Atrial fibrillation is a common less than 140/90 mmHg. The affliction of older adults and a major American Heart risk factor for stroke. Its management Association/American Stroke is directed at preventing Association guidelines recommends thromboembolism with warfarin, as slowly reducing the blood pressure to well as controlling the heart rate and goal level. These guidelines state that rhythm. Regardless of extent or hypercholesterolemia should be duration of acute effects, TIA is a managed according to National prodrome (warning sign) for ischemic Cholesterol Education Panel stroke and carries the risk for guidelines. Statins should be used to secondary stroke comparable to that achieve an LDL-cholesterol level associated with ischemic stroke. under 100 mg/dL, or less than 70 Pharmacologic and mg/dL for patients with multiple risk nonpharmacologic interventions factors. Other lifestyle aimed at reducing the risk of recommendations include smoking secondary stroke should, therefore, be cessation with reduction or initiated as soon as possible after the elimination of alcohol consumption. initial event. Patients who are heavy drinkers (more than five drinks/day) should eliminate The content of this lesson was or reduce their consumption; light to developed by the Ohio Pharmacists moderate intake (fewer than two Foundation, UPN: 129-000-08-011drinks/day for men and one/day for H01-P. Participants should not seek nonpregnant women) may be credit for duplicate content.
dâ|Ê
Ischemic Stroke: Prevention and Treatment 1. The most common cause of ischemic stroke is: a. deep vein thrombosis. c. myocardial infarction. b. large-vessel atherosclerosis. d. variant angina. 2. The tissue surrounding the area of necrosis following ischemia-induced cell death due to oxygen deprivation is called the: a. thrombus. c. penumbra. b. tamponade. d. plaque. 3. A meta-analysis of 31 published reports found that most strokes occur between: a. 12 noon and 6 p.m. c. 12 midnight and 6 a.m. b. 6 p.m. and 12 midnight. d. 6 a.m. and 12 noon. The Georgia Pharmacy Journal
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4. The linear relationship between serum cholesterol concentration and cardiovascular disease is: a. more clear than that between serum cholesterol concentration and stroke. b. less clear than that between serum cholesterol concentration and stroke. 5. The most urgent need for a patient with symptoms suggesting TIA or stroke is to identify the: a. nature of the event. c. renal perfusion rate. b. patient’s blood type. d. serum cholesterol levels.
March 2009
6. The most effective drug to use to prevent stroke in patients with atrial fibrillation is: a. aspirin. c. heparin. b. digoxin. d. warfarin.
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7. A patient with dysphasia is experiencing impaired: a. body movements. c. speech. b. breathing. d. swallowing. 8. The effect of aspirin in combination with rt-PA is best described as: a. effective. c. ineffective. b. unknown.
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9. All of the following are true EXCEPT: a. the use of heparin in patients with ischemic stroke, even progressing stroke, remains controversial. b. HMG-CoA reductase inhibitors reduce stroke risk in persons with hyperlipidemia. c. patients with a history of ischemic stroke treated with aspirin have a lower risk of stroke and death, compared with placebo. d. combination therapy with clopidogrel plus aspirin is superior to clopidogrel monotherapy in preventing secondary ischemic stroke.
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10. In patients with multiple risk factors, the National Cholesterol Education Panel guidelines state that statins should be used to achieve an LDL-cholesterol level under: a. 70 mg/dL. c. 50 mg/dL. b. 60 mg/dL. d. 40 mg/dL. The Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Ischemic Stoke: Prevention and Stroke Volume XXVI, No. 11 This lesson is a Knowledge Based CPE Activity and is targeted to pharmacists in all practice settings. GPhA Code J09-03 Program Number: 142-999-09-003-H01-P CE Hours: 1.5 (0.15 CEUs) Release Date: 3/5/2009 Expiration: 11/15/2011
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2008 - 2009 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 © 2009, 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 nonmembers 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.
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The Georgia Pharmacy Journal
Position
Sharon Sherrer Robert C. Bowles Eddie Madden Dale Coker Jack Dunn Jim Bracewell Burnis Breland Hugh Chancy Judy Gardner Keith Herist John McKinnon Andy Rogers Tommy Whitworth Alex Tucker Tony Singletary Renee Adamson Bill McLeer Shobhna Butler Bobby Moody Pam Marquess Larry Batten Alissa Rich Chris Thurmond Marshall Frost Ken Eiland Rusty Lee Liza Chapman Debbie Nowlin Tim Short Michelle Bishop Hillary Volsteadt John T. Sherrer Michael Farmer Fred Sharpe
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
Cynthia Pangburn Gina Ryan Meagan Spencer Rusty Fetterman Rebecca Cubbedge Brian Buck Kyle Burcher
GPhA HEADQUARTERS 50 Lenox Pointe, NE Atlanta, Georgia 30324 Office: 404.231.5074 Fax: 404.237.8435
Name
30
March 2009
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Georgia Pharmacy Journal速 50 Lenox Pointe, N.E. Atlanta, Georgia 30324