The Kentucky Pharmacist Vol. 8 #1 by Kentucky Pharmacists Association

Y K C U T N E K E H T T S I C A M PHAR

Want to serve YOUR KPhA on the Board of Directors?

Vol. 8, No. 1 January 2013

Have a deserving potential Bowl of Hygeia winner in mind? Information on Awards nominations and Board of Director elections. Pages 9-11

KPhA Mid Mid--Year Conference on Legislative Priorities and Emergency Preparedness More photos and information on Pages 4-5. All continuing education credit will be uploaded to CPE Monitor. Quizzes submitted without NABP eProfile ID number and birthdate will not be accepted. Visit www.mycpemonitor.net for more information and to check your credit. News & Information for Members of the Kentucky Pharmacists Association

Table of Contents

January 2013

Table of Contents Table of Contents— Oath— Mission Statement President’s Perspective 2012 KPhA Mid-Year Conference KPPAC and KPhA Government Affairs Report 135th KPhA Annual Meeting Save the Date 2013 KPhA Professional Awards KPhA Emergency Preparedness Initiative January 2013 CE—HIV January Pharmacist/Pharmacy Tech Quiz Senior Care Corner AB Rating Scale KPhA New Members

Message from Your Executive Director Continuing Education Article Guidelines February 2013 CE—Constipation Treatment February Pharmacist/Pharmacy Tech Quiz Bowl of Hygeia Pharmacy Law Brief APSC/HD Smith Pharmacy Policy Issues Kentucky Renaissance Pharmacy Museum Pharmacists Mutual Cardinal Health Foundation Generation Rx Award KPhA Board of Directors 50 Years Ago/Frequently Called and Contacted

2 3 4 6 8 9 12 13 18 19 20 22

23 24 25 30 31 32 33 34 35 36 37 38 39

Oath of a Pharmacist At this time, I vow to devote my professional life to the service of all humankind through the profession of pharmacy. I will consider the welfare of humanity and relief of human suffering my primary concerns. I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy outcomes for the patients I serve. I will keep abreast of developments and maintain professional competency in my profession of pharmacy. I will embrace and advocate change in the profession of pharmacy that improves patient care. I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.

The Kentucky Pharmacy Education and Research Foundation (KPERF), established in 1980 as a non-profit subsidiary corporation of the Kentucky Pharmacists Association (KPhA), fosters educational activities and research projects in the field of pharmacy including career counseling, student assistance, post-graduate education, continuing and professional development and public health education and assistance.

Kentucky Pharmacists Association The mission of the Kentucky Pharmacists Association is to promote the profession of pharmacy, enhance the practice standards of the profession, and demonstrate the value of pharmacist services within the health care system.

It is the goal of KPERF to ensure that pharmacy in Kentucky and throughout the nation may sustain the continuing need for sufficient and adequately trained pharmacists. KPERF will provide a minimum of 15 continuing pharmacy education hours. In addition, KPERF will provide at least three educational interventions through other mediums — such as webinars — to continuously improve healthcare for all. Programming will be determined by assessing the gaps between actual practice and ideal practice, with activities designed to narrow those gaps using interaction, learning assessment, and evaluation. Additionally, feedback from learners will be used to improve the overall programming designed by KPERF.

Editorial Office: © Copyright 2013 to the Kentucky Pharmacists Association. The Kentucky Pharmacist is the official journal of the Kentucky Pharmacists Association published bimonthly. The Kentucky Pharmacist is distributed to KPhA members, paid through allocations of membership dues. All views expressed in articles are those of the writer, and not necessarily the official position of the Kentucky Pharmacists Association. Editorial, advertising and executive offices at 1228 US 127 South, Frankfort, KY 40601. Phone 502.227.2303 Fax 502.227.2258. Email ssisco@kphanet.org. Website http://www.kphanet.org.

THE KENTUCKY PHARMACIST

President’s Perspective

Kimberly Sasser Croley KPhA President 2012-2013

As we continue our journey through “Relevance and Relationships”, I wanted to share with you more of the opportunities I have been given to represent KPhA on your behalf. The three opportunities I have chosen to tell you about are different in some respects but all share the ability to show the importance of “Relevance and Relationships” and add the dimension of “Resolutions”. You know how it goes every January 1st; we all make “New Year’s Resolutions” that are going to set our goals and keep us on track. I hope at the end of this article, you will be ready to make your “Pharmacist Resolutions”. First, I had the opportunity to attend the White Coat Ceremony for SUCOP. It is a little different from the ceremony at UKCOP but still just as meaningful and heartwarming. Family members were in attendance to see their loved ones receive their White Coats and join the ranks of a professional. The special guest speaker for the day was Bill Ellis formerly of the APhA Foundation and now the head of BCS. He spoke of the heavy yoke of responsibility that wearing the coat represented and that each of the student pharmacists there needed to make a resolution to do nothing that would tarnish their White Coat. I was able to have my picture made with the student pharmacists, Dean Tran,

January 2013 and Bill Ellis on the front step of the Olmstead, the venue for the program. I did not have the opportunity to speak with the students but I hope they all found out who the woman in the Red coat was and that she was thrilled to take part in their special day. Secondly, I was invited to speak for the PLS CLASS group at UKCOP. This is an event that PLS puts on for the firstyear class to build leadership skills and hopefully entice them to take on leadership roles within the college. I talked about different aspects of leadership and different types of leaders, and I hope I was able to help them see that they all can make a resolution to be a leader. I left them with the thought that all pharmacists are leaders every day as they “lead” their patients through the maze that healthcare and medication use often represents. Lastly, I was the replacement speaker at convocation at UKCOP. Their main topic of interest was the legislative agenda for this year’s session, and how they might become more involved in the process. We discussed several issues on both the federal and state levels, including the current petition to achieve provider status for pharmacists and the potential for expanding practice roles for pharmacists that could come with that. I reminded them of our role as the medication expert but cautioned them that many people do not have the same picture of our role and consider us expendable in the grand scheme of things. I reminded them that we must remain vigilant in our protection of the pharmacy profession because nobody else will. I warned them that Apathy is the root of many of our current issues within the profession, and that we must make a resolution to replace Apathy with enthusiasm and ingenuity. We must all make a Resolution to replace Apathy with Advocacy both within ourselves and to those outside the profession. We are the medication experts. We work in community pharmacies and see our patients daily, weekly, monthly. They rely on us because of the Relationships we have cultivated with them and the Relevance of the work that we do on their behalf. Relevance + Relationships + Resolutions = Pharmacist Power KPhA staff asked me to remind our wonderful members that a small dues increase was voted on and approved during the 134th KPhA Annual Meeting in 2012. I told staff I would be happy to remind everyone of this information and I asked them to research the last time that a dues increase had occurred. Imagine my astonishment when the information came back to me that in 1997 (the year I was elected PresidentElect the first time), the House of Delegates voted on and approved a dues increase from $150 to $210 for Active Membership. Fast forward to 2012 (the year I became President for the second time) where the House of Delegates ratified a dues increase from $210 to $225. I am not entirely sure what kind of statement that makes about my presidencies but at least the increase in dues this time was very small! I do promise that we will put the money to good use!!

THE KENTUCKY PHARMACIST

2012 KPhA Mid-Year Conference

January 2013

2012 Mid-Year Conference on Legislative Priorities and Emergency Preparedness Attendees at the 2012 KPhA Mid-Year Conference expanded their knowledge of the legislative process, learned how they can impact change in legislative issues and how pharmacists can impact the lives of patients in a disaster situation. The attendees included 248 student pharmacists from the UK and Sullivan Colleges of Pharmacy. The KPhA House of Delegates also met during the event, and approved the following legislative priorities for the 2013 Kentucky Legislative Session. Legislative Priorities where KPhA will provide Active Leadership: Fitting of Therapeutic Shoes for Diabetics by Technicians—work to amend KRS 319B.909. Seek legislation to maintain and preserve the ability of pharmacy technicians and pharmacist interns to assist pharmacists in the fitting of diabetic shoes. Include “emergency clause” to make it effective on passage.

Top: Jan Gould, Senior VP-Government Affairs for the Kentucky Retail Federation, presents on Legislative Advocacy. Above: Sen. Julie Denton receives the KPhA Meritorious Service Award from KPhA Chair Lewis Wilkerson and President Kim Croley. Left: Participants renewed their CPR certification during a pre-conference event. Opposite Page: Almost 250 student pharmacists attended the event from UK (top) and Sullivan University.

THE KENTUCKY PHARMACIST

2012 KPhA Mid-Year Conference

January 2013

PBM Pricing Transparency (as it relates to MACs). Seek legislation requiring PBM transparency as it relates to drug pricing reimbursement. Keep it simple. Focus on notification/disclosure (not on methodology of setting MACs); require posting of a NDC that is available at that price or below. Research and use alternative language to “MAC”, i.e., drug product reimbursement, to better inform and educate our elected officials about “maximum allowable costs.” Look at remedy to underpricing by prohibiting contracts from requiring pharmacies to dispense products below the cost of reimbursement unless the contract also contains a provision that permits pharmacies to retroactively re-bill after the cost is adjusted.

Top photo by Dave Melanson, UKCOP

Proposed Revisions to Collaborative Care Agreements: Support Board of Pharmacy/Advancing Pharmacy Practice of Kentucky Coalition’s efforts to amend KPhA will oppose legislation collaborative care agreement to require dispensing of language in KRS Chapter 315 tamper-proof opioids exclu- to allow collaborative care sively. agreements to be expanded Legislative Priorities where among multiple pharmacists, prescribers and patients. KPhA Support Partners: KPhA will look to support legislative efforts from our Partners or other Stakeholders on these issues: Amendments to SS2012 HB 1: Seek revision to HB 1 to repeal KASPER reporting of Schedule II and Schedule III drugs containing hydrocodone by hospital and long term care pharmacies. KPhA believes this effort will be led by legislators on the HB1 Implementation Committee.

Pseudoephedrine: Support legislation offered by the Office of Drug Control Policy to clarify that written logs can continue to be used to verify the sale of PSE. Specialty Drugs: Support legislation offered by EPIC to define and level the playing field for pharmacy participation in contracts for specialty drugs. This effort may center on requiring a study—EPIC to keep KPhA informed.

KPhA Thanks the 2012 Mid-Year Conference Sponsors American Pharmacy Cooperative Inc. American Pharmacy Services Corporation Kentucky Health Information Exchange National Association of Chain Drug Stores Richard and Zena Slone Sullivan University College of Pharmacy

THE KENTUCKY PHARMACIST

KPPAC and Government Affairs

January 2013

2012 KPPAC and KPhA Government Affairs Report The KPhA House of Delegates met on November 30, 2012 and established our legislative priorities for the 2013 legislative session. While the legislature convenes in January, the real work of the session will be accomplished in February. This is an important time of year for the profession as legislators consider proposals that could affect every practice setting of pharmacy. Your paid annual membership, financial support of KPhA Government Affairs work and individual contributions to the Kentucky Pharmacists PAC (KPPAC) make it possible for KPhA to maintain an influential presence in Frankfort and to represent your interests.

you might ask? Funds contributed to KPhA Government Affairs are applied directly to our lobbying efforts in terms of staffing and contracted lobbying services; on the other hand, KPPAC uses its contributions externally to support state candidates who are advocates for our profession and who promote pharmacy-friendly legislation. We would like to challenge you to join us in contributing on a regular basis to both the KPHA Government Affairs Fund and to KPPAC. Maintaining strong relationships with our legislators, governor and health care stakeholders keep YOUR KPhA relevant in policy discussions and actions. Thank you for doing your part at all levels.

Your engagement is the key to success. Individually, you make a difference by dialoguing with your state senator and representative. Collectively, you make a difference by making a financial contribution to both the KPhA Government Affairs Fund and to KPPAC. Whatâ&#x20AC;&#x2122;s the difference

2012 Government Affairs Contributors $1,000 and above Richard K. Slone, Hindman

$200-$999 Kim S. Croley, Corbin Darren G. Lacefield, Bowling Green Robert L. Lester, Elkhorn City Benjamin C. Scott, Lexington Rick Slone, Jr., Lexington

$199 and below Franklin J. Abner, Barbourville Sandra F. Anderson, Monticello G. Timothy Armstrong, Mt Washington Patrick J. Ary, Grove City, Ohio Victoria M. Bond, Louisville Charlotte L. Bowling, London Amanda Burton, Danville C. Joseph Carr, Owensboro Timothy P. Castagno, Louisville William A. Conyers III, Glasgow Paul M. Cooper, Morehead James E. Dunaway, Henderson Jackie G. Evans, Gray Mary Ann Fricke, London Len Gore, Nicholasville Richard E. Griffieth, Lexington Charles Gross, Hazard Michael Hall, Danville George F. Hammons, Barbourville Jeffrey W. Harrison, Tompkinsville Emily Henderson, Shelbyville

Richard Slone, Chair, Government Affairs Committee Matt Carrico, Chair, Kentucky Pharmacists Political Action Committee

Gregory S. Hines, Bowling Green Jan Houchens, London Tom M. Houchens, London Karen Hubbs, Gray Sherrie Hyman, Louisville James D. Koontz, Crestwood Donald Kupper, Crestwood Thomas R. Lawrence, Carlisle John R. Lutz, Louisville Thomas G. McConnell, Kuttawa David Doug Morgan, Manchester Johnny P. Nixon, Tompkinsville Paul Wendell Nixon, Tompkinsville Patrick Noonan, Louisville Robert Oakley, Louisville Peter J. Orzali, Jr., Cold Spring David Parrino, Louisville George H. Patterson, Jr., Gilbertsville Walter W. Powell, Louisville James E. Ray, Hopkinsville Ronald Renfrow, Bowling Green C. Levi Rice, Jr., Beaver Dam Eugene Carroll Riley, Jr., Russellville Denise Robison, Louisville Phillip Sandlin, Louisville Larry K. Schaefer, Madisonville Terrence J. Seiter, Burlington William David Smallwood, Independence Glenn W. Stark, Frankfort Donnie K. Starnes, Pikeville Sandra Rose Staton, Albany Patrick Sumner, Louisville Joanne Taheri, Louisville

Neil Taylor, Hardinsburg Deborah Thorn, Bowling Green Joel C. Thornbury, Pikeville Patricia H. Thornbury, Lexington Sandra P. Thornbury, Dorton Leah Tolliver, Lexington Terry W. Vest, Russell Carol C. Wills, Lexington Christine E. Windham, London David Wren, Louisville

2012 KPPAC Contributors $1,000 and up Leon Claywell, Bardstown Richard & Zena Slone, Hindman $100 to $999 Chelsea Hamilton, Louisville Mike Lusk, Betsy Layne Judy & Dan Minogue, Louisville Ron Poole, Central City Jerry Rickard, Madisonville Kent Shearer, Albany Rick Slone, Jr., Lexington Patricia H. Thornbury, Lexington Jerry White, Russellville $50 and below Margaret Christopher, Winchester Stephen Dean, Brooksville Linda Gormley, Villa Hills Robert T. Walker, Owenton Ron Whitmore, Alvaton

THE KENTUCKY PHARMACIST

KPPAC and Government Affairs

January 2013

KPPAC Contribution Name: _________________________________ Pharmacy: __________________________________________ Address: _________________________ City: ___________________ State: _________ Zip: ____________ Phone: ________________ Fax: __--_______________ E-Mail: ______________________________________ Contribution Amount: $_________ Check ____ (make checks payable to KPPAC)

Mail to: Kentucky Pharmacists Political Advocacy Council, 1228 US Highway 127 South, Frankfort, KY 40601

CONTRIBUTION LIMITS The primary, runoff primary and general elections are separate elections. The maximum contribution from a PAC to a candidate or slate of candidates is $1,000 per election. Individuals may contribute no more than $1,500 per year to all PACs in the aggregate. In-kind contributions are subject to the same limits as monetary contributions.

Cash Contributions: $50 per contributor, per election. Contributions by cashierâ&#x20AC;&#x2122;s check or money order are limited to $50 per election unless the instrument identifies the payor and payee. KRS 121.150(4) Anonymous Contributions: $50 per contributor, per election, maximum total of $1,000 per election. (This information is in accordance with KRS 121. 150)

KPhA Government Affairs Contribution Name: ______________________________________________________________

Pharmacy: ___________________________________________________________ Email: ______________________________________________________________ Address: _____________________________________________________________ City: _______________________________________________ State: _________ Zip: ____________ Phone: ________________ Fax: __--_______________ E-Mail: ______________________________ Contribution Amount: $_________ Check ____ (make checks payable to KPhA Government Affairs) Credit Card (AMEX; Discover; MasterCard; VISA) Account #: ____________________________________________________ Expiration date: _______ Address to which credit card statement is mailed (if different from above) ___________________________________________________________________________________

Mail to: Kentucky Pharmacists Association, 1228 US Highway 127 South, Frankfort, KY 40601

THE KENTUCKY PHARMACIST

135th KPhA Annual Meeting

January 2013

135th KPhA Annual Meeting June 6 6--9, 2013 Louisville Marriott Downtown

Nominate your peers for a new feature in

The Kentucky Pharmacist We are looking for members to profile in coming editions of The Kentucky Pharmacist who are making the world a better place. Do you know someone who goes above and beyond the “above and beyond the call of duty”? Let us know! Email Scott Sisco at ssisco@kphanet.org with a brief description of the story or to schedule a time to discuss.

THE KENTUCKY PHARMACIST

2013 KPhA Professional Awards

January 2013

2013 KPhA Professional Awards The Kentucky Pharmacists Association annually recognizes individuals from across the Commonwealth that exhibit exceptional service to patients and their community, continuously promote the profession of pharmacy, and demonstrate innovative pharmacy practice. The KPhA Organizational Affairs Committee is accepting nominations for the professional awards below: Bowl of Hygeia

Distinguished Service Award

Pharmacist of the Year

Professional Promotion Award

Young Pharmacist of the Year

Excellence in Innovation Award

Technician of the Year

Cardinal Health Generation Rx Champions Award

To nominate an individual, please submit a letter of nomination including the award information and the nominee’s accomplishments with regard to the award criteria. Multiple letters of support are accepted and highly encouraged. Individuals and recognized pharmacy organizations in Kentucky are encouraged to submit nominations. Individual nominators need not be a member of the Association; however, pharmacist and technician nominees must be a member of KPhA. Nominations: Nominations may be submitted electronically to Scott Sisco at ssisco@kphanet.org or mailed to KPhA, Attn: Scott Sisco 1228 US 127 South, Frankfort, KY 40601 no later than March 31, 2013. The KPhA President, President-Elect, and the Chairman of the Board, participating in any voting for awards shall not be eligible for nomination or selection for any award. Conferral of any of the awards of the Association shall be at the discretion of the Organizational Affairs Committee and is not mandatory on an annual basis.

2013 KPhA Professional Award Criteria and Past Recipients Bowl of Hygeia Award Criteria – To recognize an individual who has demonstrated outstanding community service in pharmacy. Eligibility – The recipient must be an Active or Honorary Life member of the Association. The recipient must be a pharmacist with a current valid license to practice in Kentucky. The recipient must be living, awards are not presented posthumously. The recipient has not previously received the award and is not currently serving nor has he/she served within the past two years on the selection committee or as an officer of the Association in other than ex-officio capacity. The recipient has compiled an outstanding record of community service that apart from his/ her specific identifications as a pharmacist reflects well on the profession.

Patricia Thornbury Dave Peterson Charles Fletcher Gloria Doughty Larry Hadley Harold Cooley Brian Fingerson Simon Wolf Richard Ross Tom Houchens Phil Losch Lucy Easley Nick Schwartz Michael Cayce Bill Borders Gerald Deom Kenneth Calvert Joseph G. Bessler Michel A. Burleson Lynn Harrelson William A. Conyers, Jr. Daniel R. Kovar, Jr. Bowl of Hygeia Previous Recipients Martin W. Nie George F. Hammons 2012 Ralph Schwartz William I. McMakin, III 2011 Dwaine K. Green Kim Croley 2010 W. Vance Smith 9

2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984

Richard L. Roeding William J. Farrell, Sr. Joseph L. Scanlon Joseph T. Elmes, Jr. H. Joe Russell Alvin R. Bertram Norman C. Horn H. Joseph Schutte D.H. "Sonny" Ralston Arthur G. Jacob James M. Brockman Richard E. Murray Randolph N. Smith Oliver E. Mayer Donald C. Morwessel James Phillip Arnold William D. Morgan Ernest M. Davis W.F. Bettinger Arvid E. Tucker Vernon B. Hager Sidney Passamaneck John H. Voige E. Crawford Meyer James J. Hamilton

1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959

THE KENTUCKY PHARMACIST

2013 KPhA Professional Awards

January 2013

Distinguished Service Award Criteria- To recognize individual members who have made significant contributions to the Association or the profession at large over an extended period of time. Eligibility – Only Active or Honorary Life members of the Association shall be eligible for the award. No individual shall be a recipient of the award more than once. Distinguished Service Award Previous Recipients Glenn Stark 2012 Kenneth Roberts 2011 Ann Amerson & Lynn Harrelson 2010 Larry Hadley 2009 Dwaine Green 2008 John Brislin 2007 Donnie Riley 2005 Gloria Doughty 2004 Coleman Friedman 2003 Joe Fink III 2002 Melinda Joyce 2002 David Jaquith 1999 R. Paul Easley & Jeff Osman 1998 Ralph Bouvette 1997 Pat Chadwell 1996 Jordan Cohen and Marty Nie 1995 Mike Montgomery 1994 Richard Ross 1993 Thomas Weisert 1991 R. David Cobb 1990 Joseph G. Bessler & Arthur G. Jacob 1989 Paul E. Davis 1988 Norman Horn & Robert E. Lee Sandlin 1987 Joseph V. Swintosky 1986 J.H. (Jack) Voige 1985 Charles T. Lesshafft, Jr. 1984 Jerry Budde 1983 William H. Nie 1982 R.N. (Randy) Smith 1981

proper application of pharmacists’ professional services. Eligibility – Open to persons or organizations. Professional Promotion Previous Recipients SUCOP student chapter of APhA-ASP 2012 Lynne Eckmann 2011 Gloria Doughty & Lynn Harrelson 2010 Jordan Covvey 2009 Jeff Mills 2008 Trish Freeman 2007 Sherry DeCuir 2006 Pete Orzali 2005 John Armistead, Don Kupper & Willie Newby 2004 Kroger Pharmacy Mid South Division, Holly Divine, Randy Gaither, Bill Grise & Laura Jones 2003 JCAP, Dean Ken Roberts, Ph.D 2002 Paul Easley, Bob Oakley and Michael Wyant 2001 Judy Minogue 2000 Ralph Bouvette 1999 Rodger Smith, Barbara Woerner, Mary Ann Wyant, and Rick Vissing 1998 Larry Spears 1997 John B. Anneken 1996 Phil Losch 1995 Jordan Cohen 1994 Judy Minogue 1994 Kentucky Academy of Student of Pharmacy 1993 Celeste Flick & Clarence Sullivan III 1988 William H. Nie 1987 Student Kentucky APhA 1986 Northern KY Pharmacists Association 1986

Dave Sallengs 2009 Kelly Smith 2008 Joseph Bickett 2007 Paul Easley 2006 John Anneken 2005 Kim Croley 2004 Ralph Bouvette 2003 David Jaquith 2001 Melinda Joyce 1999 Michael Wyant 1998 Phil Losch 1997 Tom Houchens & Bob Kuhn 1996 Don Ruwe 1995 Mark Edwards 1994 C. Dave Peterson 1993 Brian Fingerson 1992 Martin W. Nie 1991 Judy Minogue 1990 Paul Ruwe 1989 Joseph L. Fink III 1988 Steven R. Adams 1987 William J. Farrell 1986 Harold G. Becker 1985 Dwaine K. Green 1984 R. David Cobb 1983 Richard E. Murray 1982 Richard Rolfsen 1981 Gloria H. Doughty 1980 Joseph G. Bessler 1979 Emil Baker 1978 Robert L. Barnett 1977 Joseph L. Scanlon 1976 John B. Anneken 1975 Alvin R. Bertram 1974 Patricia A. Donahue 1973 H. Joseph Schutte 1972 Willard Alls 1971 Joe D. Taylor 1970 Richard L. Ross 1969 Ralph J. Schwartz 1968 George W. Grider 1967 Robert J. Lichtefeld 1966 E.M. Josey 1965 Julius T. Toll 1964 Charles E. Otto 1963 Pharmacist of the Year Award Charles F. Rosenberg 1962 Criteria – To recognize a pharmacist R.N. Smith 1961 for outstanding professional activities E. Crawford Meyer 1960 undertaken during the current or previ- Charles A. Walton 1959 ous calendar year, which resulted in Ernest C. Williams 1958 demonstrable benefit to the profession George W. Grider 1957 of pharmacy. Ray Wirth 1956 Eligibility – Only Active or Honorary Nathan Kaplin 1955 Life members of the Association shall Marion Hardesty 1954 be eligible for nominations and receipt of this award. Professional Promotion Award Pharmacist of the Year Previous Criteria – To recognize individuals or Recipients organizations who have exhibited outAlyson Schwartz 2012 standing efforts to demonstrate the William Grise 2011 importance of pharmacy as a health Holly Byrnes 2010 care profession, and which promote 10

Young Pharmacists of the Year Award sponsored by Pharmacists Mutual Insurance Company Criteria – To recognize a young pharmacist’s outstanding contribution to the profession and/or community. Eligibility – The recipient must be an Active member of the Association. The recipient must be licensed to practice for nine years or less. The recipient must have a valid, active license to practice in Kentucky. The recipient must have demonstrated participation in a national pharmacy association, professional program(s) and/or community service.

THE KENTUCKY PHARMACIST

2013 KPhA Professional Awards Distinguished Young Pharmacist Award Previous Recipients Stacy Rowe 2012 Aimee Ruder 2011 Karen Hubbs 2010 Matt Martin 2009 Tiffany Self 2008 Angela Parrett 2007 Janet Mills 2006 Alyson Schwartz 2005 Nancy Horn 2004 Jennifer O’Hearn 2003 Karen Altsman 2001 Kim Wilson 1999 Kim Harned 1998 Michael Box 1997 Dan Yeager 1996 Dan Minogue 1995 Pan Haeberlin 1994 Kim Croley 1993 Phillip Sandlin 1992 Jeffrey W. Danhauer 1991 Mark S. Edwards 1990 Susan Murray Kathman 1989 Melinda Cummins Joyce 1987

January 2013 macist who is an Active or Honorary Life member of the Association. A recipient may receive the award more than once. Excellence in Innovation Award Previous Recipients Lynn Harrelson 2012 James Nash & BC Childress 2011 Lynne Eckmann & Cathy Hanna 2010 Ann Albrecht 2008 Lisa Short 2005 Holly Divine, Amy Nicholas 2004 Judy Minogue 2003 Trish Freeman 2002 Mary Ann Wyant 2001 Joyce Korfhage Rhea 2000 Cathy Edwards 1999 Celeste Flick 1998 Jeanne Zeis 1997 Dave Wren 1996 Preston Art 1995 W. Michael Leake 1994

Lisa Sawvel Margaret Sinkhorn Charlotte Bowling Mary Jane Wathen Kent Williams Tammy Newsome Frank Ray Jane Woerner

2008 2007 2006 2005 2004 2003 2002 2001

Cardinal Health Generation Rx Champions Award Criteria – Started in 2012, this award program recognizes excellence in community-based prescription drug abuse prevention at state pharmacy associations. This award honors a pharmacist who has demonstrated outstanding commitment to raising awareness of the dangers of prescription drug abuse among the general public and among the pharmacy community. The award is also intended to encourage educational prevention efTechnician of the Year Award forts aimed at patients, youth and othCriteria – To recognize a Certified er members of the community. In addiPharmacy Technician for outstanding tion to the award, to honor the pharmaExcellence in Innovation Award professional activities. cist’s work to fight prescription drug Sponsored by Upsher-Smith Eligibility – Only active Pharmacy abuse, APMS, state pharmacy associLaboratories Technician members of the Associaations and the Cardinal Health FounCriteria – To recognize a pharmacist tion shall be eligible for nomination and dation will donate $500 to a charity of who has demonstrated innovative receipt of this award. the award recipient’s choice. Technician of the Year Award Cardinal Health Generation Rx pharmacy practice resulting in improved patient care in the previous Previous Recipients Champions Award Previous year or over an extended period of Patricia Robinson 2012 Recipient time. Jessica Salmons 2011 Brian Fingerson 2012 Eligibility – A recipient must be a phar- Gwen Otter 2010

KPhA Board of Directors Nominations for 2013-14 Serve YOUR profession by serving on YOUR KPhA Board of Directors! The Kentucky Pharmacists Board of Directors is accepting nominations for the following positions to serve on the KPhA Board for the 2013-14 year: President-Elect

Treasurer

Director (3 open spots)

Nominations: Nominations may be submitted electronically to Scott Sisco at ssisco@kphanet.org or mailed to KPhA, Attn: Scott Sisco 1228 US 127 South, Frankfort, KY 40601 no later than March 31, 2013.

THE KENTUCKY PHARMACIST

KPhA Emergency Preparedness Initiative

January 2013

For more information on how you can be involved in the KPhA Emergency Preparedness Initiative, contact Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness at 502-227-2303 or by email at ltolliver@kphanet.org. KPhA is a partner with the Kentucky Department of Public Health for emergency preparedness and disaster response.

Have you logged in yet? Check out the all-new KPhAnet.org!

THE KENTUCKY PHARMACIST

Jan. 2013 CEâ&#x20AC;&#x201D;HIV: An Overview of Treatment Strategies

January 2013

Human Immunodeficiency Virus: An Overview of Treatment Strategies Reprinted with permission of the authors and the Mississippi Pharmacists Association where this article originally appeared. This activity may appear in other state pharmacy association journals. There are no financial relationships that could be perceived as real or apparent conflicts of interest.

KPERF offers all CE articles to members online at www.kphanet.org

By: Lucy Cadwallader, PharmD, Lindsey Tillman, PharmD and Deborah Minor, PharmD, The University of Mississippi Medical Center, Departments of Pharmacy and Medicine, Jackson, Mississippi Universal Activity # 0143-9999-13-001-H02-P&T 1 Contact Hour (0.1 CEU) Goal - To describe and discuss the treatment of HIV infection. Learning Objectives - Upon successful completion of this course, the reader should be able to: 1. Review the prevalence and progression of HIV infection. 2. Describe specific medication classes and recommended treatments for HIV. 3. Distinguish major side effects and warnings of the major drug classes for HIV treatment. 4. Review prophylaxis strategies for the more common opportunistic infections. Human immunodeficiency virus (HIV) is a single-stranded RNA virus that is a member of the Lentivirinae subfamily of retroviruses. The earliest documented case of human HIV infection has been traced to Africa in 1959. With modern transportation, drug abuse and promiscuity, the virus has rapidly spread worldwide.1 It was estimated that some 34 million individuals worldwide were living with HIV in 2009, with as many as 25 percent of these undiagnosed. In 2008, 1.1 million persons in the United States aged 13 and older were living with HIV infection.2

reduce morbidity, preserve immunologic function, suppress viral load and prevent transmission. It is recommended that ART be initiated in all patients with HIV infection who have a history of an AIDS-defining illness, HIV-associated nephropathy, hepatitis B co-infection, or a CD4+ count of less than 350 cells/mm 3. In addition, all pregnant women with HIV should receive combination ART to prevent mother-to-child transmission, regardless of CD4+ count. 3,4 HIV TREATMENT OPTIONS

Infection of the virus occurs by sexual, parenteral or perinatal transmission. The HIV virus attacks the immune system, causing a progressive decline in the number of cluster of differentiation 4 (CD4+) T cells, a type of white blood cell that fights infection. The CD4+ T cell count is used as one of the parameters for initiating antiretroviral therapy (ART). In addition, the viral load quantifies the amount of HIV RNA in the blood and is used to assess disease progression and possible drug resistance.1 The most serious stage of HIV infection, acquired immune deficiency syndrome (AIDS), is diagnosed when an HIV-infected individual has a CD4+ T cell count below 200 cells/mm3 or a documented AIDSdefining condition (one of 26 conditions including tuberculosis, mycobacterium avium complex [MAC], and Pneumocystis carnii [PCP]).3 The primary goals in the treatment of HIV infection are to

Great strides have been made in the treatment of HIV over the last several years. There are now more than 20 antiretroviral medications in six unique classes, the nonnucleoside reverse transcriptase inhibitors (NNRTIs), nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), protease inhibitors (PIs), fusion inhibitors (FIs), CCR5 antagonists and integrase strand transfer inhibitors (INSTIs). Highlights and dosing information for these medications and classes are identified in Table 1. Please see product labeling for more specific information. For patients receiving treatment, ART regimens with at least two drugs from two unique medication classes are required to achieve viral suppression. Combination products now help simplify this process (Table 2). Selection of the regimen should be individualized and should consider efficacy, toxicities, dosing frequency, drug interactions, resistance patterns and comorbid conditions.3

THE KENTUCKY PHARMACIST

Jan. 2013 CE—HIV: An Overview of Treatment Strategies

January 2013

Table 1: Drugs used for Treatment of HIV Medication

Dosing**

Comments / Warnings / Precautions

Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) Delavirdine (Rescriptor®) Efavirenz (Sustiva®)* Etravirine (Intelence®) Nevirapine (Viramune®)

400 mg TID

Abacavir (Ziagen®) * Didanosine (Videx/ Videx EC®) Emtricitabine (Emtriva®)*

300 mg BID or 600 mg daily 250 mg - 400 mg daily

Lamivudine (Epivir®)* Stavudine (Zerit®)

150 mg BID or 300 mg daily 30-40 mg Q 12 hours

600 mg daily 200 mg BID

Separate dose from antacid by 1 hour Strong inhibitor of 2C9, 2C19, 2D6, 3A4 Take on empty stomach Inhibits 2CP and 3A4 (moderate); induces 3A4 (strong) Take after full meal

200 mg daily X 14 days; then 200 mg BID

BBW: Severe hepatotoxic reactions (risk > first 6 weeks); life-threatening skin reactions 3A4 inducer Rilpivirine 25 mg daily Take with food (Edurant™)* Do not use with drugs that increase gastric pH 3A4 metabolism Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs)

200 mg daily

Zidovudine 300 mg BID (Retrovir®) Tenofovir 300 mg daily (Viread®)* Protease Inhibitors (PIs) Atazanavir (Reyataz®)

300 mg + 100 mg ritonavir daily

Darunavir (Prezista®)

Tx naïve: 400 mg daily Tx naïve: 800 mg + 100 mg ritonavir daily

Fosamprenavir (Lexiva®)

Indinavir (Crixivan®) Nelfinavir (Viracept®)

Tx experienced: 600 mg + 100 mg ritonavir daily Tx naïve: 1400 mg BID or 1400 mg daily + 100 mg ritonavir daily Tx experienced: 700 mg + 100 mg ritonavir BID 800 mg Q 8 hours 750 mg TID or 1250 mg BID

Must screen for HLA-B*5701 allele (increased risk of reaction) BBW: Severe hypersensitivity reaction Take on an empty stomach BBW: Pancreatitis Refrigerate solution until dispensed; after dispensing, store at room temp for 3 months Atripla® (combination) – take on empty stomach BBW: May exacerbate Hep B after drug discontinuation BBW: Do not use for Hep B treatment Reconstituted oral solution - store in refrigerator; stable for 30 days BBW: Pancreatitis seen in combo with didanosine BBW: Hematologic toxicities; myopathy and myositis BBW: May exacerbate Hep B when discontinued

Take with food for better absorption Separate dosing - 10 hours after H2-receptor antagonist, 12 hours after proton pump inhibitor May prolong PR interval Take with food Must be given with ritonavir Caution with sulfa allergy

Oral suspension - take without food Tablets - take with or without meals Caution with sulfa allergy

Take without food Drink at least 48 oz water daily to help prevent nephrolithiasis Take with food May cause diarrhea

THE KENTUCKY PHARMACIST

Jan. 2013 CE—HIV: An Overview of Treatment Strategies

January 2013

Table 1: Drugs used for Treatment of HIV (Continued) Medication Ritonavir (Norvir®)

Dosing** 100-400 mg/day for booster effect

Lopinavir + ritonavir (Kaletra®)

Tx naïve: 800 mg/200 mg daily or 400 mg/100 mg BID

Saquinavir (Invirase®) Tipranavir (Aptivus®)

Tx experienced: 400/100 mg BID 1000 mg + 100 mg ritonavir BID 500 mg + 200 mg ritonavir BID

Comments / Warnings / Precautions Take with food Refrigerate capsules Oral solution contains 43 percent ethanol BBW: Drug interactions Solution - take with food Pancreatitis risk

Take within 2 hours of full meal PR and QT interval prolongation Capsules - refrigerate unopened bottle. Once opened, stable 60 days at room temp Solution - store at room temp Take with a high fat meal BBW: May cause hepatitis; rare reports of intracranial hemorrhage Caution with sulfa allergy

Other Classes Fusion Inhibitor (FI): Enfurvirtide (Fuzeon®)

90 mg SC BID

Reconstituted solution - refrigerate and use in 24 hours Injection site and hypersensitivity reactions are possible

CCR5 antagonist: Maraviroc (Selzentry®)

300 mg BID

Integrase Strand Transfer Inhibitor (INSTI): Raltegravir (Isentress®)

400 mg BID

Tropism screening - required prior to tx to determine medication eligibility (efficacy) Contraindicated - with 3A4 inhibitors and inducers in patients with CrCl<30 ml/min BBW: Hepatotoxicity Very few drug interactions Immune reconstitution syndrome, myopathy, and rhabdomyolysis are possible

Growth hormone stimulator: Tesamorelin (Egrifta®)

2 mg SC daily

No effect on weight Use immediately after reconstitution Contraindicated - with active malignancy, pregnancy, or hypothalamic-pituitary axis disruption

Tx – treatment, *Available in combination (Table 2), **All PO unless otherwise specified. Information compiled from manufacturer information and ref 3. by CYP3A4 and is contraindicated with medications that can decrease its concentration due to CYP induction or The NNRTIs bind to the enzyme reverse transcriptase, increased gastric pH: carbamazepine, oxcarbazepine, blocking RNA and DNA-dependent DNA polymerase acphenobarbital, phenytoin, rifabutin, rifampin, rifapentine, tivities including HIV-1 replication. All NNRTIs may cause proton pump inhibitors, systemic dexamethasone and St. hepatotoxic reactions, including transaminase elevations, John’s wort. Rilpivirine should be taken with food to inand may cause a rash (most common and severe with crease absorption. The package information warns about 1,3 nevirapine). the possibility of developing depressive disorders, fat reRilpivirine (Edurant®), a new NNRTI was FDA approved distribution and immune reconstitution syndrome when in May 2011. Like several of the NNRTIs, it is metabolized starting therapy. In clinical trials, it was determined to be Non-Nucleoside Reverse Transcriptase Inhibitors

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Jan. 2013 CE—HIV: An Overview of Treatment Strategies

January 2013

noninferior to the commonly used NNRTI efavirenz (Sustiva®).5

Table 2: Medication Combination Products3 Brand name Generic name

Nucleoside/Nucleotide Reverse Transcriptase Inhibitors

Atripla®

Efavirenz, Tenofovir, Emtricitabine Tenofovir, Emtricitabine

development of resistance to existing ART therapies.1 In 2011, the Department of Health and Human Services added raltegravir (Isentress®), an INSTI, as an initial option for treatmentnaïve patients.3

Truvada® The NRTIs bind to the catalytic Complera® Relpivirine, Emtricitabine, site on reverse transcriptase and and Tenofovir Tesamoralin (Egrifta™) is another new interfere with HIV viral RNAEpzicom® Abacavir, Lamivudine adjunctive therapy that is specifically dependent DNA polymerase, reapproved for the treatment of lipoTrizivir® Abacavir, Lamivudine, sulting in inhibition of viral replicaZidovudine dystrophy in HIV patients. A common tion. All NRTIs have a black box Combivir® Lamivudine, Zidovudine side effect of many of the HIV medicawarning (BBW) regarding lactic tions, tesamoralin targets lipodystrophy acidosis and fatal hepatomegaly with steatosis. Other class by binding and stimulating human growth hormone releasside effects include neuropathy, pancreatitis, lipoatrophy, ing factor. It is given as a once daily subcutaneous (SC) myopathy and anemia.1,3 injection. While this drug may be beneficial in some paProtease Inhibitors tients who experience lipodystrophy, its use involves a The protease enzyme is an essential component of the HIV complex process for reconstitution and self-administration. In clinical trials, visceral adipose tissue decreased (per CT viral maturation process through cleavage of the gag-pol polyprotein. Protease inhibition results in the production of scan); however, it is unknown if this effect translates into clinical significance for patients who are at risk for cardiononinfectious, immature virion. Ritonavir, an older PI, is vascular or metabolic complications. This medication is not now often used for boosting the effects of the other PIs. Class side effects include gastrointestinal distress and met- indicated for 6weight loss, and it had no effect on weight in abolic disturbances, including hyperglycemia, dyslipidemia, clinical trials. insulin sensitivity, fat maldistribution and lipodystrophy (buffalo hump, facial atrophy, increased abdominal girth). PIs are cleared by the liver, so baseline and periodic (every 3-6 months) monitoring of transaminases and lipids is necessary. Hemophiliacs may have increased bleeding with the use of PIs. The PIs are major inhibitors of the CYP3A4 enzyme, causing many drug interactions. Simvastatin, lovastatin, rifampin, ergot derivatives, cisapride, St. John’s wort, sildenafil (for pulmonary hypertension), pimozide and triazolam are contraindicated with the PI class. Anticonvulsants, antiarrhythmics, warfarin, colchicine, clarithromycin and contraceptives are just a few of the other drugs and classes that can interact with the PIs.1,3

RECOMMENDED REGIMENS Initial treatment regimens as recommended by the Department of Health and Human Services in patients that are antiretroviral naïve should be one of the following: 3    

Efavirenz/tenofovir/emtricitabine (NNRTI and 2 NRTIs) Tenofovir/emtricitabine + Ritonavir-boosted atazanavir (2 NRTIs + Boosted PI) Tenofovir/emtricitabine + Ritonavir-boosted darunavir (2 NRTIs + Boosted PI) Tenofovir/emtricitabine + Raltegravir (2 NRTIs + INSTI)

Products that are available as combinations are listed in Table 2. The preferred regimen for pregnant women is Other Classes twice daily ritonavir-boosted lopinavir + zidovudine/ lamivudine. Other regimens have been considered Other drugs that are used as adjunctive therapies for the “alternative” or “acceptable” for use in pregnancy but may treatment of HIV include FIs, CCR5 antagonists and INbe associated with concerns for safety, resistance or efficaSTIs. These classes and drugs have been developed to 3 inhibit different steps in the HIV cell cycle and to reduce the cy. Table 3: Common Opportunistic Infections – Prophylaxis3 Pathogen Pneumocystis carnii (PCP) Toxoplasma gondii Mycobacterium avium complex (MAC)

Indication

Drug regimen 3

CD4+ count <200 cells/mm or oropharyngeal candidiasis Toxoplasma IgG positive and CD4+ count <100 cells/mm3 CD4+ count <50 cells/mm3

Sulfamethoxazole/Trimethoprim DS 1 tablet daily Sulfamethoxazole/Trimethoprim DS 1 tablet daily Azithromycin 1200 mg weekly or clarithromycin 500 mg BID

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Jan. 2013 CE—HIV: An Overview of Treatment Strategies

January 2013

nodeficiency virus infection. In: Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy:a pathophysiological approach. 8th ed. New York: McGraw-Hill Medical; c2011. p. 206583.

OPPORTUNISTIC INFECTIONS

Individuals with HIV are at risk for opportunistic infections when the immune system can no longer protect against certain pathogens. Recommended prophylactic treatments against the most common opportunistic infections are identified in Table 3. 2. CDC. HIV Surveillance --- United States, 1981-2008MMWR Morb Mortal Wkly 2011; 60(21):689-693. CONCLUSION 3. Panel on Antiretroviral Guidelines for Adults and AdoHIV is an incurable infection that affects more than one millescents. Guidelines for the use of antiretroviral agents lion individuals in the United States. The current goals of in HIV-1-infected adults and adolescents. Department treatment are to reduce HIV-associated morbidity, prolong of Health and Human Services. Jan 10, 2011:1-164. survival, preserve immunologic function, suppress HIV viral Accessed (2011 Dec 13). Available at: http:// load and prevent HIV transmission. Significant progress aidsinfo.nih.gov/contentfiles/ has been made in the treatment of HIV, with six drug clasAdultandAdolescentGL.pdf. ses now available. Remaining cognizant of the drug interactions and potential adverse effects and educating pa4. Branson BM, Handsfield HH, Lampe MA, et al. Revised tients on the appropriate use of these medications are recommendations for HIV testing of adults, adolesways that pharmacists can play an important role in the cents, and pregnant women in health-care settings. lives of patients dealing with HIV. Assessing and encouragMMWR Recomm Rep 2006;55(RR-14):1-17. ing compliance with treatment regimens is also crucial to 5. Tibotec Pharmaceuticals America, Inc. Edurant® the management of the disease and achieving the goals of (rilpivirine) tablets [prescribing information]. Raritan therapy. (NJ): Feb 2011. References 6. Thertechnologies, Inc. Egrifta® (tesamorelin) injection 1. Anderson PL, Kakuda TN, Fletcher CV. Human immu[prescribing information]. Rockland (MA): Nov 2010.

January 2013 — Human Immunodeficiency Virus: An Overview of Treatment Strategies 1. In general, treatment with ARTs is indicated in a HIV patient with: A. CD4+ count < 350 cells/mm3 B. History of an AIDS-defining illness C. Co-infected with Hepatitis B D. All of the above

5. Protease inhibitors are contraindicated with: A. Simvastatin B. St. John’s wort C. Rifampin D. All of the above

2. Which of the following agents is not an NNRTI? A. Efavirenz B. Nevirapine C. Etravirine D. Rilpivirine E. Ritonavir

6. A patient presents a prescription for Reyataz® (atazanavir). You counsel the patient that: A. This medication may cause fat redistribution B. This medication may cause increased urinary frequency. C. You should take this medication just after your omeprazole dose.

3. Lactic acidosis and severe hepatomegaly with steatosis are associated with the NRTIs. A. True B. False 4. Which of the following is not a protease inhibitor? A. Atazanavir B. Darunavir C. Nelfinavir D. Stavudine

7. Tesamorelin is administered: A. As a monthly IV infusion B. By daily subcutaneous injection C. By mouth twice daily D. As a weekly transdermal patch

8. An HIV positive female has found out she is pregnant. Her CD4+ count is 435. Which of the following is the most appropriate treatment regimen? A. No treatment is indicated. B. Lopinavir + ritonavir, zidovudine, lamivudine C. Emtricitabine, efavirenz, tenofovir D. Raltegravir + atazanavir 9. Relpivirine comes in a combination product. A. True B. False 10. JL has HIV and presents with a CD4+ count of 180 cells/mm3. Which opportunistic pathogen should he receive prophylaxis against? A. Toxoplasma gondii B. Pneumocystis carnii C. Mycobacterium avium complex

Quizzes submitted without NABP eProfile ID # and Birthdate cannot be accepted.

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Jan. 2013 CE—HIV: An Overview of Treatment Strategies

January 2013

This activity is a FREE service to members of the Kentucky Pharmacists Association. The fee for non-members is $30. Mail completed forms to: KPERF, 1228 US 127 South, Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile. Expiration Date: January 1, 2016 Successful Completion: Score of 80% will result in 1.0 contact hours or 0.1 CEUs. Participants who score less than 80% will be notified and permitted one re-examination. TECHNICIANS ANSWER SHEET. January 2013 — Human Immunodeficiency Virus: An Overview of Treatment Strategies Universal Activity # 0143-9999-13-001-H02-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 2. A B C D E

3. A B 4. A B C D

5. A B C D 6. A B C

7. A B C D 8. A B C D

9. A B 10. A B C

Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________

NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) PHARMACISTS ANSWER SHEET January 2013 — Human Immunodeficiency Virus: An Overview of Treatment Strategies Universal Activity # 0143-9999-13-001-H02-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 2. A B C D E

3. A B 4. A B C D

5. A B C D 6. A B C

7. A B C D 8. A B C D

9. A B 10. A B C

Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________

NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy Education as a provider of continuing Pharmacy education.

Quizzes submitted without NABP eProfile ID # and Birthdate cannot be accepted.

THE KENTUCKY PHARMACIST

Senior Care Corner

January 2013

Senior Care Corner from the KPhA Academy of Consultant Pharmacists Making the Leap to Long Term Care I’m a retail guy. I knew it when I began bagging groceries in a retail store in Bardstown, Ky. The interaction with customers and involvement in the community fit my personality almost perfectly. I felt destined for a career in retail after graduation from pharmacy school. With support from a few wonderful mentors, I moved to Louisville and hit the ground running with a large pharmacy chain. Everything seemed to fall in place for the retail career I had envisioned until a random opportunity presented itself from a contact on a professional networking website. A new Long Term Care (LTC) pharmacy company was being built and, oddly enough, they wanted to hire this retail guy to lead their site in Indianapolis. Embracing the retail guy Changing practice settings was definitely intimidating. The first few weeks with my new company provided many obstacles as coworkers questioned my abilities. With no LTC experience, technicians and pharmacists wondered how a retail pharmacist could possibly lead and efficiently serve the needs of patients within a Skilled Nursing Facility (SNF). Can you blame them? To tackle the challenge, I kept an open mind and tried not to take the criticism personally. I asked many questions and remained honest about my ignorance. More experienced colleagues were happy to share their wealth of knowledge and embraced me as a temporary apprentice.

Save the date for the American Society of Consultant Pharmacist KY Chapter/KPhA Academy of Consultant Pharmacists Joint CE Program April 20, 2013 at the Sullivan University College of Pharmacy in Louisville. See www.kphanet.org for more. connection to patients that I had grown accustomed to in a community pharmacy. My new role shifted my focus from serving patients directly to serving the nurses who would ultimately take care of the patient. My passion for pharmacy was fueled by the patient relationships I had experienced daily in retail, and I wasn’t sure how I would be motivated in this new environment until my cell phone rang late one night after we began servicing a new facility. Somehow there was confusion between the facility and pharmacy that resulted in a patient not receiving a medication. I immediately went to the pharmacy, filled the order and delivered the medication personally around midnight. The night shift nurse was surprised when I arrived at her station and also relieved now that she had the medication for the patient. She smiled and pointed to a little old man in a wheel chair outside of his room and explained that he had trouble sleeping without that particular medication. Immediately, I felt recharged as a pharmacist. “A ship in the harbor is safe…”

As a self proclaimed fan of Successories® posters, I am often reminded that ships are not built to remain in the harNew Setting + New Challenges = Better Pharmacist bor. The decision to leave a successful retail career and In order to make the transition from retail, I had to rely on risk failure in a completely new field was not an easy one. the foundation of knowledge that was etched in my brain While everyone has a different personal situation, we owe by the dynamic faculty at the University of Kentucky. My it to ourselves to explore opportunities to grow. I’m not adprofessors armed me with the tools to practice in any setvocating that everyone needs to quit their job, but rather ting and helped me develop skills that translate across encouraging practitioners to keep their eyes open to the many fields. I soon realized that this change would not hurt endless possibilities in the profession of pharmacy. Whethmy knowledge as a medication expert, but I would argue er it is attending a professional meeting for the first time, that this shift has actually advanced my ability to practice subscribing to a new journal or volunteering as a preceptor pharmacy. In retail, my exposure to inpatient medications for your alma mater, we all have opportunities to make ourand intravenous therapies was limited. This simple change selves better pharmacists. I challenge all pharmacists to in setting and patient population has forced me to exercise commit to lifelong learning, embrace change and focus a different pharmacy muscle. your efforts to benefit the patients you serve. I still consider myself a retail guy, just with a new type of customer. Staying connected to patient care - By: Joey Mattingly, Pharm.D., M.B.A.

After leaving retail, I was worried I would lose the personal 19

THE KENTUCKY PHARMACIST

AB Rating Scale

January 2013

The AB rating scale and the controversies that exist within it By: Nathaniel Adams, PharmD Candidate c/o 2013, Sullivan University College of Pharmacy In the practice of Pharmacy, pharmacists’ key roles are the observation and detection of medicinal interactions, precise dosing calculations and, in some instances, accurate substitutions of bioequivalent medications. The Orange Book provides pharmacists with up-to-date FDA approved brand medications and the therapeutic bioequivalent products available in the United States.1,3 This searchable, public database further enhances delivery of accurate prescription medications to the public and allows pharmacists to deliver the best quality care to their patients. However, we need not to forget that within the scope of pharmacy practice, state boards of pharmacy include their own rules and regulations that relate to drug substitutions and therapeutic equivalency.

tions that are “B” rated are placed in one of three groups 1: 

Products containing an active ingredient or in a dosage form with documented or potential bioequivalence problems for which adequate data to support bioequivalence has not been submitted to the FDA.



Products with inadequate quality standards or insufficient basis to determine therapeutic equivalence.



Products currently undergoing FDA review.

The second letter of the code represents additional information that is obtained from the FDA evaluation of that drug. This letter usually correlates to a specific dosage form of the product.1,3 For oral dosage formulated products labeled as “AB,” actual or potential bioequivalence probWhat does it mean to be therapeutically equivalent? Medilems have been resolved with adequate in-vivo or in-vitro cations that are deemed therapeutically equivalent have evidence supporting bioequivalence.3 Within special cases ample in-vivo or in-vitro bioequivalent evidence and all acof multisource products, “BX” ratings appear representing tual or potential bioequivalent complications have been that bioequivalency has not been established. 1 In other resolved.1 Clinical safety and efficacy profile for these prodsituations, multisource medications that are considered ucts when given to patients must also be pharmaceutically pharmaceutical equivalents may have numerous “reference equivalent.3 The FDA defines pharmaceutical equivalents listed drug” comparisons. In this case, a number is added as products that contain the same active ingredient, dosto the end of the two-letter code (i.e. AB1, AB2, AB3) to age form, dosage strength and route of administration. provide an indication of the “reference” product.1,6 MedicaHowever, these pharmaceutical products may differ in tions that contain corresponding letters and numbers are shape, color and excipients. At the time of a bioequivalent considered therapeutically equivalent.3 A great example of study, the brand name medication is called the “referenced this would be levothyroxine. listed drug.” Once the results are determined, therapeutic Levothyroxine has been a controversy for some time now equivalent ratings are given.3 in regards to bioequivalency and correct substitutions. This The Orange Book encompasses four sections; one section anti-hypothyroid agent 3,4 has been on the market for more includes evaluations of terminology and the therapeutic than 50 years with multiple NDAs of levothyroxine. Since coding system.3 Pharmacists who use the Orange Book then, many NDAs have been submitted and are waiting coding system should be mindful and familiar with this sysapproval from the FDA to advance towards research and tem’s utilization. Each multi-source product is assigned by evaluation. Due to the reality of numerous products, comthe FDA a specific two-letter code. This code offers inforplications and confusion arise in regards to bioequivalency mation that allows doctors and pharmacists to quickly asin the Orange Book. Since multiple levothyroxine products sess and determine if the particular product is therapeutiare out on the market, the FDA has placed numerical valcally equivalent.3 For each product, the first letter of the ues at the end of each two-letter code. Only AB1 products code contains either an “A” or “B”. Medications that are “A” should be interchanged with AB1 substitutions; only AB2 rated, are considered therapeutically equivalent to other products should be interchanged with AB2 substitutions; pharmaceutically equivalent products.1 Medications that and only AB3 products should be interchanged with AB3 are “B” rated, are considered not therapeutically equivalent substitutions. You can start seeing the picture here. In the to other pharmaceutically equivalent medications.1 Medicacircumstance that a patient is being switched from one 20

THE KENTUCKY PHARMACIST

AB Rating Scale

January 2013

manufacturer of levothyroxine to another (whether it be generic or brand), care and pharmaceutical judgment should be positioned on the bioequivalency standing of the new product, comparative to the one the patient was previously taking.1,5,6

Orange Book regarding its bioequivalency status. Wellbutrin is FDA approved for major depressive disorder and social anxiety disorder. Recently, the FDA issued a Postmarket Drug Safety alert for patients and providers. This alert states that Budeprion XL 300mg is NOT therapeutically equivalent to Wellbutrin XL 300mg. The FDA has changed The question still remains: why are not all brands of levothe therapeutic equivalency ratings in the Orange Book thyroxine equivalent? Multiple crossover study design trifrom “AB” to “BX” showing that Budeprion XL 300mg is als have been implemented to assess levothyroxine’s bioeNOT interchangeable with Wellbutrin XL 300mg. This anquivalence. Within these studies, a dose well above the nouncement only affects Budeprion XL 300mg and not norm (0.6mg) was used to prevent discrepancies from enBudeprion XL 150mg. dogenous thyroid hormone circulating in the body, as well to guarantee the levels of levothyroxine can be detected in With regards to Wellbutrin XL 300mg, the FDA currently testing to ensure accuracy and precision of results. The has five approved generic versions. Budeprion XL 300mg obvious outcome was to see that if the same amount of was approved December 2006. Later, reports of patients active ingredient is found in each tablet, then the amount who were switched from Wellbutrin XL 150mg to its generof drug distributed in the body should be equivalent. How- ic equivalents were experiencing reduced efficacy. After ever, these bioequivalency levothyroxine studies have investigating and examining their findings, the FDA linked found that endogenous thyroid hormone may skew the the complaints with the Budeprion XL 300mg product. The actual levels of thyroxine detected in testing after levothy- FDA mandated that the makers of Budeprion XL 300mg roxine was administered. Also patient’s serum TSH levels create a study to show efficacy from patients who were slowly change over the course of 8-weeks, making levothy- switched to Budeprion XL 300mg from Wellbutrin XL roxine levels not the most appropriate concentrate to 300mg. The study was terminated early due to unsuccessmeasure. Furthermore, using a dose of 0.6mg does not ful attempts in recruiting sufficient patients. The FDA took simulate what is seen in real life clinical practice. The final measures into their own hands creating a study with reassumption from these bioequivalency studies are3: spect to patients switching to Budeprion XL 300mg from Wellbutrin XL 300mg. The results of their study became  Different formulations of levothyroxine may be evidentavailable in August 2012 showing that Budeprion XL ly seen as bioequivalent, but patients do not benefit 300mg did not release bupropion in the blood at the same from them interchangeably. rate and extent as Wellbutrin XL 300mg. Patients currently  Equal doses of Levothyroid and Synthroid are similar, on Budeprion XL 300mg as a substitute for Wellbutrin XL but not bioequivalent. 300mg should consult with their pharmacist or healthcare provider about taking this medication.2  All formulations of levothyroxine are not equivalent, Pharmacists who utilize the Orange Book should take spegeneric products should not be substituted for brand cial precautions when it comes to determining appropriate name products. product substitution. As we have seen, medications that From these controversies, we can see why it has been a share the same indication of use may not be therapeuticaldiscussion and how it may continue to confuse healthcare ly equivalent. Furthermore, Levothyroxine and Wellbutrin practitioners when discussing levothyroxine’s bioequivamay be the start of more stringent FDA post surveillance lency. Further evaluation and studies are needed for the among products that share multiple equivalent generics. FDA to hold steadfastly on levothyroxine’s bioequivalency. As pharmacists, it is our duty to pay close attention to upA joint statement from the American Association of Clinical dates, alerts and post market surveillance. Most importantEndocrinologists (AACE), The Endocrine Society (TES), ly, listen to our patients and act upon their concerns using and the American Thyroid Association (ATA), announced, best pharmacy practice. It is for this reason we have a rat“there is a concern regarding the amount variation allowed ing scale, but it will not serve its purpose if we do not know by the FDA’s test could lead to a substantial difference in how to use it, or apply it to our practice. therapeutic effect in a patient. Based on best practice recommendations, levothyroxine generics should not be sub- References stituted for brand products.”1,3 1. Online Continuing Education for Pharmacists. 2008. “Drug Store News CE Online.” Retrieved on DecemLevothyroxine is not the only marketed drug causing conber 8, 2012. (http://www.cedrugstorenews.com/ troversy; Wellbutrin has recently undergone changes in the 21

THE KENTUCKY PHARMACIST

AB Rating Scale/New and Renewing Members

January 2013

userapp//lessons/page_view_ui.cfm? lessonuid=&pageid=B658D29113124E3E0B98C1855405 1009)

equal?” Retrieved on December 8, 2012. (http:// dig.pharm.uic.edu/faq/levothyroxine.aspx) 4. Micromedex® Healthcare Series (Internet database). Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Assessed on December 9, 2012.

2. U.S. Food Drug Administration. October 3, 2012. “FDA Update: Budeprion XL 300mg NOT Therpeutical5. Food and Drug Administration Center for Drug Evalualy Equivalent to Wellbutrin XL 300mg.” Retrieved on tion and Research. Approved drug products with theraDecember 8, 2012. (http://www.fda.gov/Drugs/ peutic equivalency evaluations (preface). 32th ed. AsDrugSafety/ sessed on December 9, 2012. PostmarketDrugSafetyInformationforPatientsandProviders/ucm322161.htm) 6. Food and Drug Administration Orange Book Publications. 2012. Orange Book Cumulative Supplement 10 3. University of Illinois at Chicago College of Pharmacy. October 2012. Assessed on December 9, 2012. 2007. “FAQ: Are all levothyroxine products created

KPhA Welcomes New and Renewing Members November through December 2012 Paul E Arthur, Huntington, WV Greg Baker, Louisville Ellen Barger, Mt. Washington William R Broughton, Shepherdsville William R Brown, Wingo Charles L Bryant, Cave City Michael Burleson, Lexington Israel Cardenas, Louisville Heather Clayton, Elkton Bonnie K Collins, Paris Dan Moore Daffron, Monticello Pamela Decker-Meadows, Cynthiana Eldon Depew, London Ben Duvall, Big Clifty R Easley, Fisherville Suzanne Epley, Russellville Nikita M Evans, South Shore Jane J Fletcher, Leitchfield Virginia Engoglia France, Dry Ridge Randy M Gaither, Louisville Eric T Gibbs, Corbin Mary Gilvin, Mt. Sterling Susan M Girdler, Somerset Amy L Glaser, Alexandria

April Dawn Golden, Corbin Charles Len Gore, Nicholasville Jennifer O Grant, Louisville Lauren W Grant, Louisville William M Grise, Richmond Tina Hall, Greenup Catherine Hance, Louisville Amanda Harding, Louisville Kin Harmon, Louisville Marla Helton, Frenchburg Robin Hipps, New Albany, IN Jane Katherind Ingram, West Liberty Eron Jaber, Louisville Jennifer Jaber, Louisville Diane Kelly, Evarts Melissa Brewer Kennon, Lexington Martin Likins, Greenville Michael Lin, Louisville James Litmer, Edgewood Robert Little, Berea Clayton McKinney, Shelbyville Michael McWilliams, Louisville Mary Stephanie Murphy, Louisville Freddie M. Norris, Glasgow

Robert S Oakley, Louisville Charles Oliver, Glasgow Kenneth G Parsons, Louisville Hilary Pohn, Prospect Anne Policastri, Georgetown Richard Potter, Bowling Green Andrea Potter-Adams, Isom Sharon Ann Ran, Villa Hills Michael Russell, Murray Kenny Sanders, Bessemer, AL Nicholas Schwartz, Florence Janet Segers, Louisville Susanna Sexton, Cornettsville Sharon Stevens Small, Louisville Quincy S Stephenson, Providence Misty M Stutz, Crestwood William C Sutherland, Louisville Lisa Terry, Elizabethtown Gabe Van Lahr, Irvington Jonathan Van Lahr, Webster Susan Weaks, Paducah Tyler Whisman, Florence Brenda Lee Wilson, Danville Randy Windham, London

Denise Robison’s name was misspelled in the New Members section of the September 2012 issue of The Kentucky Pharmacist.

Congrats to UKCOP Graduate Max Kreitman Max Kreitman, of West Bloomfield, Mich., was honored as part of the Ability is Ageless Award Luncheon Sept. 27, 2012 in Dearborn, Mich. Kreitman, 82, has worked for CVS for 25 years and still works as a floater.

THE KENTUCKY PHARMACIST

From Your Executive Director

January 2013

MESSAGE FROM YOUR

EXECUTIVE DIRECTOR Robert “Bob” McFalls Thanks for all you do with and for YOUR KPhA 2013?! Have you retrained your brain yet to write the New Year, or are you, like me, still working on this adjustment? Another year has surely flown by, and in acknowledgement of the past year’s struggles and successes, I want to thank you for all that you have done and are doing to engage with your colleagues in support of the profession throughout the Commonwealth. I especially want to thank you for engaging with and supporting your Association throughout 2012, even as we strive for an even better 2013. There is much to pause and to celebrate, and at the same time, much remains to be done. In this regard, I am reminded of the words of Alfred Lord Tennyson as we begin anew—it is time to “Ring out the old, ring in the new. Ring out the false, ring in the true.”

team, I also want to extend my personal thanks to the KPhA officers and Directors who faithfully serve on your behalf. President Kim Croley is quick to answer the call when needed and is doing a great job in representing you. Your Directors are faithfully participating in regular Board meetings, have joined with member chairpersons to help jumpstart new committee work in health information technology and emergency preparedness, attended the Annual Meeting, joined you in convening two meetings of the House of Delegates, initiated a new strategic planning effort and most recently engaged in resurrecting and renaming the KPhA Mid-Year Conference. I also want to give a big shout-out to our 248 student pharmacists who attended and made the Mid-Year Conference such a resounding success (along with our sponsors without whom we could not have With the advent of a new year, each one of us has been granted a fresh book on whose pages we are writing a new achieved this milestone). And, to our pharmacy technician members who are working ever so diligently to formulate a chapter of our experience in pharmacy as we continue to new academy, your energy, commitment and dedication strive to provide the best service possible to our patients are an inspiration to us all. and to the community as a whole. In Gallup’s annual poll (December 2012), pharmacists were once again ranked If you have not already done so, mark your calendar for among the nation’s top professions in terms of honesty and YOUR 135th KPhA Annual Meeting (June 6-9, 2013) in ethical standards, placing second among all of the profesLouisville. Also, I am pleased that so many of you have sions listed. The rating of 75 percent represents the highest contacted us to acknowledge your new web site and its honesty rating the profession has ever received in the expanded features. In this spirit, we hope that you will conthree-decades-old poll. Respect is truly earned, and this tinue to help build a great resource by letting us know of ranking reaffirms the trust that patients are placing in their any additional resources and links that we can add that will pharmacists and pharmacy technicians as highly-trusted be mutually beneficial. medical professionals. Give yourself a well-earned pat on the back, or better yet, take a moment to thank a colleague Happy 2013! I look forward to working with you to advance for making such a difference for others. our mission and YOUR Association’s legislative and strateOn behalf of our small but committed and productive staff

Are you connected to KPhA? Join us online!

gic priorities throughout the New Year.

@KyPharmAssoc @KPhAGrassroots

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Continuing Education Article Guidelines

January 2013

Have an idea for a continuing education article? WRITE IT! Continuing Education Article Guidelines The following broad guidelines should guide an author to completing a continuing education article for publication in The Kentucky Pharmacist.  

 

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Include a quiz over the material. Usually between 10 to 12 multiple choice questions.

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Articles are reviewed for commercial bias, etc. by at least one (normally two) pharmacist reviewers.

Average length is 4-10 typed pages in a word processing document (Microsoft Word is preferred). 

When submitting the article, you also will be asked to fill out a financial disclosure statement to identify any financial considerations connected to your article.

Articles are generally written so that they are pertinent to both pharmacists and pharmacy technicians. If the subject matter absolutely is not pertinent to technicians, that needs to be stated clearly Articles should address topics designed to narrow at the beginning of the article. gaps between actual practice and ideal practice in Article should begin with the goal or goals of the pharmacy. Please see the KPhA website overall program – usually a few sentences. (www.kphanet.org) under the Education link to see Include 3 to 5 objectives using SMART and meas- previously published articles. urable verbs.

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Articles must be submitted electronically to the KPhA director of communications and continuing education Feel free to include graphs or charts, but please submit them separately, not embedded in the text (ssisco@kphanet.org) by the 15th of the month preceding publication. of the article.

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January 2013

Feb. 2013 CE — Constipation Treatment

Constipation Treatment in Infants and Children By: Dr. Julie N. Bosler, Assistant Professor, InterNational Center for Advanced Pharmacy Services (INCAPS) and Rachael Williams and Melissa Gallian, Pharm.D. Candidates, Sullivan University College of Pharmacy There are no financial relationships that could be perceived as real or apparent conflicts of interest.

KPERF offers all CE articles to members online at www.kphanet.org

Universal Activity # 0143-0000-13-002-H01-P&T 1 Contact Hour (0.1 CEUs) Objectives: At the conclusion of this lesson, the reader should be able to: 1. Define constipation in infants and children. 2. Understand the pathophysiology of constipation in infants and children. 3. Review the nonpharmacologic treatment options for constipation in infants and children. 4. Discuss pharmacologic treatment options for constipation in infants and children. The most common cause of constipation is idiopathic, or retention, which may be caused by changes in diet, freConstipation can be defined as an infrequent, difficult, painquent illness, inaccessible toilets and even toilet training. ful or incomplete delay in defecation for greater than two However, a small percentage of constipation cases are due weeks. However, a child with hard and painful stools is still to gastrointestinal diseases, metabolic causes, diabetes considered constipated even if his bowel movement fremellitus or insipidus, cystic fibrosis or neurological diseasquency is greater than three times per week. If a child has es. gone several days without defecating, they can become irritable; have abdominal distension, cramps and dePathophysiology of Constipation in Children and creased oral intake. Up to one third of children ages 6 to 12 Infants years report constipation during any given year.1 Voluntary and involuntary muscle contractions help to Table 1: Bowel Movements Based on Age2 maintain continence.1 Internally, the resting tone of the anal Ages Average number of bowel sphincter involuntarily decreases when stool enters the movements per day rectum.1 Externally, the anal sphincter is voluntarily conInfants – 3 months 2-3* trolled.1 When stool reaches the mucosa of the lower rec6-12 months 1-2 tum, the urge to defecate is triggered.1

Definition of Constipation in Infants and Children

1-3 years

Usually 1, sometimes 2

>3 years

Primary constipation occurs in the absence of an identifiable underlying cause. Secondary constipation occurs as a result of medications (opioids, anticholinergics, etc.), lifestyle factors (inadequate fluid intake, low dietary fiber, etc.) and/or medical disorders (irritable bowel syndrome, diverticulitis, etc.). Three subtypes of primary constipation include: normal transit, slow transit and pelvic floor dysfunc-

*Babies who are breastfed tend to have more frequent bowel movements

A patient must have two or more of the Rome III criteria to be diagnosed with chronic constipation.

Table 2: Rome III Criteria for Chronic Constipation3 Infants and Toddlers

Children 4-18 years

≤2 defecations/week ≥1 episode of incontinence after achieving toilet training skills History of excessive stool retention History of painful or hard bowel movements Presence of a large fecal mass in the rectum History of a large diameter stool that might obstruct the toilet

≤2 defecations/week ≥1 episode of fecal incontinence/week History of retentive posturing or excessive volitional stool retention History of painful or hard bowel movements Presence of a large fecal mass in the rectum History of a large diameter stool that might obstruct the toilet

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Feb. 2013 CE — Constipation Treatment tion. Normal transit constipation also is known as functional constipation” in which patients have normal GI motility and stool frequency but experience difficulty evacuating, passing hard stools or bloating and abdominal discomfort.4 Abnormality of GI transit time that leads to infrequent defecation is termed slow transit constipation.4 Finally, disordered defecation occurs in the presence of dysfunction of the pelvic floor muscles and/or anal sphincter.4 Ninety-five percent of children older than one year that experience constipation are diagnosed with functional constipation.1 Functional constipation in a child arises from the child not wishing to defecate which pushes feces higher into the rectal vault and reduces the urge to defecate.1 If this occurs frequently, the rectum eventually stretches and the propulsive action of the rectum decreases.1 The feces, therefore, become hard after long retainment making stool evacuation painful for the child. This subsequently turns into a continual cycle of avoiding bowel movements due to the fear of pain.

January 2013 water can be tried to soften the stool. A reduction in constipating foods, such as dairy, is recommended to try and relieve constipation. All children should have a wellbalanced diet consisting of whole grains, fruits and vegetables. Although many parents feel that iron-fortified formulas can lead to constipation, well controlled clinical trials have not demonstrated this theory. It is believed that this feeling comes from the mother’s association of taking prenatal iron supplements. It is important to educate the parents and caregivers on the lack of association of constipation from iron-fortified formulas and on adequate iron intake for their infant.

Pharmacologic Treatment Options in Infants and Children Disimpaction therapy is dependent upon age and first-line pharmacologic agents are listed in Table 3 below.

Table 3: First-Line Disimpaction Therapies5

Nonpharmacologic Treatment Options in Infants and Children

Infants (<1 year) Suppositories: Glycerin Oral: Corn syrup

Behavior and dietary modifications are first-line in treating constipation in infants and children. Behavior modifications5 Parents and caregivers also should create a toileting regimen for the child such as sitting for five to 10 minutes three to four times per day. It also is recommended to let the child use a footstool while toileting in order to support the legs, which will increase intra-abdominal pressure and allow for easier passage of the stool. They should keep a daily diary of stool frequency and reward the child for successful toileting immediately with an incentive such as stickers, which can be placed on the diary. The child should be praised for cooperating with the toileting regimen even if no bowel movement occurs. Parents and caregivers should always maintain a neutral or positive attitude in regards to toileting and the child’s progress and avoid punitive approaches and embarrassment as this could lead to further constipation. Dietary modifications2,5 Parents and caregivers should encourage children to increase fluid and fiber intake. It is recommended for children to have five to 10 grams plus their age of fiber per day with two ounces of fluid per each gram of fiber. Sorbitol containing fruit juices such as apple, pear and prune also are recommended before trying medication. If a child is having hard and painful bowel movements, then approximate one teaspoonful of corn syrup mixed in two ounces (60 ml’s) of

Children 1-2 years Suppositories: Glycerin Bisacodyl Oral: Bisacodyl Senna Magnesium citrate

Children >2 years Enemas: Glycerin Mineral oil Normal saline Suppositories Oral agents

Maintenance therapy focuses on the prevention of reoccurring constipation. Behavioral modification in addition to laxatives to ensure bowel movements at normal intervals occur with good evacuation are included in maintenance therapy.6 Dietary changes should also be implemented. Tables 4-9 summarize the most commonly used pharmacologic agents utilized in children and infants with constipation (disimpaction and maintenance). It is important to remember that only a limited number of trials exist that truly evaluate the use of laxatives in infants and children and therefore caution as well as conservative use is recommended. In general, these agents work by causing osmotic retention of fluid which distends the colon and produces increased peristaltic activity when taken orally.7 Phosphate enemas are thought to act osmotically through sodium causing large amounts of water to be drawn into the bowel thereby promoting evacuation.8 Hyperosmotic laxatives ultimately cause water retention in the stool and increase stool frequency.7 The newest guidelines regarding functional constipation in children suggest 26

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Feb. 2013 CE â&#x20AC;&#x201D; Constipation Treatment

Table 4: Osmotic Laxatives

January 2013

2,6,7

Drug

Dosage

Onset

Side Effects

Lactulose (70% solution)

1-3 mL/kg/day in divided doses

1-2 days

Sorbital (70% solution)

1-3 mL/kg/day in divided doses

24-48 hours

Magnesium hydroxide

1-3 ml/kg/day of 400 mg/5 mL liquid

0.5-6 hours

Magnesium citrate

<6: 1-3 mL/kg/day 6-12: 100-150 mL/day >12: 150-300 mL/day In divided doses

0.5-3 hours

Notes

Flatulence Abdominal cramps Flatulence Abdominal cramps Hypermagnesemia (muscle weakness, hypotension, or respiratory depression) Hyeprmagnesemia (muscle weakness, hypotension, or respiratory depression)

Well tolerated long term Can mix with fruit juice, milk or water Less expensive Use with caution in renal impairment Use with caution in renal impairment

Table 5: Osmotic Enema2,6,7 Drug Phosphate Enemas

Dosage <2: avoid >2: 6 mL/kg up to 135 mL

Onset

Side Effects

2-15 minutes

Risk trauma to rectal wall Abdominal distension Vomiting Hyperphosphatemia Hypocalcemia

Notes Well tolerated long term Can mix with fruit juice, milk or water

Table 6: Hyperosmotic Laxative2,6,7 Drug Polyethylene glycol (PEG) 3350

Dosage Disimpaction: 1-1.5 g/kg/day x 3 days Maintenance: 1 g/kg/day

Onset 48 hours

Side Effects Flatulence Abdominal pain

Notes Superior palatability and acceptance by children Contraindicated in bowel obstruction

Table 7: Lubricant Laxative2,6,7 Drug

Mineral oil

Dosage <1: Avoid Disimpaction: 15-30 mL/ yr of age, up to 240 mL/ day Maintenance: 1-3 mL/kg/ day

Onset

6-8 hours

Side Effects Cramps Lipoid pneumonitis, if aspirate

Notes More palatable if chilled Do not administer at bedtime

Table 8: Stimulant Laxatives2,6,7 Drug

Dosage

Senna

2-6: 2.5-7.5 mL/day 6-12: 5-15 mL/day 8.8 mg/5 mL liquid

Bisacodyl

<2: 5 MG PR once 2-11: 5-10 mg PR once OR 0.3 mg/kg/day PO

Onset

Side Effects

Notes

6-24 hours

Nausea Vomiting Abdominal cramps Idiosyncratic hepatitis

May be given with juice, milk or ice cream

6-10 hours (PO) 15-60 mins (PR)

Nausea Vomiting Abdominal cramps

Avoid in newborns Do not crush or chew tablets Separate milk or antacids by 1 hour of oral dose

that polyethylene glycol is now the first-line agent in this population, however, efficacy and safety is not well studied in infants and children less than two years of age.PL Therefore, further studies are necessary before widespread use

is recommended in infants and children less than two. Lubricant laxatives such as mineral oil work by easing the passage of stool through decreasing water absorption, softening the stool as well as lubricating the intestine.7 27

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Feb. 2013 CE — Constipation Treatment

January 2013

Table 9: Osmotic Dehydrating Suppository2,6,7 Drug

Glycerin

Dosage Neonates: ½ infant suppository PR once daily <6: 1 infant suppository PR once or twice daily >6: 1 adult suppository PR once or twice daily

Onset

15-30 minutes

Side Effects Minimal: Diarrhea Nausea Cramping Vomiting Rectal irritation

Stimulant laxatives work by stimulating peristalsis through direct irritation of the intestinal smooth muscle.7 Water and electrolyte secretion are altered producing a net intestinal fluid accumulation and as a result, laxation.7 Rectally, osmotic dehydrating agents work to increase osmotic pressure, draw fluid into the colon and ultimately stimulating evacuation.7

Conclusion

Notes

Insert suppository high into rectum and retain for 15 minutes

8th ed. New York: McGraw-Hill;2011. http:// www.accesspharmacy.com/content.aspx? aID=7978775. Accessed March 1, 2012. 5. Felt B, Brown P, Coran A, et al. University of Michigan Health System. Clinical Practice guideline. Functional constipation and soiling in children. February 2003. http://cme.med.umich.edu/pdf/guideline/peds03.pdf. Accessed February 27, 2012.

6. Constipation Guideline Committee of the North AmeriConstipation is responsible for an estimated 3 to 5 percent can Society for Pediatric Gastroenterology, Hepatology of child physician visits.1 This condition among children and Nutrition. Clinical practice guidelines. Evaluation poses a distressing challenge for parents and caregivers and treatment of constipation in infants and children: and often triggers fear of a serious medical condition. The recommendation of the North American Society for Pemost common type of constipation in children is functional diatric Gastroenterology, Hepatology and Nutrition. J and is rarely due to a serious organic cause. Greater eduPediatr Gastroenterol Nutr 2006;43(3):e1-e13. cation is warranted for parents and caregivers regarding 7. Taketomo CK, Hodding JH, Kraus DM. Lexi-Comp’s behavioral, dietary and pharmacologic treatment for funcPediatric Dosage Handbook. 17th ed. Hudson (OH): tional constipation although they should be aware of the Lexi-Comp;2010. signs and symptoms of more serious constipation-related conditions. It also should be clear that functional constipa- 8. Lexi-Comp OnlineTM, Lex-Drugs Online: Laxatives, tion is often times difficult to treat and relapse rate is high. If Classifications and PropertiesTM, Hudson, Ohio: Lexia child’s symptoms do not improve after six months of good Comp, Inc.; 2012. February 27, 2012. adherence to a treatment regimen, physician referral may be necessary.

References 1. Biggs WS, Dery WH. Evaluation and treatment of constipation in infants and children. Am Fam Physician 2006;73(3):469-477. 2. Treatment of constipation in children. Pharmacist’s Letter 2012 February. Detail No.:280207 [Electronic version]. Available at: http://www.pharmacistsletter.com. Accessed February 27, 2012.

Mycpemonitor.com

3. Fiorino KN, Liacouras CA. Chapter 324.2. Functional constipation. In: Kliegman R, Behrman R, Jenson H, Nelson SB. Textbook of Pediatrics. 18th ed. Philadelphia: Saunders Elsevier;2007:1284.

All of your CE Credit for 2013 will be uploaded to CPE Monitor

4. Powell PH, Fleming VH. Chapter 43. Diarrhea, constipation, and irritable bowel syndrome. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 28

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Feb. 2013 CE — Constipation Treatment

January 2013

February 2013 — Constipation Treatments in Infants and Children 1. Constipation is diagnosed when symptoms last longer than ___ days? A. 5 B. 10 C. 14 D. 30

6. Which pharmacologic therapy has the QUICKEST onset of action? A. Glycerin suppository B. Oral lactulose C. Oral polyethylene glycol D. Oral mineral oil

2. What is the MOST common subtype of primary constipation in children? A. Slow transit constipation B. Pelvic floor dysfunction constipation C. Drug-induced constipation D. Normal transit or “functional constipation”

7. Which class of medications works by promoting peristalsis through direct irritation of the intestinal smooth muscle thereby altering electrolyte secretion? A. Osmotic laxatives B. Lubricant laxatives C. Simulant laxatives D. Corn syrup

3. Which of the following food groups can cause constipation? A. Fruits B. Dairy C. Vegetables D. Grains

8. Which statement is true regarding glycerin suppositories? A. Insert suppository low into the rectum and retain for 15 minutes B. Onset of action is 24 to 48 hours C. Neonates should receive ½ adult suppository rec4. Iron-fortified formulas lead to constipation in infants tally once daily and children. D. Children >6 should receive 1 adult suppository A. True rectally once to twice daily B. False 5. Which dosage form should be AVOIDED in children less than 2 years of age? A. Oral B. Enema C. Suppositories D. All are recommended

ATTENTION PHARMACISTS AND PHARMACY TECHNICIANS TAKING THIS QUIZ! You MUST provide YOUR NABP e-Profile ID and birthdate (Month and Day only) on the answer sheet to receive continuing education credit for this activity. Visit www.mycpemonitor.net for more information. 29

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Feb. 2013 CE — Constipation Treatment

January 2013

This activity is a FREE service to members of the Kentucky Pharmacists Association. The fee for non-members is $30. Mail completed forms to: KPERF, 1228 US 127 South, Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile. Expiration Date: January 1, 2016 Successful Completion: Score of 80% will result in 1.0 contact hours or 0.1 CEUs. Participants who score less than 80% will be notified and permitted one re-examination. TECHNICIANS ANSWER SHEET. February 2013 — Constipation Treatment in Infants and Children Universal Activity # 0143-0000-13-002-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 2. A B C D

3. A B C D 4. A B

5. A B C D 6. A B C D

7. A B C D 8. A B C D

NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) PHARMACISTS ANSWER SHEET February 2013 — Constipation Treatment in Infants and Children Universal Activity # 0143-0000-13-002-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 2. A B C D

3. A B C D 4. A B

5. A B C D 6. A B C D

7. A B C D 8. A B C D

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The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy Education as a provider of continuing Pharmacy education.

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Bowl of Hygeia Fundraising Efforts

January 2013

Help support the Bowl of Hygeia Award! This year another 50+ Bowl of Hygeia recipients will be added to our ranks. All are dedicated pharmacists who take community service seriously and endeavor to make a difference in a way that is meaningful. Their stories are inspiring, and their attitudes are humble. All will make you proud.

sonally giving to this fund, and it’s why I think you’ll be interested to join me in making an investment in the future of the award. After all, it is the future recipients of the award that guarantee the legacy of our own awards. Our goal is to raise $5,000 as a collective gift from members of the Kentucky Pharmacists Association. As of December 2012, we had collected $700. We’re eager to show our state pride by either meeting or exceeding this goal. Won’t you please help by making a contribution? There are two ways to give:

The Bowl of Hygeia has a rich history within pharmacy and it represents well members of our profession. That’s why I’m excited to be helping to carry forth the Bowl of Hygeia tradition through collaboration with the Kentucky Pharmacists Association as our Association works with the “stewards” of the Bowl of Hygeia, the National Alliance of State Pharmacy Associations, the APhA Foundation and the American Pharmacists Association. Before these national Pharmacy groups assumed responsibility for the Bowl, this prestigious award was in jeopardy of being extinguished. If it were not for their agreement to carry forward the honor through a professional collaboration, 2010 would have been the last year the Bowl of Hygeia was awarded.

Online at: http://www.aphafoundation.org and choose the Bowl of Hygeia endowment button. Kentucky will get credit by your address. Or, you can send your check to: APhA Foundation – Bowl of Hygeia 2215 Constitution Ave., NW Washington, DC 20037-2985 Thank you in advance for joining me in this effort. Sincerely in Service I am,

George Hammons, RPh Owner/President Knox Professional Pharmacy Given that this is an award presented at the state lev- Bowl of Hygeia Award Recipient, 2012 el, the State Pharmacy Associations — including your Kentucky Pharmacists Association — along with NASPA, are working together to help make sure this award we hold so dearly is never at risk again. In order to sustain the award, each state association is working together to build an endowment sufficient to generate dividends that will fund the program in perpetuity. The APhA Foundation, a national nonprofit 501 (c) (3), has agreed to be the home of the endowment account, and to date we are almost half way to our goal of $600,000. As a recipient of the award, I am excited to be a leader in helping the Kentucky Pharmacists Association kick off its campaign. I want to be sure the Bowl of Hygeia continues to represent the hallmark of community service in our profession. That’s why I am per-

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Pharmacy Law Brief

January 2013

Pharmacy Law Brief: Contemporary Legal Issues for Leadership in Non-Profits - III Author: Joseph L. Fink III, B.S.Pharm., J.D., Professor of Pharmacy Law and Policy and KPhA Professor of Leadership, Department of Pharmacy Practice and Science, UK College of Pharmacy Question: I am new to serving on the board of a nonprofit Submit Questions: jfink@uky.edu community health agency in my area. During one of the meetings an experienced board member mentioned some- tional purpose. thing called “fiduciary obligations” that I have in that role. What are some important features of this distinction? The We had no orientation session for new board members. most widely acknowledged distinction is that donations to a What is that? 501(c)(3) organization are tax deductible by the donor, Response: At the outset it should be noted that an earlier whereas that advantage does not apply to contributions to column in this series, appearing in the November 2008, a 501(c)(6) entity. The value of having the donations be tax issue, was entitled “Potential Legal Exposure with Commu- deductible to the donor cannot be understated. Many, if not nity Service as a Board Member of a Non-Profit Agency.” most, individuals and business entities have a strong prefFurther, a column entitled “Contemporary Legal Issues for erence for donating where a tax deduction results. Leadership in Non-Profits-I” appeared in the September Organizations classified under 501(c)(6) may engage in 2012, issue and that was followed with “II” during Novempolitical activities such as lobbying whereas 501(c)(3) have ber which addressed fiduciary obligations. One who serves their activities in this area limited by a provision that speciin a leadership role with a non-profit organization should fies that no “substantial part” of their activities may be for have a basic understanding of the legal environment within “carrying on propaganda or otherwise attempting to influwhich such entities operate. This installment addresses ence legislation.” If a 501(c)(3) group were to engage in issues related to the distinction between being categorized political activity to too large an extent it is likely its tax exas nonprofit versus being considered tax exempt and supempt status, a very valuable asset, would be revoked. plements or extends those earlier discussions. Congress has provided an alternative to handle such situaAt the outset of this discussion it is important to emphasize tions. Section 501(h) of the Internal Revenue Code allows that an organization’s status as a non-profit entity is quite a 501(c)(3) organization to elect to be covered under §501 separate from its classification as being a tax exempt or(h), a provision that permits a non-profit to spend funds for ganization. As a side note, today’s phrasing can be either that purpose. The total that can be so spent varies with the “nonprofit” or “not-for-profit”; they are used interchangeaamount of the exempt purpose expenditure. bly. So it is noteworthy that a nonprofit organization need Another issue for nonprofit tax exempt organizations is unnot have a charitable purpose. That charitable purpose related business income tax (UBIT). The organization must relates to the tax exempt classification, not to the non-profit have a tax exempt purpose stated in its charter or other status of the entity. formative papers. It can generate an excess of revenue To illustrate this with a local example, think of the nonprofit over expenses and incur no tax liability if those “retained organization that is KPhA and contrast that with the nonearnings” are applied to advancing the charitable purpose profit and tax exempt entity that is the Kentucky Pharmacy of the organization. If the organization engages in activities Education and Research Foundation, Inc. (KPERF). The deemed “unrelated” to its exempt purpose then it may incur former falls under §501(c)(6) of the Internal Revenue Code liability for paying taxes on that income, something that because it is an association of persons with common or does not generally occur with tax exempt organizations. shared interests. It must be supported by membership Income generated by business activities unrelated to the dues and other income from activities substantially related tax exempt purpose of the organization can create tax liato its exempt purpose. bility which is sometimes surprising to those without extenContrast and compare that with KPERF, which falls under sive experience dealing with nonprofit tax exempt organi§501(c)(3) because it engages in activities with an educa- zations. Disclaimer: The information in this column is intended for educational use and to stimulate professional discussion among colleagues. It should not be construed as legal advice. There is no way such a brief discussion of an issue or topic for educational or discussion purposes can adequately and fully address the multifaceted and often complex issues that arise in the course of professional practice. It is always the best advice for a pharmacist to seek counsel from an attorney who can become thoroughly familiar with the intricacies of a specific situation, and render advice in accordance with the full information.

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APSC/HD Smith

January 2013

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Pharmacy Policy Issues

January 2013

PHARMACY POLICY ISSUES: The Pharmacist’s Role, Development, and Education in Veterinary Pharmacy Author:

Mary Oelmann is a fourth professional year PharmD student at the University of Kentucky College of Pharmacy. A native of Waterloo, Iowa, Mary graduated from Iowa State University with a B.A. in Chemistry and will receive her M.S. in Pharmaceutical Sciences along with her PharmD in May 2013 from UK College of Pharmacy.

Issue:

Should community pharmacies dispense pet medications on a more regular basis, not just prescription medication, but OTC pet medications, too?

Discussion: Many community pharmacies are looking to expand business into markets not previously utilized, like veterinary pharmacy, in an attempt to make up for the loss in reimbursements many of them are experiencing on a number of fronts. Some community pharmacies are starting to promote and carry OTC pet medications such as Heartgard® and Frontline®. Along with these OTC medications, they also promote their prescription medication related services and the fact that many common pet medications like levothyroxine, cephalexin, tramadol and enalipril, just to name a few, are on the $4 list at some pharmacies.

what a pharmacist would customarily see for a human patient when compared on a mcg/kg dosage.

At this writing HR 1406 is still in committee; however, as a profession there is much to be done before we truly are ready for such a bill to be passed. As pharmacists we are capable of dispensing medications for pets, but to do it safely there is education that needs to be done. If education is not done, we will likely be calling the prescriber often for answers to questions that a well-developed CE program could answer. An example of this would be calling to verify a levothyroxine dosage for a cat. Felines don’t absorb thyroid medication well at all so they require higher doses than

knowledge to treat this special patient population.

Have an Idea?: This column is designed to address timely and practical issues of interest to pharmacists, pharmacy interns and pharmacy technicians with the goal being to encourage thought, reflection and exchange among practitioners. Suggestions regarding topics for consideration are welcome. Please send them to jfink@uky.edu.

Not only may there be a bombardment of phone calls to veterinarians, but there also may be an increase in adverse drug reactions if pharA bill was introduced in Congress during April 2011 called macists are making the Fairness to Pet Owners Act (HR 1406) that would reOTC recommendations. quire the veterinarian to provide the pet owner with a copy Many know, and it can of the prescription, and a written disclosure that the owner be determined by the may obtain the medication from the veterinarian or through packaging, that most of a pharmacy.1 This would remind owners that they do have the flea, tick and heartworm medications are all weight the option to get the medication elsewhere and do not have based. A pharmacist would make his or her recommendato use the veterinarian’s office to get their pet’s medication. tion based on the size of the dog. However, the breed of Passing this bill would potentially help increase the number dog needs to be known, too. The Collie breed is known to of prescriptions dispensed for pets at the local pharmacy. be more sensitive to ivermectin, a sensitivity that can lead Increasing the number of places owners can get their pet to many adverse reactions including death. medications has many believing this has helped lower the In conclusion, if more pet owners begin to present their preprices on some of the pet medications. While there may be scriptions at pharmacies not associated with their veterinary more competition, there is still a way to go in making all clinic, there is a risk of increase adverse drug reactions if medications competitively priced.2 we as pharmacists do not prepare ourselves with the References: 1. H.R. 1406--112th Congress: Fairness to Pet Owners Act of 2011.” GovTrack.us (database of federal legislation). 2011. December 10, 2012 http://www.govtrack.us/ congress/bills/112/hr1406. 2. Burns, Katie. “FTC workshop explores pet medication.” Journal of the American Veterinary Medical Association. 2012(Nov.);241(10):1260-1261.

THE KENTUCKY PHARMACIST

January 2013

Kentucky Renaissance Pharmacy Museum

The Kentucky Renaissance Pharmacy Museum offers several ways way to show support of the Museum, our state's leading preservation organization for pharmacy. While contributions of any size are greatly appreciated, the following levels of annual giving have been established for your consideration. Friend of the Museum $100  Proctor Society $250 Damien Society $500 Galen Society $1,000

Name______________________________________ Specify gift amount________________________ Address ____________________________________ City____________________Zip______________ Phone H____________________W________________ Email___________________________________ Employer name_____________________________________________________for possible matching gift. Tributes in honor or memory of_____________________________________________________ Mail to: Kentucky Renaissance Pharmacy Museum, P.O.Box 910502, Lexington, KY 40591-0502 The Kentucky Renaissance Pharmacy Museum is a non-profit 501(c)(3) business entity and as such donations are tax deductible. A notice of your tax deductible contributions will be mailed to you annually.

Questions: Contact Lynn Harrelson @ 502-425-8642 or Lharrelsonky@aol.com

Pharmacists Mutual Insurance offers Medicare Surety Bond In 2009 the Centers for Medicare and Medicaid Services (CMS) implemented Surety Bond Requirements for suppliers of Durable Medical Equipment, Prosthetics and Supplies (CMS-6006 -F). This ruling requires that each existing supplier must have a $50,000 surety bond to CMS.

To see if you qualify for a $250 Medicare Surety Bond, or would like information regarding our other products, please contact us:   

Pharmacists Mutual Insurance Company, through its subsidiary Pro Advantage Services, Inc. d/b/a Pharmacists Insurance Agency (in California), led the way to meet this requirement by negotiating  the price of the bond from $1,500 down to $250 for qualifying risks.

Call 800.247.5930 Extension 4260 E-mail medbond@phmic.com Contact a Pharmacists Mutual Field Representative or Sales Associate http:// www.phmic.com/phmc/services/ibs/Pages/ Home.aspx In Kentucky, contact Bruce Lafferre at 800.247.5930 ext. 7132 or 502.551.4815 or Tracy Curtis at 800.247.5930 ext. 7103 or 270.799.8756.

THE KENTUCKY PHARMACIST

January 2013

Pharmacists Mutual

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Cardinal Health Foundation Generation Rx Award

January 2013

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KPhA Board of Directors

January 2013

KPhA BOARD OF DIRECTORS

HOUSE OF DELEGATES

Lewis Wilkerson, Frankfort rphs2@aol.com

Chairman 502.695.6920

Matt Martin, Louisville matt67martin@gmail.com

Kimberly Croley, Corbin kscroley@yahoo.com

President 606.304.1029

Cassandra Beyerle, Louisville Vice Speaker of the House cbeyerle01@gmail.com

Duane Parsons, Richmond dandlparsons@roadrunner.com

President-Elect 502.553.0312

KPERF ADVISORY COUNCIL

Frankie Hammons Abner, Barbourville frankiehammons@gmail.com

Secretary 606.627.7575

Glenn Stark, Frankfort glennwstark@aol.com

Treasurer

Donnie Riley, Russelville Past President donnierileyatclinicpharmacy@msn.com Directors Molly Trent, Georgetown mjtren2@uky.edu

Student Representative

Lance Murphy, Louisville lmurph8942@my.sullivan.edu

Student Representative

Matt Carrico, Louisville matt@boonevilledrugs.com Chris Clifton, Erlanger chrisclifton@hotmail.com Trish Freeman, Lexington* trish.freeman@uky.edu Joey Mattingly, Prospect joeymattingly@gmail.com Jeff Mills, Louisville jeff.mills@nortonhealthcare.org Bob Oakley, Louisville Boakley@BHSI.com Richard Slone, Hindman richardkslone@msn.com Sam Willett, Mayfield duncancenter@bellsouth.net * At-Large Member to Executive Committee

KPhA sends email announcements weekly. If you arenâ&#x20AC;&#x2122;t receiving: eNews, Legislative Updates, Grassroots Alerts and other important announcements, send your email address to ssisco@kphanet.org to get on the list.

Speaker of the House

Kim Croley, Corbin kscroley@yahoo.com Ann Amerson, Lexington amerson@insightbb.com

KPhA/KPERF HEADQUARTERS 1228 US 127 South, Frankfort, KY 40601 502.227.2303 (Phone) 502.227.2258 (Fax) www.kphanet.org www.facebook.com/KyPharmAssoc www.twitter.com/KyPharmAssoc Robert McFalls, M.Div. Executive Director rmcfalls@kphanet.org Scott Sisco, MA Director of Communications and Continuing Education ssisco@kphanet.org Kelli Sheets Office Manager ksheets@kphanet.org Christine Richardson, PharmD Clinical Pharmacist, Interim Director of Professional & Clinical Services crichardson@kphanet.org Leah Tolliver, PharmD Director of Pharmacy Emergency Preparedness ltolliver@kphanet.org Nancy Baldwin Receptionist/Office Assistant nbaldwin@kphanet.org Angela Gibson Administrative Coordinator & Billing Specialist (Temporary placement) agibson@kphanet.org

THE KENTUCKY PHARMACIST

50 Years Ago/Frequently Called and Contacted

January 2013

50 Years Ago at KPhA Eight candidates successfully passed the State Board of Pharmacy Examination in January. They are: Evin P. Vann, Shelbyville; Pony Walker Lykins, Jr., Greenup; Robert Smith Clark, Owensboro; Billy Lynn Barrett, Lexington; Jacquelyn Worth Arnold, Franklin; James F. Grasty, Henderson; John S. Street, Evansville, Ind.; and Jack R. Osman, Portsmouth, Ohio. The highest grade was made by Jack R. Osman, a graduate of the University of Kentucky College of Pharmacy, from Portsmouth, Ohio, with an average of 89.8.â&#x20AC;&#x201D; From The Kentucky Pharmacist, February 1963, Volume XXVI Number 2.

Frequently Called and Contacted Kentucky Pharmacists Association 1228 US 127 South Frankfort, KY 40601 (502) 227-2303 www.kphanet.org Kentucky Board of Pharmacy State Office Building Annex, Ste. 300 125 Holmes Street Frankfort, KY 40601 (502) 564-7910 www.pharmacy.ky.gov Pharmacy Technician Certification Board 2215 Constitution Avenue Washington, DC 20037-2985 (800) 363-8012 www.ptcb.org Kentucky Society of Health-System Pharmacists P.O. Box 4961 Louisville, KY 40204 (502) 456-1851 x2 (502) 456-1821 (fax) www.kshp.org info@kshp.org

Kentucky Regional Poison Center (800) 222-1222 American Pharmacists Association (APhA) 2215 Constitution Avenue NW Washington, DC 20037-2985 (800) 237-2742 www.aphanet.org National Community Pharmacists Association (NCPA) 100 Daingerfield Road Alexandria, VA 22314 (703) 683-8200 info@ncpanet.org Drug Information Center Sullivan University College of Pharmacy 2100 Gardiner Lane Louisville, KY 40205 (502) 413-8638 www.sullivan.edu

KPhA Remembers KPhA desires to honor members who are no longer with us. Please keep KPhA informed by sending this information to ksheets@kphanet.org. Deceased members for each year will be honored permanently at the KPhA office. 39

THE KENTUCKY PHARMACIST

January 2013

THE

Kentucky PHARMACIST 1228 US 127 South Frankfort, KY 40601

Save the Date! 135th KPhA Annual Meeting June 6-9, 2013 Louisville Marriott Downtown

Visit www.kphanet.org to register.

THE KENTUCKY PHARMACIST