The Kentucky Pharmacist Vol. 11, No. 1 by Kentucky Pharmacists Association

THE KENTUCKY PHARMACIST Vol. 11, No. 1 January/February 2016 News & Informat ion for Members of the Kentucky Pharmacists Ass ociation

OUR KPhA

Guardian of the Profession in Frankfort

Table of Contents

January/February 2016 February Pharmacist/Pharmacy Tech Quiz Answer Sheet 28 KPhA Emergency Preparedness 29 Infinitrak 30 Campaign for Kentucky’s Pharmacy Future: The Next 50 Years 31 KPhA New and Returning Members 32 Naloxone Certification Training 35 Pharmacy Law Brief 36 Pharmacy Policy Issues 38 Pharmacists Mutual 40 Cardinal Health 41 KPhA Board of Directors 42 50 Years Ago/Frequently Called and Contacted 43

Table of Contents Table of Contents— Oath— Mission Statement President’s Perspective We’ve Moved: New KPhA Headquarters 2016-17 KPhA Board Election/Call for HOD Resolutions From your Executive Director APSC 2016-17 KPhA Professional Awards KPhA Membership Challenge Drive Jan. 2016 CE — COPD Treatment Guide January Pharmacist/Pharmacy Tech Quiz Answer Sheet Feb. 2016 CE — CNS Modulating Drugs for Pets

2 3 4 5 6 8 9 12 13 20 21

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.

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.

Editorial Office: © Copyright 2016 to the Kentucky Pharmacists Association. The Kentucky Pharmacist is the official journal of the Kentucky Pharmacists Association published bi-monthly. 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. Editor-in-Chief: Robert McFalls Managing Editor: Scott Sisco Editorial, advertising and executive offices at 96 C. Michael Davenport Blvd., Frankfort, KY 40601. Phone 502.227.2303 Fax 502.227.2258. Email ssisco@kphanet.org. Website http://www.kphanet.org.

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. 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. 2

THE KENTUCKY PHARMACIST

President’s Perspective

January/February 2016

PRESIDENT’S PERSPECTIVE Chris Clifton KPhA President 2015-2016

Why do we as a profession continue to try and segregate ourselves out into different practices of pharmacy? Are we not all pharmacists? Do we all not preach and practice the same oath and pledge as a pharmacist? Are we not in this to better all our patients’ lives and at the same time move the profession together as one? These are questions that I wondered as a student pharmacist and continue to question today. But as I write this, there are currently eight national pharmacy associations; American Association of Colleges of Pharmacy (AACP), American Pharmacists Associations (APhA), American Society for Pharmacy Law, American Society of Consultant Pharmacists (ASCP), American Society of Health-System Pharmacists (ASHP), National Community Pharmacists Association (NCPA), National Association of Chain Drug Stores (NACDS) and Professional Compounding Centers of America. How on earth can you communicate one voice or message when you have eight different people or organizations representing pharmacy? And this holds true at the state level, where the bulk of pharmacy practice legislation and regulation work gets done.

sometimes too concerned with “OUR” own needs and wants in our practice setting that we forget the true cause or reason we went into this profession: “OUR” patients’ needs. Once we start focusing on the bigger picture and stop concerning ourselves with what’s better for “OUR” lives, the further and brighter this profession will go. This legislative session, we as an association will be working on finally putting some muscle behind the PBM bill that was passed in 2013. The legislature passed a bill regulating the use of MACs in 2013, but pharmacists continue to report problems with PBMs not updating pricing and failing to respond to appeals on a timely basis. KPhA began meeting with legislators before the session began to draft a bill designed to make enforcement of the existing law easier and to clarify the responsibilities of PBMs. We also will be seeking legislation to address the issue of specialty drugs. PBMs and insurance companies are moving more and more drugs into the “specialty” category and requiring that they be dispensed by “specialty pharmacies.” Oftentimes the onerous requirements for the designation of “specialty pharmacy” cannot be met by most pharmacies. The legislation will basically require insurers and PBMs to allow any contracted pharmacy to dispense any drug unless the FDA has limited the distribution of the drug or the pharmacy cannot meet specialized requirements for handling, education or monitoring established by the manufacturer. We also are considering a provision to prohibit insurers or PBMs from directing business to pharmacies in which they have an ownership interest.

Having a successful legislative session will not be easy and is going to require a lot of work from “ALL” pharmacists. With a new administration in the executive branch as well as political elections coming up in 2016, it is going to take a “UNITED” voice, one that is loud and clear, to express what we as pharmacists need for our profession to In our profession we promise to devote ourselves to a life- move forward. Now is not the time for individuals or associtime of service to others through the profession of pharma- ations to be selfish in their actions or decisions. Remember cy. In many ways we are servant leaders as we take care we are self-servant leaders, and we are all pharmacists. So of our patients’ needs and “OUR” profession. However, join us and help move this profession forward and stronger having multiple messages being shouted or differing points for the future. Contact your legislators now and tell them to of view being promoted causes “OUR” profession to look support the legislative priorities set forth by “OUR” KPhA disorganized and unfocused. We as a profession are for 2016.

The Campaign for Kentucky’s Pharmacy Future: The Next 50 Years http://www.kphanet.org/?page=buildingcampaign 3

THE KENTUCKY PHARMACIST

President’s Perspective

January/February 2016

We’ve Moved! The KPhA Headquarters moved to its new location at 96 C. Michael Davenport Blvd. in Frankfort between Christmas and New Years. We sincerely appreciate Director Chris Killmeier (who, accompanied by Roamey, climbed the ladder to take down the print that hung over the stairwell for MANY years), Director Richard Slone, Members Ralph Bouvette and Lewis Wilkerson and UKCOP students Emily Sudkamp and Brian Garcia for their hands-on assistance, tremendous support and moral encouragement with the complete office relocation.

When you’re in Frankfort, come by to see OUR new KPhA Home. Email addresses, phone numbers and the fax number all stayed the same.

The Campaign for Kentucky’s Pharmacy Future: The Next 50 Years

96 C. Michael Davenport Blvd. Join the Committee of 100 and help OUR KPhA accelerate to 50 percent of our Campaign Goal! http://www.kphanet.org/?page=buildingcampaign 4

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KPhA Board of Directors Nominations

January/February 2016

Call for Resolutions for KPhA House of Delegates OUR KPhA House of Delegates will meet at the 138th KPhA Annual Meeting and Convention June 2-5, 2016 at the Louisville Marriott Downtown. Resolutions, formal statements expressing the opinion, will, or intent of a body of persons, may be submitted by individual members, district organizations, other associations or interests or committees. The most effective resolutions are carefully constructed to use as few words as possible to convey the basic issues and reasons for the stand. All proposed resolutions received prior to May 15, 2016 will be submitted to the KPhA Board of Directors, who will review them and make recommendations to the House of Delegates. The Board reserves the right to edit any proposed resolutions submitted and may, at its discretion and upon its own initiative, develop additional proposed resolutions. The Board will report all resolutions to the House of Delegates. Each resolution will carry with it the Board's action to recommend or not recommend, or with no recommendation. After the Board has considered all submitted resolutions, it will provide those resolutions for publication on the KPhA website (www.kphanet.org). These resolutions will be provided in writing to the Delegates. Following the action of the House of Delegates at the KPhA Annual Meeting, the resolutions adopted will be published on the website and in the next edition of The Kentucky Pharmacist. Submit resolutions to Scott Sisco (ssisco@kphanet.org) or Robert McFalls (rmcfalls@kphanet.org) or via mail to KPhA, 96 C. Michael Davenport Blvd., Frankfort, KY 40601 by May 15, 2016. If you are interested in serving as a delegate, contact the leader of your local organization. If you do not know who that is, contact Scott Sisco at ssisco@kphanet.org or 502-227-2303.

THE KENTUCKY PHARMACIST

From Your Executive Director

January/February 2016

MESSAGE FROM YOUR

EXECUTIVE DIRECTOR

Robert “Bob” McFalls

OUR KPhA: Guardian of the Profession in our State Capital January is always a time of new beginnings and brings with it the traditional start of a new legislative session. This is OUR KPhA – formed by pharmacists for pharmacists, serving Kentucky’s pharmacists since 1879 with a commitment to join all practice areas of the profession together to collectively advocate for statutory and regulatory changes that will improve the profession of pharmacy and overall healthcare throughout the Commonwealth. As the largest organization representing the entire practice setting of pharmacists throughout Kentucky, we are committed to advancing OUR legislative accomplishments, which include passing legislation allowing pharmacists to give immunizations, enacting the nation’s first Pharmacy Benefit Manager (PBM) transparency legislation, pharmacy audit legislation, collaborative care legislation and many others. It is OUR collective voice that is OUR greatest strength and makes OUR past successes possible as WE unite as members.

country’s first MAC Transparency legislation, it was the most progressive law nationally in requiring PBMs to provide MAC lists, creating an appeals process and allowing the Kentucky Department of Insurance (DOI) to have regulatory authority over the PBMs. Now that the law has been fully implemented, it is clear there are changes that need to be made in order to make sure that the intent of the legislation, as passed in 2013, is fully implemented. When KPhA and OUR members realized changes needed to be made, and these concerns were brought forward to the Kentucky Department of Insurance (DOI), DOI also noted that it was receiving more and more complaints from consumers and pharmacists about the actions of PBMs. OUR KPhA drafted legislation, collaborated with our pharmacy partners and led meetings with DOI since the adjournment of the 2015 legislative session. PBM Licensure: KPhA’s and DOI’s draft legislation would require PBMs to be licensed separately, instead of being licensed as third party administrators.  By requiring PBMs to be licensed, DOI is given clear regulatory authority over PBMs.  PBMs would be required to be bonded.  DOI would have the power to suspend, revoke or refuse to renew a PBM license for violations of the PBM law or other provisions of the insurance code.  DOI also could issue penalties of up to $250,000 in lieu of suspending a PBM’s license. MAC Transparency: Along with DOI licensure, KPhA has drafted and supports proposed statutory changes that would require additional MAC transparency. Pharmacies are often frustrated because they spend an unreasonable amount of time trying to find a MAC price list.  PBMs would be required to notify pharmacies as to where a drug can be purchased at a price equal to or below the MAC if an appeal is denied.  MAC lists would be required to be updated every seven days.  PBMs would be required to update MAC in a manner determined by DOI. Clarify Appeals Process: KPhA also recommends additional changes to clarify the appeals process.  PBMs must respond to all appeal requests, including denials, regardless of the reason for the denial.  In the cases where the pharmacy is successful in its MAC

Most assume that legislative advocacy work only begins when the session starts in January. But OUR KPhA started work on the 2016 legislative session the moment the final gavel rang down on the 2015 session. It takes all year to build relationships with legislators, draft legislation, collaborate with executive agencies, strategize with OUR pharmacy partners, craft policy solutions and monitor legislative and executive agency initiatives impacting the pharmacy profession. During this time period, OUR KPhA also is monitoring proposed legislation and working to comment upon and impact regulatory issues. In this spirit, OUR KPhA gladly presents the culmination of these efforts in the KPhA 2016 Legislative Agenda. OUR KPhA welcomes pharmacists to Frankfort and looks forward to engaging with you in visiting with your legislators and other key elected officials. For those unable to make the trip to Frankfort this year, we will continue to keep you informed about legislative issues affecting the profession through OUR KPhA Weekly Legislative Updates and to ask for your active engagement on issues as communicated through OUR KPhA Grassroots Alerts. OUR 2016 LEGISLATIVE PRIORITIES Pharmacy Benefit Manager (PBM) Licensure & Maximum Allowable Cost (MAC) Transparency Enforcement In 2013, when KPhA worked with legislators to draft and work with OUR members and pharmacy partners to enact the 6

THE KENTUCKY PHARMACIST

From Your Executive Director

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January/February 2016

appeals, the PBM would be required to make retroactive adjustments for all contracted pharmacies in the network. Appeals must be investigated and resolved within 10 calendar days.

on Health & Welfare in November 2015 to this position. OUR KPhA will continue to monitor this legislation and work against a mandatory notification requirement. Clarify in Statute that PBMs and Insurance Companies can Only Restrict Medication Dispensing under Specific Circumstances

Update Kentucky’s Generic Drug Law to Allow for Seamless Substitution of FDA approved Interchangeable Biosimilars for the Brand Name Biologic Product Kentucky’s rural and independent pharmacies play a vital role in Kentucky’s healthcare system. For many of Kentucky’s ruWith the passage of the legislation by the U.S. Congress to allow the U.S. Food and Drug Administration (FDA) to provide ral residents, a pharmacy may be the closest healthcare provider for miles. And that is why it is critically important to ena path for approving biosimilar products subsequently detersure that patients have access to rural pharmacies. Recent mining what products are interchangeable, Kentucky must update its generic drug law to allow for the seamless and au- efforts by PBMs, insurance companies and some Managed Care Organizations (MCOs) to arbitrarily limit the dispensing tomatic substitution of interchangeable biosimilar products. of certain medications needs to be addressed. In order for Biosimilar products have the potential to save payers, like Kentucky’s patients to continue to be able to access employers and patients, millions of dollars. As generic drugs have saved millions since the passage of Kentucky’s generic healthcare through a pharmacist, the General Assembly should pass legislation stating that MCOs, PBMs and insurdrug law in the 1970s, biosimilars are expected to save billions. According to a 2014 Rand Corporation Report, the Unit- ance companies can only limit the dispensing of certain medications under specific circumstances. ed States could save close to $44 billion over the next 10 years as a result of making the switch to interchangeable bioKPhA drafted and supports legislation stating Pharmacy Bensimilar products. efit Managers (PBMs) or Managed Care Organizations While it is critical for Kentucky to change its generic drug law (MCOs) cannot prohibit licensed and contracted Kentucky pharmacies from dispensing medications unless drug manuto allow for the automatic substitution of these medications, KPhA opposes any attempts by major pharmaceutical manu- facturers require special handling requirements, the pharmacy cannot provide proper patient education or the U.S. Food and facturers to require burdensome prescriber notification reDrug Administration has issued distribution restrictions. KPhA quirements on pharmacies. While it may sound simple for pharmacists to notify prescribers, the electronic methods de- also supports legislation requiring insurers, PBMs and MCOs scribed in the draft legislation are mostly not available to Ken- to charge the same co-pays and co-insurance regardless of tucky’s community pharmacies, especially the 575 independ- which contracted pharmacy dispenses the medication. Finally, KPhA supports legislation prohibiting insurers, PBMs and ent pharmacies. The manual notification requirements, as MCOs from coercing, compelling or misleading an insured or contained in pre-filed legislation, will take the pharmacist’s Medicaid recipient into using a pharmacy in which they have a time away from patient care by requiring unnecessary notififinancial interest. cations. Pharmacists can always communicate with the prescriber when they think it necessary, but this should not be a KPhA supports Legislation to address Medical mandate. Malpractice Reform Pharmaceutical companies have tried many times to put unKPhA supports the collaborative effort by healthcare providers necessary prescriber notification requirements in state law, to enact Medical Malpractice Reform. Past legislative efforts but every time the Kentucky General Assembly sees this for were made to establish “medical review panels” of a health what it is — an attempt to protect prescribing of the brand profession’s peers to prescreen medical malpractice claims. name product. A notification requirement could be very costly The panel’s decision would be non-binding but would be adfor the Commonwealth of Kentucky, too. Moreover, when missible in court. Indiana, Louisiana and several other states Tennessee decided to require prescriber notification on seiutilize medical review panels. This proposal is supported by a zure medications, brand dispensing increased by 29.3 perlarge coalition of health care provider groups, and KPhA is an cent, costing the state’s Medicaid program some $4 million. active member of the coalition. While this has not been a big issue for pharmacists, being able to establish medical review KPhA agrees that Kentucky’s generic drug laws need to be panels could prove a useful legal option in the future. updated in order to allow for the automatic substitution of interchangeable biosimilars. However, KPhA opposes any attempts for required prescriber notification requirements by pharmacists and testified before the Interim Joint Committee

Continued on Page 35

THE KENTUCKY PHARMACIST

APSC

January/February 2016

THE KENTUCKY PHARMACIST

2016 KPhA Professional Awards

January/February 2016

2016 KPhA Professional Awards 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. Recipients Larry Stovall 2015 Jerry White 2014 Leon Claywell 2013 George F. Hammons 2012 William I. McMakin, III 2011 Kim Croley 2010 Patricia Thornbury 2009 Dave Peterson 2008 Charles Fletcher 2007 Gloria Doughty 2006 Larry Hadley 2005 Harold Cooley 2004 Brian Fingerson 2003 Simon Wolf 2002 Richard Ross 2001 Tom Houchens 2000 Phil Losch 1999 Lucy Easley 1998 Nick Schwartz 1997

E IS N I DL 31 ! A DE RCH MA

Michael Cayce Bill Borders Gerald Deom Kenneth Calvert Joseph G. Bessler Michel A. Burleson Lynn Harrelson William A. Conyers, Jr. Daniel R. Kovar, Jr. Martin W. Nie Ralph Schwartz Dwaine K. Green W. Vance Smith 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

1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 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

bers 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. Recipients Michael A. Burleson 2015 William Grise & Judy Minogue 2014 Catherine Hanna 2013 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 Distinguished Service Award J.H. (Jack) Voige 1985 Criteria- To recognize individual mem- Charles T. Lesshafft, Jr. 1984

Nominate your peers today!

Email your letter of nomination with any supporting documents to ssisco@kphanet.org or submit to:

KPhA Awards, 96 C. Michael Davenport Blvd., Frankfort, KY 40601 9

THE KENTUCKY PHARMACIST

2016 KPhA Professional Awards Jerry Budde William H. Nie R.N. (Randy) Smith

1983 1982 1981

Pharmacist of the Year Award Criteria – To recognize a pharmacist for outstanding professional activities undertaken during the current or previous calendar year, which resulted in demonstrable benefit to the profession of pharmacy. Eligibility – Only Active or Honorary Life members of the Association shall be eligible for nominations and receipt of this award. Recipients Claire Love 2015 Jill Rhodes 2014 Trish Freeman 2013 Alyson Schwartz 2012 William Grise 2011 Holly Byrnes 2010 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

January/February 2016 Ralph J. Schwartz George W. Grider Robert J. Lichtefeld E.M. Josey Julius T. Toll Charles E. Otto Charles F. Rosenberg R.N. Smith E. Crawford Meyer Charles A. Walton Ernest C. Williams George W. Grider Ray Wirth Nathan Kaplin Marion Hardesty

1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954

Celeste Flick & Clarence Sullivan III 1988 William H. Nie 1987 Student Kentucky APhA 1986 NKY Pharmacists Association 1986

Distinguished Young Pharmacists of the Year Award sponsored by Pharmacists Mutual 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 Professional Promotion Award practice in Kentucky. The recipient Criteria – To recognize individuals or must have demonstrated participation organizations who have exhibited out- in a national pharmacy association, standing efforts to demonstrate the professional program(s) and/or comimportance of pharmacy as a health munity service. care profession, and which promote Recipients proper application of pharmacists’ pro- Cassandra Beyerle 2015 fessional services. Chris Harlow 2014 Eligibility – Open to persons or organ- Brooke Hudspeth 2013 izations. Stacy Rowe 2012 Recipients Aimee Ruder 2011 Kerry Hettinger 2015 Karen Hubbs 2010 Cassandra Beyerle 2014 Matt Martin 2009 Julie N. Burris & Tiffany Self 2008 Walgreens Corporation 2013 Angela Parrett 2007 SUCOP chapter of APhA-ASP 2012 Janet Mills 2006 Lynne Eckmann 2011 Alyson Schwartz 2005 Gloria Doughty & Lynn Harrelson Nancy Horn 2004 2010 Jennifer O’Hearn 2003 Jordan Covvey 2009 Karen Altsman 2001 Jeff Mills 2008 Kim Wilson 1999 Trish Freeman 2007 Kim Harned 1998 Sherry DeCuir 2006 Michael Box 1997 Pete Orzali 2005 Dan Yeager 1996 John Armistead, Don Kupper Dan Minogue 1995 & Willie Newby 2004 Pan Haeberlin 1994 Kroger Pharmacy Mid South Division, Kim Croley 1993 Holly Divine, Randy Gaither, Bill Grise Phillip Sandlin 1992 & Laura Jones 2003 Jeffrey W. Danhauer 1991 JCAP, Dean Ken Roberts, Ph.D 2002 Mark S. Edwards 1990 Paul Easley, Bob Oakley Susan Murray Kathman 1989 & Michael Wyant 2001 Melinda Cummins Joyce 1987 Judy Minogue 2000 Ralph Bouvette 1999 Excellence in Innovation Award Rodger Smith, Barbara Woerner, Sponsored by Upsher-Smith Mary Ann Wyant, Laboratories & Rick Vissing 1998 Criteria – To recognize a pharmacist Larry Spears 1997 who has demonstrated innovative John B. Anneken 1996 pharmacy practice resulting in imPhil Losch 1995 proved patient care in the previous Jordan Cohen 1994 year or over an extended period of Judy Minogue 1994 time. Kentucky Academy of Student Eligibility – A recipient must be a of Pharmacy 1993 pharmacist who is an Active or 10

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2016 KPhA Professional Awards Honorary Life member of the Association. A recipient may receive the award more than once. Recipients Matt Carrico 2015 Brooke Hudspeth 2014 Buddy Wheeler 2013 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 Technician of the Year Award Criteria – To recognize a Certified Pharmacy Technician for outstanding professional activities.

January/February 2016 Eligibility – Only active Pharmacy Technician members of the Association shall be eligible for nomination and receipt of this award. Recipients Heather Daniels 2015 Don Carpenter 2014 Leslie Lochner & Robin Lillpop 2013 Patricia Robinson 2012 Jessica Salmons 2011 Gwen Otter 2010 Lisa Sawvel 2008 Margaret Sinkhorn 2007 Charlotte Bowling 2006 Mary Jane Wathen 2005 Kent Williams 2004 Tammy Newsome 2003 Frank Ray 2002 Jane Woerner 2001

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 efforts aimed at patients, youth and other members of the community. In addition to the award, to honor the pharmacist’s work to fight prescription drug abuse, APMS, state pharmacy associations and the Cardinal Health Foundation will donate $500 to a charity of the award recipient’s choice. Recipients Laurel Taylor 2015 Amber Cann 2014 Raymond Float 2013 Brian Fingerson 2012

Cardinal Health Generation Rx Champions Award Criteria – 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

INE L AD CH E D AR M IS 31!

THE KENTUCKY PHARMACIST

2016 KPhA Membership Challenge Drive

January/February 2016

YOU are needed to answer the KPhA Membership Challenge Drive As the calendar rolls to a new year, I am reflecting on all the great things that OUR KPhA has accomplished in the interest of advancing our profession. As you know, KPhA works diligently on our behalf to ensure that our interests are represented in Frankfort, and that we are positioned to respond to the professional opportunities that may come our way. I am proud to be a member of KPhA and am honored to serve as your President-Elect this year. I know that great things are in store for our profession as we move forward into 2016. With this in mind, I am writing to challenge you to reach out to the pharmacists and technicians you know who are NOT members of KPhA, tell them about the benefits of KPhA membership and encourage them to join. We are stronger when we work together as a united group. As part of our MEMBERSHIP CHALLENGE DRIVE, KPhA members who recruit and refer a new member will receive a chance at winning a free membership for 2016. Your name will be added to the lottery once for each new member you refer between now and March 1, 2016. If you refer 10 new members, you will have 10 chances entered into the drawing for a free 2016 membership! Please note for the purposes of the challenge, a new member is defined as an individual who has not been a member of KPhA in the past year. Our goal is to recruit 100 new members by March 1st. If every member recruits one additional member, our membership would grow by over 1,231! With more than 5,300 pharmacists and 13,000 technicians registered in Kentucky, we believe this goal is attainable. Please help OUR KPhA become a stronger organization in 2016 by participating in this MEMBERSHIP CHALLENGE DRIVE. A membership application form which includes an area to identify the referring member can be found below. Alternatively, individuals can complete the referral form and join online at the KPhA website at Kphanet.org. Best regards, Trish Freeman, KPhA President-Elect

Name _____________________________ Preferred E-Mail _____________________________________________ Preferred Address ________________________________________________________________________________________ City/State/Zip _____________________________________________________________________________________________ Preferred Phone _____________________________ License Number _________________________NABP #_____________________________Birthdate (MM/DD)________________ Preferred Mailing Address ___ Home ___ Office Check enclosed: ___ (Payable to Kentucky Pharmacists Association)

Referred By: __________________________________

For credit card payments, go to www.kphanet.org and click on Membership, or call 502-227-2303. 

$225 Active Member (licensed in KY)

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Free New Practitioner 1st Year

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$335 Joint Member (both spouses licensed in KY)

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$70 New Practitioner 2nd Year

 $225 Associate Member (licensed in another state or non-pharmacist)

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$140 New Practitioner 3rd Year

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$120 Retired Member

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Academy for Pharmacy Technicians (no additional cost)

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$180 Joint Retired

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$15 Academy for Consultant Pharmacist Member

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$150 Senior Pharmacist Member (65+)

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$50 Pharmacy Technician

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CONTACT ME—I want to be involved with KPhA!

THE KENTUCKY PHARMACIST

January 2016 CE—COPD Treatment Guide

January/February 2016

COPD Treatment Guidelines By: Alex Brewer, PharmD Candidate 2016 - University of Kentucky; Aleah Rodriguez, PharmD – Creighton University Center for Drug Information and Evidence-Based Practice; Sarah M. Lawrence, PharmD, MA, CGP – PharMerica The authors declare no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-0000-16-001-H01-P&T 1.0 Contact Hours (0.1 CEU)

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

Goal: Pharmacists should be able to classify COPD patients based on risks and symptoms using the GOLD classification system and develop an appropriate treatment plan based on GOLD guidelines. Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: 1. Recognize the epidemiology, basic pathophysiology and signs/symptoms of COPD; 2. Classify COPD patients based on the GOLD model using patient symptoms and risk factors; and 3. Develop a treatment plan, including both non-pharmacological and pharmacological options, for a COPD patient based on the patient’s GOLD classification. Introduction Chronic respiratory disease – which includes chronic obstructive pulmonary disease (COPD), asthma and pulmonary fibrosis – is the current third-leading cause of death in the United States, according to the Centers for Disease Control and Prevention (CDC).1 COPD presents a major burden on the healthcare system of the United States. The total cost of COPD, which includes not only medical costs, but also lost income from work absenteeism, was approximately $36 billion in 2010.2 According to CDC estimates, COPD affected about 12.7 million adults in 2011, and an additional 24 million adults had some form of impaired lung function.3 Although it has historically been stereotyped as a “men’s disease,” women are actually 37 percent more likely to have COPD and are more vulnerable to lung damage from pollutants and cigarette smoke. The southeastern United States tends to have higher rates of COPD compared to the rest of the country. Unfortunately, Kentucky has the highest prevalence of COPD, with greater than 9 percent of the population affected.4 In a 2014 Gallup poll, Kentucky reported to have the highest rate of cigarette smoking among all 50 states. Given that cigarette smoking is the number one risk factor for COPD, we should not expect to see a drop in our COPD rates without a corresponding drop in cigarette use. COPD not only imposes a high burden on the healthcare system of the United States but also drastically lowers the quality of life experienced by patients. COPD patients experience decreased exercise tolerance and become fa-

tigued more easily. A study of 1,266 Kentucky adults with COPD found that 24.6 percent experienced a hospital or emergency department visit within the past 12 months, and 71.8 percent reported that the disease had an effect on their quality of life.5 COPD Overview COPD is a progressive disease characterized by chronic inflammation and persistent airflow limitations. There are two traditional phenotypes: emphysema and chronic bronchitis. Emphysema – which patients also are known by the less scientific moniker “pink puffers,” due to their tendency to develop pinkish-colored skin – affects alveoli, the grapelike clusters of air sacs at the end of our bronchioles. Within the alveoli, structural and functional tissue is destroyed due to chronic inflammatory responses. This results in inhibited carbon dioxide and oxygen exchange, reducing the efficiency of breathing. As a result, emphysema patients suffer from shortness of breath, must use more energy to breathe and experience variations in blood gases, resulting in muscle wasting and weight loss. Chronic bronchitis – also referred to as “blue bloaters” – is the more common of the two phenotypes. It is defined as having a productive cough, occurring at least three months in two consecutive years. Chronic inflammation leads to excessive mucus, which creates clogged and swollen airways, leaving less room for air flow. Chronic bronchitis patients are generally characterized as bloated or obese. As the disease progresses, patients may develop pulmonary hypertension as the body attempts to compensate for low 13

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January 2016 CE—COPD Treatment Guide Table 1

Table 2

January/February 2016 (such as ipratropium) alone or in combination with a shortacting beta2-agonist (such as albuterol/ipratropium). Spirometry is measuring forced vital capacity, or FVC, which represents the maximum volume of air a patient can force out of the lungs during exhale. Spirometry also measures forced expiratory volume in one second, or FEV1, which is the maximum amount of air the patient exhales during the first second. After conducting the test, the patient’s ratio is calculated. A diagnosis of COPD is made if the ratio is less than 0.7. The patient’s FEV1 is then compared to a “healthy standard,” a person of similar age, biological gender, height and race, to determine the patient’s GOLD classification.6 GOLD Model of Risk and Symptom Evaluation We assess a COPD patient’s risk for hospitalization by comparing the patient’s FEV1 to a healthy standard. Table 1 is used to group patients into one of four risk categories: mild, moderate, severe or very severe.6 For example, a patient with an FEV1 less than 80 percent but more than 50 percent of their predicted FEV1 value would be categorized as GOLD-2 for risk assessment.

blood oxygen levels. This can result in right-sided heart failure and edema.

For determining treatment, the GOLD Model of Risk and Symptom Evaluation table is used (see Table 2).6 On the Screening for risk factors is an important role for pharmaleft axis, the previous GOLD risk classification can be used cists. Over 90 percent of COPD patients are current or for- to decide if the patient falls into one of the top two groups mer smokers, but we also must probe for relevant occupa- or one of the bottom two groups. Instead of using the tional history. Jobs with exposure to chemical agents/ GOLD risk classification, we also have the option of using fumes, organic/inorganic dusts, wood or coal burning and the patient’s exacerbation history within the past year, crop residues can pose a high risk for developing COPD. which is on the right axis. If the patient experienced 0-1 There are also environmental exposures (such as pollution) exacerbations within the past year which did NOT require and genetic factors (such as protein alpha-1 antitrypsin de- hospitalization, the patient is considered low risk and falls ficiency) that can play a role in disease development.6 Table 3 There are three “cardinal” symptoms of COPD: chronic cough, chronic sputum production and dyspnea. The chronic cough may be intermittent and be either productive or unproductive. The key point is whether it is a long-term issue. Dyspnea is often described by COPD patients as an increased effort to breathe, with gasping and heaviness associated with inhalation. In COPD patients, dyspnea is progressive and often will get worse with exercise. Other nonspecific symptoms include chest tightness and wheezing. If COPD is suspected, assess respiratory status via physical exam, observing breath sounds, vital signs, pulse oximetry and activity limitations.

Grade 0 1

Spirometry is the gold standard for COPD diagnosis. Readings should be taken after administration of a bronchodilator – not exceeding 400 mcg of a short-acting beta2agonist (such as albuterol) or 160 mcg of an anticholinergic

mMRC Dyspnea Scale10 Description of Breathlessness I only get breathless with strenuous exercise. I get short of breath when hurrying on level ground, or walking up a slight hill. On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace. I stop for breath after walking about 100 yards or after a few minutes on level ground. I am too breathless to leave the house or I am breathless when dressing.

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January 2016 CE—COPD Treatment Guide Table 4 Patient Group A B

January/February 2016

1st-line Treatment SABA PRN or SAMA PRN

Alternative LABA or LAMA or SABA + SAMA

Other Options Theophylline

LABA or LAMA

LABA + LAMA

SABA and/or SAMA Theophylline

ICS + LABA or LAMA

LABA + LAMA SABA and/or SAMA Or LAMA + PDE4I Theophylline Or LABA + PDE4I ICS + LABA and/or ICS + LABA + LAMA Carbocysteine* LAMA Or ICS + LABA + SABA and/or SAMA D PDE4-I Theophylline Or LABA + LAMA Or LAMA + PDE4I SABA = short-acting beta2-agonist; SAMA = short-acting muscarinic antagonist; LABA = long-acting beta2-agonist; LAMA = long-acting muscarinic antagonist; ICS = inhaled corticosteroid; PDE4I = phosphodiesterase-4 inhibitor *not approved in the US C

Table 5 Short-acting beta2 -agonists (SABA) Long-acting beta2 -agonists (LABA) Long-acting muscarinic antagonists LABA+LAMA combination products ICS+LABA combination products Short-acting muscarinic antagonists (SAMA) PDE4Is Methylxanthines SABA+SAMA combination products

0 to grade 4. Patients scoring less than 10 on the CAT, or 0 -1 on the mMRC, would fall into either group A or C on the left. Patients scoring at or above 10 on the CAT, or at or above 2 on the mMRC, would be placed in either group B or D on the right.

If there is discrepancy between risk assessments (for example, a patient with a GOLD-4 classification but zero exacerbations in the past year), use your clinical judgment to classify a patient, or err on the side of caution and classify the patient into the higher risk group.

albuterol, levalbuterol, terbutaline, metaproterenol salmeterol, formoterol, arformoterol, indacaterol, olodaterol, vilanterol tiotropium, aclidinium, umeclidinium

Treatment of COPD The goals of treatment in a COPD patient are to reduce risk via prevention of disease progression, prevention and treatment of exacerbations and reduction of mortality, and to reduce disease symptoms, via relief medications, improving exercise tolerance and improving the overall health status of the patient.

vilanterol + umeclidinium, olodaterol + tiotropium, indacaterol + glycopyrrolate fluticasone + salmeterol, budesonide + formoterol, fluticasone + vilanterol ipratropium roflumilast theophylline albuterol + ipratropium

into either category A or B. If a patient experienced an exacerbation requiring hospitalization, or experienced two or more exacerbations not requiring hospitalization, the patient is placed in either category C or D. The horizontal axis assesses patient symptoms. Two tools are recommended by the GOLD guidelines: the COPD Assessment Test (CAT, available at http://www.catestonline.org/images/pdfs/ CATest.pdf) and the modified Medical Research Council (mMRC) questionnaire (see Table 3).7 The CAT is the more comprehensive of the two, and involves rating eight symptoms on a scale of 0 to 5. The mMRC assesses symptoms based on severity of breathlessness and ranges from grade

Pharmacological treatment is based on the GOLD group under which the patient falls . Table 4 breaks down treatment options for each GOLD group:6 First-line treatment options have more supporting evidence for use, while agents listed as “other” tend to have a lower level of evidence or may have a higher propensity for adverse effects. As always, use guidelines to guide treatment decisions, but individualize treatment for the specific patient. For example, long-term care patients may benefit more from long-acting monotherapy compared to short-acting agents; anticholinergic agents have fewer cardiac adverse effects and fewer tremors compared to beta2-agonists and thus may be preferred in this population. Table 5 lists pharmacologic treatment options classified by drug class. Beta2-agonists (such as albuterol) activate beta2 receptors on the lungs, causing relaxation of bronchial smooth muscle, which produces bronchodilation. It is important to note that terbutaline and metaproterenol are not as selective for beta2 receptors as other short-acting beta2agonists. These two agents can cause a higher degree of cardiac adverse events and should be avoided in certain patient populations (such as the elderly). The long-acting beta agonists are considered interchangeable.

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January 2016 CE—COPD Treatment Guide

January/February 2016

Table 6 Medication Class

Products

LABA + ICS

Fluticasone/salmeterol Fluticasone/vilanterol Budesonide/formoterol Tiotropium

LAMA LABA + LAMA

FDA indicated for exacerbation? Yes Yes No Yes

Olodaterol/tiotropium Indacaterol/glycopyrrolate

Muscarinic antagonists (also known as anticholinergics) work by decreasing the contractility of bronchial smooth muscle. Currently, ipratropium is the only available shortacting muscarinic antagonist, while there are a variety of long-acting options available.

Soft mist inhalers do not require the patient to breathe in a certain way and synchronization is not required.

Nebulizers are appropriate if the patient is unable to use an inhaler properly; they require additional time for administration, and not all medications are available in a nebulizer soluYes tion (for example, no long-acting muscarinic No antagonists are available in a nebulizer solution). Spacers and holder chambers are another option in patients who are unable to use a MDI; use of these devices results in increased lung deposition and reduced systemic drug absorption in patients struggling to synchronize actuation and inhalation.

Inhaled corticosteroids (ICS) are anti-inflammatory and decrease COPD symptoms caused by inflammation, such as sputum production. It is important to note that NONE of the ICS agents are approved for use as monotherapy in COPD treatment and should never be used alone in a COPD patient.

Device selection should be patient-specific and is dependent on multiple factors. Each device has its own advantages and disadvantages. Nebulizers can be used with any age and with any disease severity and do not require hand-mouth coordination; however, nebulizers are more time-consuming to use and are less portable. MeteredTheophylline is an older agent with bronchodilatory, antidose inhalers (MDIs) are small, portable, inexpensive and inflammatory and immunomodulatory actions. It seems to can be used quickly. Disadvantages to MDIs include the be less well-tolerated than other agents, and has a narrow requirement for hand-mouth coordination and the need for therapeutic index. It is a CYP3A4 substrate, so it has many a spacer or holding chamber in some patients. Dry-powder drug interactions of which a pharmacist must be cognizant. inhalers (DPIs) are easier to use compared to MDIs since Given the narrow therapeutic window and increased risk for they are breath-actuated, while still being portable and drug interactions, patients on theophylline must be moniquick to use. However, DPIs require a higher inspiratory tored carefully. Cigarette smoking can decrease theophylflow and a certain level of cognitive ability to use.13 line blood levels, so it likely will be less effective in current Exacerbations smokers. An exacerbation is defined as an acute event characterized Phosphodiesterase-4 inhibitors (PDE4I) are a relatively by a change in a patient’s symptoms from baseline beyond new class of medications. PDE4-inhibitors work by denormal day-to-day variations.6 COPD exacerbations are creasing inflammation and are NOT bronchodilators. The most commonly caused by infection. Exacerbations often only FDA-approved PDE4I currently on the market is cause acute increases in inflammation and affect the roflumilast. course of disease in five different manners: increased morEquipment tality; reduction in health-related quality of life; accelerated rate of decline in lung function; increased symptom severiVarious equipment options exist for medication delivery to COPD patients. Inhaled medications are the current main- ty; and marked decline in lung function for several weeks stay of COPD treatment and allow for direct administration following resolution and higher socioeconomic costs. to the site of action. There are currently three types of inThe treatment drug of choice is a short-acting beta2-agonist halers available: metered dose inhalers (MDIs), dry powder (SABA), with or without addition of a short-acting muscainhalers (DPIs) and soft mist inhalers (“respimats”). rinic antagonist (SAMA), as needed. IV theophylline is conMDIs require slow, constant inhalation and tend to have the sidered a second-line option if the patient fails to respond to a bronchodilator. Systemic corticosteroids are recomhighest error rates. Specifically, synchronization between actuation of the inhaler and inhalation is the biggest cause mended, as they can shorten recovery time, improve FEV1 of error (especially in elderly patients, as error rate increas- and improve hypoxia. The GOLD guidelines recommend 40mg prednisone for five days. Antibiotics are reserved for es with age and disease severity).8 Other potential probmoderately to severely ill patients having at least two of the lems include poor hand-eye coordination, inability to ade9 following three symptoms showing strong evidence of bacquately inhale and cognitive impairment among others. 16

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January 2016 CE—COPD Treatment Guide

January/February 2016

Table 7 Type of Pneumococcal Vaccination Pneumococcal conjugate vaccine (PCV13)

hearing loss and development of microbial resistance. As always, tailor therapy for the individual patient.

Indicated Patient Population

Children younger than 5 years of age All adults 65 years or older Patients 6 years of age and older with certain risk factors Pneumococcal All adults 65 years or older polysaccharide vaccine Patients 2 through 64 years of age who (PPS23) are at high risk of pneumococcal disease For more information: http://www.cdc.gov/vaccines/vpd-vac/pneumo/vacc-in-short.htm

Systemic corticosteroids (oral or IV) are recommended in patients with an acute COPD exacerbation within the first 30 days, as they have been shown to reduce risk of treatment failure, lower relapse rate and shorten hospital stay (Grade 2B evidence).11 Data supports use of short-burst therapy, as no difference in outcomes has been shown between five day and 10-14 day therapy, with the longer treatment course showing an increase in adverse events.12

terial infection: increased dyspnea, increased sputum volume or increased sputum purulence.6 The biggest risk factor for re-hospitalization is a prior history of a COPD exacerbation requiring hospitalization.10 Thus, it is imperative to implement preventive strategies to reduce the risk for an acute exacerbation. As pharmacists, one of the biggest impacts we can make is ensuring our COPD patients receive appropriate vaccination. COPD patients should receive the annual influenza vaccine and should be screened for appropriate pneumococcal vaccination based on CDC guidelines (see Table 7) and the patient’s vaccination history. Smoking cessation, via a combination of behavioral counseling and pharmacologic options, has been shown to have numerous benefits in COPD patients, including reduced mortality, reduced rate of decline in lung function, reduced exacerbations, reduced pneumonia risk and improved quality of life. Pulmonary rehabilitation – a comprehensive intervention based on exercise, training, education and behavior change – may help restore lung function and educate the patient on breathing strategies; it is strongly recommended for patients who have experienced an exacerbation within the past four weeks. Finally, proper case management and patient education also can reduce the risk of exacerbations and hospitalization.11

Roflumilast, approved in 2011, is indicated to reduce the risk of COPD exacerbations in patients with a GOLD risk classification of 3 or 4 and a history of chronic bronchitis and exacerbations (Grade 2A evidence).11 Potential adverse effects include suicidal ideation, weight loss, decreased appetite, headache, insomnia, diarrhea, back pain and dizziness. Theophylline can be considered to prevent acute exacerbations in stable patients (Grade 2B evidence).11 It can have mild diuretic effects and may cause nausea/vomiting/ diarrhea, tachycardia, headache, abdominal pain/ discomfort and insomnia. The GI adverse effects may be alleviated by taking the medication with food or milk. Finally, n-acetyl cysteine (NAC) may be used to prevent acute exacerbations for patients with moderate-severe COPD and a history of two or more exacerbations in the past two years (Grade 2B evidence).11 NAC may act as a mucolytic in the respiratory tract, helping to eliminate secretions and reduce their viscosity. High-dose (600mg PO BID) NAC has been shown to reduce exacerbations, but further research is needed to clarify the mechanism of action and confirm treatment outcomes.

There are also pharmacological treatment options which Certain medications may put a patient at greater risk for an are FDA-approved and/or have been shown to decrease exacerbation, or can negatively impact the disease state. COPD exacerbations.11 Inhaled products for reducing exacInhaled insulin (Afrezza®), loxapine aerosol powder for inerbations are outlined in Table 6. halation (Adasuve®), hydromorphone and certain ophthalIt is important to note that, although budesonide/formoterol mic beta blockers (brimonidine/timolol; dorzolamide/timolol; latanoprost/timolol; levobunolol; metipranolol; timolol) are and indacaterol/glycopyrrolate do not carry an FDAcontraindicated for use in COPD patients. Caution should indication for decreasing exacerbations, there is evidence be taken when considering use of non-selective beta blockto support their use for this purpose. ers, narcotics, benzodiazepines, barbiturates, firstLong-term macrolide prophylaxis therapy is recommended generation antihistamines, amiodarone and dextromefor patients with moderate-severe COPD who have experithorphan. enced one or more exacerbations in the past year (Grade 11 2A evidence). It is important to keep in mind potential ad- Pharmacists play a key role on the healthcare team in manverse effects of macrolides, including QT-prolongation, aging patients with COPD. Proper patient work-up and his-

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January 2016 CE—COPD Treatment Guide

January/February 2016

tory helps identify risk factors and symptoms, allowing early diagnosis and initiation of treatment as soon as possible. Each patient should be evaluated using GOLD classification, and this classification is used to initiate appropriate maintenance therapy. Pharmacists also must utilize appropriate strategies and treatment options to reduce exacerbations and hospitalizations. Although challenging and complex, management of COPD patients is an important role for all pharmacists as we seek to improve access to quality care while lowering cost burden.

2. Ford, Earl S. "Total and State-Specific Medical and Absenteeism Costs of COPD Among Adults Aged ≥ 18 Years in the United States for 2010 and Projections Through 2020." CHEST Journal. N.p., n.d. Web. 20 Oct. 2015. 3. "COPD." American Lung Association. N.p., n.d. Web. May 2014. 4. CDC COPD Data and Statistics, May 2014

5. Landis, Sarah H. "Continuing to Confront COPD International Patient Survey: Methods, COPD Prevalence, Pharmacy technicians can augment the role of the pharmaand Disease Burden in 2012–2013." International Jourcist in managing patients with COPD. Technicians have an nal of Chronic Obstructive Pulmonary Disease, 14 June opportunity to evaluate and encourage patient compliance 2014. Web. with their COPD treatment regimen by monitoring frequency of medication refills and assessing patient understand6. GOLD Guidelines 2015 ing of their medications at the point of sale. By screening 7. Launois et al. BMC Pulmonary Medicine2012,12:61 for patients who may need assistance in understanding their medications and/or medical devices such as inhalers, 8. J Am Acad Nurse Pract. 2012;24(2):113-20 and making referrals to the pharmacist for counseling, the 9. Respir Care. 2006;51(2):158-72 technician can help increase the quality of care for COPD patients. Technicians also have an opportunity to observe 10. Chest. 2015;147(4):999-1007; N Engl J Med. 2010;363 and interact with patients and look for signs and symptoms (12):1128-38 of disease progression and/or exacerbation such as short11. Chest. 2015;147(4):894-942 ness of breath. These patients also can be referred to the 12. Chest. 2015;147(4):894-942; Cochrane Database Syst pharmacist for counseling and other care. Rev. 2014;12:CD006897 References 13. Geller, David E. "Comparing Clinical Features of the 1. CDC/National Center for Health Statistics. (2015, FebNebulizer, Metered-Dose Inhaler, and Dry Powder Inruary). haler." Respiratory Care, October 2005. Web.

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January 2016 CEâ&#x20AC;&#x201D;COPD Treatment Guide

January/February 2016

January 2016 â&#x20AC;&#x201D; COPD Treatment Guidelines 1. Which is a documented risk factor for the 6. Which of the following is a phosphodiesterase-4 development of COPD? inhibitor approved to treat COPD? A. Smoking A. Roflumilast B. Heart Failure B. Theophylline C. Diabetes C. Sildenafil D. Pulmonary hypertension D. Terbutaline 2. Which of the following statement(s) about COPD is/are true? A. COPD is primarily a disease experienced by men. B. The northeastern USA has the highest rates of COPD compared to other areas of the country. C. COPD is characterized by persistent airflow limitations without chronic inflammation. D. Kentucky has the highest prevalence of COPD in the USA. 3. What are the three cardinal symptoms of COPD? A. Dyspnea, chronic cough, wheezing B. Dyspnea, chronic sputum production, wheezing C. Dyspnea, chronic cough, chronic sputum production D. Dyspnea, chronic cough, chest tightness 4. For a patient classified in category B based on the GOLD model for risk and symptom evaluation, which of the following would be an appropriate treatment based on the GOLD guidelines? A. A combination of an inhaled corticosteroid and a long-acting beta2-agonist B. A combination of a long-acting beta2-agonist and long-acting muscarinic antagonist C. A combination of an inhaled corticosteroid and a long-acting muscarinic antagonist D. A combination of a long-acting beta2-agonist and a phosphodiesterase-4 inhibitor

7. Which of the following strategies should be employed to reduce the risk of acute exacerbations of COPD? A. Smoking cessation B. Pneumococcal vaccination C. Herpes zoster vaccination D. A and B E. A, B, and C 8. Which of the following medications (or medication classes) is contraindicated in patients with COPD? A. Insulin B. Opioid pain medications C. Timolol D. Benzodiazepines 9. Which class of medications is NOT approved as monotherapy in COPD patients? A. Long acting muscarinic antagonists B. Short acting muscarinic antagonists C. Inhaled corticosteroids D. Long acting beta agonists 10. What type of inhalation device has the highest error rates, in terms of administration? A. Metered Dose Inhaler B. Dry Power Inhaler C. Soft Mist Inhaler D. Nebulizer

5. Which of the following medications is FDA approved to reduce exacerbations in COPD patients? A. Albuterol sulfate B. Tiotropium bromide C. Budesonide and formoterol D. Aclidinium bromide

Send potential continuing education topics to Scott Sisco at ssisco@kphanet.org 19

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January 2016 CE—COPD Treatment Guide

January/February 2016

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, 96 C. Michael Davenport Blvd., Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile. Expiration Date: December 26, 2018 Successful Completion: Score of 80% will result in 1.0 contact hour or .1 CEU. Participants who score less than 80% will be notified and permitted one re-examination. TECHNICIANS ANSWER SHEET. January 2016 — COPD Treatment Guidelines (1.0 contact hours) Universal Activity # 0143-0000-16-001-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D

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

9. A B C D 10. A B C D

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 If yes, please explain on a separate sheet. Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature ____________________________________________Completion Date___________________________

Personal NABP eProfile ID #_____________________________ Birthdate ____________(MM/DD) PHARMACISTS ANSWER SHEET January 2016 — COPD Treatment Guidelines (1.0 contact hours) Universal Activity # 0143-0000-16-001-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D

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

9. A B C D 10. A B C D

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 If yes, please explain on a separate sheet. Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature ____________________________________________Completion Date___________________________

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

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February 2016 CE â&#x20AC;&#x201D; CNS Modulating Drugs for Pets

January/February 2016

Part 1. Central Nervous System (CNS) Modulating Drugs for Pet Fear and Anxiety Related Behaviors That are Referred to Retail Pharmaciesâ&#x20AC;&#x201D;What the Pharmacist Needs to Know By: Ivana Catriona Rosieka, PharmD candidate; Rachael Bilitera, PharmD candidate; Megan Petersona, RPh; Sara L Bennettb, DVM, MS, DACVB; Inder Sehgala, DVM, Ph.D. a Marshall University School of Pharmacy, Huntington, West Virginia. b Veterinary Behavior Consultant, Evansville, Indiana

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

There are no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-0000-16-002-H01-P&T 2.0 Contact Hours (0.2 CEU) Goals: Pharmacists should be able to provide pet owners with information regarding time to therapeutic effect and counseling on potential adverse effects associated with specific fear and anxiety related behavior drugs prescribed by veterinarians. Pharmacists also should have a basic understanding of dog and cat behavior disorders in order to provide the most effective counseling while also demonstrating empathy and appreciation for the client's distress. Objectives At the conclusion of this Knowledge-based article, the reader should be able to: 1. Identify and briefly describe abnormal fear and anxiety related behavior conditions in dogs and cats for which psychopharmaceuticals are used; 2. Classify and differentiate treatments commonly used as pharmacotherapy for these behavioral conditions in dogs and cats; 3. Compare and contrast dosing of fear and anxiety related agents between medium-sized dogs and humans; 4. Predict time periods needed for behavioral improvement and potential adverse effects in dogs and cats related to fear and anxiety behavioral pharmacotherapy; and 5. Assess the potential for drug interactions with select behavioral drug treatments. Introduction An increasing number of complex animal-related prescriptions are being referred to retail community pharmacies. It is important for pharmacists in these practice settings to recognize the comparative similarities and differences in pet physiology, disease states, pharmacology, pharmacokinetics, drug administration and adverse effects. It also is important for pharmacists to possess basic knowledge in these areas as the basis for developing sound and accurate disease and drug counseling (Miller & Sehgal, 2016). Central nervous system (CNS) medications approved for human treatment also are used for pet behavior management and as anticonvulsant therapies. These medications constitute an expanding field of animal health. Veterinarians may refer these prescriptions to retail pharmacies to maintain a lower in-clinic inventory of drugs or to avoid the added paperwork associated with stocking controlled

drugs. This discussion offers a summary of essential facets of dog and cat behavioral therapy for fear and anxiety. Behavior problems in dogs and cats can arise from multiple circumstances such as genetics, learning during frightening or traumatic events, deficits in environmental or social needs, a change in the social or physical environment or changes in the household dynamics or schedule. Veterinary behaviorists and current best practices for veterinary behavioral health support medication, when indicated, as an adjunct to concurrent behavior management and modification. Behavioral concerns in pets can be roughly divided into normal behaviors which are viewed as unacceptable by the owner (i.e., puppy chewing the ownerâ&#x20AC;&#x2122;s new shoes) and abnormal behaviors (i.e., aggression toward family and phobias). This discussion focuses on medications used as

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February 2016 CE — CNS Modulating Drugs for Pets part of a treatment plan to address abnormal fear and anxiety behaviors. This includes generalized anxieties and fears, as well as specific fears including fear of objects and species (other dogs or strangers) and situational fears (fears of places or situations such as veterinary visits). Panic disorders, such as separation anxiety and noise/ storm phobia, also will be covered. These behavior disorders are treated with the goal of reducing anxiety and facilitating behavior management through a finite time of therapy.

ing. A monoamine oxidase inhibitor (MAOI) should not be combined with an SSRI or TCA since the MAOI would prevent the inactivation of neuroamines that have built up in the synaptic cleft due to inhibition of pre-synaptic re-uptake channels caused by the SSRI or TCA. The MAOI would lead to further build-up of amines in the synaptic cleft predisposing the pet to dangerously high neuroamine levels potentially precipitating serotonin syndrome. Due to this interaction, MAOIs and reuptake inhibitors should be separated by at least 14 days; however, if a dog is being transitioned from fluoxetine (Prozac®) to selegiline, there should be a washout period of five weeks due to the longer half-life of fluoxetine in dogs (Horwitz D., 2000). Although the MAOI selegiline is used for a very specific circumstance in animals, the MAOI anti-parasitic amitraz is used in a wider population in both prescription and over-the-counter (OTC) parasiticides for dogs (cats cannot be administered amitraz). These include the OTC products Certifect® (Drugs.comb, 2015), Preventic® tick collar for dogs and prescription Mitaban® dip. Because of the potential for this MAOI-reuptake inhibitor interaction, clients receiving SSRIs and/or TCAs should be asked about other prescribed drugs, as well as recent application of OTC flea and tick products. If the pet has recently received an amitraz product, the SSRI/TCA should not be administered without veterinary consultation.

The majority of pharmacologic options for the treatment of these conditions in dogs and cats involve three major families of psychotropic drugs: 

Benzodiazepines



Tricyclic Antidepressants (TCAs)



Selective Serotonin Reuptake Inhibitors (SSRIs)

Agents that are less frequently used and/or used as adjuncts for additional or situational control of behavior conditions are from the following drug classes: 

Serotonin (5-HT) agonists (Buspirone)



Selective serotonin 2A antagonist reuptake inhibitors (Trazodone)



Central selective alpha-2 agonists (Clonidine)

January/February 2016

Some of the indications for these drugs in pets are the same as those for humans because abnormal behavior in both pets and humans often is associated with CNS monoamine imbalances, particularly dopamine and serotonin (Landsberg et al., 2013; Crowell-Davis and Murray, 2006). Conversely, some first-line options for behavior modification in pets are not considered first-line options in humans. Furthermore, some pet drug indications and doses are significantly different from those in humans. In most cases, the doses of fear and anxiety modifying agents administered to pets on a basis of quantity per kilogram (kg) body weight will seem high to pharmacists accustomed to dosing levels for humans. Dispensing pharmacists should be aware of these similarities and differences when counseling the owner on drug administration, expected benefits and potential adverse effects. The referring veterinarian should be consulted for additional information on drug dosing, therapeutic response, adverse effects and administration difficulties concerning individual pets.

Therapy of Fear and anxiety related behaviors in dogs and cats a. Specific or situational fears (objects, species, places, situations) b. General anxiety c. Separation anxiety d. Storm/noise phobia a. and b. Specific or situational fears and general anxiety

In pets, benzodiazepines are used for short-term treatment of situational fear or anxiety. Many veterinarians dispense small quantities of benzodiazepines from their own pharmacies, but, since benzodiazepines are schedule IV controlled substances, some veterinarians will refer the prescription and paperwork to a retail pharmacy. Alprazolam (Xanax®), lorazepam (Ativan®), clonazepam (Klonopin®) or oxazepam (Serax®) can be used to reduce fear associated with trips, such as veterinary visits, and other anxieties Drug interactions: In contrast to people, pets are not such as separation anxiety or storm phobias. Within one to typically administered multiple concurrent drug therapies; two hours following benzodiazepine treatment in a dog or therefore drug-drug interactions are far less frequent. One cat, the client should expect to notice beneficial effects ininteraction in the field of fear, phobia and anxiety therapy cluding both reduced excitation and reduced fear-related that is the same in humans and dogs and cats is worth not- behaviors such as pacing, panting, vocalizing and anxiety. 22

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February 2016 CE — CNS Modulating Drugs for Pets Adverse effects of benzodiazepines include excess sedation, muscle relaxation, increased appetite and increased disinhibited behaviors such as aggression. Chronic administration of benzodiazepines can lead to dependence and withdrawal. In pets, signs of withdrawal are vomiting, shaking and light sensitivity. Withdrawal also may precipitate seizures. Any benzodiazepine, if administered chronically, should be gradually tapered to reduce chances of withdrawal signs. One particularly significant adverse reaction to oral diazepam in cats is an idiosyncratic, fatal hepatic lipidosis. This has been documented with oral diazepam, but veterinarians also have reported it with other benzodiazepines (Hughes et al., 1996). Signs of hepatic lipidosis that a pet owner might notice in cats are anorexia, vomiting and jaundice noticeable by yellowing of the sclera (Armstrong and Blanchard, 2014). Other signs of benzodiazepine toxicity seen in humans such as hypotension, respiratory depression and cardiac arrest, are rare in pets (Plumb, 2015).

January/February 2016

rone and fluoxetine are offered by some compounding pharmacies as alternatives to orally medicating cats, there are available pharmacokinetic data which suggests transdermal preparations have very poor and unreliable bioavailability compared to oral administration (Mealey et al., 2004; Ciribassi et al., 2003).

Use of SSRIs and TCAs is often with a secondary, shorter acting medication such as a benzodiazepine or trazodone (Desyrel®) or clonidine (Catapres®) for situational or bridging use. Trazodone is an atypical antidepressant and a serotonin 2A reuptake inhibitor. It could be prescribed by a veterinarian along with an SSRI, TCA or benzodiazepine for the therapy of generalized anxiety, separation anxiety and storm phobia (Landsberg et al., 2013). Potential adverse effects of trazodone use are vomiting, diarrhea, sedation, hypotension and excitement or agitation. These negative effects often dissipate with time (Ciribassi and Ballantyne, 2014). Clonidine, a centrally acting selective alpha-2 agonist, also may be used as an add-on with Buspirone (Buspar®) also is used to treat general and situ- SSRIs or buspirone for canine separation anxiety or noise ational anxieties, but it is not effective for acute circumand storm phobias. It reduces sympathetic neural outflow stances (Plumb, 2015). For low-to-moderate grade anxiety, resulting in reduced autonomic responses to the anxiety. a 25 kg dog could take buspirone every eight to 24 hours. Relevant adverse effects in dogs are hypotension, constiBuspirone, when used as a general anxiolytic, is considpation and at higher doses, sedation (Landsberg et al., ered to be similar to benzodiazepines; however, it does not 2013). have anticonvulsant, muscle relaxant or sedative effects, c. Separation anxiety and it is not associated with withdrawal or abuse. The lack Separation anxiety is a common behavioral concern of of sedation is a big advantage but one drawback includes owners, affecting up to 20 percent of dogs in veterinary time to behavioral effect, which can be several weeks after practice (Karagiannis et al., 2015). There is an increased daily dosing. Although buspirone as a single agent is effecprevalence of separation anxiety in shelter or rescue dogs tive when used as a general anxiolytic for mild circumstancas well as in older dogs that experience a significant es, it is not effective as monotherapy for severe anxiety or change in their household (Lem, 2002). This anxiety can phobias. In the cat, it has been used to address the social lead to destructive behaviors toward the owner’s possesanxiety associated with urine spraying behaviors and intersions or points of exit, specifically when the owner has left cat fighting in the same household. In order for the dog or the home. Additional behaviors associated with separation cat to receive optimal effect from therapy, the client should anxiety include distress vocalization, house soiling, salivabe counseled to administer buspirone on a daily basis, tion, pacing, inability to settle, anorexia, repetitive or comeven if no immediate effect is noted, since it will take time pulsive behaviors, destructive behaviors directed towards for behavioral effects to be seen. the environment and escaping, sometimes resulting in selfTreatment of moderate-to-severe general anxieties usually injury in the absence of the owner. These behaviors are includes the use of SSRIs or TCAs for long-term manage- exhibited when the dog is left alone and generally occur ment over a period of months. Fluoxetine (Prozac®), serwithin the first 15–30 min after departure. They can occur traline (Zoloft®), paroxetine (Paxil®), amitriptyline (Elavil®) intermittently during the departure or for the entire duration and clomipramine (Anafranil®) are the reuptake inhibitors of the owner’s absence. most frequently used in the treatment of anxiety; however, In addition to non-pharmacologic environmental manageother class members such as doxepin (Aponal®), imiprament and behavior modification, pets can be treated with mine (Deprenil®), desipramine (Norpramin®) or nortriptySSRIs and TCAs. In both pets and humans, SSRIs are line (Sensoval®) also may be options in some pets. more selective in their inhibition of neuroamine reuptake It should be noted that although transdermal formulations and offer fewer potential adverse effects when compared of several psychotropic agents such as amitriptyline, buspi- with TCAs. Therefore, separation anxiety therapy often be23

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February 2016 CE — CNS Modulating Drugs for Pets gins with an SSRI. Because of its relative safety, fluoxetine is often the first choice SSRI by veterinarians to help manage canine anxiety disorders (Merckvetmanual.com, 2015). In addition, fluoxetine has been evaluated in and licensed in dogs for the treatment of separation anxiety in combination with a behavior modification plan. Fluoxetine was historically marketed as a veterinary chewable under the brand name Reconcile®. SSRIs have the potential to induce adverse signs such as nausea, anorexia and vomiting (Fitzgerald and Bronstein, 2013). These effects result from buildup of serotonin in the central nervous system. Fluoxetine-induced anorexia may warrant a switch to another SSRI such as paroxetine or sertraline. Paroxetine, when used as an alternative to fluoxetine, is commonly associated with temporary anorexia in dogs (as are all SSRIs), as well as occasional lethargy, or conversely, hyperactivity. In cats, paroxetine can lead to increased anxiety, anorexia and constipation (Plumb, 2015). Particular care should be made to monitor appetite in cats taking any SSRI or TCA to avoid inappetence that can lead to secondary hepatic lipidosis, a condition that can cause high morbidity and mortality. As opposed to benzodiazepines, SSRIs such as fluoxetine are more likely to be prescribed through a retail pharmacy because of their long-term use and likely lower cost at retail pharmacies.

January/February 2016

tention and constipation. Conversely, diarrhea and increased urination may be associated with TCA use in dogs and cats. A client administering a TCA such as clomipramine to a dog or cat should be advised to give their pet ample opportunities to urinate and defecate (ASPCA.com; Plumb, 2015). Dogs and cats also can experience sedation, although dogs may occasionally show hyper-excitability. Additional adverse effects are orthostatic hypotension and weight gain, though these are less noted in veterinary patients. It should be emphasized to pet clients that the benefits of TCAs may take up to four or more weeks to occur and that TCAs are used for long-term management, not intermittent situational use. TCAs are prescribed for daily use and will not adequately benefit the pet without daily administration. As signs of distress become less and with the implementation of non-pharmacologic behavior modifications, the dose is then gradually reduced at a minimum of weekly intervals, often being weaned at a slower pace. d. Storm/noise phobia

Thunderstorm or Noise Phobia (e.g., phobia to fireworks) manifests in dogs as panting, pacing, trembling, remaining near the caregiver, hiding, excessive salivation, destructiveness, excessive vocalization, self-trauma and housesoiling (Crowell-Davis et al., 2003). Treatment for storm/noise phobias may consist of a rapidly-acting medication such as a Separation anxiety that is not adequately controlled with an benzodiazepine, trazodone or clonidine and/or a chronically SSRI also can be treated with TCAs. Among the TCAs, administered medication such as an SSRI or TCA, dependclomipramine may be more effective in calming than SSRIs, ing on the frequency and predictability of the noise trigger. and it is licensed for use in dogs for the treatment of sepaAlprazolam and other benzodiazepines are useful for storm ration anxiety in combination with a behavior modification fears in dogs due to their rapid onset. Alprazolam should be plan (Landsberg, et al., 2013; Drugs.com a, 2015). Clomiadministered, if possible, one to two hours before the arrival pramine also can be used for compulsive disorders as an of the anticipated storm or noise and then every four hours alternative to SSRIs since clomipramine is the most serotoas needed thereafter. Alprazolam reaches peak effect in 30 nin selective of the TCAs. Amitriptyline also is commonly to 45 minutes and lasts one to three hours. Diazepam prescribed by veterinarians; however, it carries a greater (Valium®), another option, often reaches peak effect in 20 risk of adverse effects and requires two to three times daily minutes and lasts one to two hours (Veterinarypartner.com, dosing compared with once-a-day for clomipramine. Costs 2015). Other suitable rapid-acting, situational medications are an important consideration with pet prescriptions since include trazodone and clonidine. In contrast, if an SSRI they are paid out-of-pocket. Cost of treatment can impact such as fluoxetine or a TCA such as clomipramine are adwhether or not owners treat their pets’ conditions; and ministered, they should be given daily over the course of therefore, a veterinarian may prescribe a less optimal drug storm season, usually several months, and then gradually based on affordability for a particular client. Amitriptyline is tapered down over a period of weeks at the end of the seathe least expensive of common behavior drugs making it son. Buspirone also is an alternative that can be given daithe preferred drug for some clients, though not necessarily ly. In addition to these pharmacologic therapies, the owner the most appropriate choice for the pet’s condition. also should have received from their veterinarian an enviTCAs are not considered first line therapy in humans due to ronmental management and behavior modification plan for their adverse effects which include sedation, autonomic their pet that will likely include systematic desensitization to dysregulation and anticholinergic effects. In dogs and cats, storm noise with audio stimulation, though this generally will TCAs also produce anticholinergic effects which include be set up outside of storm season. water retention, dry mouth with increased thirst, urinary re24

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February 2016 CE — CNS Modulating Drugs for Pets

January/February 2016 lam, and behavior modification for treatment of storm phobia in dogs. J Am Vet Med Assoc., 222(6): 744-8

Summary

Veterinarians may prescribe human drugs as part of the treatment plan for several pet behavioral concerns. When 6. Crowell-Davis, S., Murray, T. (2006) Veterinary Psythese prescriptions are dispensed at a community pharmachopharmacology, First ed., Blackwell Pub., Ltd. Oxcy, pharmacists can integrate their expertise with that of the ford, UK. referring veterinarian to optimize the success of these be7. Drugs.coma. (2015). Retrieved from havioral therapies. In order to best accomplish this integrahttp://www.drugs.com/pro/clomicalm.html Accessed tion, pharmacists and technicians should be familiar with November 10, 2015 the drug classes, desired and undesired effects and genb eral purposes of human behavior modifying agents in dogs 8. Drugs.com . (2015). Retrieved from http://www.drugs.com/vet/certifect-for-dogs.html Acand cats. cessed November 5, 2015 For anxiety and fear related behavior concerns, human9. Fitzgerald, K. T., Bronstein, A. C. (2013). Selective serapproved agents include benzodiazepines, SSRIs and otonin reuptake inhibitor exposure. Top Companion TCAs. While benzodiazepines are administered to achieve Anim Med., 28(1):13-17 rapid short-term effects, SSRIs and TCAs are used longer term and require patience on the part of the client for behavioral modifications to become apparent. Additional adjunct medications such as trazodone, buspirone and clonidine also might be used in conjunction with the above for chronic anxiety control, situational anxieties or phobias. Pharmacists and pharmacy technicians should freely consult with the referring veterinarian to exchange ideas such as oral compounding options that may enhance chances for successful therapy or to inquire about any concerns or questions that they or their clients have about a prescription. References 1. Armstrong, J., Blanchard, G. (2009). Hepatic Lipidosis in Cats. Vet Clinics Small Anim. 39:599-616 2. ASPCA.com. (2015). Retrieved from http://www.aspca.org/pet-care/virtual-pet-behaviorist/ dog-behavior/behavioral-medications-dogs Accessed November 5, 2015 3. Ciribassi, J., Ballantyne, K. (2014) Using clonidine and trazodone for anxiety-based behavior disorders in dogs. Veterinary Medicine, DVM360 http://veterinarymedicine.dvm360.com/using-clonidineand-trazodone-anxiety-based-behavior-disordersdogs?id=&pageID=1&sk=&date= Accessed November 5, 2015 4. Ciribassi, J., Luescher, A., Pasloske K.S., RobersonPlouch C., Zimmerman, A., Whittymore, L.K. (2003) Comparative bioavailability of fluoxetine after transdermal and oral administration to healthy cats. AJVR. 64 (8):994-998 5. Crowell-Davis, S. L., Seibert, L. M., Sung, W., & Parthasarathy, V. (2003). Use of clomipramine, alprazo-

10. Horwitz, D. (2000). Diagnosis and treatment of canine separation anxiety and the use of clomipramine hydrochloride (clomicalm). Jrl Am Anim Hosp Asso., 36(2): 107-09 11. Hughes, D., Moreau, R.E., Overall, K.L., Van Winkle, T.J. (1996) Acute Hepatic Necrosis And Liver Failure Associated With Benzodiazepine Therapy In Six Cats, 1986-1995. Jrl Vet Emergency Crit Care. 6(1): 13-20 12. Karagiannis, C. I., Burman, O. H., & Mills, D. S. (2015). Dogs with separation-related problems show a “less pessimistic” cognitive bias during treatment with fluoxetine (Reconcile™) and a behaviour modification plan. BMC Vet Res., 11:80 13. Landsberg, G., Hunthausen, W., Ackerman, L. (2013) Behavior Problems of the Dog and Cat. (2013) 3rd Ed., Elsevier, Edinburgh UK 14. Lem, M. (2002). Can Vet J. Behavior modification and pharmacotherapy for separation anxiety in a 2-year-old pointer cross. Can Vet J., 43(3): 220-2 15. Mealey, K.L., Peck, K.E., Bennett, B.S., Sellon, R.K., Swinney G.R., Melzer, K., Gokhale, S.A., Krone, T.M. (2004) Systemic Absorption of Amitriptyline and Buspirone after Oral and Transdermal Administration to Healthy Cats. J Vet Intern Med. 18:43-46 16. Merckvetmanual.com. (2015). Retrieved from http://www.merckvetmanual.com/mvm/behavior/ normal_social_behavior_and_behavioral_problems_of_do mestic_animals/behavioral_problems_of_dogs.html? qt=aggression&alt=sh Accessed November 5, 2015 17. Miller, J. C., & Sehgal, I. (2016). A veterinary compara-

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February 2016 CE — CNS Modulating Drugs for Pets tive counseling elective featuring web-based, studentcreated, client information sheets. Am Jrl Pharm Edu, In Press. 18. Plumb, D. C. (2015). Plumb’s Veterinary Drug Handbook Eighth Edition. Stockholm, WI.: John Wiley &

January/February 2016 Sons, Inc.

19. Veterinarypartner.com. (2015). Retrieved from http://www.veterinarypartner.com/Content.plx? S=0&C=0&A=3144 Accessed November 5, 2015

February 2016 — CNS Modulating Drugs for Pet Fear and Anxiety Related Behaviors 1. Which agent has been evaluated in and is licensed for use in dogs to treat separation anxiety in combination with a behavior modification plan? A. trazodone B. clonidine C. buspirone D. fluoxetine 2. Separation anxiety that is not adequately controlled with an SSRI can be alternatively treated with TCAs. A client presents a prescription for clomipramine to treat separation anxiety in her 3 year-old female Jack Russel terrier named “Jackie.” Jackie’s anxiety was not adequately controlled with fluoxetine. They should be advised: A. that no behavior modification plan is necessary with clomipramine. B. to give Jackie ample opportunities to urinate and defecate. C. this drug is for intermittent situational use. D. this class of behavior modifier generally has less adverse effects than the SSRI fluoxetine. 3. An important piece of client counseling information to provide when dispensing alprazolam to a male poodle two hours before a car trip when the poodle has fear of car trips is that: A. beneficial effects will require over a month or two of administration. B. adverse effects are the same as in humans and include hypotension and respiratory depression. C. beneficial effects include reduced excitation, pacing, panting and vocalizing within an hour or two. D. adverse effects to be expected are hyperactivity and anorexia. 4. In cats, oral diazepam may be associated with an idiosyncratic, fatal condition accompanied by signs such as anorexia, vomiting and jaundice. This condition is: A. hepatic lipidosis. B. renal glomerulonephritis. C. pulmonary hypertension. D. forelimb tendinitis. 5. Which of the following classes of agent used to treat dog and cat anxieties generally has the most rapid onset of beneficial effects? A. serotonin (5-HT) agonists B. benzodiazepines C. tricyclic antidepressants D. selective serotonin reuptake inhibitors

6. Select the true statement below: A. First-line anxiety treatments for dogs and cats are always the same as those for humans. B. Doses for dogs receiving anxiolytic therapies are generally equivalent to humans on a kilograms-of-body weight basis. C. Drug-drug interactions in dogs and cats are generally less frequent than in humans. D. Serotonin syndrome is a drug-drug interaction that cannot occur in dogs and cats. 7. What drug class(es) are most commonly used long-term to treat general anxiety, fears and phobias, and aggression due to fear and anxiety? I. TCA’s, II. serotonin agonists, III. serotonin antagonists or IV.SSRIs A. I. only B. I. & IV C. 1 & III D. II & IIII 8. A pet owner brings in a veterinary prescription to your pharmacy for her 12 year old female Samoyed dog named Fluffy. Your pharmacy has filled previous prescriptions for Fluffy and your pharmacy staff are aware that Fluffy has a history of generalized anxiety. Fluffy has been receiving therapy for the anxiety with Fluoxetine for the past 9 months; however, the new prescription is for Selegline. Fluffy is being transitioned to selegiline because she has been diagnosed with cognitive dysfunction syndrome, a progressive neurodegenerative condition similar to human Alzheimer’s disease. After verifying with the veterinarian that this is the correct medication, the veterinarian mentions an important counseling point. Which of the following is most likely to be the counseling advice given from the veterinarian? A. Fluffy needs to have a “wash out” period of 14 days before starting Selegline to prevent risk of serotonin syndrome. B. Fluffy should take an antibiotic with the Selegline for the first week to prevent infections. C. Fluffy should wait 5 weeks for a “wash out” period D. before starting Selegline to prevent risk of serotonin syndrome. E. Fluffy should avoid all flea preventive medications while taking Selegline.

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February 2016 CE — CNS Modulating Drugs for Pets 9. What drug, administered one to two hours before the arrival of a storm, can reduce a dog’s acute fear associated with storm noise? A. alprazolam B. buspirone C. clonidine D. sertraline 10. Several psychotropic agents are offered by compounding pharmacies as alternatives to oral medications for cats. Which agent below has been shown to possess excellent and consistent bioavailability in cats in a transdermal preparation? A. amitriptyline B. buspirone C. fluoxetine D. none of the above

January/February 2016

12. A pet owner presents a prescription for his 4 year old male Bichon, Sabre, to your pharmacy. Sabre was previously treated with an SSRI for separation anxiety without success and the veterinarian has now switched Sabre to amitriptyline. Which of the choices below is an advantage to the use of the TCA amitriptyline over clomipramine? A. Amitriptyline is the most serotonin selective of the TCAs. B. Amitriptyline is the least expensive of common behavior drugs. C. Amitriptyline is licensed for canine separation anxiety, while clomipramine is not. D. Amitriptyline can be dosed once daily, while clomipramine must be administered two to three times daily.

11. Which of the following is a drawback in the use of Buspirone (Buspar®) when being used to treat general and situational anxieties? A. Withdrawal effects B. Sedative effects C. Time to behavioral effect D. Muscle relaxant effect

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.   

 

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



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



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

Articles must be submitted electronically to the KPhA director of communications and continuing education (ssisco@kphanet.org) by the first of the month preceding publication.

Feel free to include graphs or charts, but please submit them separately, not embedded in the text of the article.

138th KPhA Annual Meeting and Convention June 2-5, 2016 Louisville Marriott Downtown 27

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February 2016 CE — CNS Modulating Drugs for Pets

January/February 2016

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, 96 C. Michael Davenport Blvd., Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile. Expiration Date: January 6, 2019 Successful Completion: Score of 80% will result in 2.0 contact hours or .2 CEU. Participants who score less than 80% will be notified and permitted one re-examination. TECHNICIANS ANSWER SHEET. February 2016 — CNS Modulating Drugs for Pet Fear and Anxiety Related Behaviors(2.0 contact hours) Universal Activity # 0143-0000-16-002-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D

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

9. A B C D 10. A B C D

11. A B C D 12. A B C D

Personal NABP eProfile ID #_____________________________ Birthdate ____________(MM/DD) PHARMACISTS ANSWER SHEET February 2016 — CNS Modulating Drugs for Pet Fear and Anxiety Related Behaviors(2.0 contact hours) Universal Activity # 0143-0000-16-002-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D

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

9. A B C D 10. A B C D

11. A B C D 12. A B C D

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

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KPhA Pharmacy Emergency Preparedness

January/February 2016

The KPhA Emergency Preparedness Program now offers several educational opportunities and resources for emergency response. These include programs provided by FEMA, CDC, Pharmacists Letter and others. Some of the programs offer continuing education for pharmacists. There are a variety of topics including mass dispensing, drug shortages, continuity of business operations resources, mass vaccination and medical countermeasures. Visit kphanet.org, click on Resourcesâ&#x20AC;&#x201D;Emergency Preparedness to access the educational programs and online resources. For more information on how you can be involved in the KPhA Pharmacy 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 for Public Health for emergency preparedness and disaster response.

For more resources, visit YOUR www.kphanet.org and click on Resourcesâ&#x20AC;&#x201D;Emergency Preparedness.

KPhA Pharmacy Emergency Preparedness Initiative Interest Form

Name: ______________________

Status (Pharmacist, Technician, Other): ___________________

Email: ______________________________ Phone: ___________________________ Interest in serving as a volunteer: Yes____ No ____ Interest in serving as a Volunteer District Coordinator: Yes____ No _____ You also may join the Medical Reserve Corps by following the KHELPS link on KPhA Website to register (www.kphanet.org under Resources) Please send this information to Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness via email at ltolliver@kphanet.org, fax to 502-227-2258 or mail at KPhA, 96 C. Michael Davenport Blvd., Frankfort, KY 40601.

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

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InfiniTrak

January/February 2016

Special New Year Pricing – Limited Time Only for InfiniTrak Partners!! Start the New Year with savings! KPhA and InfiniTrak are partnering to help you get a solid, low-cost solution in place before the enforcement of these new regulations begins, March 1. You won’t see another offer like this. From now until the end of February, KPhA members can purchase InfiniTrak’s track and trace software solution for less than half of its market price! Sign up before March 1 and receive the InfiniTrak solution for just $89/month. No set up fees, no additional costs. In fact, if you sign a yearlong contract, we’ll reduce the price by another 10 percent, bringing your total annual expense for Track and Trace compliance and peace of mind in under $1,000. Lock into this unparalleled deal now and get your DSCSA compliance solution in place. On March 1, InfiniTrak returns to established pricing. To subscribe to InfiniTrak, visit www.infinitrak.us For more information contact Sally Flynn at sally@infinitrak.us Questions? Contact: customercare@infinitrak.us Want More Information? Visit: www.infinitrak.us

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

For more information on the Kentucky Renaissance Pharmacy Museum, see www.pharmacymuseumky.org or contact Gloria Doughty at g.doughty@twc.com or Lynn Harrelson at lharrelsonky@aol.com.

THE KENTUCKY PHARMACIST

Campaign for Kentucky’s Pharmacy Future

January/February 2016

The Campaign for Kentucky’s Pharmacy Future: The Next 50 Years

Leave a legacy by participating in the campaign to replace OUR KPERF/KPhA Headquarters! Learn more about options for payment and levels of recognition at http://www.kphanet.org/?page=buildingcampaign or call 502-227-2303.

THE KENTUCKY PHARMACIST

KPhA New and Returning Members

January/February 2016

KPhA Welcomes New and Renewing Members November-December 2015 Zaki Abdullah Florence

Terri L Chism Brandenburg

John Dickerson Olive Hill

Jennifer Anderson Morehead

William E. Clark Collierville Tenn.

Brad Doering Florence

Matthew Andrews Fisherville

Kem Dowell Coe Tompkinsville

Donald Kenneth Dove Winchester

John Bryan Anneken Edgewood

Adam Coffman Nortonville

Ben Doyle Nicholasville

Paul E Arthur Huntington, W.Virg.

Samuel Joseph Coletta Cincinnati Ohio

Sarah Durham Indianapolis Ind.

Emily Brooke Balenovich Corbin

Bonnie Collins Paris

Paul Easley Fisherville

To YOU, To YOUR Patients To YOUR Profession!

Holly A Barber Central City

Stephanie Sue Collins Corbin

Joseph Max Eiler Louisville

Michael Stephen Goeing Melvin

Walter Michael Bauman Lancaster

George M Combs Louisville

Anna Eiler Shepherdsville

Patty Guinn Somerset

Robert Michael Bero New Bern, N.C.

Charlotte Cornett London

Suzanne Epley Russellville

David Guion Russellville

Stacey Marie Blackburn Richmond

Melvin R Croley Park City

William Farmer Henderson

Cara Hale Inez

Kaleb Blair Whitesburg

Matt Cull Owenton

Matt Flanders Bowling Green

Gary Hamm Elizabethtown

Brenda G Brewer Stanton

Dan Moore Daffron Monticello

Lindsey K Flanders Bowling Green

Robert Haney Bedford

William Brown Wingo

William E Danhauer Owensboro

Martha J Ford Fort Thomas

Amanda Harding Louisville

Christen Bruening Cincinnati. Ohio

Matthew Daniels Smiths Grove

Larry T Fortenberry Pikeville

Henry W Harris Louisville

Charles L Bryant Cave City

Lysette Daniels Smiths Grove

Tom G Frazier Salyersville

Ellen Harrison Tompkinsville

Robert S Bunting Alexandria

Marshall Davis Paducah

Randy M Gaither Louisville

Jessica A. Hemmer Dayton

Michael A Burleson Lexington

Alicia Dawson McDowell

Milton E Gardner Jeffersontown

Tiffany Herald Hazard

Todd Carter Hazard

Kecia Dawson Prospect

Eric T Gibbs Corbin

Michael Paul Herald Hazard

Timothy P Castagno Louisville

Pamela Decker-Meadows Cynthiana

Mary Gilvin Mt. Sterling

Rebecca J. Hernandez Louisville

MEMBERSHIP MATTERS:

THE KENTUCKY PHARMACIST

KPhA New and Returning Members

January/February 2016

Whitney Herringshaw Winchester

Leigh Ann Keeton Flatwoods

John Lutz Louisville

Wayne Morris Frankfort

Jennifer Hibbs Louisville

Michael Keller Salem

Laura Madison Paducah

Sherri Muha Hazard

Linette Hieneman Flatwoods

James Kelley Nicholasville

Calvin Lynn Manis Barbourville

Stephanie Myers Louisville

Marylou S Hoskins Hawesville

Diane Kelly Evarts

Korey Ray Manning Florence

Chasity Brooke Nichols London

Marylou Hoskins Owensboro

Rene Kendrick Taylorsville

Samantha Martin Greenville

Edwin Nickell Eddyville

Peter W Hovis Louisville

Melissa Brewer Kennon Lexington

Nancy J. Matyunas Louisville

Kenneth Niemann Harrodsburg

Taryn Howell Hagerhill

Anita J. King Richmond

Thomas McConnell Kuttawa

Paul Nixon Tompkinsville

Travis Hudnall Smiths Grove

Ethan Klein Louisville

Thomas McCurry Harlan

Donald Noble Garrison

Melissa A Hudson Louisville

Don Kupper Louisville

Clayton Mckinney Shelbyville

Freddie M. Norris Glasgow

Melissa Hudson Villa Hills

Richard S. Lacefield Bowling Green

Michael McWilliams Louisville

Jennifer A O'Hearn Louisville

John Hutchinson Lexington

Randall Lange Butler

Beverly Meeks Paducah

Charles Oliver Glasgow

Bernard Hyman Louisville

Amanda Leathers Lebanon

Ross Melton Mount Sterling

Angela Onkst Louisville

Arthur Jacob Louisville

Teresa Leslie Prestonsburg

Paula Miller Fort Thomas

Chris Palutis Richmond

Ella L Johnson Hazard

Carl Lewis Owensboro

Christopher Matthew Miller Louisville

Eileen Palutis Richmond

Linda Johnston Georgetown

Martin Likins Greenville

Mickey Monroe Frankfort

Kenneth G Parsons Louisville

Frederick Johnston Georgetown

Michael Lin Louisville

Lindsay Monroe Emmalena

Vikram J Patel Bowling Green

Misty Jones Augusta

Robert Little Berea

Michael Montgomery Nicholasville

Bijalkumar Patel Lexington

Kimberly Jones Williamsburg

Sheri Lucas Millstone

Jason Moore Corbin

Lindsey Peden Smiths Grove

Robin Justice Pikeville

Mike Lusk Betsy Layne

Megan B Morgan Manchester

Alfred H Pence Stanford

KPhA Honorary Life Members Ralph Bouvette Leon Claywell R. David Cobb Gloria Doughty Kenneth Roberts Ann Amerson Mazone 33

David Peyton West Liberty Sam J Pilotte Prospect

THE KENTUCKY PHARMACIST

KPhA New and Returning Members

January/February 2016

Ronald Poole Central City

Stacie Silvers Pendleton

Paul A. Thompson Harrodsburg

Amy N Wilder Booneville

David E Powers Jenkins

Michael Sizemore Pittsburg

Rick Timmons Paducah

John Curtis Willett Clarksville, Tenn.

Kris Preston Pikeville

Sharon Stevens Small Louisville

Ryan Allen Timmons Gilbertsville

Eric Willis Lexington

Samuel Roland Reader Louisville

Jamie R Smith Booneville

Fred Toncray Maysville

Laura Willoughby Hardinsburg

Fran Reasor Pikeville

Jessica R Smith Booneville

Sheryl Lorene Turley Horse Cave

Brenda Lee Wilson Danville

Vendonna Rickard Madisonville

Wayne D Sparrow Eminence

Geanie Umberger Lexington

Christine Windham London

Jerry Rickard Madisonville

Larry Spears Dry Ridge

G Steven Underwood Louisville

Randy Windham London

Donald Glenn Riley Russellville

James Corey Stark Louisville

Jonathan Gabriel Van Lahr Webster

Dachea A. Wooton Hazard

Matthew C Robinson Owensboro

Janet Stephens Scottsville

Benjamin Vice London

Greg Wright Paducah

Andrew Rudd Floyds Knobs, Ind.

Quincy S Stephenson Providence

Frank Vice Flemingsburg

Joseph M Wright Lucasville, Ohio

Angela Rudd Floyds Knobs, Ind.

Elizabeth Stivers Lexington

Steven Wagers London

Navas Yoonus Elizabethtown

Jesse L Rudd Salyersville

Doris Stone Kevil

Anthony Daren Warford Clay

Timothy Young Mount Vernon

Gary Russell Madisonville

David Riley Stultz Greenup

Susan Weaks Paducah

Laban Young Louisa

Paul Ruwe Covington

Amanda J Sublett Lexington

Stacy Wedeking Metropolis, Ill.

Nicholas J Schwartz Florence

Clarence F. Sullivan Richmond

Leslie Joe Wells Mt. Sterling

Ginger Scott Morgantown, W.Virg.

William C Sutherland Louisville

Sara Wells Gilbertsville

Terrence Seiter Burlington

Carolyn Taylor Crestwood

William Wheeler Lexington

William Shely Morehead

David Taylor Crestwood

Tyler Whisman Union

Alison Shirley Shepherdsville

Mark Taylor Danville

Marcia White Richmond

Jennifer R Shown Hopkinsville

Jason Taylor Pineville

Jerrold White Russellville

Know someone who should be on this list? Ask them to join YOU in supporting OUR KPhA! THE KENTUCKY PHARMACIST

Naloxone Training

January/February 2016

Continued from Page 7 KPHA POLICY POSITIONS Policy Position on Medical Marijuana KPhA does not endorse or oppose proposed legislation in the General Assembly related to Medical Marijuana. Rather, KPhA has adopted a Policy Position. KPhA supports regulatory changes to further facilitate clinical research related to the clinical efficacy and safety associated with the use of cannabis and its various components. Also, we support pharmacist participation in furnishing cannabis and its various components if and when specific data support the

legitimate medical use of the products and delivery mechanisms, and federal, state or territory laws or regulations permit pharmacists to furnish them. Pharmacists should always be involved in reviewing a patientâ&#x20AC;&#x2122;s complete medication regimen. KPhA opposes pharmacist involvement in furnishing cannabis and its various components for recreational use. We welcome your engagement in helping to fulfill OUR KPhA Legislative Agenda. Please contact me, Government Affairs Chair Richard Slone and/or Scott Sisco with any questions as we work to advance our legislative priorities this session.

KPERF Naloxone Certification Training The online training program can be found at the following link on the KPhA website: http://www.kphanet.org/?page=NaloxoneCert2015 The cost of the training is $5 for KPhA members, and $10 for non-KPhA members. After successfully completing the course, credit will be applied to your CPE Monitor Profile and you will be emailed a certificate of completion.

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)

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

Donate online to the Kentucky Pharmacists Political Advocacy Council! Go to www.kphanet.org and click on the Advocacy tab for more information about KPPAC and the donation form.

THE KENTUCKY PHARMACIST

Pharmacy Law Brief

January/February 2016

Pharmacy Law Brief: Returning to Active Practice of Pharmacy Author: Joseph L. Fink III, B.S.Pharm., J.D., Professor of Pharmacy Law and Policy and Kentucky Pharmacists Association Professor of Leadership, Department of Pharmacy Practice and Science, UK College of Pharmacy Question: I took some time away from pharmacy practice to spend with my young family members, something I am very thankful that my chosen profession made possible. I’d now like to return to active practice because dealing with patients has always been my passion (at least most of them!). What do I need to do to get back in the swing of things?

Submit Questions: jfink@uky.edu 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.

Response: Your situation is not that unusual these days. Pharmacists step away from active practice for any number of reasons – raising children, caring for a family member who is sick or addressing personal health challenges. Some pharmacists retire and then find they really during the spring of 2015. The mandatory continuing edumiss the interaction with colleagues and patients while othcation expectation on issues with HIV/AIDS every 10 years ers have “moved on” to other endeavors and later decide to was removed as a condition for renewal of licensure. Cerreturn to their professional roots. tainly that continues to be an important topic and those topBut there can be challenges in the form of newly introduced ics readily qualify for CPE credit; it is merely the every-10products, both medications and medical devices, with which years specification that was modified. the contemporary pharmacist must deal authoritatively. Next, has the pharmacist been pursuing renewal of KenMoreover, changes related to payment for services and tucky pharmacy licensure each year? That is addressed in insurance program coverage of pharmacy services and KRS 315.120, the statute covering expired licenses that pharmaceuticals is always a moving target. Finally, while uses a five year breaking point for requirements. A pharmadevelopments related to information technology have greatcist who has failed to renew for up to five years, with those ly facilitated contemporary practice and enabled pharmayears running consecutively, must meet the Board’s CE cists to meet heightened output expectations, one who has requirements – 15 hours of CE for each year the license been away from practice for a while may need some brushwas not renewed, up to a maximum of 75 hours. [210 KAR ing up in that area as well. 2.015(7)] One who has failed to renew for five years or The first question to consider is whether the pharmacist has more in a row must satisfy the CE completion requirements met the yearly Board expectations with regard to participa- and pass a “satisfactory examination.” tion in continuing professional education. The regulations specify that the pharmacist must complete 15 contact hours annually between January 1 and December 31 and any excess over 15 may not be carried over to a subsequent year. [201 KAR 2.015(5)] The regulations also contain a provision stating that a licensee may request and be granted a deferral of CPE expectations on a year-to-year basis for “illness, incapacity or other extenuating circumstances.” Approval of such a request is totally discretionary with the Board. Hopefully the pharmacist seeking to return has been completing those requirements.

Moreover, the relevant statute [KRS 315.110] established the authority of the Board to assess and collect a “delinquent renewal penalty fee not to exceed the renewal fee” and that applies to “each renewal period the licensee fails to renew the license after expiration.” At this writing the annual renewal fee is $70.00 and the delinquent renewal penalty fee is an additional $70.00 [201 KAR 2:050(1)(4) and (1)(5)].

Kentucky pharmacists have the option of applying to shift licensure status from active to inactive. The inactive classification is available to those who do not “desire to meet the It also is deserving of emphasis that one who has been dis- qualifications for active license renewal” but it is not availaengaged from professional practice may not be aware of ble to a Kentucky licensed pharmacist who also currently the change effected by the General Assembly when it met holds an active pharmacist’s license in another state. [KRS 36

THE KENTUCKY PHARMACIST

Pharmacy Law Brief

January/February 2016

315.120(4)] While one is in the inactive category he or she may not engage in the practice of pharmacy but the person is permitted to use the term “pharmacist.” The inactive license renewal fee is currently set at $10.00 and it is payable yearly. [201 KAR2:050(1)(6)]. Should the pharmacist in inactive status wish to return to an active classification he or she must meet the conditions outlined in 201 KAR 2:160(3). And here once again we see differentiated expectations before and after the five year point. All the foregoing relates to licensure and expectations com-

ing from the Kentucky General Assembly and the Kentucky Board of Pharmacy. Now let’s turn attention to malpractice insurance. Some may advance the notion that the need for good malpractice insurance coverage is greater for one who has been inactive in the profession for a while than that of one who has been in continuous active practice. The pharmacist returning to active practice after a hiatus should certainly seek out a good individual policy and not rely on the employer’s coverage. Associations, like OUR KPhA often endorse underwriters and policies after reviewing them so that’s a good first place to check on availability.

Are you connected to YOUR KPhA? Join us online!

Facebook.com/KyPharmAssoc Facebook.com/ KPhANewPractitioners

@KyPharmAssoc @KPhAGrassroots

KPhA Company Page 37

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Pharmacy Policy Issues

January/February 2016

PHARMACY POLICY ISSUES: STATUS OF “RIGHT TO DIE” LAWS IN THE U.S. Author: Chelsea L. Collard is a third professional year PharmD student at the University of Kentucky College of Pharmacy. She hails from Louisville and completed her Bachelor of Science in Biology degree at Centre College. Issue: Proposals for or the enactment of “right to die” laws are becoming much more prevalent in the United States. What is the role of the pharmacist in relation to the right to die? Discussion: The “right to die” has become a pertinent and controversial issue in recent years. Oregon is most well established in the right to die realm with the implementation of the Death with Dignity Act (DWDA) passed in 1994. Washington followed suit in 2008, establishing the northwest as the most dignified place to die. Montana does not have a statute per se, but the state does not prohibit a physician from prescribing a medication that can end a terminally ill but mentally competent patient’s life. Vermont passed the DWDA in May of 2013, after failing in 2012 by a Senate vote of 11-18. This was preceded by seven other previously failed attempts. Most recently, in 2015, California passed a bill in support of the right to die.8 Alaska, Iowa, Kansas, Maryland, Missouri, New York and Oklahoma saw bills introduced in support of the right to die in 2015. Recently, a new audience was introduced to the right to die via the public journey of a young woman, Brittany Maynard, diagnosed with glioblastoma. She moved to Oregon and chose to end her life on Nov. 1, 2014. America took to social media outlets to express their opinions on this highly sensitive subject. In October 2015, Governor Jerry Brown of California signed a bill in support of the right to die after significant deliberation at the Capitol. Brown stated that he took the opinions of Maynard’s family into consideration when he signed this bill; her journey has already been influential to the future of right-to-die laws.8 Through the growing dialogue and proposal of laws for the right to die, it is possible that the DWDA could become an option for certain terminally ill patients in the future. These discussions have spurred a debate among healthcare professionals about who should be involved in the care of those who choose to end their lives with dignity.

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.

fied agent.1,2,3 Vermont has specific provisions in the bill, which states the physician, nurse or pharmacist must not actually administer the lethal dose of medication to the patient, and that the pharmacist must not be punished (suspension or revocation of pharmacist licensure) for dispensing a life-ending medication.3

It is apparent that the pharmacist may be actively involved in a patient’s life-ending care. The American Society of Health-System Pharmacists (ASHP) has developed a pharmacist-specific policy on the right to die. It is paradoxical in that it states pharmacists are allowed to exclude themselves from participating in a patient’s end of life care for moral, ethical or religious reasons, but that it is also the duty of the pharmacist to provide patient-specific care and respect the autonomy of the patient. In the future, pharmacists could play a more intimate role in end-of-life care. A feasible role for the pharmacist could be patient counseling and education on end-of-life care. Pharmacists are perfectly poised to educate patients on pain management options at the end of life, how to maximize efficacy for the patient’s current medication regimen and what to expect from a medication that is prescribed to end a patient’s life. Although there are no proposed bills for the DWDA in KenPharmacists undoubtedly play an active role in a patient’s tucky, there is a conceivable expansion of the DWDA in decision to end his or her life. In all three states that have upcoming years. It is crucial that pharmacists establish a passed the DWDA, a physician may directly present a lifeposition and educate themselves on end-of-life care. ending medication to a patient, but the patient also may request in writing that the physician contact a pharmacist to References dispense the medication. The physician then specifically 1. Oregon Death with Dignity Act, Oregon Code §127.800 gives the pharmacist the prescription without it passing through the hands of someone else, and the pharmacist 2. Washington Death with Dignity Act, Wash, Rev. Code §70.245 (2008). may dispense it directly to the patient or the patient’s identi38

THE KENTUCKY PHARMACIST

January/February 2016

Pharmacy Policy Issues 3. 39 V.S.A. §5281

15, 2015, from http://www.usatoday.com/story/news/ nation-now/2014/11/02/brittany-maynard-/18390069/

4. Patients’ Rights Council Vermont. (n.d.). Retrieved February 10, 2015, from http:// www.patientsrightscouncil.org/site/vermont/

7. American Society of Health-System Pharmacists. ASHP statement on pharmacist’s decision-making on assisted suicide. Am J Health-Syst. Pharm. 1999; 56:1661–4.

5. Death with Dignity Around the U.S. (2015, February). Retrieved February 10, 2015, from http:// www.deathwithdignity.org/advocates/national

8. Siders, D., Koseff, A. (2015, October 5). Jerry Brown signs doctor-assisted death bill. Retrieved October 14, 2015, from http://www.sacbee.com/news/politicsgovernment/capitol-alert/article37818555.html

6. Durando, J. (2014, November 3). Brittany Maynard, right-to-die advocate, ends her life. Retrieved February

Join the campaign! Select one of the History of Pharmacy in Pictures Prints to be framed and displayed in the new headquarters. There are 36 prints in the series remaining to be claimed. KPhA will include a plaque on the frame to commemorate a minimum $1,000 donation. You can dedicate the donation to yourself, a colleague or honor another entity. http://www.kphanet.org/?page=buildingcampaign or call 502-227-2303.

Kentucky Pharmacists Political Advocacy Contribution Form 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 cashier’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)

THE KENTUCKY PHARMACIST

January/February 2016

Pharmacists Mutual

THE KENTUCKY PHARMACIST

Cardinal Health

January/February 2016

THE KENTUCKY PHARMACIST

KPhA Board of Directors/Staff

January/February 2016

KPhA BOARD OF DIRECTORS

HOUSE OF DELEGATES

Bob Oakley, Louisville Boakley@BHSI.com

Chair

Chris Harlow, Louisville cpharlow@gmail.com

Chris Clifton, Villa Hills chrisclifton@hotmail.com

President

Lance Murphy, Louisville Vice Speaker of the House lancemurphy84@gmail.com

Trish Freeman trish.freeman@uky.edu

President-Elect

KPERF ADVISORY COUNCIL

Brooke Hudspeth, Lexington brooke.hudspeth@kroger.com

Secretary

Christen S Bruening cschenkenfelder@sullivan.edu

Chris Palutis, Lexington chris@candcrx.com

Treasurer

Matt Carrico, Louisville matt@boonevilledrugs.com

Duane Parsons, Richmond dandlparsons@roadrunner.com

Past President Representative

Matt Carrico, Louisville* matt@boonevilledrugs.com

Mary Thacker, Louisville mary.thacker@att.net

Chad Corum pharmdky21@gmail.com

KPhA/KPERF HEADQUARTERS 96 C. Michael Davenport Blvd., Frankfort, KY 40601 502.227.2303 (Phone) 502.227.2258 (Fax) www.kphanet.org www.facebook.com/KyPharmAssoc www.twitter.com/KyPharmAssoc www.twitter.com/KPhAGrassroots www.youtube.com/KyPharmAssoc

Tony Esterly, Louisville tonye50@hotmail.com Matt Foltz, Villa Hills mfoltz@gomedcare.com Chris Killmeier, Louisville cdkillmeier@hotmail.com University of Kentucky Student Representative

Jeff Mills, Louisville jeff.mills@nortonhealthcare.org Catherine Serratore cserra4007@my.sullivan.edu

Kim Croley, Corbin kscroley@yahoo.com Kimberly Daugherty, Louisville kdaugherty@sullivan.edu

Directors

Kevin Mercer kevin.mercer@uky.edu

Speaker of the House

Sullivan University Student Representative

Richard Slone, Hindman richardkslone@msn.com Mary Thacker, Louisville mary.thacker@att.net Sam Willett, Mayfield duncancenter@bellsouth.net * At-Large Member to Executive Committee

Robert McFalls, M.Div. Executive Director rmcfalls@kphanet.org Scott Sisco, MA Director of Communications & Continuing Education ssisco@kphanet.org Angela Gibson Director of Membership & Administrative Services agibson@kphanet.org Leah Tolliver, PharmD Director of Pharmacy Emergency Preparedness ltolliver@kphanet.org Elizabeth Ramey Receptionist/Office Assistant eramey@kphanet.org

THE KENTUCKY PHARMACIST

50 Years Ago/Frequently Called and Contacted

January/February 2016

50 Years Ago at KPhA BLUE GRASS PHARMACISTS MEET The Blue Grass Pharmaceutical Association met at the Springs Motel in Lexington on January 19th. Guests for the meeting were Robert J. Lichtefeld, Executive Secretary of the Kentucky Pharmaceutical Association, and A.E. “Doc” Tucker, RPh, and State Representative from Bowling Green. The new Proposed Pharmacy legislation was discussed at length before a record turnout of the pharmacists in this district. Officers for 1966 are: President, J.B. Hitt II, RPh, Lexington; Vice President, Jewell Harper, RPh, Lexington; Sec’y, Mrs. Gloria Doughty, RPh, Lexington; Treasurer, Miss Patricia Donohue, RPh, Lexington. Executive Committee: Jesse DeJarnette, RPh, Lexington; William Curry, RPh, Lexington; Norman Frank, RPh, Lexington; Vernon B. Hager, RPh, Nicholasville. (Two vacancies on this committee at present.) - From The Kentucky Pharmacist, February 1966, Volume XXIX, Number 2.

Frequently Called and Contacted Kentucky Pharmacists Association 96 C. Michael Davenport Blvd. 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 (PTCB) 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 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 Kentucky Regional Poison Center (800) 222-1222

KPhA sends email announcements weekly. If you aren’t receiving: eNews, Legislative Updates, Grassroots Alerts and other important announcements, send your email address to ssisco@kphanet.org to get on the list. 43

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January/February 2016

THE

Kentucky PHARMACIST 96 C. Michael Davenport Blvd. Frankfort, KY 40601

Show your Pharmacist Pride with a KPhA Roamey Window Cling ($5) or your own personalized Roamey ($25)! All proceeds benefit the KPhA Building Fund

Louisville Marriott Downtown

Available at the KPhA Online Store www.kphanet.org, click on About Tab, Online Store 44

THE KENTUCKY PHARMACIST