Y K C U T N E K E H T T S I C A M PHAR 135th KPhA Annual Meeting Vol. 8, No. 2 March 2013
Tentative Schedule, Topics and Registration information inside!
LEGISLATIVE ACTION Senate Bill 107 Passes with no dissenting votes! Thanks to your calls, visits and testimony, KPhA’s top priority moved quickly!
House Bill 217 corrects pharmacy issues legislators learned about from KPhA led testimony. Flanked by bipartisan supporters, Gov. Steve Beshear signs HB 217 into law. News & Information for Members of the Kentucky Pharmacists Association
Table of Contents
March 2013 KPhA New and Returning Members Adventures in Compounding Helping Hands, Big Heart April 2013 CE—Herbals in Cancer Treatment April Pharmacist/Pharmacy Tech Quiz Why should I connect with KPhA? Pharmacy Law Brief Advancing Pharmacy Practice Summit Save the Date Pharmacy Policy Issues Kentucky Renaissance Pharmacy Museum Pharmacists Mutual KPhA Government Affairs Contribution KPhA Board of Directors 50 Years Ago/Frequently Called and Contacted
Table of Contents Table of Contents— Oath— Mission Statement President’s Perspective 2012 Bowl of Hygeia Winners 135th KPhA Annual Meeting Message from Your Executive Director 135th KPhA Annual Meeting Registration Form Kentucky at APhA Board of Directors Election/Professional Awards Board of Pharmacy letter regarding fitting of therapeutic shoes by technicians and interns March 2013 CE—Pertussis March Pharmacist/Pharmacy Tech Quiz Senior Care Corner
2 3 4 5 6 7 8 9 10 12 18 19
20 22 25 26 38 39 40 41 42 43 44 45 46 47
Oath of a Pharmacist At this time, I vow to devote my professional life to the service of all humankind through the profession of pharmacy. I will consider the welfare of humanity and relief of human suffering my primary concerns. I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy outcomes for the patients I serve. I will keep abreast of developments and maintain professional competency in my profession of pharmacy. I will embrace and advocate change in the profession of pharmacy that improves patient care. I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public. The Kentucky Pharmacy Education and Research Foundation (KPERF), established in 1980 as a non-profit subsidiary corporation of the Kentucky Pharmacists Association (KPhA), fosters educational activities and research projects in the field of pharmacy including career counseling, student assistance, post-graduate education, continuing and professional development and public health education and assistance.
Kentucky Pharmacists Association The mission of the Kentucky Pharmacists Association is to promote the profession of pharmacy, enhance the practice standards of the profession, and demonstrate the value of pharmacist services within the health care system.
It is the goal of KPERF to ensure that pharmacy in Kentucky and throughout the nation may sustain the continuing need for sufficient and adequately trained pharmacists. KPERF will provide a minimum of 15 continuing pharmacy education hours. In addition, KPERF will provide at least three educational interventions through other mediums — such as webinars — to continuously improve healthcare for all. Programming will be determined by assessing the gaps between actual practice and ideal practice, with activities designed to narrow those gaps using interaction, learning assessment, and evaluation. Additionally, feedback from learners will be used to improve the overall programming designed by KPERF.
Editorial Office: © Copyright 2013 to the Kentucky Pharmacists Association. The Kentucky Pharmacist is the official journal of the Kentucky Pharmacists Association published bimonthly. The Kentucky Pharmacist is distributed to KPhA members, paid through allocations of membership dues. All views expressed in articles are those of the writer, and not necessarily the official position of the Kentucky Pharmacists Association. Editorial, advertising and executive offices at 1228 US 127 South, Frankfort, KY 40601. Phone 502.227.2303 Fax 502.227.2258. Email ssisco@kphanet.org. Website http://www.kphanet.org.
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President’s Perspective
President’s Perspective Kimberly Sasser Croley KPhA President 2012-2013
This next issue of relevance and relationships centers on the necessary infrastructure of YOUR KPhA in order for the “business” of the Association to move forward. However, I wanted to make two comments before I get into the message about the importance of “One Heart, One Voice” when it comes to Advocacy. In our state, the recent passage of SB107 through the Kentucky House of Representatives and Senate without a dissenting vote shows without a doubt that Together WE are POWERFUL! I also wanted to let you know that at the recent APhA Annual Meeting in Los Angeles, the House of Delegates passed the following Policy Statement without a dissenting vote: “Pharmacists are Providers which should be recognized/ compensated by payers.” Sometimes short and sweet gets the job done best! Now, we are coming to the time of year when YOUR KPhA is seeking individuals to step up and volunteer. Every year, we nominate and elect a President-Elect, a Secretary OR Treasurer (alternating years) and three Directors. These individuals join the Board of Directors which will still include the Chair of the Board, the President, the Secretary OR Treasurer and the other Directors. Each College of Pharmacy sends a student pharmacist Director member to serve as a liaison as well. Our Executive Director, Director of Communications, Office Manager and Director of Emergency Preparedness also participate in the meetings. Our lobbyists and legislative experts also drop by to lend their expertise. It is a dynamic and exciting group that carries the weight of the Association on its shoulders. We desire and need the support, knowledge and expertise of the membership as a whole. Our Standing and Special Committees are the backbone of the Association. We need individuals on these committees who bring drive, determination and creativity to the work of the committee. You may ask yourself, “How is a committee member relevant to the work of KPhA?” or “I am just one person; how can I make a difference?” I would answer these queries by saying it is the
March 2013 one-to-one relationships that are fostered in the Committee process that builds and constantly improves the work of the committee which in turn strengthens YOUR KPhA. This “call to action” by YOUR KPhA is meant for each of you reading these words. Continuing with this theme but in a different vein, this call also includes nominations of yourself or a peer for a Board of Pharmacy appointment. By statute, YOUR KPhA provides a listing of five names annually for the Governor to choose from for a Board of Pharmacy appointment. Please consider the people you know who practice pharmacy the way it should be so that Best Practice is the Standard Practice across our Commonwealth, protecting the health and welfare of our citizens and continuing the level of trust we have established with our patients. It is also time for nomination to the Professional Awards given annually at YOUR KPhA Annual Meeting. These include the Bowl of Hygeia; Pharmacist of the Year; Young Pharmacist of the Year; Professional Promotion; and Innovative Practice Awards. All of you know pharmacists who are deserving of these awards. Student Pharmacists and New Practitioners, consider the awesome preceptors you honed your practice skills under and nominate them for an award! Look around at your peers; see the relationships that the pharmacists you work with forge on a daily basis with their patients. Pharmacists that you know provide excellent patient care on a daily basis, and we need you to tell us about them! Now to discuss a slightly different matter of relevance and relationships. I want to tell you of a recent decision by YOUR KPhA Board of Directors. In response to a “Call for Action” by Gloria Doughty (Bluegrass), Pharmacist Extraordinaire and Developer-Curator of the KY Renaissance Pharmacy Museum, YOUR KPhA has offered to provide storage for the museum’s collections until a permanent home can be found. Its current home in downtown Lexington has been found to contain lead in its interior paint that exceeds federally prescribed limits and the building must be closed down. Where the museum will reopen in the future is still uncertain and so KPhA’s offer of assistance provides a safe and secure storage location for these precious pharmacy artifacts until a permanent home (or perhaps homes) can be found. The Directors of YOUR KPhA felt this was the least we could offer to do after the time, money and expertise Gloria and Lynn Harrelson have donated to our profession by preserving our pharmacy heritage. I hope you agree and will consider making a donation to the museum directly or through the KPERF 501(c)(3) for the preservation of our heritage now and when it finds its final home. 3
THE KENTUCKY PHARMACIST
2012 Bowl of Hygeia Recipients
March 2013
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135th KPhA Annual Meeting
March 2013 To book your hotel room online, visit YOUR www.kphanet.org and follow the link from the 135th Annual Meeting page. Or contact Louisville Marriott Downtown at 1-800-266-9432 and reference Group Code KY Pharmacists Association for the special rate of $119/night. Cut-off for this rate is May 14, 2013. Lodging rate includes wireless internet access.
Tentative Schedule Friday, June 7, 2013 (7.5 CE) 7 am Registrations Open 8 am-8:30 am Opening Breakfast 9 am Opening House of Delegates 9 am-10:15 am CE program (1.25 hr) 10:30-11:45 am CE program (1.25 hr) 10:30-noon Pharmacy Transitions Program (Not-CE) 12 noon KPhA Awards Luncheon 1:30-4 pm Finance 101 for Pharmacy (2.5 hr) 1:30 -2:30 pm CE program (1 hr) 2:45-3:45 pm CE program (1 hr) 4-5:30 pm OTC Self-Care Championship (1.5 hr) 4-5:30 pm Clinical CE program (1.5 hr) 5:30-7:30 pm Opening of Hall of Exhibits 8 pm Student/New Practitioner event 8 pm – 9 pm Dessert reception/CE program (1 hr.)
Saturday, June 8, 2013 (5 CE) 7:30 am Continental Breakfast 7:30 am Reference Committee 8 am-10 am New Drugs CE Program (2 hr.) 8 am -9 am CE Program (1 hr.) 9 am-10 am Preceptor CE Program (1 hr.) 10 am to noon Hall of Exhibits Open 12 noon Lunch (UK Preceptor Recognition) 1:30-2:30 pm Law Update CE Program (1 hr) 2:45-3:45 pm Creating a Career Ladder for Pharmacy Technicians (1 hr) 2:45-3:45 pm MTM CE Program (1 hr) 3:15 pm-5pm House of Delegates Closing Session 4-5 pm CE Program (1hr) 6 pm President’s Reception 7 pm Ray Wirth Banquet Sunday, June 9, 2013 (2 CE) 7:30 am Continental Breakfast 8 am to 10 am Handling Skin/Eye/Ear Complaints in the Community Pharmacy CE(2 hr)
Preconference events on June 6 include:
Immunization Training (5 hour CE credit) CPR Recertification KPERF Golf Scramble
Continuing Education Topics:
New Drugs
Skin/Eye/Ear Complaints in Community Pharmacy
Technician Track
Register now at
including Creating a Career Ladder, New Drugs Update, Law Update
www.kphanet.org The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy Education as a provider of continuing Pharmacy education.
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OTC Self-Care Championship
Finance 101 for Pharmacy
Law Update
Preceptor Training Program
And more clinical topics to come! THE KENTUCKY PHARMACIST
From Your Executive Director
March 2013
MESSAGE FROM YOUR
EXECUTIVE DIRECTOR Robert “Bob” McFalls It is known as the “Short Session” in Frankfort—the legislative session in odd-numbered years where no budget is discussed. It lasts 30 days, which in legislative speak I have learned means 30 days strategically calendared across a span of three months with adjournment no later than March 30.
tablishes parameters for price appeals by pharmacies. The bill was amended in the Senate to delay the requirement that PBMs provide retroactive reimbursement for successful MAC appeals. The new language requires the PBM to include in their contracts with pharmacies a process for retroactive reimbursement no later than one year following the effective date of the act. Hopefully, by the time you Working with you, our members and partners, YOUR KPhA read this, the bill will be signed into law by Governor has been very active during the 2013 Regular Legislative Beshear. Session. As everyone certainly knows by now, KPhA’s top legislative priority was SB 107 — developed through the While SB 107 took most of our focus this legislative seswork of the KPhA Governmental Affairs Committee and sion, YOUR KPhA also tracked several other bills. HB 1 as subsequently approved by the House of Delegates. While passed in 2012 was amended in 2013 by HB 217 with KPhA staff was busy at work in generating Grassroots strong bi-partisan support by leaders in both chambers and Alerts, YOU were busy making telephone calls with your the Governor’s office. As another of our top legislative priSenator and Representative. Thirty days seems like a long orities, YOUR KPhA worked on two key provisions within time until it is time to move a bill through all of the steps of HB 217 with respect to their impact on pharmacies. One the legislative process. We had to secure a sponsor, work was to repeal the requirement that Schedule II and Schedthrough the committee process in each chamber and get ule III drugs administered directly to the patient be reported the bill to a vote in both the Senate and the House. First to the state’s electronic prescription drug tracking system came the 37-0 vote in the Senate, which was followed sev- (KASPER). Legislators heard KPhA-led testimony during eral days later by the 96-0 House vote. On the day of the the interim that this provision is unnecessary and would SB 107 vote in the House, only 47 bills had passed both cause significant problems for hospital pharmacies and chambers. KPhA gratefully acknowledges Senator Julie pharmacies serving long term care facilities. Another proviDenton’s leadership and sponsorship, along with the critision of HB 217 deletes the requirement that pharmacies cal support of Senate President Robert Stivers, Reprereport the loss or theft of controlled substances to the state sentative Tommy Thompson, Representative Jeff Greer police. Pharmacies are already required to file reports with and SB 107 Senate co-sponsors, Senator Walter Blevins, local law enforcement agencies, the Board of Pharmacy Senator Denise Harper Angel, Senator Jimmy Higdon, and the DEA. HB 217 enacted a number of other practical Senator Jerry Rhoads and Senator Johnny Ray Turner. At improvements by cleaning up unintended consequences of the same time, we appreciate all 133 Senators and Repre- the original bill. KPhA attended the bill signing ceremony sentatives who voted in favor of the bill with not one diswith Governor Beshear on March 5. senting vote in either chamber. On a related note, KPhA has worked diligently with the SB 107 establishes a set of basic disclosures that PBMs Board of Pharmacy, APSC and KRF to obtain clarification must make in their dealings with contracted pharmacies. It on the fitting of therapeutic shoes. Following a series of requires that a PBM disclose in its contract with the pharmeetings and consultations, the Board of Pharmacy has macy the pricing indices used to calculate the reimburseissued a letter of clarification on this issue in consultation ment paid to the pharmacy for drug products. It also speci- with the Board of Prosthetics, Orthotics and Pedorthics fies that, if the PBM uses maximum allowable cost (MAC) (See Page 10-11 for more information.) KPhA would like to to determine reimbursement, the PBM must disclose to the acknowledge and to thank the two boards for their work on pharmacy what products are subject to MAC and what the MAC is for each of those drugs. SB 107 also requires PBMs to update MAC lists at least every 14 days and es-
Continued on Page 43
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THE KENTUCKY PHARMACIST
135th KPhA Annual Meeting
March 2013
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THE KENTUCKY PHARMACIST
Kentucky at APhA Annual Meeting 2013
March 2013
Kentucky at APhA
KPhA congratulates Brian Fingerson on his election as an APhA-APPM Fellow at the 2013 APhA Annual Meeting in Los Angeles.
President Kim Croley congratulates KPhA’s first female President, Dr. Virginia “Ginger” Scott, who was elected as an APhA Fellow by APhA-APRS in 2013.
Kentucky Delegates Croley, Joe Carr and Greg Baker attend the opening session of the House of Delegates.
REGISTER ONLINE AT WWW.KPHANET.ORG! For more information, contact Scott Sisco at ssisco@kphanet.org. 8
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2013-14 KPhA Board Election
March 2013
The 2013 KPhA Board of Directors Election will be held online at www.kphanet.org. You will need to log in to the site to cast your vote. Paper ballots will be available, but ONLY upon request. Call the KPhA Office at 502-227-2303 for more information.
KPhA Board of Directors Nominations for 2013-14 Serve YOUR profession by serving on YOUR KPhA Board of Directors! The Kentucky Pharmacists Board of Directors is accepting nominations for the following positions to serve on the KPhA Board for the 2013-14 year: President-Elect
Treasurer
Director (3 open spots)
Nominations: Nominations may be submitted electronically to Scott Sisco at ssisco@kphanet.org or mailed to KPhA, Attn: Scott Sisco 1228 US 127 South, Frankfort, KY 40601 no later than March 31, 2013. For descriptions and nomination form, see www.kphanet.org, click on About, Board of Directors.
2013 KPhA Professional Awards The Kentucky Pharmacists Association annually recognizes individuals from across the Commonwealth that exhibit exceptional service to patients and their community, continuously promote the profession of pharmacy, and demonstrate innovative pharmacy practice. The KPhA Organizational Affairs Committee is accepting nominations for the professional awards below: Bowl of Hygeia
Distinguished Service Award
Pharmacist of the Year
Professional Promotion Award
Young Pharmacist of the Year
Excellence in Innovation Award
Technician of the Year
Cardinal Health Generation Rx Champions Award
To nominate an individual, please submit a letter of nomination including the award information and the nominee’s accomplishments with regard to the award criteria. Multiple letters of support are accepted and highly encouraged. Individuals and recognized pharmacy organizations in Kentucky are encouraged to submit nominations. Individual nominators need not be a member of the Association; however, pharmacist and technician nominees must be a member of KPhA. See www.kphanet.org, click on About, Professional Awards for past winners and criteria. Nominations: Nominations may be submitted electronically to Scott Sisco at ssisco@kphanet.org or mailed to KPhA, Attn: Scott Sisco 1228 US 127 South, Frankfort, KY 40601 no later than March 31, 2013. The KPhA President, President-Elect, and the Chairman of the Board, participating in any voting for awards shall not be eligible for nomination or selection for any award. Conferral of any of the awards of the Association shall be at the discretion of the Organizational Affairs Committee and is not mandatory on an annual basis.
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Kentucky Board of Pharmacy Update
March 2013
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Kentucky Board of Pharmacy Update
March 2013
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March 2013 CE—Preventative Treatment of Pertussis
March 2013
“Don’t Let Pertussis “WHOOP UP” (on) Your Patients” - Preventative Treatment of Pertussis KPERF offers all There are no financial relationships that could be perceived as real or apparent conflicts of interest. By: Leah Ryan, PharmD Candidate, Tram Thai, PharmD Candidate, Daniel Nguyen, PharmD Candidate, Holly L. Byrnes, PharmD, BCPS, Sullivan University College of Pharmacy, Louisville, KY
CE articles to members online at www.kphanet.org
Universal Activity # 0143-0000-13-003-H04-P&T 1 Contact Hour (0.1 CEU) Goal of the Program: Discuss the recent outbreak of pertussis and review preventative treatment options. Objectives At the conclusion of this program, the reader should be able to: 1. Identify the clinical symptoms and possible treatment options for pertussis. 2. Identify at-risk populations for acquiring pertussis. 3. Compare and contrast the DTaP and Tdap vaccinations. 4. Identify patient populations that should receive a Tdap booster versus Td booster. 5. Recognize the impact pharmacists can have to reduce pertussis infections. Pertussis, more commonly known as whooping cough, is a highly contagious infection in the respiratory tract.1 Pertussis is extremely important due to the recent outbreaks and deaths throughout the United States. The Centers for Disease Control and Prevention (CDC) have reported an increase in the number of outbreaks in 49 states and Washington, D.C. as of Nov. 21, 2012, compared to this same time period last year. This increase in pertussis displays the importance of early vaccination and what we can do as pharmacists to help control this outbreak. According to recent statistics, more than 41,000 cases of pertussis have been reported to the CDC throughout 2012, including 18 pertussis-related deaths.2 It is imperative that pertussis is better controlled in the United States to minimize these outbreaks and pertussis-related morbidity/mortality. This infection is not only a public health concern for our nation, but it is specifically important for our area because Kentucky is among one of the many states in which the incidence of pertussis is higher than the national average. According to Kentucky law, urgent notification of a pertussis occurrence must be reported to a health facility licensed under KRS Chapter 216B within 24 hours.3 Weekend or urgent evening notifications require health professionals to report via electronic submission or telephone, stating only the name of the disease being reported and a call-back number.3
An important strategy that pharmacists can utilize to help control the incidence of pertussis is educating caregivers and ensuring infants are properly vaccinated, as most deaths occur in infants younger than 3 months of age. Other vulnerable age groups include children 7 to 10 years of age, as well as adolescents 13 and 14 years of age.2 By reviewing the etiology and preventative measures available, pharmacists should be well equipped to educate and vaccinate patients across Kentucky against this preventable disease. What is Pertussis? Pertussis is caused by the bacterium Bordetella pertussis. Pertussis also is commonly known, as the whooping cough because someone infected often needs to take deep breaths, resulting in the characteristic “whooping” sound. Infants and young children are most commonly affected by pertussis, which can be fatal.4 Pertussis mainly affects infants younger than 6 months of age due to their incomplete immunizations and children aged 11 to 18 because of their fading immunity. Infected individuals most commonly spread pertussis by coughing or sneezing while in close contact with others, who then inhale the bacteria.4 Caregivers of infants may not even realize that they are infected since symptoms of per12
THE KENTUCKY PHARMACIST
March 2013 CE—Preventative Treatment of Pertussis tussis normally do not develop until seven to 10 days after exposure and may sometimes last as long as six weeks. This is important because an infected individual may spread the disease without knowing it.
March 2013
in contact with infants younger than 12 months of age and pregnant women lacking previous Tdap administration. 8 Capitalized letters in the vaccination denote full-strength doses in the formulation and lower-case letters denote reduced doses in the formulation. The “a” refers to “acellular” pertussis which means the vaccine only contains a portion of the pertussis organism and the letters “T” and “D” represent protection against tetanus and diphtheria, respectively. Tetanus, often referred to as “lockjaw”, can cause the muscles in the head and neck to tighten and restrict opening of the mouth and prevent swallowing. It also can cause stiffness and painful muscle spasms all over the body. Tetanus can enter the body through cuts, scratches or wounds and is fatal in approximately one out of five infected individuals.9 Diphtheria infection can cause breathing difficulty, paralysis, heart failure and sometimes death by covering the back of the throat with a thick membrane. Similar to pertussis, diphtheria is spread person to person.
Pertussis may be difficult to identify because the early symptoms are very similar to those of a common cold. The progression of pertussis is divided into three stages: 5 Stage 1 (Catarrhal Stage) - Symptoms runny nose, sneezing, mild cough, low-grade fever, and apnea (infants). Patient is highly contagious. May last one to two weeks. Stage 2 (Paroxysmal Stage) – Symptoms: fits of numerous, rapid coughs followed by “whoop” sound, vomiting and exhaustion after coughing fits. Last from one to six weeks, may extend to 10 weeks. Stage 3 (Convalescent Stage) – Gradual recovery with a lessening of cough. Lasts about two to three weeks. Patients are contagious from the beginning of the catarrhal stage through the third week after the onset of paroxysmal stage or until five days after the start of effective antibiotic treatment. Since the symptoms of the early stages of pertussis appear to be just a common cold, the diagnosis of pertussis normally does not occur until more severe symptoms appear. If a patient is suspected of having pertussis, it is important to seek out medical care in order for a proper diagnosis.5 In addition to a physical examination, a nasopharyngeal specimen for isolation of Bordetella pertussis and a blood test are utilized to help identify the disease.
DTaP = full strength of diphtheria (D) and tetanus (T) toxoids and pertussis (P) vaccine
Tdap = full strength of Tetanus (T), reduced doses of diphtheria (D) and pertussis (p) vaccine
DT and Td do not protect against pertussis and therefore DTaP and Tdap are recommended for initial doses and booster, respectively
Immunizations are the best way to protect against pertussis. Even adults who are fully immunized still can contract pertussis, as the vaccine wanes over time. In a recent study, the overall effectiveness of DTaP was measured at 88.7 percent.10 For children who received their fifth DTaP dose within the past year, the vaccine effectiveness was Treatment of pertussis normally includes the use of antibi98.1 percent.10 For children who were five or more years otics and it is important for early treatment to help reduce past their last DTaP dose, the long-term effectiveness had the chance of spreading the disease.6 Antibiotic use in the fallen to 71.2 percent.10 This study also showed children early stages may help lessen the symptoms; however, if who never received doses of DTaP have at least eight there is a late diagnosis, antibiotics will not help reduce the times higher likelihood of developing whooping cough comcourse of illness. Macrolides such as azithromycin, clarpared to those children who received all five doses.10 ithromycin and erythromycin are the agents of choice for Table 1 compares the difference between DTaP and Tdap persons aged ≥ 1 month when antibiotics are used. 7 Azithromycin is the preferred agent for infants < 1 month of immunizations and includes the recommended dosing schedule for each. If a child’s vaccinations have been deage. Trimethoprim-sulfamethoxazole is an alternative layed, refer to Table 2 for the recommended catch-up agent that can be used for persons aged ≥ 2 months of schedule. It is not necessary to initiate a new DTaP series age. during catch up vaccinations. Table 3 provides a list of all Prevention of Pertussis the FDA approved DTaP and Tdap vaccinations, including For the prevention of pertussis, there are two different for- trade names and indications. mulations that can be used: DTaP and Tdap. DTap is the Special Populations Recommended to Receive Tdap childhood vaccine used in infants and children, while Tdap Booster is the pertussis booster vaccine used in adolescents and adults. Tdap is highly recommended, instead of the previIn most cases, all adults age 19 years and older should ous recommended Td, for adolescents and teens that are receive a booster dose every 10 years with Td vaccination; 13
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March 2013 CE—Preventative Treatment of Pertussis however, there are special populations that exist in which a booster dose with Tdap is more beneficial because of its added protection against pertussis.24 Because infants are too young to be fully vaccinated and have the highest mortality rates from pertussis, it is crucial adolescents and adults who have or anticipate coming into close contact with an infant younger than 12 months of age receive a single dose of Tdap at least two weeks before to protect the baby against an infection, if they have not already been vaccinated.8,24 This includes parents, siblings, grandparents and child care providers like daycare workers, babysitters and nannies. People that have direct patient contact in hospitals and clinics also should receive a dose of Tdap to prevent pertussis and decrease transmission to others. For adults under 65 years of age who have never received Tdap, Tdap is recommended as their next booster dose. Adults age 65 and older may receive one booster dose of Tdap as well. Women who are pregnant or planning to become pregnant should receive one dose of Tdap regardless of the number of years since prior Td or Tdap vaccination.25 It is recommended for pregnant women to receive Tdap during 27 to 36 weeks’ gestation for each pregnancy, to
March 2013
extend the amount of protection that is passed to the newborn. What Can Pharmacists Do to Minimize the Pertussis Outbreak? Pharmacists are in a unique position to raise awareness about the importance of vaccinations against pertussis. Higginbotham et al. reported the considerable impact pharmacists can have on immunization rates, showing a statistically significant increase of influenza and Tdap vaccinations to underserved populations when compared to other health care providers who provided the same awareness.26 Pharmacists are more easily accessible than physicians and are exceptionally trusted providers in the community to help increase immunization rates. Additionally, if a patient presents to the pharmacy with a prescription for pertussis treatment, education regarding infection control may be warranted at that time as well. Through advocacy, education and administration of vaccine through prescriberapproved protocols, pharmacists are well suited to reduce the incidence of pertussis.
Table 1: DTaP and Tdap Comparison Chart(11-16) Formulation Age Recommendations
DTaP 6 weeks through 6 years
Minimum Age for Dose 1
6 weeks
Number of Doses
5 doses
Recommended Dosing Schedule Adverse Effects
2, 4, 6, 15-18 months, and 4-6 years Common: Fussiness, tiredness, poor appetite and vomiting Fever and redness, swelling or tenderness more common after fourth and fifth dose of series Very Rare: long-term seizure, coma and permanent brain damage
Comments
Serious allergic reactions (1 out of 1 million) Do not give to children ≥ 7 years 14
Tdap 7-10 years not fully immunized ≥ 11 years Children 7 years of age not fully immunized with DTaP series 1 dose only; then booster with Td every 10 years 11-12 years for first dose Common: Pain, redness or swelling at injection site, mild fever, headache, tiredness, nausea, vomiting, diarrhea, stomach ache Very Rare: Swelling, severe pain, bleeding and redness at injection site Serious allergic reactions (1 out of 1 million)
Tdap can be administered regardless of when the last Td dose was given THE KENTUCKY PHARMACIST
March 2013 CE—Preventative Treatment of Pertussis
March 2013
Table2: Catch Up Schedule17 Age 4 months through 6 years Minimum Interval Between Doses Dose 1 to Dose 2 Dose 2 to Dose 3 Dose 3 to Dose 4 4 weeks 8 weeks 6 months
Vaccine DTaP
Td/Tdap
+
4 weeks
Age 7 years through 18 years 4 weeks 6 months if Dose 1 was given <12 months of age
Dose 4 to Dose 5 6 months*
*not necessary
if Dose 1 was given <12 months of age
6 months if Dose 1 was given ≥12 months of age
*Dose 5 not necessary if Dose 4 was given at age ≥ 4 years +Unvaccinated or behind schedule children age 7 years and teens should complete a primary Td +Tdap is preferably to be given as Dose 1 or can be substituted as a 1-time for any dose in the series
Table 3: FDA approved DTaP and Tdap vaccinations18-23 Vaccine DTaP
Trade Name Daptacel®
Type Inactivated Bacterial
Route Comments IM Approved as five dose series in ages 6 weeks through 6 years of age (prior to 7th birthday)
DTaP
Infanrix®
Inactivated Bacterial
IM
Approved as five dose series in ages 6 weeks through 6 years of age (prior to 7th birthday)
DTaP-IPV
Kinrix®
Inactivated Bacterial & Viral
IM
Approved as the 5th dose of the vaccine series
DTaP-HepB-IPV
Pediarix®
IM
Approved for Dose 1-3 of the vaccine series at age 2, 4, and 6 months
DTaP-IPV/Hib
Pentacel®
IM
Tdap*
Boostrix®
IM
Approved for Dose 1-4 of vaccine series from age 6 weeks through 4 years (prior to 5th birthday) Approved for use in ages ≥10 years
Tdap*
Adacel®
Inactivated Bacterial & Viral Inactivated Bacterial & Viral Inactivated Bacterial Inactivated Bacterial
IM
Approved for use in ages 11-64 years
*May still be used in persons 7 to 9 years of age that missed any one of the DTaP dose series IPV= Inactivated poliovirus, Hep B=Hepatitis B, Hib=Haemophilus Influenzae Type b
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March 2013 CE—Preventative Treatment of Pertussis Conclusion The best way pharmacists can prevent a further outbreak of pertussis in the United States is to actively educate patients and surrounding community. Reviewing the various formulations and booster indications is vital to identifying appropriate prevention for at risk populations. Encourage children and adults to get vaccinated against pertussis to reduce the amount of outbreaks each year and advise adults who are planning to come into close contact with an infant to get vaccinated with Tdap at least two weeks before, particularly due to the lack of fully immunized infants. It also is important to inform patients that the risk of developing pertussis is far more risky than the side effects of the vaccine. Common minor side effects such as redness, swelling or tenderness at the injection site usually resolve after a couple of days and severe problems are very rare. Since pertussis is difficult to identify and the symptoms of pertussis closely resemble symptoms of other infections, prevention is the most effective method to combat the spread of this preventable tragedy.
March 2013
8. Pertussis: Vaccination (1/29/2012). Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/pertussis/vaccines.html. Accesses Dec. 10, 2012. 9. Vaccines and Immunization: Possible Side Effects from Vaccines (8/29, 2012). Centers for Disease Control and Prevention Web site. Available at: http:// www.cdc.gov/vaccines/vac-gen/side-effects.htm#dtap. Accessed on Nov. 24, 2012. 10. Childhood Whooping Cough Vaccine Protects Most Children For At Least 5 years (n.d.). 11. Available at: http://www.cdc.gov/media/ matte/2011/10_whooping_cough.pdf. Accessed on Nov. 24. 2012. 12. Vaccine Information Statement: Td & Tdap Vaccines (1/24/2012). Centers for Disease Control Web site. Available at http://www.cdc.gov/vaccines/pubs/vis/ downloads/vis-td-tdap.pdf. Accessed on Nov. 24, 2012.
1. Whooping cough (2/21/2012). Mayo Clinic Web site. Available at: http://www.mayoclinic.com/health/ whooping-cough/DS00445. Accessed Jan. 21, 2013.
13. Vaccine Information Statement: Diptheria, Pertussis, and Tetanus Vaccines (5/17/2007). Centers for Disease Control Web site. Available at http:// www.cdc.gov/vaccines/pubs/vis/downloads/visdtap.pdf. Accessed on Nov. 24, 2012.
2. Pertussis: Outbreaks Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/ p.ertussis/outbreaks.html. Accessed Jan. 21, 2013.
14. Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 018 years-United States, 2012. MMWR. 2012;61(5).
3. 902 KAR 2:020-Disease Surveillance. Kentucky Board of Pharmacy. Available at: http://www.lrc.state.ky.us/ kar/902/002/020.htm. Accessed Jan. 31, 2013.
15. Centers for Disease Control and Prevention. Recommended adult immunization schedule-United States, 2012. MMWR. 2012;61(4).
4. Pertussis: Causes and Transmission (5/7/2012). Centers for Disease Control and Prevention. Available at: Web site http://www.cdc.gov/pertussis/about/causestransmission.html. Accessed Dec. 13, 2012.
16. Committee on Infectious Diseases. Policy Statement Recommended Childhood and Adolescent Immunization Schedules - United States, 2012. Pediatrics. 2012 Feb;129 (2): 385-386.
References
5. Pertussis: Signs and Symptoms (5/7/2012). Centers for 17. Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United Disease Control and Prevention. Available at: Web site States, 2012. Ann Intern Med. 2012;156(3):211-217. http://www.cdc.gov/pertussis/about/signssymptoms.html. Accessed Dec. 13, 2012. 18. Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are 6. Pertussis: Treatment (4/9/2012). Centers for Disease more than 1 month behind —United States (2013). Control and Prevention Web site. Available at: http:// Centers for Disease Control Web site. Available at: www.cdc.gov/pertussis/clinical/treatment.html. Achttp://www.cdc.gov/vaccines/schedules/downloads/ cessed Dec. 13, 2012. child/catchup-schedule-bw.pdf. Accessed on Feb. 2, 7. Recommended Antimicrobial Agents for the Treatment 2013. and Postexposure Prophylaxis of Pertussis. Centers for Disease Control and Prevention Web site. Available 19. Daptacel® [package insert]. Swiftwater, PA: Sanofi Pasteur; 2012 July. at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5414a1.htm#tab4. Accessed Jan. 27, 2013. 20. Infanrix® [package insert]. Research Triangle Park, 16
THE KENTUCKY PHARMACIST
March 2013 CE—Preventative Treatment of Pertussis NC: GlaxoSmithKline; 2012 March.
March 2013 Vaccines (12/19/2012). Available at: http:// www.cdc.gov/vaccines/vpd-vac/combo-vaccines/dtaptd-dt/tdap.htm. Accessed Jan. 23, 2012.
21. Kinrix® [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2012 March.
26. CDC. Advisory Committee on Immunization Practices (ACIP) recommended immunization schedules for persons aged 0 through 18 years and adults aged 19 years and older-United States, 2013. February 1, 2013. Available at: http://www.cdc.gov/mmwr/pdf/other/ su6201.pdf. Accessed Feb. 27, 2013.
22. Pediarix® [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2012 March. 23. Boostrix® [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2012 March. 24. Adacel® [package insert]. Swiftwater, PA: Sanofi Pasteur; 2012 February.
27. Higginbotham S, Stewart A, Pfalzgra A. Impact of a pharmacist immunizer on adult immunization rates. J Am Pharm Assoc. 2012;52:367-71.
25. Vaccines and Preventable Diseases:Combined Tdap Vaccine: Tetanus, Diphtheria and Pertussis (Tdap)
March 2013 — “Don’t Let Pertussis “WHOOP UP” (on) Your Patients” - Preventative Treatment of Pertussis 1. JG is a 45 year old male who recently started antibiotic treatment for suspected pertussis. After which point is JG no longer contagious? A. The first dose of antibiotic B. Five days of treatment C. Resolution of symptoms D. Three weeks post treatment
6. What is the recommended dosing schedule for the 5-dose series of DTaP? A. At birth, 2, 4, 15 to 18 months, and 4 to 6 years B. 6 weeks, 4, 6, 15 to 18 months, and 4 to 6 years C. 2, 4, 6, 15 to18 months, and 4 to 6 years D. 2, 4, 6, 15 to 18 months, and ≥7 years 7. Which vaccination(s) is/are FDA approved as the complete 5-dose series of DTaP? A. Daptacel® B. Infanrix® C. Pediarix® D. A and B
2. In which stage of pertussis is a patient considered most contagious? A. Stage 1 B. Stage 2 C. Stage 3 D. All stages are equally contagious
8. Which special population is recommended to receive a single booster dose of Tdap instead of Td if they have not already received a vaccination? A. Daycare workers B. Health care workers C. Sibling of an infant less than 12 months of age D. All of the above individuals should receive Tdap
3. During which stage of pertussis would the characteristic “whoop” sound occur? A. Stage 1 B. Stage 2 C. Stage 3 D. May start in any stage 4. Why does pertussis mainly affect infants younger than 6 months of age? A. Caregivers do not know they have it and transmit it to the infant B. Infants are not as sanitary and therefore are more prone to infections C. Immune system is not fully vaccinated and more prone to infection D. Immune system is still developing and more susceptible to infection
9. When coming into contact with an infant less than 12 months of age, a Tdap booster should be administered at least _____________ before contact. A. 1 week B. 2 weeks C. 3 weeks D. 4 weeks
10. NT is a 25 year old female who just found out she was pregnant. She received a Td booster five years ago. When should she receive a Tdap booster? 5. What is the antibiotic of choice for pertussis treatment in an A. In five years due to her tetanus booster five years ago infant less than 1 month of age? B. During her first trimester or as soon as possible A. Trimethoprim/Sulfamethoxazole C. Anytime between 27 to 36 weeks’ gestation B. Azithromycin D. Immediately in the postpartum period C. Cefdinir D. Amoxicillin/Clavulanate Potassium
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THE KENTUCKY PHARMACIST
March 2013 CE—Preventative Treatment of Pertussis
March 2013
This activity is a FREE service to members of the Kentucky Pharmacists Association. The fee for non-members is $30. Mail completed forms to: KPERF, 1228 US 127 South, Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile. Expiration Date: March 20, 2016 Successful Completion: Score of 80% will result in 1.0 contact hours or 0.1 CEUs. Participants who score less than 80% will be notified and permitted one re-examination. TECHNICIANS ANSWER SHEET. March 2013 — “Don’t Let Pertussis “WHOOP UP” (on) Your Patients” - Preventative Treatment of Pertussis Universal Activity # 0143-0000-13-003-H04-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 2. A B C D
3. A B C D 4. A B C D
5. A B C D 6. A B C D
7. A B C D 8. A B C D
9. A B C D 10. A B C D
Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________
NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) PHARMACISTS ANSWER SHEET March 2013 — “Don’t Let Pertussis “WHOOP UP” (on) Your Patients” - Preventative Treatment of Pertussis Universal Activity # 0143-0000-13-003-H04-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 2. A B C D
3. A B C D 4. A B C D
5. A B C D 6. A B C D
7. A B C D 8. A B C D
9. A B C D 10. A B C D
Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________
NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy Education as a provider of continuing Pharmacy education.
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Quizzes submitted without NABP eProfile ID # and Birthdate cannot be accepted.
THE KENTUCKY PHARMACIST
Senior Care Corner
March 2013
Senior Care Corner from the KPhA Academy of Consultant Pharmacists The KPhA Academy of Consultant Pharmacists and the Kentucky Chapter of ASCP have planned an excellent continuing education program to be held on April 20, 2013. Please see the agenda below for details on the program topics. Registration forms will be available soon but please mark your calendars and plan to attend.
Kentucky Long Term Care Pharmacy Spring CE Program and Exhibition Co-hosted by Kentucky Chapter of American Society of Consultant Pharmacists Kentucky Pharmacists Association – Academy of Consultant Pharmacy
Saturday, April 20, 2013
8:30 am – 3:00 pm (registration begins at 8)
At Sullivan University College of Pharmacy, 2100 Gardiner Lane, Louisville, KY 40205
Agenda 8:00 am - all day – Registration / Check-in (Ground Floor Entrance on 2nd Floor) 8:00 am – 8:30 am – Registration (2nd Floor)/ Continental Breakfast (3rd Floor) 8:30 am – 9:30 am – Law/Regulatory Update (Leah Tolliver, Pharm.D.) (3rd Floor – Auditorium B) ACPE 1.0 CEU-Pending Approval 9:30 am - 9:35 am – Announcements 9:35 am - 10:30 am – Exhibitors and snacks (2nd Floor Main Hallway) Novartis Novo Nordisk Abbott HealthPoint Mylan Specialty Tolliver Management Group 10:30 am - 11:30 am – Geriatric Pharmacotherapy Principles (3rd Floor – Auditorium B) (Noll Campbell, Pharm.D) ACPE 1.0 CEU-Pending approval 11:30 am - 12:25 pm – Lunch (Sponsored by PCA Pharmacy) (1st floor café) 12:25 pm – 1:25 pm - Anticholinergic Medications and Risk of Cognitive Impairment and Delirium (Demetra Antimisiaris, Pharm.D.) (3rd Floor – Auditorium B) ACPE 1.0 CEU-Pending approval 1:25 pm - 1:30 pm – Break (Please visit the organizational tables in the 3rd Floor Hallway) 1:30 pm–2:30 pm – The Affordable Care Act & Accountable Care Organizations: The changing face of pharmacy (BC Childress, PharmD; Sean Jeffery, PharmD; Bonnie Lazor, M.D.) (3rd Floor – Auditorium B) ACPE 1.0 CEU- Pending approval 2:30 pm – 2:50 pm – ASCP Initiatives (Sean Jeffery, Pharm.D) (3rd Floor – Auditorium B) 2:50 pm – 3:00 pm – Announcements (3rd Floor – Auditorium B) 3:00 pm – 3:00 pm – Optional Activity: Thunder Over Louisville (offsite) no CE. In conjunction with the KPhA Young Practitioners Committee. The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy Education as a provider of continuing Pharmacy education.
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THE KENTUCKY PHARMACIST
New and Returning KPhA Members
March 2013
KPhA Welcomes New and Renewing Members January â&#x20AC;&#x201C;February 2013 Valerie Akers Prestonsburg, KY
Mark A Capps Burkesville, KY
Paul Elmes Louisville, KY
Deborah A Harden Campbellsville, KY
Crystal D Akridge Shepherdsville, KY
Shelia Ann Carrico Lawrenceburg, KY
Kay Collins Embrey Brandenburg, KY
David Harris Mayfield, KY
Matthew Andrews Fisherville, KY
Wayne Keith Carter Russell, KY
Nikita M Evans South Shore, KY
Greg Hayse Shelbyville, KY
Doug Antle Louisville, KY
Alan D Cash Albany, KY
Edward J Feeney Louisville, KY
Dale Heise Harrodsburg, KY
Glenn Timothy Armstrong Mount Washington, KY
Timothy P Castagno Louisville, KY
Brooke Feltner London, KY
Linette Hieneman Flatwoods, KY
Lisa K Babb Guston, KY
Brian Cheek Louisville, KY
Dana Fuller Lexington, KY
Kristina Hinkle Heidrick, KY
Heidi Bainer Pedro, OH
Jane Cheek Louisville, KY
John Martin Fuller Versailles, KY
Susan Hogsten Flatwoods, KY
Garry J Baker Russell, KY
Carolyn Chou Louisville, KY
Lynn Z Fuller Versailles, KY
Barry W Horne Danville, KY
Cathy Barker Flatwoods, KY
Carrie Christofield Ft Mitchell, KY
Patty Gayheart Hindman, KY
Brooke Hudspeth Lexington, KY
Mary E Beimesch Hebron, KY
David M Conyer Paducah, KY
Lisa Goodlett Springfield, KY
Tawnya Hunt Greenup, KY
Danny Bentley Russell, KY
William A Conyers Glasgow, KY
Charles L Gore Russell Springs, KY
John Inabnitt Somerset, KY
Gregory F Blank Covington, KY
Karen Cornelius Middlesboro, KY
Lauren W Grant Louisville, KY
H Dale Johnson Corbin, KY
Nick Boggess Flatwoods, KY
Freddie Lee Cox Corbin, KY
Darrell T Greenwalt Livermore, KY
Rene Kendrick Taylorsville, KY
Charles Boggs Dandridge, TN
Terry Lee Coyle Campbellsville, KY
Scott A Greenwell Louisville, KY
Christopher Killmeier Louisville, KY
Michael P Borders Williamsburg, KY
Helen L Danser Tyner, KY
Michael Gruber Carrollton, KY
Kay Lloyd Louisville, KY
Clayton Bridgeman Flatwoods, KY
Joey Darling Wheelersburg, OH
Dale Gunkel Madisonville, KY
Morris Lloyd Louisville, KY
Amy Brown Greenup, KY
Amy Delcourt Greenup, KY
Carolyn Loy Hale Columbia, KY
Joseph Mashni Florence, KY
Clyde E Brown Mayfield, KY
Jane Dunbar-Suwalski Longmont, CO
Jessica Hall Flatwoods, KY
Tom Mattingly Olive Hill, KY
John W Bushong Tompkinsville, KY
Barry L. Eadens Paducah, KY
Kristin Hall Quincy, KY
Okey Mbadike Louisville, KY
Donell N Busroe Harlan, KY
Catherine Elmes Louisville, KY
Tina Hall Greenup, KY
Ronald Moreland Falmouth, KY
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THE KENTUCKY PHARMACIST
New and Returning KPhA Members
March 2013
Jerry B. Morris Louisville, KY
Timothy Quillen Greenup, KY
Barry Siegel Evansville, IN
Terry Vest Russell, KY
Shelley Nall Lexington, KY
James Rhodes Louisville, KY
Roberta Sloan Lexington, KY
Melissa Vice Dry Ridge, KY
Burnice Napier Hazard, KY
Jill Rhodes Louisville, KY
Richard Slone Lexington, KY
Joseph Wagner Louisville, KY
Patrick Noonan Louisville, KY
Patricia D Robinson Whitesburg, KY
Sheel Slone Lexington, KY
Kathy Wagner Louisville, KY
Karl Andrew Tucker O'Dell Flatwoods, KY
Helen E Rose Kevil, KY
Billy Smith Shepherdsville, KY
Nancy Walker Cynthiana, KY
Kathy O'Dell Ashland, KY
Scott Ross Hopkinsville, KY
R James Spencer Beaver Dam, KY
Jason Wallace Dry Ridge, KY
Tara Olash Louisville, KY
Jesse L Rudd Salyersville, KY
Cheryl Stevens Louisville, KY
Sara Wells Gilbertsville, KY
Peter Orzali Cold Spring, KY
Thomas Russell Independence, KY
David Bradley Stultz Flatwoods, KY
Sandy Wethington Liberty, KY
Beth Parks Coralville, IA
Larry Schaefer Madisonville, KY
Leslie Stultz Flatwoods, KY
Paul Williams Hardinsburg, KY
Duane Parsons Richmond, KY
Jim Scott Earlington, KY
Judy B Thompson Argillite, KY
Christine Windham London, KY
Jarred Patrick Russell, KY
Becky Sue Sergent Bowling Green, KY
Mykel Tidwell Mayfield, KY
Dan P Yeager Lexington, KY
George Patterson Gilbertsville, KY
Catherine l Shely Morehead, KY
Gisela Torres Louisville, KY
Jane B Yeager Lexington, KY
Richard Preece Ashland, KY
Harold Shields Ashland, KY
Elizabeth Traxel Maysville, KY
Artie L Young Brownsville, KY
Vicky Pulliam Bardstown, KY
Jennifer Shugars Liberty, KY
John Turpin Pineville, KY
Our goal is to raise $5,000 as a collective gift from members of the Kentucky Pharmacists Association. As of March 2013, we have collected $900. We’re The Bowl of Hygeia has a rich history within pharma- eager to show our state pride by either meeting or cy, and we need to step up and make sure this history exceeding this goal. Won’t you please help by making continues. a contribution?
Saving the Bowl of Hygeia
Given that this is an award presented at the state lev- There are two ways to give: el, the State Pharmacy Associations — including YOUR KPhA — along with NASPA, are working toOnline at: http://www.aphafoundation.org and gether to help make sure this award we hold so dearchoose the Bowl of Hygeia endowment button. ly is never at risk of being extinguished. In order to Kentucky will get credit by your address. sustain the award, each state association is working to build an endowment sufficient to generate diviOr, you can send your check to: dends that will fund the program in perpetuity. APhA Foundation – Bowl of Hygeia 2215 Constitution Ave., NW The APhA Foundation, a national nonprofit 501 (c) Washington, DC 20037-2985 (3), has agreed to be the home of the endowment account, and to date we are almost half way to our goal Thank you in advance for joining YOUR KPhA in this of $600,000. effort. 21
THE KENTUCKY PHARMACIST
Adventures in Compounding
March 2013
Adventures In Compounding: Through The Eyes Of A Pharmacy Student By: Emily G. Boone, PharmD Candidate 2013, University of Kentucky College of Pharmacy As the last summer break for the Class of 2013 drew to a close, I took advantage of one of the best-kept secrets in student compounding educational opportunities. On Aug. 11-12, 2011, I made the trip to Houston, Texas, to experience the Professional Compounding Centers of America (PCCA) Compounding Boot Camp. After learning about this student oriented crash course in compounding at the 2010 NCPA Annual Convention in Philadelphia, I decided this would be an excellent summer activity to enhance my preparation for entry into the increasingly competitive world of pharmacy practice.
Why Compounding? Progressive Patient Care As the evolution of pharmacy practice gives way to the future, the art and science of compounding medication remains a staple in the scope of practice for the modern pharmacist. The mortar and pestle has been a widely recognized symbol of pharmacy since the dawn of practice, and this is not likely to change any time soon.
provide a flexible, ever-changing menu of services to a variety of patients who do not fit the manufactured mold. From researching innovative formulations, to laboratory activities, to patient consultation and counseling, this specialty area of pharmacy practice promises a stimulating environment that will satisfy the pharmacists who desire the challenge of both clinical problem solving and direct patient care in their daily practice.1
Despite the vast number of manufactured drug products currently available, there remains a vast number of patient needs that simply cannot be met through this traditional market. Pharmacists have the unique ability to create drug products that are tailored to the individual patient, which Something for Everyone can dramatically improve the quality of care. The increasing Compounding practice provides no shortage of opportunity problem of drug shortages is also a significant challenge for the pharmacist who desires a career centered on a parthat can sometimes be overcome through compounding. ticular niche area of expertise. For example, 20 percent of the US population is under the age of 14. With only 1,000 of A Spoonful of Sugar 250,000 pharmacists in the United States specializing in Patient compliance is an ongoing battle that all healthcare pediatrics, and 99 percent of those specialists working in providers face in trying to implement effective treatments, hospitals, there lies a wealth of opportunity in the communias no medication is less effective than one the patient does ty setting for the development of services focused in this not take. Some of these obstacles can be overcome area.2 through consultation with a compounding pharmacist. These professionals are equipped to recommend and cre- Another specialty area of practice is veterinary compoundate a more pleasing dosage form for the sensitive palette of ing. There are millions of families in the United States that a very young patient, or perhaps a combination product that include at least one pet, and there is a great deal of value can reduce pill burden for an older patient being treated for placed on the health of these furry family members. Other patient sources can include animal shelters, breeders, zoos several chronic conditions. Other patients need a strength of drug that is simply not available commercially, or require and theme parks. With a wide range of needs introduced by ongoing therapy with a product that is on backorder. A com- such a diverse clientele, this specialty may appeal to pharmacists who enjoy creating the extraordinary measures that pounding pharmacist has the broad skill set necessary to 22
THE KENTUCKY PHARMACIST
Adventures in Compounding
March 2013
are sometimes needed for the patients the freedom to pay cash successful administration of for their medication, thus elimimedication to the animal kingnating the cost of the middleman dom. One clever pharmacist and the reliance on reimbursewas able to develop a delivery ments. Additionally, the use of system for giving eye drops to raw materials allows a coman angry gorilla without intropounding pharmacy to maintain ducing the risks of repeated a much less expensive inventory sedation – via a Super Soaker than the manufactured inventory 1 water gun. Chris Simmons, of a traditional retail pharmacy.1 RPh and Vice President of Summer Experience at Creative Development at PCCA Compounding Boot PCCA, jokingly referred to Camp compounding as the MacGyver of medicine thanks to unconventional methods such The Compounding Boot Camp at PCCA is an introductory as this.3 class that serves as a prerequisite for two other PharmD A newer area of practice that is appearing in pharmacies is student course offerings. The class consists of both classcalled cosmeceutical compounding. This field utilizes cos- room instruction and hands-on lab experience. metic bases such as skin cream or shampoo to deliver dermatologic medications to the aesthetically minded patient.1 As a licensed cosmetologist, I find this area particularly fascinating as an opportunity to fuse the beauty industry with the specialized treatment of skin conditions that create obstacles for so many patients.
A Profitable Opportunity
Prior to attending the Boot Camp, I was curious how they would manage to squeeze 11 unique dosage forms into the two eight hour sessions, but I had ample time to complete each and every lab. I felt like a celebrity compounder having the PCCA staff heat up my hot water bath prior to lab and doing my dishes for me after I was finished, but this assistance is what allowed the class to move seamlessly from one topic to the next.
Emerging Specialties in Compounding Practice
Once the passion has been ignited to Bio-Identical Hormone Some of the most interesting labs inpursue business ownership, the first Replacement Therapy cluded making Kahlua flavored lollithing any entrepreneur must ask himNutritionals pops, peppermint lip balm and my first or herself is, “Will this be profitable?” Thyroid & Adrenal Fatigue time working with a capsule machine. Compounding services offer the Veterinary After punching capsules by hand in pharmacy owner the most generous Pediatric the University of Kentucky pharmacy profit margin available in community Pain Management lab, I had a true appreciation for the pharmacy practice. A testament to Cosmeceuticals efficiency of the capsule machine. this success is Cheri Garvin, RPh, and owner of Leesburg Pharmacy in Advanced Student Opportunities with PCCA Virginia. While 49 percent of her pharmacy’s total sales After completing the Compounding Boot Camp, PharmD come from traditional manufactured prescriptions, an astonishing -0.2 percent of the net profit can be attributed students have the option of taking two more compounding courses with PCCA: the Advanced Compounding Training to this area. Compounding services demonstrate a sharp Program and the Veterinary Compounding Training Procontrast to this figure, with 20 percent of total pharmacy 4 gram. Both advanced courses consist of a 10 module sales and 21 percent of net profit credited to this area. online component followed by a two-day lab experience at Why such a difference? One reason is due to the modest the PCCA facility in Houston. reimbursements paid to community pharmacies by third party insurance providers for traditional prescriptions. Very Although PCCA has not yet been established as a rotation often these payments barely cover dispensing cost, leavsite for pharmacy students in Kentucky, the facility offers ing little room for profit for the pharmacy. Many compound- three unique APPE rotation opportunities, including an ed prescriptions are less expensive, as they are often Academia/Compounding (Non Patient Care) rotation, a made from bulk raw chemicals rather than from the more Pharmacy Management Rotation and a Drug Information costly manufactured products. This allows a number of Rotation. Students choosing to spend a rotation at PCCA 23
THE KENTUCKY PHARMACIST
Adventures in Compounding
March 2013
have the opportunity to develop skills in areas such as teaching, compounding pharmacy ownership and formulation development. Consultant pharmacists at PCCA field roughly 500 calls per day from member pharmacists seeking advice on compound formulation, offering students a wide range of creative challenges from which to learn. 1
working in a range of settings, from the operating room to a home office, and can be employed by anyone from a major insurance company to their very own conscience. With so many career paths to choose from and the uncertain climate of healthcare reform, compounding offers both new and seasoned pharmacists an avenue to continue a long-standing, profitable tradition in pharmacy practice. Even with so many changes on the horizon itâ&#x20AC;&#x2122;s difficult to envision a healthcare world where compounding skills are not in demand, as pharmacists in this field continue to thrive as they fulfill the needs of each individual patient in a way that no one else can.
A Link to the Past As new pharmacy graduates prepare to enter the workforce, they are presented with a professional landscape that is hard to match with regard to the wide variety of opportunities. Modern day pharmacists can be found
A Special Thanks to: 1. PCCA Staff. Compounding Pharmacy Practice. Lecture presented at: PCCA Compounding Boot Camp; August 2011; Houston, TX. 2. Wolsoncroft L. Pediatric Pharmacy Practice. Lecture presented at: NCPA Annual Convention; October 2011; Nashville, TN. 3. Simmons C. Innovations in Veterinary Compounding. Lecture presented at: NCPA Annual Convention; October 2011; Nashville, TN. 4. Garvin C. Innovations in Compounding Pharmacy. Lecture presented at: NCPA Annual Convention; October 2011; Nashville, TN.
KPPAC Contribution Name: _________________________________ Pharmacy: __________________________________________ Address: _________________________ City: ___________________ State: _________ Zip: ____________ Phone: ________________ Fax: __--_______________ E-Mail: ______________________________________ Contribution Amount: $_________ Check ____ (make checks payable to KPPAC)
Mail to: Kentucky Pharmacists Political Advocacy Council, 1228 US Highway 127 South, Frankfort, KY 40601
CONTRIBUTION LIMITS The primary, runoff primary and general elections are separate elections. The maximum contribution from a PAC to a candidate or slate of candidates is $1,000 per election. Individuals may contribute no more than $1,500 per year to all PACs in the aggregate. In-kind contributions are subject to the same limits as monetary contributions.
Cash Contributions: $50 per contributor, per election. Contributions by cashierâ&#x20AC;&#x2122;s check or money order are limited to $50 per election unless the instrument identifies the payor and payee. KRS 121.150(4) Anonymous Contributions: $50 per contributor, per election, maximum total of $1,000 per election. (This information is in accordance with KRS 121. 150)
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THE KENTUCKY PHARMACIST
Helping hands, big hearts
March 2013
Helping hands, big hearts By Lance Murphy, second-year PharmD candidate at Sullivan University College of Pharmacy At its core, volunteerism means embracing the desire and passion to give back to the community. A community, however, is not simply defined as the nearby geographic area. In colleges of pharmacy across the nation, local APhA– ASP Chapters are leaders in volunteering and patient care events. At the Sullivan University College of Pharmacy we define community as those sharing the same values and beliefs representing the best of our profession, our country and the idea of freedom. Showing our thanks Starting in August 2011, the chapter decided to do something extra to support the men and women fighting in the United States Armed Forces. We started the annual Support our Troops drive, where our APhA–ASP Chapter leaders conduct fundraisers and donation drives to make care packages, and buy telephone cards to send to troops overseas and to the families of military personnel. Various events held during the drives include hopper ball races, penny wars, material item collections and soliciting private donations from the school and community. Since 2011, we have raised more than $2,000 to purchase phone cards and collected a large number of items donated to the troops. On top of the items we sent, we also included a panoramic picture of our students holding letters spelling out “We Love Our Troops” with American flags in the care packages to add a personal touch.
Always do more Those of us involved in the Support our Troops drive, were proud to receive a letter last year from a commanding officer in Afghanistan thanking us and letting us know that the items were very much appreciated. Given this event’s success, we are seeking more involvement for our local community as well as other colleges of pharmacy and APhA–ASP Chapters. Some of the needed items outlined by troops include the following:
Phone cards
Visa or MasterCard gift cards
Personal hygiene items
CD/DVD/iPod
Books/magazines
Non-perishable snack foods (beef jerky, peanuts, candy, gum, mints)
If you are interested in starting your own local Support our Troops drive, e-mail our faculty advisor Stacy Rowe, PharmD, at srowe@sullivan.edu, our APhA–ASP Chapter Vice-President of Patient Care Amelia Wiechart at arsoen1803@my.sullivan.edu, or our APhA–ASP Chapter President Lance Murphy at lmurph8942@my.sullivan.edu.
Congressman Andy Barr visits Capital Pharmacy New Congressman Andy Barr visited Capital Pharmacy and Medical Equipment in February, thanks to a program with the UK College of Pharmacy. Pictured are: KPhA Executive Director Robert McFalls, KPhA Board Director Trish Freeman, UKCOP students Rachel Clark and David Roy, Barr, Capital Pharmacy co-owner and UKCOP professor Tera McIntosh, UKCOP students Jessica Stokes and Brent Simpkins, and Capital Pharmacy co-owner Aaron McIntosh.
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THE KENTUCKY PHARMACIST
April 2013 CE — Review of Herbals in Cancer Patients
March 2013
A Review of Herbals in Cancer Patients: Use This Not That? By: Lesley Hall Volz, PharmD, Jill Rhodes, PharmD, BCOP, Aimee Ruder Cloud, PharmD, BCOP University of Louisville Health Care There are no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-0000-13-004-H04-P&T 1.5 Contact Hour (0.15 CEUs)
KPERF offers all CE articles to members online at www.kphanet.org
Objectives: At the conclusion of this lesson, the reader should be able to: 1. Review recent literature regarding the use of complementary and alternative medicine (CAM) in cancer patients. 2. Identify reasons cancer patients utilize CAM. 3. Categorize common herbals used to treat pain, sleep disturbances, depression and menopausal symptoms. 4. Identify herbal-drug interactions amongst various herbals and anticancer agents. Background According to the National Center for Complementary and Alternative Medicine (NCCAM), complementary and alternative medicine (CAM) is defined as “a group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine.”1 In the past two decades, worldwide expenditure on CAM has dramatically increased depending on the geographical region.2 The expenditure for CAM in the United States is remarkable, totaling $33.9 billion in 2007. Based on a National Health Interview Survey, 75 percent of US adults have used some form of CAM.3 Since the advent of the World Wide Web and increased media exposure through television, radio and magazines, patients can readily access information regarding CAM. Cited sources of information include internet, media, support groups and family or friends.4-6 The most influential group, family and friends, is reported to be the source of information 49 percent of the time.5 The quality and accuracy of this readily retrievable information is questionable when obtained from non-validated sources. As patients take a more active role in their own healthcare, inaccurate information may lead patients to self-treat using ineffective and potentially dangerous remedies.2 Several studies have indicated that utilization of CAM amongst cancer patients is higher than the general public.2,4,7 The most common forms of CAM used by cancer patients are herbals, vitamins and minerals.2,5,8 While the majority of cancer patients seek CAM as an additional therapy modality, many of their perceptions about CAM are false. Consumers consider CAM safe and effective, though scientific evidence proving such is inconclusive. Following
the 1994 Dietary Supplements Health Education Act, manufacturers may freely distribute dietary supplements without proving their safety and efficacy. Consequently, consumers believe CAM is ‘natural’ and often consider the therapies innocent. As a result of relaxed regulations, the quality of products varies and may be contaminated with pollutants, microorganisms and metals.2 Microorganisms such as E.coli and Aspergillus are of particular concern in immunocompromised cancer patients and can potentially cause serious infections. Furthermore, the safety of CAM is a concern when used concurrently with conventional therapies. Tascilar and colleagues reported that 65 percent of patients receiving chemotherapy were concurrently using CAM.2 Conventional therapies used concurrently with CAM raises concern for significant herb-drug interactions, potentially leading to serious adverse effects and toxicities.9 This article will discuss the motivation behind cancer patients that seek CAM as a therapy and focus specifically on agents that are often used for the primary causes, including pain, depression, insomnia and menopausal symptom management.3,10 The effectiveness of the natural medicine for each particular condition will be described using the effectiveness ratings provided by the Natural Medicines Comprehensive Database. The rating description can be found in Table 1. Reasons for Use Previous studies have indicated a variety of demographics and socioeconomic factors influence higher CAM use amongst cancer patients. Factors observed include: female gender, younger age, higher level of education, lower quality of life and advanced disease.2,4,5,7,11 Documented reasons cancer patients use CAM include: to improve their
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THE KENTUCKY PHARMACIST
April 2013 CE — Review of Herbals in Cancer Patients Table 1
10
Rating Level
Definition
Effective
Very high level of reliable clinical evidence supporting its use for a specific indication. Products rated “Effective” are generally considered appropriate to recommend. Very high level of reliable clinical evidence supporting its use for a specific indication. Products rated "Likely Effective" are generally considered appropriate to recommend. Some clinical evidence supporting its use for a specific indication; however, the evidence is limited by quantity, quality or contradictory findings. Products rated "Possibly Effective" might be beneficial, but do not have enough high-quality evidence to recommend for most people. Some clinical evidence showing ineffectiveness for a specific indication; however, the evidence is limited by quantity, quality or contradictory findings. People should be advised NOT to take products with a "Possibly Ineffective" rating. Very high level of reliable clinical evidence showing ineffectiveness for its use for a specific indication. People should be discouraged from taking products with a "Likely Ineffective" rating. Very high level of reliable clinical evidence showing ineffectiveness for its use for a specific indication. People should be discouraged from taking products with an "Ineffective" rating. There is not enough reliable scientific evidence to provide an effectiveness rating.
Likely Effective
Possibly Effective
Possibly Ineffective
Likely Ineffective
Ineffective
Insufficient Evidence
Table 22 Rank 1 2
Herb Garlic Gingko biloba
3 4 5
Echinacea Soy Saw palmetto
6 7 8 9 10 11 12
Ginseng St. John’s wort Black cohosh Cranberry Valerian Milk thistle Evening primrose
13 14 15
Kava Bilberry Grape seed
Primary Indication hypercholesterolemia dementia, intermittent claudication common cold prevention menopausal symptoms benign prostate hyperplasia (BPH) fatigue depression menopausal symptoms urinary tract infection (UTI) insomnia, stress alcoholic cirrhosis, hepatitis premenstrual syndrome (PMS), menopausal symptoms anxiety diabetic retinopathy allergic rhinitis
27
March 2013 well-being, prevent progression of disease or treat disease, gain a sense of control over their health, boost immunity and manage side effects of conventional therapies.4-6,12-14 The most commonly utilized herbals in the United States, irrespective of the diagnosis of cancer, are outlined in Table 2.2 Supplementation within the cancer population is often initiated for symptomatic relief of adverse effects related to conventional treatment modalities and for purposes of enhancing their quality of life.
It is estimated that 25 percent of patients newly diagnosed with cancer and 75 percent of patients with advanced disease will experience pain.1517 As one of the most feared consequences of cancer, it is imperative for healthcare providers to perform continual assessments to ensure adequate relief. Pain is often not an isolated symptom, but rather clusters with depression and insomnia, ultimately leading to cancer-related fatigue. All of these symptoms are subjective based on patient report and contribute to the patient’s quality of life. The incidence of cancer-related fatigue is difficult to quantify due to inconsistency in assessment methods, yet rates as high as 70 to 100 percent have been reported.18 Depression occurs in approximately one-third of cancer patients and is often experienced simultaneously with cancerrelated fatigue.19 Additionally, sleep disturbances whether hypersomnia or insomnia, occur in up to threefourths of cancer patients.20 When patients do not obtain adequate control of their cancer-related symptoms through conventional therapies they may seek alternative medicine. Herbals Used Pain The most common herbal supplements patients utilize for symptomatic pain control include: ginger, cat’s claw, turmeric, willow bark, marijuana and glucosamine/ chondroitin. Their application in pain management will be described and summarized below. Ginger has multiple indications including motion sickness, morning sickness, colic, dyspepsia, nausea, oste-
THE KENTUCKY PHARMACIST
April 2013 CE — Review of Herbals in Cancer Patients
March 2013
Table 3 Indication
Herbal
Doses*
Adverse Effects
Drugs to avoid**
Contraindications
Pain
Ginger
Diabetes
Turmeric
500 mg orally 2 to 4 times daily
Willow Bark
120 to 240 mg orally daily
abdominal discomfort, heartburn and diarrhea headache, dizziness and vomiting dyspepsia, nausea, vomiting, dizziness, and diarrhea Heartburn, nausea
antiepileptics, antidepressants
Cat’s Claw
1 gram/daily (1 to 4 divided doses orally) 60 to 100 mg orally daily
Marijuana
16-195 mg
Glucosamine/ Chondroitin
glucosamine 1500 mg/ chondroitin 1200 mg orally daily
tachycardia, hypertension, anxiety, and cognitive impairment gas, bloating, abdominal cramping
barbiturates, CNS depressants, theophylline anticoagulants
Melatonin
0.3 to 6 mg orally daily
daytime drowsiness, headache and dizziness
CNS depressants
Valerian
400 to 900 mg orally 2 hours before bedtime
alcohol, benzodiazepines, CNS depressants
Chamomile
9 to 15 grams orally daily
headache, gastrointestinal upset, cardiac disturbances, morning drowsiness, vivid dreams and dry mouth Hypersensitivity reaction
Kava
100 mg three times daily
alcohol, barbiturates, benzodiazepines
Lavender St. John’s wort
Instill 2 to 4 drops in 2 to 3 cups of boiling water in an aromatic diffuser 300 mg orally three times daily
gastrointestinal upset, headache, dizziness, dry mouth and vision disturbances constipation, headache and increased appetite photosensitivity, insomnia, vivid dreams, restlessness gastrointestinal discomfort, dry mouth, dizziness, diarrhea and headache
SAM-e
400 to 1600 mg orally daily
MAOI, SSRI, TCAs, oral contraceptives, cyclosporine, tacrolimus, digoxin, imatinib, irinotecan, NNRTIs, phenytoin, protease inhibitors, alprazolam, meperidine, warfarin, barbiturates MAOI, SSRI
5-HTP
150 to 300 mg orally daily
Inositol
12 grams orally daily
Soy
20 to 60 grams orally daily
Black cohosh
40 to 80 mg orally twice daily
Flaxseed Gingko
40-50 grams orally daily 120 to 160 mg orally daily divided in two doses 200 mg orally twice daily
Sleep disturbances
Depression
Menopausal symptoms
Ginseng
*Doses refer to adults only
gastrointestinal upset, dry mouth, headache, insomnia, anorexia, sweating, dizziness, nervousness heartburn, nausea, vomiting, abdominal pain and anorexia nausea, fatigue, headache and dizziness gastrointestinal upset, migraines and insomnia gastrointestinal upset, headache, dizziness, weight gain, cramping, breast tenderness and vaginal spotting bloating and flatulence headache, nausea, diarrhea and occasional dermatitis hypertension, insomnia, vomiting, headache and epistaxis
Autoimmune disorders
anticoagulants
tamoxifen
aspirin allergy, renal dysfunction Seizure disorder, immunocompromised warfarin, shellfish allergy, diabetes, hyperlipidemia, hypertension, asthma Diabetes, seizure disorder, hypertension
Allergic to ragweed, chrysanthemums, marigolds, or daisies Liver disease
MAOI, SSRI
MAOI
Renal failure, hypothyroid Liver disease
anticoagulants
Diabetes Diabetes, epilepsy
anticoagulants
Diabetes
**Anticoagulant interactions data limited with newer agents
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April 2013 CE — Review of Herbals in Cancer Patients
March 2013
Table 4 Herbal
Likely Effective
Possibly Effective
Bilberry
diabetic retinopathy
Black cohosh
menopausal symptoms Pain
Cat’s claw Chamomile Cranberry
Inconclusive
Insomnia
Premenstrual syndrome, menopausal symptoms
Evening primrose gastrointestinal disorders
Flaxseed Garlic
Hypercholesterolemia morning sickness, nausea, osteoarthritis dementia, intermittent claudication
Ginger Ginkgo biloba
colic, dyspepsia
allergic rhinitis OCD, panic disorder, PCOS, respiratory distress syndrome Anxiety
Inositol
Kava
depression
insomnia insomnia pain
Circadian rhythm disruption
insomnia, jet lag
shift-work disorder alcoholic cirrhosis, hepatitis dementia, alzheimer’s, parkinson’s disease
Milk thistle depression, arthritis
depression
Soy
Turmeric
Hearing loss
fatigue, menopausal symptoms pain
Glucosamine/chondroitin Grape seed
Saw palmetto St. John’s wort
motion sickness, rheumatoid arthritis, myalgias
menopausal symptoms
Ginseng
SAM-e
Likely ineffective
urinary tract infection common cold prevention
Echinacea
Lavender Marijuana Melatonin
Possibly Ineffective
menopausal symptoms hyperlipidemia, menopausal symptoms, osteoporosis
OCD, SAD, anxiety prevention of cardiovascular disease
dyspepsia, osteoarthritis
BPH ADHD
pain
Valerian
Insomnia
Willow bark
Pain
anxiety, mood disorders
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THE KENTUCKY PHARMACIST
April 2013 CE — Review of Herbals in Cancer Patients
March 2013
toid arthritis and gout.23 As a treatment option for pain, willow bark is possibly effective and Hormonal Therapy Herbals with Estrogenic Activity has been shown to be at least as effective as rofecoxib for back pain.23 Willow bark’s active Raloxifene alfalfa fennel red clover ingredient, salicin, is metabolized to salicylic Tamoxifen chasteberry genestein (soy) sage acid, which functions similar to aspirin. Similar Exemestane black cohosh ginseng valerian to aspirin, willow bark may cause gastrointesLetrozole DHEA gingko tinal adverse effects and should not be used concurrently with other anticoagulants without anastrozole dong quai hops first seeking medical advice. Due to the simiflaxseed licorice larity between willow bark and aspirin, it is advisable to use aspirin in lieu of willow bark, oarthritis, rheumatoid arthritis and myalgias.21-23 Ginger is since efficacy and safety with aspirin is proven and it is thought to reduce nausea by acting on muscarinic and regulated by the FDA. Patients who are allergic to aspirin serotonin receptors in the gastrointestinal tract. Additional- should avoid use of willow bark.10 Willow bark is available ly, ginger may mediate inflammation and reduce pain orally as a liquid or capsule. 23 through cyclooxygenase inhibition. Although ginger is Glucosamine and chondroitin are endogenous substrates utilized for pain and considered possibly effective for arin the formation of cartilage used in combination commonthritis, it is not unexpected to require up to three months ly for relief of arthritis pain.28,29 Glucosamine is likely effecbefore relief of symptoms is observed. The more common tive and chrondroitin is possibly effective in providing knee indication where ginger is used and considered possibly pain relief due to arthritis.23 It is recommended to not exeffective is to provide acute improvement in symptoms of ceed daily dosing as it may lead to toxic levels of mangamorning sickness and nausea. Ginger is available as a nese causing central nervous system toxicity when greater dried powder, topical oil or fresh root. Ginger should be than 11 mg of elemental manganese is ingested.30,31 Lastused cautiously in combination with anticoagulants as ly, recommend patients to avoid with shellfish allergy as these agents may cause prolonged bleeding. Patients with the supplement is derived from crab or shrimp skeletons. epilepsy should avoid ginger due to the risk of lowering the Additionally, there is a potential interaction with anticoaguseizure threshold.21 lants and glucosamine may increase anticoagulant efCat’s claw, a proposed anti-inflammatory herbal supplefects.32 ment is primarily taken by individuals for symptomatic control of gastrointestinal disorders such as diverticulitis, pep- Marijuana is commonly used for treatment of pain, nausea and glaucoma. The active constituent tetrahydrocannatic ulcers, colitis and gastritis, yet it only has reliable evidence to support being possibly effective for pain manage- binol (THC) acts on opiate receptors in the forebrain thereby directly reducing pain and indirectly inhibiting the emetment specifically related to arthritic joint pain.23 Ingested ic center.33 Although regulations vary from state to state, orally, cat’s claw is available as an aqueous solution or freeze dried powder packaged into a capsule. Cat’s claw, marijuana is still considered an illicit drug within the United States rendering a lack of the product’s quality control. may cause headache, dizziness and vomiting.24 Currently, two products containing THC are FDA approved Turmeric, whose active constituent is curcumin, is thought in the United States for antiemesis and/or appetite stimulato control pain by inhibiting cyclooxygenase-2 (COX-2), tion: dronabinol and nabilone. When marijuana is used in prostaglandins and leukotrienes.25 While indications are its natural form, it is considered possibly effective for glauabundant, turmeric’s activity in providing symptomatic recoma and anorexia but has insufficient reliable evidence to lief in dyspepsia and osteoarthritis is plausible and considrate effectiveness for pain. Whether marijuana is orally ered possibly effective.26,27 However, it should be noted ingested or smoked, both are considered unsafe. Smoking that turmeric may need to be taken up to eight weeks bemarijuana can lead to a multitude of acute effects including fore symptomatic relief occurs. Turmeric is available as a tachycardia, hypertension, anxiety and cognitive impairtopical oil or orally as an analgesic.23 Common adverse ment. Additionally, when smoked a variety of carcinogens effects seen with turmeric administration are dyspepsia, are inhaled which may lead to decreased pulmonary funcnausea, vomiting, dizziness and diarrhea.27 tion and increased risk of cancer. Due to quality control Willow bark is utilized for multiple pain indications such as issues, not only does the amount of THC vary based on headache, myalgia, osteoarthritis, dysmenorrhea, rheuma- the source of supply, studies have shown that marijuana is
Table 5
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THE KENTUCKY PHARMACIST
April 2013 CE — Review of Herbals in Cancer Patients often contaminated. Contaminants include heavy metals, pesticides, shards of glass and sand as well as harmful bacteria and fungi such as Aspergillus, which could ultimately lead to pneumonia in an immunocompromised host.34 Sleep Disturbances The majority of cancer patients suffer from sleep disturbances such as hypersomnia or insomnia. Supplements commonly used include melatonin, valerian, chamomile, kava and lavender. Each of these agents will be described and summarized in their effectiveness in management of sleep disturbances. Melatonin, in an oral formulation is used for a multitude of sleep disturbances such as jet lag, insomnia, shift-work disorder or circadian rhythm disruption.23 Melatonin is synthesized endogenously in the pineal gland and functions primarily to regulate circadian rhythm and sleep patterns. The efficacy of melatonin in regulating sleep stems from a multitude of actions within the brain. Melatonin increases the binding of gamma-aminobenzoic acid (GABA) and decreases neurotransmission, and has been reported to be useful in circadian rhythm disruption, causing a minor reduction in sleep latency. It is considered to be possibly effective for insomnia; however, more research is needed.23 Common side effects of melatonin include daytime drowsiness, headache and dizziness.35
March 2013
sibly effective for the treatment of anxiety whereas there is insufficient reliable evidence to rate effectiveness for insomnia, and evidence available does not indicate that it improves sleep.23 The active components of kava are the root, stem and rhizome. Kava is a central nervous system depressant (CNS); the exact mechanism of action is unknown. As a CNS depressant, concomitant use with other CNS depressants such as alcohol, barbiturates and benzodiazepines should be avoided.38 When taken orally, kava may cause gastrointestinal upset, headache, dizziness, dry mouth, extrapyramidal side effects and vision disturbances.39 Additionally, case reports indicate kava is associated with hepatoxicity. Kava is available as a beverage, oral tablet or capsule. Lavender is available as oil and originates from an aromatic evergreen sub-shrub. Lavender has been historically recognized to relieve agitation by increasing relaxation and sedation, although the exact mechanism is unknown. However, there is insufficient reliable evidence to rate lavender’s efficacy for the treatment of insomnia or agitation.23 Lavender is thought to decrease electroencephalogram (EEG) potentials and alertness.40 Active components of lavender include the flower, leaves and oil.41 Administration can occur via multiple routes such as orally, as an inhalation and topically.42 Typically for treatment of insomnia lavender is vaporized and inhaled as aromatherapy.43 Lavender taken orally as one to four drops often given on a sugar cube may cause constipation, headache and increased appetite when an excess of four drops is ingested.42 Important to note, lavender containing supplements may increase anticoagulant effects when given concurrently as well as increase sedation with CNS depressants and anticonvulsants.
Valerian is possibly effective for treatment of insomnia by decreasing sleep latency and reportedly improves sleep quality. In addition to insomnia, valerian is often used for anxiety and mood disorders.21 The root or rhizome of valerian is the source of the active constituent responsible for valerian’s sedative properties. Side effects reported with the use of valerian include headache, gastrointestinal upDepression set, cardiac disturbances, morning drowsiness, vivid A cancer diagnosis can leave a huge impact on an individudreams and dry mouth.21,36 Valerian also has been reported al’s psychological health. Depression is a common comorto cause hepatic failure.23 bidity among cancer patients that is often under-recognized Chamomile, a German flower available as a tea, is another and undertreated.44 Herbal supplements that have been used to treat depression include but are not limited to St. remedy for insomnia as it is mildly sedating; however, the John’s wort, SAMe (S-adenosylmethionine), 5-HTP (5level of effectiveness is unknown. Overall chamomile is hydroxytryptophan) and inositol. All of the aforementioned well tolerated with the exception of individuals who are alherbal supplements exhibit their antidepressant effects by lergic to members of the Asteraceae/Compositae family which includes ragweed, chrysanthemums (“mums”), mari- interfering with neurotransmitters such as dopamine, serotonin and norepinephrine. Due to this purported mechanism golds and daisies. These patients are at higher risk of an of action, it would be appropriate to caution patients in conallergic reaction. An allergic reaction to chamomile may present as abdominal cramps with or without anaphylactic comitant administration of these herbal supplements, as symptoms such as tongue thickness, tight sensation in the well as avoid using with MAOIs (monoamine oxidase inhibitors), SSRIs (selective-serotonin reuptake inhibitors) or throat and angioedema.21,37 SNRIs (selective-norepinephrine reuptake inhibitors). Kava, an herbal supplement used for insomnia, also is commonly utilized in the treatment of anxiety. Kava is pos- St. John’s wort, used for depression, anxiety, obsessive 31
THE KENTUCKY PHARMACIST
April 2013 CE — Review of Herbals in Cancer Patients compulsive disorder (OCD), attention deficit-hyperactivity disorder (ADHD,) seasonal affective disorder (SAD) and menopausal symptoms, is thought to act as an MAOI and/ or SSRI. St. John’s wort is likely effective for depression and possibly ineffective for ADHD. Unfortunately, there is insufficient reliable evidence to rate efficacy in OCD and SAD. Pharmacists should instruct patients to avoid consuming tyramine containing foods just as they would if prescribed an MAOI. St. John’s wort is likely effective for treatment of insomnia and possibly effective in relieving menopausal symptoms.23 Therapeutic activity is primarily derived from the flower of St. John’s wort. When using St. John’s wort patients should take precautions to reduce sun exposure to avoid photosensitivity resulting from the dose related hypericin component of St. John’s wort.45 Other reported adverse effects include insomnia, vivid dreams, restlessness gastrointestinal discomfort, dry mouth, dizziness, diarrhea and headache.46 SAM-e is thought to reduce symptoms of depression by increasing serotonin turnover as well as increasing the availability of dopamine and norepinephrine in the neural synapse. It is found on all living cells and is a naturally occurring precursor of amino acids cysteine, glutathione and taurine. SAM-e is commercially produced in yeast cell cultures. In addition to depression, SAM-e is commonly used for arthritis, dementia, Alzheimer’s and Parkinson’s disease. It is available orally, intravenously or intramuscularly.23 Of the previous indications, SAM-e is likely effective when used for depression and arthritis.23 Side effects common with higher doses are similar to those seen with St. John’s wort with the addition of sweating, constipation, vomiting and anorexia.47 Caution in bipolar disorder as SAM-e increases anxiety and mania in depressed patients.
March 2013
tive-serotonin reuptake inhibitor to treat depression. It is most commonly found in beans, fruits, nuts and grains. Unfortunately, inositol is considered possibly ineffective for depression. Indications other than depression in which inositol is possibly effective include obsessive-compulsive disorder (OCD), panic disorder, polycystic ovary syndrome (PCOS) and respiratory distress syndrome.23 Adverse events commonly reported are nausea, fatigue, headache and dizziness.49 Menopausal Symptoms Breast cancer patients are the most frequent users of complementary and alternative medicine. Individuals treated for breast cancer are subject to menopausal symptoms as a result of estrogen deprivation therapy and/or chemotherapy -induced menopause.4 As the majority of breast cancer patients are estrogen and/or progesterone receptor positive, treatment modalities aim to ablate endogenous hormone concentrations to reduce the risk of breast cancer recurrence.50 However, many pre-menopausal women diagnosed with non-breast cancers often seek CAM as well. Chemotherapy can advance the onset of menopause in young women leading to the early development of perimenopausal symptoms. As a result, many women treated for cancer within the pre- and peri-menopausal period of life may utilize herbal supplements to relieve typical menopausal symptoms such as hot flashes, vaginal dryness, mood changes and decreased libido.51
Phytoestrogens, agents which endogenously mimic estradiol, are commonly utilized for symptomatic relief of menopausal symptoms.52 While multiple herbal supplements are classified as phytoestrogens, those with the highest utilization and/or most sales within the United States include soy, black cohosh, flaxseed, gingko and ginseng.3,53 Soy is in5-HTP a precursor to serotonin crosses the blood brain barrier and aids in the synthesis of serotonin within the cen- gested orally via herbal supplements or food products and may cause gastrointestinal upset, migraines and insomtral nervous system. 5-HTP comes from seeds of the 54 woody climbing shrub G. simplicifolia found in tropical Afri- nia. ca. Indications aside from depression include headache, Soy has a multitude of proposed indications, yet the most fibromyalgia, binge eating disorder and pre-menstrual syn- common indications are treatment of menopausal sympdrome.23 5-HTP is considered possibly effective for both toms, hyperlipidemia and prevention of osteoporosis and fibromyalgia and depression, whereas it is possibly ineffec- cardiovascular disease.23 Soy is considered possibly effective for headache. Efficacy for other indications is untive for menopausal symptom management, hyperlipidemia known.23 Similar to St. John’s wort and SAM-e, the majority and osteoporosis prevention. The relief rendered for menoof side effects seen with 5-HTP are gastrointestinal related pausal symptoms with soy use is limited to a reduction in such as heartburn, nausea, vomiting, abdominal pain and the rate and severity of hot flashes.23 Due to the fermenta48 anorexia. tion process in manufacturing some soy products, patients Inositol endogenously functions as part of the intracellular second messenger system linked to serotonin, norepinephrine and cholinergic receptors. Due to its interaction with serotonin, inositol is thought to function similar to a selec-
taking MAOIs should avoid soy due to the increased risk of serotonin syndrome.55 The maximum safe dosing quantity is unknown; yet it is recommended to not exceed the amount contained in food.
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April 2013 CE â&#x20AC;&#x201D; Review of Herbals in Cancer Patients
March 2013
Black cohosh, unlike soy, is indicated predominantly for relief of menopausal symptoms and dysmenorrhea. Black cohosh, derived from the rhizome and root of the plant, is possibly effective in relieving menopausal symptoms, including lowering the frequency of hot flashes.23 Similar to soy, black cohosh may cause gastrointestinal upset, headache, dizziness, weight gain, cramping, breast tenderness and vaginal spotting.56 Patients with aspirin allergies should use caution due to salicylate content. Black cohosh has sound alike look alike herbals that should not be confused with blue and white cohosh.23
bination with anticoagulants to avoid an increased risk of bleeding.21
Ginseng also is commonly used as an adaptogen to aid in environmental adaptation to stressors and regulation of blood sugar in diabetics. As an adaptogen it is thought to be a stimulant, diuretic and digestive aid. There is some evidence-based literature to support ginseng as an effective option for menopausal symptom management, although more data is needed to elucidate its true potential.6062 The root of ginseng is considered the applicable part of the plant.23 Common adverse effects of ginseng include hypertension, insomnia, vomiting, headache and epistaxis. Like ginkgo biloba, ginseng should also be avoided in com-
100-fold higher than endogenous estrogen. As a result of the agonistic effects phytoestrogens impose on breast tissue of hormone receptor positive breast cancer patients, women should not concurrently receive phytoestrogens and hormonal therapy. Caution is advised for patients who have a history of hormone receptor breast cancer prior to initiating phytoestrogens following completion of hormonal treatment as well.63 See Table 5 for a list of phytoestrogen herbal supplements.
Herb-Drug and Herb-Disease Interactions: Anticancer Agents
As the interest in complementary and alternative medicine grows, there is concern for herbal-drug interactions with cancer as well as anticancer agents. Nearly three-fourths of patients taking CAM do not voluntarily inform their physician. Use of herbal medications in conjunction with anticancer agents can alter critical drug pharmacokinetic parameters such as absorption, distribution, metabolism and Flaxseed, gingko and ginseng are less commonly used excretion. The most commonly known herbal-drug interacthan soy and black cohosh to relieve menopausal symptions affect the metabolism of anticancer agents, thus aftoms. However, flaxseed does have a wide range of other fecting the functionality of the cytochrome P450 system. indications including gastrointestinal disorders and sympSpecifically, many chemotherapeutic agents are metabotoms such as constipation, diarrhea, diverticulitis, irritable lized via the CYP3A4 enzyme. Herbal agents that induce bowel syndrome and ulcerative colitis.23 Flaxseed is conCYP3A4 may lead to sub-therapeutic blood concentrations sidered possibly effective for menopausal symptom manof the antineoplastic agent, ultimately leading to decreased agement and has been shown to reduce both hot flashes efficacy. Contrarily, herbal agents that inhibit CYP3A4 may and night sweats.23 Being a naturally occurring dietary fiber, lead to supra-therapeutic blood concentrations of chemoflaxseed is generally well tolerated most commonly causing therapy increasing the likelihood of toxicity. A final mechabloating and flatulence.57 Flaxseed is a rich source of fiber nism of herbal-drug interactions occurs via drug transportdue to the seed coating.23 ers found in the gut lumen such as P-glycoprotein, multiGinkgo biloba has other commonly reported uses including drug resistance-associated protein-1 and breast cancerdementia, circulatory disorders and hearing loss. Ginkgo is resistance protein. If chemotherapeutic agents are unable possibly effective for treatment of dementia and intermittent to be transported across the intestinal lumen for absorption, systemic concentrations are limited impairing efficacy. 53 claudication.23 There is little data to state it is useful in the management of menopausal symptoms although it has Since the majority of breast cancer patients are hormone evidence for possible efficacy for mood disorders during receptor positive, caution is advised before recommending premenstrual syndrome..23 The definite mechanism of acherbal products that manipulate hormone exposure. Phytion is unknown; yet ginkgo biloba is thought to be an anti- toestrogens as an herbal class pose significant herbaloxidant, thus reducing oxidative stress and minimizing cell disease interactions for breast cancer patients that are esdamage.58 Ginkgo biloba, derived from the leaf of the trogen and/or progesterone receptor positive receiving enworldâ&#x20AC;&#x2122;s oldest living tree, should be used cautiously in padocrine therapy (anastrazole, exemestane, letrozole, raloxitients on anticoagulation due to antagonism of plateletfene, tamoxifen). The purpose of endocrine therapy within activating factor and increased risk of bleeding. Less serithis population is to cease estrogen and/or progesterone ous side effects of ginkgo biloba include headache, naustimulation of tumor proliferation. Phytoestrogens, even sea, diarrhea and occasional dermatitis.59 though weakly estrogenic, can reach concentrations of
While human studies are limited, the most commonly studied herb-anticancer drug interactions have been done with
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April 2013 CE — Review of Herbals in Cancer Patients St. John’s wort. The drug-drug interaction between St. John’s wort and irinotecan provides a good example of the resulting harm of herb-anticancer drug interactions. Irinotecan is a prodrug which must be converted into its active metabolite and used for colorectal and lung cancer. Concurrent use of St. John’s wort with irinotecan can inhibit the conversion of the prodrug to the active metabolite by up to 42 percent, greatly diminishing its activity and any potential benefit to the patient. To obtain maximal efficacy, patients receiving irinotecan should be counseled to avoid use of St. John’s wort. The tyrosine kinase inhibitor drug class used to treat chronic myeloid leukemia, which includes imatinib, dasatinib, nilotinib, bosutinib and ponatinib, also have been shown to interact with St. John’s wort. Several studies have shown that coadministration of St. John’s wort significantly reduces the efficacy of these drugs and could potentially lead to inadequate control of disease or promote drug resistance.64 Discussion As interest and use of CAM in the United States continues to rise, the necessity of herbal knowledge within the healthcare profession also must follow sequence. Due to loose regulations regarding the manufacturing and quality of these products, the safety and efficacy of CAM is questionable.2 In particular, utilization of CAM amongst cancer patients is higher than that of the general public.2 Patients most commonly rely on the internet or family and friends as sources of information regarding CAM, rather than healthcare professionals.4 While a multitude of reasons have been identified for CAM usage amongst this population, the most common reason is to improve quality of life. Cancer patients often suffer from pain, sleep disturbances, depression and menopausal symptoms as a result of their disease and conventional therapy.3 Herbal supplements indicated to treat such symptoms are numerous. Many herbal supplements are metabolized via the same enzymatic pathway as anticancer agents. Herbals pose a significant risk for anticancer-herb drug interactions putting the patient at risk of harm.65 By administering herbals concurrently with anticancer agents, plasma concentrations of anticancer agents can significantly differ resulting in unanticipated toxicity or treatment failure.65 Additionally, use of specific CAM agents may negatively affect patients with particular types of cancer, such as breast cancer. By having an adequate knowledgebase regarding CAM, healthcare professionals can continually assess CAM utilization amongst patients and identify whether the herbal is safe and effective for the individual. By assessing herbal utilization at each visit, healthcare professionals can anticipate herbal-drug interactions, as well as optimize patient
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safety and therapeutic efficacy. In doing so, one can endow optimal patient care. References 1. What is Complementary and Alternative Medicine. NCAAM, 2012. at http://nccam.nih.gov/health/whatiscam) 2. Tascilar M, de Jong FA, Verweij J, Mathijssen RHJ. Complementary and alternative medicine during cancer treatment: beyond innocence. The Oncologist 2006;11:73241. 3. Anderson JG, Taylor AG. Use of Complementary Therapies for Cancer Symptom Management: Results of the 2007 National Health Interview Survey. The Journal of Alternative and Complementary Medicine 2012;18:235-41. 4. Tautz E, Momm F, Hasenburg A, Guethlin C. Use of Complementary and Alternative Medicine in breast cancer patients and their experiences: A cross-sectional study. European Journal of Cancer 2012. 5. Boon H, Stewart M, Kennard MA, et al. Use of complementary/alternative medicine by breast cancer survivors in Ontario: prevalence and perceptions. Journal of Clinical Oncology 2000;18:2515-21. 6. Molassiotis A, Fernandez-Ortega P, Pud D, et al. Complementary and alternative medicine use in colorectal cancer patients in seven European countries. Complementary therapies in medicine 2005;13:251. 7. Hlubocky FJ, Ratain MJ, Wen M, Daugherty CK. Complementary and alternative medicine among advanced cancer patients enrolled on phase I trials: a study of prognosis, quality of life, and preferences for decision making. Journal of clinical oncology 2007;25:548-54. 8. McCune JS, Hatfield AJ, Blackburn AAR, Leith PO, Livingston RB, Ellis GK. Potential of chemotherapy–herb interactions in adult cancer patients. Supportive care in cancer 2004;12:454-62. 9. OH B, BUTOW P, MULLAN B, et al. The use and perceived benefits resulting from the use of complementary and alternative medicine by cancer patients in Australia. Asia‐Pacific Journal of Clinical Oncology 2010;6:342-9. 10. Schmid B, Lüdtke R, Selbmann HK, et al. Efficacy and tolerability of a standardized willow bark extract in patients with osteoarthritis: randomized placebo‐controlled, double blind clinical trial. Phytotherapy Research 2001;15:344-50. 11. Fouladbakhsh JM, Stommel M. Gender, symptom experience, and use of complementary and alternative medicine practices among cancer survivors in the US cancer population. 2010: Onc Nurs Society. p. 7-15. 34
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April 2013 CE — Review of Herbals in Cancer Patients 12. Amichai T, Grossman M, Richard M. Lung cancer patients’ beliefs about complementary and alternative medicine in the promotion of their wellness. European Journal of Oncology Nursing 2012.
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24. Piscoya J, Rodriguez Z, Bustamante S, Okuhama N, Miller M, Sandoval M. Efficacy and safety of freeze-dried cat's claw in osteoarthritis of the knee: mechanisms of action of the species Uncaria guianensis. Inflammation Research 2001;50:442-8.
13. Ramsey SD, Zeliadt SB, Blough DK, et al. Complementary and Alternative Medicine Use, Patient-reported Out25. Zhang F, Altorki NK, Mestre JR, Subbaramaiah K, Dancomes, and Treatment Satisfaction Among Men With Lonenberg AJ. Curcumin inhibits cyclooxygenase-2 transcripcalized Prostate Cancer. Urology 2012;79:1034-41. tion in bile acid-and phorbol ester-treated human gastrointestinal epithelial cells. Carcinogenesis 1999;20:445-51. 14. Sewitch MJ, Rajput Y. A literature review of complementary and alternative medicine use by colorectal cancer 26. Thamlikitkul V, Bunyapraphatsara N, Dechatiwongse T, patients. Complementary Therapies In Clinical Practice et al. Randomized double blind study of Curcuma domesti2010;16:52. ca Val. for dyspepsia. J Med Assoc Thai 1989;72:613-20. 15. Goudas LC, Bloch R, Gialeli-Goudas M, Lau J, Carr DB. The epidemiology of cancer pain. Cancer investigation 2005;23:182-90. 16. Cohen MZ, Easley MK, Ellis C, et al. Cancer pain management and the JCAHO's pain standards: an institutional challenge. Journal of pain and symptom management 2003;25:519-27.
27. Kuptniratsaikul V, Thanakhumtorn S, Chinswangwatanakul P, Wattanamongkonsil L, Thamlikitkul V. Efficacy and safety of Curcuma domestica extracts in patients with knee osteoarthritis. The Journal of Alternative and Complementary Medicine 2009;15:891-7. 28. Olszewski AJ, Szostak WB, McCully KS. Plasma glucosamine and galactosamine in ischemic heart disease. Atherosclerosis 1990;82:75-83.
17. Svendsen KB, Andersen S, Arnason S, et al. Breakthrough pain in malignant and non-malignant diseases: a 29. Bucsi L, Poór G. Efficacy and tolerability of oral chonreview of prevalence, characteristics and mechanisms. Eu- droitin sulfate as a symptomatic slow-acting drug for osteoropean Journal of Pain 2005;9:195-206. arthritis (SYSADOA) in the treatment of knee osteoarthritis. Osteoarthritis and cartilage 1998;6:31-6. 18. Ahlberg K, Ekman T, Gaston-Johansson F, Mock V. Assessment and management of cancer-related fatigue in 30. Leffler C, Philippi A, Leffler S, Mosure J, Kim P. Gluadults. The Lancet 2003;362:640-50. cosamine, chondroitin, and manganese ascorbate for degenerative joint disease of the knee or low back: a random19. Newell S, Sanson-Fisher RW, Girgis A, Ackland S. The ized, double-blind, placebo-controlled pilot study. Military physical and psycho-social experiences of patients attendMedicine 1999;164:85-91. ing an outpatient medical oncology department: a crosssectional study. European Journal of Cancer Care 31. Trumbo P, Yates AA, Schlicker S, Poos M. Dietary ref1999;8:73-82. erence intakes: vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nick20. Gordon DB, Dahl JL, Miaskowski C, et al. American el, silicon, vanadium, and zinc. Journal of the American Pain Society recommendations for improving the quality of Dietetic Association 2001;101:294. acute and cancer pain management: American Pain Society Quality of Care Task Force. Archives of Internal Medi32. Rozenfeld V, Crain JL, Callahan AK. Possible augmencine 2005;165:1574. tation of warfarin effect by glucosamine-chondroitin. American journal of health-system pharmacy: AJHP: official jour21. Miller LG. Herbal medicinals: selected clinical considernal of the American Society of Health-System Pharmacists ations focusing on known or potential drug-herb interac2004;61:306. tions. Archives of Internal Medicine 1998;158:2200. 33. Robbers JE, Speedie MK, Tyler VE. Pharmacognosy 22. Black CD, O'Connor PJ. Acute effects of dietary ginger and pharmacobiotechnology. 1996. on quadriceps muscle pain during moderate-intensity cycling exercise. International journal of sport nutrition and 34. Leung L. Cannabis and its derivatives: review of mediexercise metabolism 2008;18:653-64. cal use. The Journal of the American Board of Family Medicine 2011;24:452-62. 23. Jellin JM. Pharmacist's Letter, Prescriber's Letter Natural Medicines Comprehensive Database: Therapeutic Re35. Buscemi N, Vandermeer B, Pandya R, et al. Melatonin search Faculty; 2012. for treatment of sleep disorders. 2004. 35
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April 2013 CE — Review of Herbals in Cancer Patients 36. Klepser TB, Doucette WR, Horton MR, et al. Assessment of patients' perceptions and beliefs regarding herbal therapies. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy 2000;20:83-7.
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hydroxytryptophan for depression. Cochrane Database Syst Rev 2002;1. 49. Benjamin J, Agam G, Levine J, Bersudsky Y. Inositol treatment in psychiatry. Psychopharmacology bulletin 1995.
37. Subiza J, Subiza JL, Hinojosa M, et al. Anaphylactic reaction after the ingestion of chamomile tea: a study of cross-reactivity with other composite pollens. Journal of allergy and clinical immunology 1989;84:353-8.
50. Burstein HJ, Prestrud AA, Seidenfeld J, et al. American Society of Clinical Oncology clinical practice guideline: Update on adjuvant endocrine therapy for women with hormone receptor–positive breast cancer. Journal of Clinical Oncology 2010;28:3784-96.
38. Pittler MH, Ernst E. Efficacy of kava extract for treating anxiety: systematic review and meta-analysis. Journal of clinical psychopharmacology 2000;20:84-9.
51. This P, De La Rochefordi A, Clough K, Fourquet A, 39. Wheatley D. Stress-induced insomnia treated with kava Magdelenat H. Phytoestrogens after breast cancer. Endoand valerian: singly and in combination. Human Psychocrine-related cancer 2001;8:129-34. pharmacology: Clinical and Experimental 2001;16:353-6. 52. Duffy C, Cyr M. Phytoestrogens: potential benefits and 40. Schulz V, Hänsel R, Tyler VE. Rational phytotherapy: a implications for breast cancer survivors. Journal of Womphysician's guide to herbal medicine: Routledge; 2001. en's Health 2003;12:617-31. 41. Hajhashemi V, Ghannadi A, Sharif B. Anti-inflammatory and analgesic properties of the leaf extracts and essential oil of Lavandula angustifolia Mill. Journal of ethnopharmacology 2003;89:67-71.
53. Sparreboom A, Cox MC, Acharya MR, Figg WD. Herbal remedies in the United States: potential adverse interactions with anticancer agents. Journal of Clinical Oncology 2004;22:2489-503.
42. Akhondzadeh S, Kashani L, Fotouhi A, et al. Comparison of Lavandula angustifolia Mill. tincture and imipramine in the treatment of mild to moderate depression: a doubleblind, randomized trial. Progress in NeuroPsychopharmacology and Biological Psychiatry 2003;27:123-7.
54. Albertazzi P, Pansini F, Bonaccorsi G, Zanotti L, Forini E, De Aloysio D. The effect of dietary soy supplementation on hot flushes. Obstetrics & Gynecology 1998;91:129-35.
43. Lewith GT, Godfrey AD, Prescott P. A single-blinded, randomized pilot study evaluating the aroma of Lavandula augustifolia as a treatment for mild insomnia. Journal of Alternative & Complementary Medicine 2005;11:631-7. 44. Ng CG, Boks MPM, Zainal NZ, de Wit NJ. The prevalence and pharmacotherapy of depression in cancer patients. Journal of affective disorders 2011;131:1-7. 45. Schulz V. Incidence and clinical relevance of the interactions and side effects of Hypericum preparations. Phytomedicine: international journal of phytotherapy and phytopharmacology 2001;8:152. 46. Whiskey E, Werneke U, Taylor D. A systematic review and meta-analysis of Hypericum perforatum in depression: a comprehensive clinical review. International clinical psychopharmacology 2001;16:239-52. 47. Rosenbaum JF, Fava M, Falk W, et al. The antidepressant potential of oral S-adenosyl-l-methionine*. Acta Psychiatrica Scandinavica 1990;81:432-6. 48. Shaw K, Turner J, Del Mar C. Tryptophan and 5-
55. Shulman KI, Walker SE. Refining the MAOI diet: tyramine content of pizzas and soy products. The Journal of clinical psychiatry 1999;60:191. 56. Jacobson JS, Troxel AB, Evans J, et al. Randomized trial of black cohosh for the treatment of hot flashes among women with a history of breast cancer. Journal of Clinical Oncology 2001;19:2739-45. 57. Dodin S, Lemay A, Jacques H, Legare F, Forest JC, Masse B. The effects of flaxseed dietary supplement on lipid profile, bone mineral density, and symptoms in menopausal women: a randomized, double-blind, wheat germ placebo-controlled clinical trial. Journal of Clinical Endocrinology & Metabolism 2005;90:1390-7. 58. Logani S, Chen MC, Tran T, Le T, Raffa RB. Actions of Ginkgo Biloba related to potential utility for the treatment of conditions involving cerebral hypoxia. Life sciences 2000;67:1389-96. 59. Wood AJJ, De Smet PAGM. Herbal remedies. New England Journal of Medicine 2002;347:2046-56. 60. Kim SY, Seo SK, Choi YM, et al. Effects of red ginseng supplementation on menopausal symptoms and cardiovascular risk factors in postmenopausal women: a double-blind
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April 2013 CE — Review of Herbals in Cancer Patients
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randomized controlled trial. Menopause 2012;19:461.
63. Holmberg L, Iversen OE, Rudenstam CM, et al. Increased risk of recurrence after hormone replacement 61. Wiklund I, Mattsson L, Lindgren R, Limoni C. Effects of therapy in breast cancer survivors. Journal of the National a standardized ginseng extract on quality of life and physiCancer Institute 2008;100:475-82. ological parameters in symptomatic postmenopausal women: a double-blind, placebo-controlled trial. Swedish Alter- 64. Yang AK, He SM, Liu L, Liu JP, Qian Wei M, Zhou SF. native Medicine Group. International journal of clinical Herbal interactions with anticancer drugs: mechanistic and pharmacology research 1999;19:89. clinical considerations. Current Medicinal Chemistry 2010;17:1635-78. 62. Cheema D, Coomarasamy A, El-Toukhy T. Nonhormonal therapy of post-menopausal vasomotor symp65. Izzo AA. Herb–drug interactions: an overview of the toms: a structured evidence-based review. Archives of clinical evidence. Fundamental & clinical pharmacology gynecology and obstetrics 2007;276:463-9. 2005;19:1-16.
April 2013 — A Review of Herbals in Cancer Patients: Use This Not That? 1. What percentage of adults in the United States are reported to utilize CAM? A. 75 percent B. 50 percent C. 33 percent D. 25 percent
6. Kava should not be used concurrently with all of the following EXCEPT? A. Alcohol B. Barbiturates C. Benzodiazepines D. Antiepileptics
2. Which law allowed manufacturers to freely distribute dietary supplements without proving safety and efficacy? A. Complementary and Alternative Medicine Act B. Dietary Supplements Health Education Act C. Vitamin and Herbal Supplement Act D. Homeopathic Regulations and Policies Act
7. Which of the following herbals used to treat depression can be used concurrently with MAOIs and SSRIs? A. Inositol B. SAM-e C. 5-HTP D. St. John’s wort
3. Which of the following are reasons cancer patients utilize CAM? A. Pain B. Depression C. Sleep disturbances D. Menopausal symptoms E. All of the above
8. Which of the following is an approved FDA indication for THC? A. Pain B. Insomnia C. Nausea D. Anxiety
4. Which of the following herbals CAN be used concurrently with anticoagulants? A. Ginger B. Gingko C. Willow bark D. Kava 5. Patients allergic to which of the following should not take chamomile? A. Cat dander B. Ragweed C. Black tea D. Lavender
9. Which herbal supplement is the most likely to interact with anticancer agents? A. Gingko B. Kava C. Black Cohosh D. St. John’s wort 10. Which of the following is NOT a phytoestrogen? A. Chamomile B. Soy C. Flaxseed D. Licorice
The Kentucky Pharmacists Board of Directors is accepting nominations for the following positions to serve on the KPhA Board for the 2013-14 year: President-Elect, Treasurer, Director (3 open spots) Nominations may be submitted electronically to Scott Sisco at ssisco@kphanet.org or mailed to KPhA, Attn: Scott Sisco 1228 US 127 South, Frankfort, KY 40601 no later than March 31, 2013.
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April 2013 CE — Review of Herbals in Cancer Patients
March 2013
This activity is a FREE service to members of the Kentucky Pharmacists Association. The fee for non-members is $30. Mail completed forms to: KPERF, 1228 US 127 South, Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile. Expiration Date: March 20, 2016 Successful Completion: Score of 80% will result in 1.5 contact hours or 0.15 CEUs. Participants who score less than 80% will be notified and permitted one re-examination. TECHNICIANS ANSWER SHEET. April 2013 — A Review of Herbals in Cancer Patients: Use This Not That? Universal Activity # 0143-0000-13-004-H04-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 2. A B C D
3. A B C D E 4. A B C D
5. A B C D 6. A B C D
7. A B C D 8. A B C D
9. A B C D 10. A B C D
Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________
NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) PHARMACISTS ANSWER SHEET April 2013 — A Review of Herbals in Cancer Patients: Use This Not That? Universal Activity # 0143-0000-13-004-H04-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 2. A B C D
3. A B C D E 4. A B C D
5. A B C D 6. A B C D
7. A B C D 8. A B C D
9. A B C D 10. A B C D
Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________
NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD)
The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy Education as a provider of continuing Pharmacy education.
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Quizzes submitted without NABP eProfile ID # and Birthdate cannot be accepted.
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Why should I connect with KPhA?
March 2013
Why should I connect with KPhA? The Value of Membership Professionals are frequently and continually asked to join one or more professional organizations. Many pharmacists will join the Kentucky Pharmacists Association; many will not. Having been involved in the workings of the association since my college days and a member since graduation, it is my belief that it is in the best interest of all professionals to join and participate in the professional association that represents the comprehensive challenges of that specific profession.
Lynn Harrelson, Pharm BS KPhA Past President, 1991-1992
One of Kentucky’s Outstanding Young Women, 1983
KPhA Bowl of Hygeia for Outstanding Community Service, 1990
Wyeth’s True Caring National Recipient, 2006
KPhA Distinguished Service Award, 2010
KPhA Professional Promotion Recipient, 2010
Lambda Kappa Sigma Meritorious Service Award (international) 2011
KPhA Excellence in Innovation, 2012
“As we continue to strive for the advancement of the profession, it is even more important that we give the Association that represents all pharmacy practitioners in the state our greatest support by membership and involvement.”
I have spoken to many practitioners over the years and they have always wanted to get something done, an initiative started, changed or stopped. They can’t get it by themselves but want others or another “body” to listen to and address their “call to action.” Singularly, that is why we have professional associations. There is strength in numbers.
As we continue to strive for the advancement of the profession, it is even more important that we give the Association that represents all pharmacy practitioners in the state our In the years since my graduation, I have seen tremendous greatest support by membership and involvement. Your changes in our profession; in my humble opinion, each and membership and involvement in your professional associaevery one of them needed a pharmacist or a representative tion is truly your greatest voice. The bottom line is that the for the profession at these “tables of change” to address Board of Pharmacy does not represent you nor does your the changes, to get them started, changed or stopped. employer. Your best interests as a professional are best Simply put, the Board of Pharmacy’s obligation is to protect served by the association dedicated to start, change or the public and provide for its well-being by oversight of our stop initiatives. They give us voice in today’s changing and profession. The Board’s charge is to police the regulations challenging business climate and they support our commitment to the public consistent with the pharmacist’s oath put in place by governing bodies that may not understand that we repeated at graduation. or appreciate the intricacies of our professional practice. Simply put, employers provide each professional a livelihood within these regulations as well at the direction and demand from their governing bodies, owners, managers, stock holders, etc.
Pharmacists deserve a strong, committed voice at the “tables of change.” Do you value the future of your profession enough to support that voice by your membership and involvement?
Upon the passage of SB 107, George Hammons, KPhA Past President (2003-04), noted: “A great day for Pharmacy! Thanks to KPhA Government Affairs, KPhA Board, Senator Stivers and Senator Denton, APSC, APCI, EPIC, KIPA, all our lobbyists and those who made calls to legislators on behalf of SB107. It shows what we can do as one voice. No pharmacist in the state of Kentucky should question why they should belong to KPhA nor that they cannot afford the dues. Passage of this bill alone is more valuable than a lifetime of dues. Thank you Bob for all you and staff do. George Hammons, Past President
Visit www.kphanet.org today to connect with YOUR KPhA! 39
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Pharmacy Law Brief
March 2013
Pharmacy Law Brief: Contemporary Legal Issues for Leadership in Non-Profits - IV Author: Joseph L. Fink III, B.S.Pharm., J.D., Professor of Pharmacy Law and Policy and KPhA Professor of Leadership, Department of Pharmacy Practice and Science, UK College of Pharmacy Question: I am new to serving on the board of a nonprofit community health agency in my area. During one of the meetings an experienced board member mentioned something called “fiduciary obligations” that I have in that role. We had no orientation session for new board members. What is that? Response: At the outset it should be noted that an earlier column in this series, appearing in the November 2008, issue, was entitled “Potential Legal Exposure with Community Service as a Board Member of a Non-Profit Agency.” Further, a column entitled “Contemporary Legal Issues for Leadership in Non-Profits-I” appeared in the September issue and that was followed with “II” and “III”. This installment addresses issues related to the IRS Form 990 filed by tax exempt non-profit organizations and will supplement or extend those earlier discussions.
Submit Questions: jfink@uky.edu has voting rights on the governing body. It also embodies an expectation that members of the governing board review the content of the form before it is filed and that the board be primarily composed of independent board members. Some of this can be traced back to a piece of federal legislation known as the Sarbanes-Oxley Act of 2002. While rooted in the Enron financial scandal and aimed primarily at the functioning and organization of publicly traded for-profit entities, this legislation had a spill over impact on nonprofit organizations.
The IRS expects that a nonprofit will have a policy in place to protect individuals who come forward to report suspected irregularities, known as a “whistleblower” policy, as well as a policy regarding retention of documents of the organiThe official title of IRS Form 990 is “Return of Organization zation. Board members should be expected to know about and review these policies. Exempt from Income Tax.” In recent years the Internal Revenue Service has placed increased emphasis on the Board members are expected to be actively engaged in role this form plays in the governance of tax exempt organ- independent and informed oversight of the organization’s izations. During 2011, it was announced that more than activities. The board should adopt a conflict of interest poli3,000 formerly tax exempt organizations in Kentucky had cy as discussed in an earlier installment in this series. lost this favored status because they had failed to file a The bottom line is that pharmacists can make very subForm 990 for three consecutive years. stantial contributions to the nonprofit organizations in their The IRS has enhanced the Form 990 with several goals in communities, be they health-related, youth or elderly sermind: [1] enhance transparency to provide the IRS and the vice oriented, or religiously affiliated through service as a public with an accurate and realistic snapshot of the organmember of the governing board. But such responsibilities ization; [2] promote compliance with the tax laws; and [3] should not be undertaken lightly and the time commitment minimize the burden on tax exempt organizations. should be understood before entering the relationship. The The revised form collects expanded information regarding days of “lending my name” to be on a board are no longer governance of the organization, such as identifying who here. 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.
Are you connected to KPhA? Join us online!
@KyPharmAssoc @KPhAGrassroots
KPhA Company Page
Facebook.com/KyPharmAssoc
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Advancing Pharmacy Practice in Kentucky
March 2013
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Pharmacy Policy Issues
March 2013
PHARMACY POLICY ISSUES: Clinical Assisted Suicide Author:
William M. Black is a third professional year PharmD student at the UK College of Pharmacy. He hails from Paducah where he completed his pre-professional course work at West Kentucky Community and Technical College as well as at UK.
Issue:
Several states have statutes authorizing “physician assisted suicide”, known specifically as “Death with Dignity” statutes. What is the role for pharmacists with that?
Discussion: Physician assisted suicide (PAS) is a practice that has been around for years but is slowly gaining acceptance in the United States. With statutes already in place in Oregon1 and Washington2, and court cases in Montana3,4 that allow for the practice, it could end up in Kentucky in the not so distant future. For example, during the past two decades California, Hawaii, Maine and Michigan have had unsuccessful attempts, either through ballot initiatives or through legislative proposals, to create the opportunity for PAS.5
is to dispense the medication. This can happen in person or through the mail and is true for any ancillary medications as well, such as anti-emetics to prevent vomiting and ensure adequate absorption. In addition, the prescriber must disclose to the pharmacist the intended use of the medications. At this time, the pharmacist must decide if he or she wants to honor the prescription. Once prepared, the patient or a designated agent may pick up the medications.1,2
Every year Oregon and Washington publish reports summarizing PAS activity for the previous year, and WashingWhile “physician assisted suicide” is the commonly accept- ton includes information regarding the number of pharmaed term, it gives the impression that this is merely an inter- cists participating. The number of pharmacists has risen in action between a patient and his doctor. In reality there are parallel with the number of prescriptions issued each year, multiple individuals, both practitioners and laypeople, who with 2.2 prescriptions per participating pharmacist over the are involved in this process from start to finish. These addi- last three years.7,8,9 This of course does not mean that the tional people include nurses, therapists, family and friends, average participating pharmacist dispenses approximately caregivers and even pharmacists. While the role of the two prescriptions each, because prescribers have the oppharmacist is not an intensive one, it is nonetheless imtion of dispensing directly to the patient. portant and for some may even pose a moral or religious While PAS is not yet allowed in Kentucky, it is not unrealisobstacle. tic to think that it may happen in the near future, certainly The statutes in Oregon and Washington clearly outline the before my time as a practicing pharmacist comes to an proper legal process for those participating in PAS right end. For now, the Kentucky pharmacist should begin to down to how the prescription may be filled. Just as in Ken- consider his or her opinion on the matter and be prepared tucky, the prescriber has the option to directly dispense the should he or she ever have to make the decision, “to fill or life-ending medication (LEM) to the patient. Most commonly not to fill” a life-ending medication. used medications are rapid-acting barbiturate elixirs, usualReferences: ly secobarbital or pentobarbital.6 Prescribers who cannot or 1. Oregon Death with Dignity Act, Oregon Code §127.800. do not want to do this can send the prescriptions to the pharmacy. This is where the difference exists. Under the 2. Washington Death with Dignity Act, Wash, Rev. Code systems in place in states where this is authorized, a pre§70.245 (2008). scription for a LEM may not be handled by the patient or 3. Baxter et al. v. State of Montana, 2008 Mont. Dist. Lexis given orally or electronically to the pharmacist. The prescriptions must be delivered directly to the pharmacist who 482 (First Jud. Dist. Ct.) (2008).
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. 42
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March 2013
Kentucky Renaissance Pharmacy Museum 4. Baxter et al. v. State of Montana, 354 Mont. 234, 224 P.3d 1211 (2009).
DWDA2009.pdf.
6. Oregon Department of Public Health. Oregon DWDA Summary, Year 14 - 2011 Table 1. Available at http:// public.health.oregon.gov/ProviderPartner Resources/ EvaluationResearch/DeathwithDignityAct/Documents/ year14-tbl-1.pdf.
9. Washington State Department of Health. 2011 Death with Dignity Act Report Executive Summary. Available at http://www.doh.wa.gov/Portals/1/Documents/5300/ DWDA2011.pdf.
8. Washington State Department of Health. 2010 Death 5. Ganzini L, Dobscha S. Clarifying Distinctions between with Dignity Act Report Executive Summary. Available at Contemplating and Completing Physician-Assisted Suicide. http://www.doh.wa.gov/Portals/1/Documents/5300/ The Journal of Clinical Ethics. (2004); 15:119-22. DWDA2010.pdf.
7. Washington State Department of Health. 2009 Death with Dignity Act Report Executive Summary. Available at http://www.doh.wa.gov/ Portals/1/Documents/5300/
Special Acknowledgement: The work reported here was completed with support from the Summer Research Program of the UK College of Pharmacy.
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
Continued from Page 6 this issue and for working together to ensure that pharmacies can continue to provide this valuable service to patients. KPhA staff and lobbyists have worked with members in both chambers to inform legislators about the impacts these bills (and others as outlined in our regular legislative updates) would have on YOU. But the biggest impact in
Frankfort doesn’t come from me or our lobbyists in Frankfort. It comes from YOU and YOUR contacts with YOUR legislators. It also comes from YOUR donations to the Kentucky Pharmacists Political Advocacy Council, which funds donations to legislative candidates friendly to the profession as well as your additional support of our legislative work through YOUR contributions to KPhA’s Government Affairs fund. YOUR engagement continues to make the difference. 43
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Pharmacists Mutual
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KPhA Government Affairs Contribution
March 2013
A Message from Richard Slone, Chairman, KPhA Governmental Affairs Committee I first want to say what a great victory it is for the practice of pharmacy with the passage of SB 107. It should remind us what can be accomplished when all segments of our profession work together. If I may borrow from Armstrong’s thinking, "One small step for a pharmacist, one giant step for the Practice of Pharmacy." Congratulations and a very much deserving thank you to our Executive Director Robert McFalls, Jan Gould and Gay Dwyer—KPhA's lobbyist team, and to our partners APSC, APCI, EPIC and KIPA for a collective and focused approach. Their combined leadership and dedicated work during this session was endless. Thanks to all those pharmacists that answered the call when needed and contacted their legislators, and those that made many trips many times to Frankfort to aid in this cause. Congratulations to our President Kim Croley, our leadership and to our entire Board of Directors for leading the Association in this victory charge and supporting the Governmental Affairs Committee’s recommendations. Congratulations to our Governmental Affairs Committee members who unanimously and with very active participation decided to stay focused on
one major legislative agenda item during this short session. I also would like to congratulate the staff at KPhA who worked countless hours behind the scenes so KPhA’s front line team could stay in the field. I would be remiss if I did not thank Senator Denton for undying and rock hard support for Pharmacy by introducing and spearheading SB 107 through the Senate and the House. I would like to remind each of you to thank your senator and representative personally now and before the next session with a monetary contribution to show them just how much they are needed and appreciated. Pharmacy will need each one of these who unanimously supported us, without a single no vote, again in the future. Let us not leave a bad taste in their minds by not supporting them either by active participation when they may request or need it or by monetary support through a campaign contribution. Congratulations and enjoy, but let us stay vigilante. Remember to support KPPAC and KPhA's Governmental Affairs Fund. These resources aided our association and profession in this great victory and will help with the next one.
Editor’s Note: KPhA gratefully acknowledges the leadership of Richard Slone, Government Affairs Committee Chairman, for his relentless devotion to Grassroots Advocacy and shepherding SB 107 through the legislative process.
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KPhA Board of Directors
March 2013
KPhA BOARD OF DIRECTORS
HOUSE OF DELEGATES
Lewis Wilkerson, Frankfort rphs2@aol.com
Chairman 502.695.6920
Matt Martin, Louisville matt67martin@gmail.com
Kimberly Croley, Corbin kscroley@yahoo.com
President 606.304.1029
Cassandra Beyerle, Louisville Vice Speaker of the House cbeyerle01@gmail.com
Duane Parsons, Richmond dandlparsons@roadrunner.com
President-Elect 502.553.0312
KPERF ADVISORY COUNCIL
Frankie Hammons Abner, Barbourville frankiehammons@gmail.com
Secretary 606.627.7575
Glenn Stark, Frankfort glennwstark@aol.com
Treasurer
Donnie Riley, Russelville Past President donnierileyatclinicpharmacy@msn.com Directors Molly Trent, Georgetown mjtren2@uky.edu
Student Representative
Lance Murphy, Louisville lmurph8942@my.sullivan.edu
Student Representative
Matt Carrico, Louisville matt@boonevilledrugs.com Chris Clifton, Erlanger chrisclifton@hotmail.com Trish Freeman, Lexington* trish.freeman@uky.edu Chris Killmeir, Louisville cdkillmeier@hotmail.com Jeff Mills, Louisville jeff.mills@nortonhealthcare.org Bob Oakley, Louisville Boakley@BHSI.com Richard Slone, Hindman richardkslone@msn.com Sam Willett, Mayfield duncancenter@bellsouth.net
Speaker of the House
Kim Croley, Corbin kscroley@yahoo.com Ann Amerson, Lexington amerson@insightbb.com
KPhA/KPERF HEADQUARTERS 1228 US 127 South, Frankfort, KY 40601 502.227.2303 (Phone) 502.227.2258 (Fax) www.kphanet.org www.facebook.com/KyPharmAssoc www.twitter.com/KyPharmAssoc Robert McFalls, M.Div. Executive Director rmcfalls@kphanet.org Scott Sisco, MA Director of Communications & Continuing Education ssisco@kphanet.org Kelli Sheets Office Manager ksheets@kphanet.org Christine Richardson, PharmD Clinical Pharmacist, Director of Professional & Clinical Services crichardson@kphanet.org Leah Tolliver, PharmD Director of Pharmacy Emergency Preparedness ltolliver@kphanet.org Nancy Baldwin Receptionist/Office Assistant nbaldwin@kphanet.org
* At-Large Member to Executive Committee
KPhA sends email announcements weekly. If you arenâ&#x20AC;&#x2122;t receiving: eNews, Legislative Updates, Grassroots Alerts and other important announcements, send your email address to ssisco@kphanet.org to get on the list.
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50 Years Ago/Frequently Called and Contacted
March 2013
50 Years Ago at KPhA From A talk given by Fred B. Kluth, prominent Louisville pharmacist at the Pharmaceutical Workshop in Lexington on March 20th. Computing the Professional Fee: There are three basic factors that must be considered in determining the prescription charge, regardless of the method used. These are — 1. The cost of the ingredient or ingredients and container, 2. The cost incurred in dispensing the prescription, 3. The profit necessary to sustain the enterprise and to permit its growth. — From The Kentucky Pharmacist, April 1963, Volume XXVI, Number 4.
Frequently Called and Contacted Kentucky Pharmacists Association 1228 US 127 South Frankfort, KY 40601 (502) 227-2303 www.kphanet.org Kentucky Board of Pharmacy State Office Building Annex, Ste. 300 125 Holmes Street Frankfort, KY 40601 (502) 564-7910 www.pharmacy.ky.gov Pharmacy Technician Certification Board 2215 Constitution Avenue Washington, DC 20037-2985 (800) 363-8012 www.ptcb.org
Kentucky Society of Health-System Pharmacists P.O. Box 4961 Louisville, KY 40204 (502) 456-1851 x2 (502) 456-1821 (fax) www.kshp.org info@kshp.org 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
For more information on how you can be involved in the KPhA Emergency Preparedness Initiative, contact Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness at 502-227-2303 or by email at ltolliver@kphanet.org. KPhA is a partner with the Kentucky Department of Public Health for emergency preparedness and disaster response.
For more resources, visit YOUR www.kphanet.org and click on Resources—Emergency Preparedness.
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THE
Kentucky PHARMACIST 1228 US 127 South Frankfort, KY 40601
Register now! 135th KPhA Annual Meeting June 6-9, 2013 Louisville Marriott Downtown
Visit www.kphanet.org to register.
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