The Kentucky Pharmacist Vol. 11, No. 2

THE KENTUCKY PHARMACIST Vol. 11, No. 2 March/April 2016 News & Informat ion for Members of the Kentucky Pharmacists Ass ociation

Kentucky at APhA Left: Kentucky Delegates Amanda Jett, KPhA President Chris Clifton, Suzi Francis and Kim Croley.

Below: KPhA Past President Melinda Joyce, Clifton, Croley and Christopher Forst from Dublin, Ohio

Roamey met some new friends! SUCOP professors Vinh Nguyen, Julie Burris and Katie Petrone. (Pictured with Amanda Jett and President Clifton.)

Former KPhA Speaker Joey Mattingly ran for APhA Speaker of the House, but was not successful this time.

APhA Executive VP/CEO Tom Menighan is seated.

Guardian of the Profession in Frankfort

Table of Contents

March/April 2016 April Pharmacist/Pharmacy Tech Quiz Answer Sheet KPERF CE Article Guidelines 138th KPhA Annual Meeting and Convention KPhA Emergency Preparedness KPhA New and Returning Members Naloxone Certification Training Pharmacy Law Brief 2015 Bowl of Hygeia Winners Pharmacy Policy Issues Pharmacists Mutual Cardinal Health KPhA Board of Directors 50 Years Ago/Frequently Called and Contacted

Table of Contents Table of Contents— Oath— Mission Statement President’s Perspective Joel Thornbury for House of Representatives Kentucky at APhA From your Executive Director The Campaign for Kentucky’s Pharmacy Future APSC KPhA 2016 Board Election March 2016 CE — The Hormone Surge March Pharmacist/Pharmacy Tech Quiz Answer Sheet April 2016 CE — Therapeutics For Pet Aggression

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28 29 30 31 32 35 36 37 38 40 41 42 43

Oath of a Pharmacist At this time, I vow to devote my professional life to the service of all humankind through the profession of pharmacy.

I will consider the welfare of humanity and relief of human suffering my primary concerns.

I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy outcomes for the patients I serve.

I will keep abreast of developments and maintain professional competency in my profession of pharmacy.

I will embrace and advocate change in the profession of pharmacy that improves patient care.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.

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

Editorial Office: © Copyright 2016 to the Kentucky Pharmacists Association. The Kentucky Pharmacist is the official journal of the Kentucky Pharmacists Association published bi-monthly. The Kentucky Pharmacist is distributed to KPhA members, paid through allocations of membership dues. All views expressed in articles are those of the writer, and not necessarily the official position of the Kentucky Pharmacists Association.

Editor-in-Chief: Robert McFalls Managing Editor: Scott Sisco Editorial, advertising and executive offices at 96 C. Michael Davenport Blvd., Frankfort, KY 40601.

Phone 502.227.2303 Fax 502.227.2258.

Email ssisco@kphanet.org.

Website http://www.kphanet.org.

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

It is the goal of KPERF to ensure that pharmacy in Kentucky and throughout the nation may sustain the continuing need for sufficient and adequately trained pharmacists. KPERF will provide a minimum of 15 continuing pharmacy education hours. In addition, KPERF will provide at least three educational interventions through other mediums — such as webinars — to continuously improve healthcare for all.

Programming will be determined by assessing the gaps between actual practice and ideal practice, with activities designed to narrow those gaps using interaction, learning assessment, and evaluation. Additionally, feedback from learners will be used to improve the overall programming designed by KPERF. 2

THE KENTUCKY PHARMACIST

President’s Perspective

March/April 2016

PRESIDENT’S PERSPECTIVE Chris Clifton KPhA President 2015-2016

In my presidential address back in June, I spoke about the problem of apathy in the pharmacy profession. First off, what is apathy? Meriam-Webster’s Dictionary defines apathy as “a lack of interest, enthusiasm or concern.” When did pharmacists become apathetic? We certainly don’t have it in taking care of our patients, but why is it in our profession. Is it a sense of “I have no time, somebody else will take care of it for me, not sure where to start, or don’t know how?” Being an advocate is what helps your profession thrive, move forward and shape how you want it to be in the future. And you can certainly advocate in several different ways, whether it is being an active member in your local, state or national association like OUR KPhA; monetarily donating with membership to your professional association, a legislative defense fund or a political action coalition or becoming politically involved yourself by running for a local, state or federal public office. Isn’t there enough time today and every day to give back to the profession that has afforded us so much and help its continued future success for the pharmacists of today and the pharmacists of tomorrow?

Two KPhA members that have decided to cross that line and get into the fight are Joel Thornbury and Danny Bentley, both who have filed to run for the Kentucky House of Representatives in their respective districts.

held the office of President multiple times.

Danny Bentley (R-Russell) is running for the 98th House District that is also an open seat after former State Representative Tanya Pullin (D-South Shore) was appointed to an administrative law judge position. Bentley is an active member of the Kentucky Pharmacists Association and a former President of the Ohio Pharmacists Association. He will face two Republican challengers in the Primary, and there are three Democrats who also have filed for the seat.

Currently, the Kentucky General Assembly does not have a pharmacist legislator. Retired Senator Richard Roeding (RLakeside Park) is the last pharmacist to serve in the legislature, and he stepped down in 2004. I want to applaud these two men for getting into the ring and representing the profession of pharmacy in the Kentucky Legislature. Having representation like this at the state level will hopefully successfully move the profession where it needs to go in the future. I wish both of these candidates good luck and know that you and OUR KPhA will be right there to support them along the way. Let’s UNITE and “Help Send a Pharmacist to Frankfort!”

So I know that not all of us have the time to devote to a full campaign and be active legislators, but we can still be involved as a fan on the sideline. Be involved with OUR KPhA in tracking legislative updates that come out every week during the legislative session. This will give you firsthand knowledge of what is happening in the legislature that may dictate how you practice your profession. Act on Grassroots Alerts when needed during the legislative session, by calling, writing or emailing your legislator when necessary or directed by OUR KPhA. Our elected officials work for their constituents (US), let them know about the issues and how they might affect our livelihood. And last but not least, and if you don’t like to communicate your interests, you can always donate monetarily to a campaign, OUR Association’s legislative defense fund or KPPAC in order to help pay for the cause.

Let’s shed the apathy cloak from our profession and become a more UNITED, LOUDER and STRONGER VOICE Joel Thornbury (D-Pikeville) has filed for the 94th House for our profession of pharmacy. So many of us are so well District. Representative Leslie Combs (D-Pikeville) has decided not to run for re-election, and as a result, the seat thought of by our local patients and communities with our passion for making peoples’ lives better every day. We can is open. There are two other Democratic candidates and four Republicans running for the seat. Joel is a past Presi- and should have that translate to the rest of state and nadent and active member of the Kentucky Pharmacists As- tional level with our increased advocacy, passion and desociation (KPhA). Joel also has served for the past 7 years votion to our profession. Join the fight today, Get Involved with KPhA!! on the Kentucky Board of Pharmacy, and during that time

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

THE KENTUCKY PHARMACIST

Joel Thornbury for House of Representatives

March/April 2016

Paid for by Joel Thornbury for House of Representatives

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THE KENTUCKY PHARMACIST

Kentucky at APhA

March/April 2016

Kentucky at APhA KPhA President-Elect Trish Freeman was recognized as an APhA-APRS Fellow at the APhA Opening Session. She is pictured with Lawrence “L.B.” Brown, APhA President and APhA-APRS President Melody Ryan.

Kim Croley received the Distinguished Achievement Award for Service at APhA Second General Session presented

by Lawrence “L.B.” Brown, APhA President.

Hanna M. Burgin, University of Cincinnati James L. Winkle College of Pharmacy, won the Good Government Student Pharmacistof-the-Year Award. Hanna is a KPhA Student Member.

UKCOP Dean Emeritus Ken Roberts received the Kappa Psi A. Richard Bliss, Jr. Grand Council Citation of Appreciation.

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THE KENTUCKY PHARMACIST

From Your Executive Director

MESSAGE FROM YOUR

EXECUTIVE DIRECTOR Engagement with OUR KPhA means being involved with an association with a rich and diverse history. It is a living history — one that we embrace throughout the year and will gladly showcase once again at the 138th KPhA Annual Meeting & Convention, June 2-5. Similarly, as we move through our professional lives and the years continue to turn, many of us think about the touchpoints of that individual journey and the legacy we are leaving. Whether they are the accomplishments through our profession or personal achievements by our families and loved ones (more than likely both!), we have the opportunity to shape the future of the world through what we leave behind. While our journey upon this earth will end one day, we have the opportunity to live on through the legacy we leave and the positive impact we make in the world.

One way OUR KPhA is adding to its legacy is the successful advocacy for several bills in the 2016 Kentucky Legislative Session, including SB 117, the PBM MAC Transparency Bill; modifying the notification requirements in SB 134, the Biosimilar bill, to make them less onerous; and working to add protocol authority language when authorized by the Board of Pharmacy related to "prescription drug orders" by working to modify HB 527 (which also adds new language to the practice act to define “administrative activities of a pharmacy”).

These are just a few of the 19+ bills that were filed in the session that could impact the profession. Some of these bills we supported. Some we opposed. Some we supported parts while opposing other sections by working with legislators and engaging with you — advocates for the profession — to improve these bills. And thanks to your calls, emails and contacts with your legislators, OUR KPhA and our pharmacy partners were very successful again this year in finalizing a new legislative legacy chapter that we will detail in the next journal.

March/April 2016

Robert “Bob” McFalls

said. A child or a book or a painting or a house or a wall built or a pair of shoes made. Or a garden planted. Something your hand touched some way so your soul has somewhere to go when you die, and when people look at that tree or that flower you planted, you're there. It doesn't matter what you do, he said, so long as you change something from the way it was before you touched it into something that's like you after you take your hands away. The difference between the man who just cuts lawns and a real gardener is in the touching, he said. The lawn-cutter might just as well not have been there at all; the gardener will be there a lifetime.”

Each of us walks a unique path, but there are many intersections. When I was dubbed a knight in The Order of St. John of Jerusalem, Knights Hospitaller of Florida on Dec.17, 2007, I didn’t know that one day I would be working with OUR KPhA to advance the profession of pharmacy and clinical services for patients within healthcare. The Order of St. John is said to be the oldest Order of Chivalry in existence and has raised funds to benefit the sick and poor of the world since 1048 A.D. From time to time, I am asked about my journey with this Order, so I will share briefly here. The Order’s motto is Pro Fide, Pro Utilitate Hominum, meaning “For Faith, For Service to Humanity.” The Order of St. John has its roots in a hospice founded in Jerusalem in the eleventh century by merchants from Amalfi, to assist Christian travelers in the Holy Land. Some knights of the First Crusade, upLikewise, several members are leaving a legacy for the pro- on entering Jerusalem in July 1099, joined in these good works already underway. And, these good works were exfession through their support of The Campaign for Kentucky’s Future: The Next 50 Years. I point your attention to tended to Christian and Muslim alike. Today, the Order of St. John of Jerusalem, Knights Hospitaller, is an ecumenical, the page to the right where we applaud the inaugural meminternational Christian organization directly descended from bers of The Campaign’s Committee of 100. Once this comthe close collaboration of crusader knights with the hospitalmittee is fully formed, OUR KPhA and KPERF will be more than halfway to The Campaign’s goal of securing a new per- ler activities of the hospice founded by Amalfi merchants for pilgrims. That legacy continues to thrive almost one thoumanent headquarters and professional home. And, we are sand years later. actively recruiting new committee members — will you be ONE?!

Thank you for the opportunity to share in this journey as your Of legacy, wrote Ray Bradbury in Fahrenheit 451: “Everyone executive director and for all that you do and will continue to must leave something behind when he dies, my grandfather do both professionally and personally.

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THE KENTUCKY PHARMACIST

The Campaign for Kentucky’s Pharmacy Future

March/April 2016

Join the Committee of 100 and help OUR KPhA accelerate to 50 percent of our Campaign Goal!

Donors to the campaign as of March 24, 2016                 

Jeff Arnold Ray Bishop Fred Carrico Matt Carrico Jessika Chinn J. Leon Claywell David Dubrock Brian Fingerson Matt Foltz Robert Goforth Cynthia Gray JCAP Bob Oakley Duane Parsons Richard & Zena Slone Leah Tolliver Mary Ann & Michael Wyant

Join the campaign!

You’re Invited to an Open House May 19, 2016

1:00-6:00 p.m. EDT

At the NEW KPhA/KPERF Headquarters 96 C. Michael Davenport Blvd. Frankfort, KY 40601 Come tour the new KPhA/KPERF Headquarters and learn about plans for the future of the profession.

Refreshments provided.

RSVPs at www.kphanet.org are encouraged but not required.

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Select one of the History of Pharmacy in Pictures Prints to be framed and displayed in the new headquarters.

There are 36 prints in the series remaining to be claimed. KPhA will include a plaque on the frame to commemorate a minimum $1,000 donation. You can dedicate the donation to yourself, a colleague or honor another entity. http://www.kphanet.org/? page=buildingcampaign or call 502-227-2303.

THE KENTUCKY PHARMACIST

APSC

March/April 2016

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THE KENTUCKY PHARMACIST

2016 KPhA Board of Directors Election

March/April 2016

2016-17 KPhA Board of Directors Candidates for Election sion of pharmacy. Over the past eight years, the success of his pharmacies Robert Goforth, PharmD, RPh has allowed him and his family to donate several hundred thousand dollars Robert Goforth is an independent back to the communities he serves. pharmacy owner of three successful Some of the great causes he supports pharmacies in southeast Kentucky.

Robert started his pharmacy career as are scholarships for pharmacy school a technician at Kentucky Clinic Outpa- students, annual Christmas gifts to the tient Pharmacy in 2001. After finishing children of the communities, orphanages, local school functions, churches, undergraduate work at University of Kentucky, Robert graduated from Mas- March of Dimes, Relay for Life and many more. His oldest son Jordan is sachusetts College of Pharmacy with currently finishing his undergraduate his Doctor of Pharmacy Degree in 2005. Upon graduation he accepted a degree and looks forward to following position as a staff pharmacist with Rite in his father’s footsteps. Robert and his wife, Ashley, are the proud parents of Aid in Manchester, Ky. Robert was triplets that arrived 11 weeks early. promoted to Pharmacy Manager in After a 23 weeks stay in Cincinnati less than one year and transferred to Children’s Hospital, they are home and the London, Ky., Rite Aid. In December 2007 Robert opened his first retail thriving. pharmacy. With a collaboration agree- Robert has always had a passion for ment from a local physician, Robert public service. At the age of 18, he was the first independent pharmacist signed up for the United States Army. in the area to provide immunizations His primary job in the Army was Comon site for his patients, from pediatric bat Engineer. Combat Engineers are a to geriatrics. Robert built his three suc- group at the forefront of the military cessful independent retail pharmacies missions, breaching mine fields, demofrom the ground up in Clay, Jackson lition of bridges or any other obstacles and McCreary counties. Robert emthat stand in the way of a troops’ misploys 32 fulltime employees, including sion. During his military service, Robthree fulltime pharmacists and four ert was awarded several service medpart-time. als including AAM (Army Achievement

President-Elect

cist, the preservation, protection and advancement of the profession for all pharmacists. My overall education and career history proves I have the education and experience to make great contributions to the Kentucky Pharmacists Association as President-Elect.

As a leader of the Kentucky Pharmacists Association, it will yield me the opportunity to lobby for legislation to protect the practice of pharmacy, the pharmacists I will serve and the public.

Thank you for your time and consideration. As the next President-Elect, I will help protect and promote all aspects of the practice of pharmacy.”

Christopher P Harlow, PharmD Chris Harlow gained acceptance to the University of Kentucky College of Pharmacy in 2006, where his passion, leadership, academic achievements and determination to promote the profession preluded his professional achievements of today.

As a student, Chris was a member of APhA-ASP, Kentucky Pharmacists Association (KPhA), ASHP, Rho Chi Academic Honor Society, Phi Lambda Sigma Pharmacy Leadership Society and served as the president of the student chapter of the National Community Pharmacists Association. He reguMedal) for exemplary service.

Robert has focused all of his efforts larly attended national conventions over the past decade to the practice of “Public service has been the forefront where he was able to network with of my entire life and now is a crucial pharmacy, his communities and his other leaders in our profession that family. Professionally, he is a member time in the practice of pharmacy, espehave become his mentors today. of Kentucky Pharmacists Association, cially as an independent owner. We UK Fellows Society, National Commu- must fight harder than we ever have in Although he is very humble about the the history of the profession to survive. awards he received as a student, they nity Pharmacy Association, National Today is the day we must energize the serve as a reflection of his passion and Pharmacy Disaster Team and Phi Lambda Sigma Pharmacy Leadership practice of pharmacy. Every pharmacy dedication to excellence in the professchool student, pharmacist and owner sion. As a student, Chris received the Society. Robert’s family has always must get more involved to ensure the been supportive of his hard work and Roche Pharmacy Communication long hours he’s devoted to the profes- survival of the independent pharmaAward, Rotary Scholarship Award, 9

THE KENTUCKY PHARMACIST

2016 KPhA Board of Directors Election

March/April 2016

ELECTION DETAILS The election will be held electronically via the KPhA website at http://www.kphanet.org/page/2016election.

When you click on the link, you will be asked to log in. If you have trouble logging in, please email Scott Sisco at ssisco@kphanet.org.

Paper ballots will be mailed to members who do not have an email on file.

Paper ballots also will be provided on request by calling 502-227-2303.

The election will be open until May 9, 2016.

LeeShafft Professionalism Award, Phi Lamba Sigma Leadership Award, National Clinical Skills Competition Top 10 Finalist, Oscar C. Dilly Award for Excellence in Pharmacy Administration and the APSC Student Achievement Award. Chris graduated summa cum laude from the College of Pharmacy in 2010.

Following graduation, he completed a community pharmacy residency at the University of Kentucky and American Pharmacy Services Corporation (APSC). During his residency, he had the opportunity to work and engage with pharmacy professionals in the local and state associations. It was this opportunity to collaborate with other pharmacy professionals in the state that would help forge the relationships that he cherishes today. These opportunities and relationships now serve as the foundation for his preparedness to lead our Kentucky Pharmacists Association.

Since graduating in 2010, Chris has served as the past Chair of the KPhA New Practitioners Committee, Treasurer and current Chair of Rx Therapy Management, President for the Jefferson County Academy of Pharmacy and as a member of the Board of Directors as Vice Speaker and current Speaker of the House for KPhA. During his time on the Board of Directors, he has gained valuable insight into the organization and looks forward to continuing serving in a leadership capacity to advance the profession of pharmacy.

He is co-owner and Director of Pharmacy Services for two independent pharmacies in Louisville. As an independent pharmacist, he is always searching for opportunities to advance the role of the pharmacist. He has implemented several clinical programs in his pharmacies, so he understands the challenges faced by his colleagues on the legislative and regulatory front. He also serves as preceptor for both UK and Sullivan University Colleges of Pharmacy.

Chris’ dedication to the profession extends beyond the success of his own pharmacies. “Promoting a pharmacy is different than promoting a pharmacist.

We are promoting pharmacists, we are promoting our value and role in providing quality care to our patients and to the communities we serve.” This dedication was recognized when he was awarded the “Distinguished Young Pharmacist of the Year” Award in 2014 by the Kentucky Pharmacists Association.

Chris also currently serves as President of the Jefferson County Academy of Pharmacy and one of his accomplishments is working with the JCAP Board of Directors to approve an affiliation agreement with KPhA in an effort to strengthen the partnership and unify the pharmacists of Kentucky. Chris views involvement in his local and state pharmacy organizations as an important way that all pharmacists should work to promote the profession.

“I think it is very important for all phar10

macists to be involved in their local pharmacy organization. The only way the profession is going to be able to move forward is by all pharmacists having a united voice, and get all pharmacists involved in legislative efforts.

The best way to promote yourself as a pharmacist is to promote the profession itself.

“I look forward to campaigning for our Kentucky Pharmacists Association’s future as we continue to raise funds for our new headquarters and professional home. KPhA is off to a great start, but we still have work to do. If elected, I will spend my time traveling the state to promote our efforts and raise capital to achieve our goal. I will continue to build on the relationships forged by our Kentucky Pharmacists Association with both colleges of pharmacy as we advance our profession. I will continue to work with other local associations to partner with KPhA. I am ready and prepared to lead. I ask for your support and vote to serve as the next President -Elect for our Kentucky Pharmacists Association.”

Secretary Brooke Hudspeth, Pharm D, CDE Brooke Hudspeth is a clinical diabetes care pharmacist for Kroger Pharmacy and serves as the Program Coordinator for Kroger’s American Diabetes Association–recognized Diabetes SelfManagement Education Program. She received her doctor of pharmacy degree from the University of Kentucky

THE KENTUCKY PHARMACIST

2016 KPhA Board of Directors Election College of Pharmacy in 2007. Upon graduation, Dr. Hudspeth completed a postgraduate (PGY1) residency with an emphasis in community care with the University of Kentucky and Kroger Pharmacy. Dr. Hudspeth’s practice interests include medication therapy management and disease state management, particularly diabetes.

March/April 2016

member. Her current role as assistant professor at Sullivan University College of Pharmacy would allow for strengthening relationships between KPhA and our colleges of pharmacy.

She also serves on the Jefferson County Academy of Pharmacy Board, where JCAP is working toward strengthening relationships between the regional associations and KPhA.

reer winds down, I believe I could contribute a little of my experience to the association and to preserve a profession I have been dedicated to my entire life.”

David DeCuir, RPh

David DeCuir has been a licensed pharmacist since 1998, and has been involved in pharmacy in many areas.

In addition to her clinical practice activHe has been a PIC at independent, ities, Dr. Hudspeth is Assistant Profes- Cassy brings a different practice backlarge and medium chain retail and long sor at the University of Kentucky Colground to the mix, practicing with in the term care pharmacies. In those setlege of Pharmacy. She serves as a primary care clinic in a federally qualitings, he has seen a need for advocapreceptor for the University of Kenfied health center. She believes dicy for the Kentucky pharmacist. tucky College of Pharmacy/Kroger verse backgrounds on the Board will Community Pharmacy Residency Pro- allow it to serve the profession across “Attending board meetings on electronic prescribing has reinvigorated my gram. She also is on the faculty of the the state more effectively and comdesire to be a part of the solution. I American Pharmacists Association’s pletely. would like the opportunity to help procertificate training program The Phar“I am excited about the prospect of mote the future of pharmacy, especialmacist and Patient-Centered Diabetes representing fellow pharmacists ly in Kentucky.”

Care. through service as a KPhA board Cathy Borders Hance, RPh “I feel that I would be a valued addition member. Service to the profession is to the KPhA Board. My perspective on something that I cherish and find imCathy Borders Hance has been praca number of issues related to our phar- portant to personal growth as well as ticing pharmacy for 26 years and has macy profession would be a positive growth of the profession. I would be co-owned an independent pharmacy, asset to the board and to KPhA’s dehonored to serve my profession by Compound Care Pharmacy, in Louissire to serve and protect our state’s serving as a KPhA board member.” ville for 11 years. Cathy comes from a pharmacists. The only way to progress family of pharmacists: Her father and Tom Beringer, RPh our profession is to be an active two sisters are pharmacists and two of Tom Beringer graduated from the Unichange agent, and I feel one of the her children are currently studying versity of Cincinnati in 1976 and spent best ways I can do this is by actively pharmacy. She is a member of JCAP, the last 38 years in the trenches of participating in my state’s pharmacy KPhA, International Association of independent pharmacy and his own organization. I am involved in many Compounding Pharmacy (IACP) and avenues to showcase and enhance the business taking care of patients. He PCCA ACT (a compounding advocacy impact of pharmacists on both the local has three great kids, a loving wife and lobbying group). She is also a precepand national levels and am extremely a passion for pharmacy since he was tor for the University of Kentucky Coleight years old. He is not a politician or passionate about my profession!” lege of Pharmacy. She resides in Louan educator, although he has menisville with her husband of 28 years, Director tored many young pharmacists, includDavid, and they have three children, ing his daughter, over the years. He is Cassandra Beyerle Hobbs, PharmD, two of whom are currently studying your “Every Day Joe” who had a MBA, BCACP, LDE pharmacy. dream to become the best that he Dr. Cassandra Hobbs has been in“Now that my children are grown and could be and that was a pharmacist. volved with KPhA since graduation ‘out of the nest,’ I am able to commit With his daughter and son-in-law, he from the University Of Kentucky Colmore time to getting involved in the has four stores that employ 40 people lege Of Pharmacy, first serving on the advocacy of my profession. I have New Practitioners Committee, then as in areas that would be otherwise deconsistently demonstrated in my pracvoid of a drug store.

Vice-Speaker and Speaker of the tice the value of pharmacist services, KPhA House of Delegates. She would “I have always supported the efforts of and I am certain that my experience very much enjoy continuing her inthe Pharmacy community, and its ulti- qualifies me to represent the voice of volvement and service as a board mate goal for patient care. As my capharmacy.”

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THE KENTUCKY PHARMACIST

2016 KPhA Board of Directors Election Ethan Klein, PharmD Ethan Klein moved to Louisville following a PGY1 residency in North Chicago. He started his career in Louisville as a clinical coordinator, and has been with Rite Aid the last four years. Experience in hospital pharmacy, as a clinical coordinator, and a community pharmacist, have helped shape his understanding of the different facets of pharmacy and his understanding of the significant challenges this profession faces.

After completing his term as KPhA Speaker of the House of Delegates, Ethan remained active within KPhA as a member of the Government Affairs Committee. Last year, with other KPhA members, he met with legislators to forward KPhA’s agenda in supporting changes to the Bio-similar Substitution bill. Ethan is currently co-chair of the Professional Affairs/Public Affairs Committee and a member of the KPPAC Board.

“With practical experience in multiple practice site settings and my previous participation with KPhA as Speaker of the House of Delegates in 2014, I feel like I would be an asset to the Board of Directors. I’ve had two years experience on the board, and am familiar with the obligations the board has to the profession of pharmacy and the KPhA membership. I would like the opportunity to serve again on the KPhA Board of Directors to continue to push forward KPhA’s legislative priori-

March/April 2016

ties, and I would appreciate your vote.” settings – allows me to insightfully contribute to the decision making of the Jeff Mills, PharmD. Board of Directors with the goal of poJeff Mills, PharmD., is a 2002 graduate sitioning our profession to capitalize on of the University of Kentucky College these opportunities. I request your vote of Pharmacy and works for Norton to allow me to continue serving our Cancer Institute in Louisville. His caprofession and our Association to that reer has spanned community, hospital end.” and ambulatory care settings. Jeff’s Mary Thacker, RPh. practice interests include oncology and legislative affairs. He has been an ac- Mary Thacker is a 1993 UK Pharmacy tive participant on the KPhA Board of Graduate, B.S. She has worked in reDirectors for over 15 years and has tail (Walgreens, Winn Dixie, Kroger) served as Speaker of the House, Chair and long term care (Omnicare) for 20 of the Public & Professional Affairs years and has a working knowledge of Committee and a member of the KPhA just about every aspect of pharmacy Executive Committee. Jeff resides in that you can think of. She has been Louisville with his wife, Janet, a pharmarried to her husband, Art for 27+ macist at KentuckyOne Health, and years and they have a son, Jack, 15 their two children, Rachel and Ryan. and a daughter, Audrey, 12. She has been a roadie for their band, a soccer “I am seeking to continue my service to mom, cross country mom, assistant the Kentucky Pharmacists Association Quick Recall and Science Olympiad on the Board of Directors for another coach and an avid proponent of the term because I believe that active parLouisville Youth Orchestra, of which ticipation in advancing our profession Jack is a long standing violin player. is paramount to the future of health She also has served on her kids’ Site care in Kentucky. Pharmacy continues Based Decision Making Council for to be in a unique position to impact the elementary and middle schools. She is lives of patients because of our accesa member of Jefferson County Associsibility and our specialized training in ation of Pharmacists and has been coaching our patients to better outactive in KPhA as a longtime member comes. With the advent of value based including the last three years on the reimbursement and the focus on the Board of Directors. overall health and well-being of patients, pharmacy has another oppor“I have enjoyed the opportunity to tunity to demonstrate that the role we serve you in this ever changing profesplay in patient care is critical. My prac- sion and would like the opportunity to tice experience – spanning ambulato- continue to do so. Thank you for your ry, inpatient and community practice continued support.”

ELECTION DETAILS The election will be held electronically via the KPhA website at http://www.kphanet.org/page/2016election.

When you click on the link, you will be asked to log in. If you have trouble logging in, please email Scott Sisco at ssisco@kphanet.org.

Paper ballots will be mailed to members who do not have an email on file.

Paper ballots also will be provided on request by calling 502-227-2303.

The election will be open until May 9, 2016.

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THE KENTUCKY PHARMACIST

The Campaign for Kentucky’s Pharmacy Future

March/April 2016

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

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

The Kentucky 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.

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

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March 2016 CE — The Hormone Surge

March/April 2016

The Hormone Surge: Bio-identical vs. Synthetic Hormones and Their Role in Current Therapy KPERF offers all CE By: Emily Blaiklock, PharmD Candidate; Sarah Raake, PharmD, LDE; & Amanda Jett, PharmD, Sullivan University College of Pharmacy The authors declare no financial relationships that could be perceived as real or apparent conflicts of interest.

articles to members online at www.kphanet.org

Universal Activity # 0143-0000-16-003-H01-P&T 1.5 Contact Hours (0.15 CEU) Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: 1. Describe the biological role of the sex hormones; 2. Explain the difference between synthetic and bio-identical hormones; and 3. Identify side effects caused by the use of synthetic hormones. mones used in replacement therapy, even though other hormones, such as cortisol, thyroid and DHEA, have grown The mainstream medical community has flip-flopped about in popularity in recent decades.1 As we age, our bodies hormone replacement therapy over the last five decades. start producing fewer sex hormones. This can lead to It’s good for you. It’s bad for you. No wonder everyone is symptoms such as fatigue, night sweats, depression, low confused. The decrease in estrogen levels in women going libido, irritability, sleep disturbances, generalized pain, through menopause has interested doctors and patients for weight gain, hair loss, loss of muscle mass and other ismany years. In fact, synthetic estrogen was developed in sues such as osteoporosis and dementia. While the benethe 1920s, and by the mid-1930s it was being used to refits of hormone replacement seem obvious, we also have lieve menopausal symptoms.1 In the 1960s, a book by Roblearned more about the risks associated with hormone therert Wilson titled Feminine Forever, touted that the benefits apy. Understanding the sex hormones in better detail, as of estrogen were essential for every woman and could well as the difference between synthetic and bio-identical keep them young and feminine forever.1 However, in the hormones, is our first step to truly understanding the risks early 1970s, estrogen therapy was linked with an increased and benefits to using hormone replacement therapy. incidence of uterine cancer, and physicians stopped prescribing it.1 By the end of the decade, new studies revealed Estrogen is a broad term that encompasses three different that estrogen combined with progestin provided cardiovas- types of estrogens: Estrone (E1), Estradiol (E2) and Estriol (E3).3 E1 is the main estrogen a woman’s body makes post cular benefits. This again led to a surge in the use of hormone replacement therapies, which continued through the -menopause. Many researchers believe high levels of estrone may increase a woman’s risk of developing breast 1990s, and was supported through the Women’s Health cancer.3 E2 is the most potent of the estrogens and can Initiative (WHI) in the early 1990s. In 2002, the WHI study increase HDL, decrease LDL, decrease total cholesterol found that conventional hormone replacement increased 1 the risk for breast cancer, heart attack and stroke. Seem- and lower triglycerides (TG). It also helps to maintain bone structure, increase serotonin, decrease fatigue, maintain ingly overnight, women all over the United States stopped using hormone replacement. More recently, the idea of hor- memory and retain calcium, magnesium and zinc absorption.3 E3 is 80 times weaker than E2, so it has fewer stimumone replacement, often in unconventional forms, has latory effects. However, considerable evidence exists to again come to the surface. This article will review horsupport its ability to protect against breast cancer.4 E3 is mones, their function and discuss the use of bio-identical currently being used experimentally in breast cancer treathormones. ment.5 E3 blocks E1 by occupying the estrogen receptor Review of the Sex Hormones: sites on the cells of the breast tissue, which is why it is be3 The sex hormones are the most commonly prescribed hor- lieved to protect against breast cancer development. E3 History of Hormone Replacement Therapy (HRT):

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THE KENTUCKY PHARMACIST

March 2016 CE — The Hormone Surge

March/April 2016 http://www.gentlepharmacy.com/ pages/q-a.html Molecular structures of natural progesterone and medroxyprogesterone acetate Black circles indicate groups added to natural progesterone.

Because of this “uniqueness,” Provera™ could be patented.

also helps to reduce pathogenic bacteria, which helps to restore the proper pH of the vagina, preventing urinary tract infections.3 Estrogen has two main receptor sites to which it binds: estrogen receptor alpha, which increases cell growth, and estrogen receptor beta, which decreases cell growth and helps to prevent breast cancer development.3 E2 equally activates estrogen-receptor alpha and beta. E1 selectively activates alpha in a ratio of 5:1, which leads to increased cell proliferation.4 E3 preferentially binds to estrogen receptor beta in a 3:1 ratio, which supports its potential to prevent breast cancer.5 In terms of metabolism, estrogen has two major competing pathways, 2-OH estrone and 16-OH estrone, and one minor pathway, 4-OH estrone. 2-OH estrone is “good” estrogen and is protective against cancer when methylated by catechol-O-methyltransferase (COMT).3 16-OH estrone, however, has significant estrogenic activity, and studies show it may be associated with an increased risk of breast cancer.5 High levels are associated with obesity, hypothyroidism, pesticide toxicity, omega-6-fatty acid excess and inflammatory cytokines.3 Studies have shown 4-OH estrone may directly damage DNA and cause mutations that enhance cancer development.3 4-OH estrones are present in greater quantities if there is a deficiency of methionine or folic acid.4 People who have uterine fibroids also can produce increased levels of 4-OH estrone during estrogen metabolism.5 Since only one of the estrogen metabolites is preferred, it is important to know the ways in which patients can increase 2-OH estrone. These methods include moderate exercise, increasing intake of cruciferous vegetables, flax, soy, weight loss, high protein diet, omega-2-fatty acids, B6, B12 and folate.3

transdermal route, none of the negative effects listed above were exhibited.5,6 Progesterone is an important intermediate in steroid biosynthesis in all tissues that secrete steroid hormones, and a small amount enters the circulation from the adrenal cortex. Progesterone has a short half-life and is converted in the liver to pregnanediol, which is conjugated to glucuronic acid and excreted in the urine.7 The principal target organs of progesterone are the uterus, the breasts and the brain.7 Progesterone has an anti-estrogenic effect on the myometrial cells, decreasing their excitability, their sensitivity to oxytocin and their spontaneous electrical activity, which increases their membrane potential.5 Progesterone downregulates the number of estrogen receptors in the endometrium and increases the rate of conversion of estradiol to less active estrogens.5 Synthetic vs. Bio-Identical Hormones:

When the findings of the WHI study were published in 2002, physicians and patients began shying away from hormone replacement therapies due to the fear of increased breast cancer, coronary heart disease and stroke risks.9 While the results from this study were certainly noteworthy, two important – but less known – points should be discussed. First, the progesterone used in this study was synthetic progesterone, brand name Provera™. The WHI showed that women aged 60 years and older in a group taking Premarin™ (an estrogen derived from pregnant horse’s urine) plus Provera™ (marketed together as Prempro™), showed a 24 percent increased risk of breast cancer and heart disease.9 Secondly, bio-identical hormones were not used in any of the study groups. This is significant because there are no published studies indicatThe route of estrogen delivery to patients also is very iming that bio-identical progesterone increases the risk of portant. Estrogens given orally can increase blood presbreast cancer or heart disease. On the contrary, biosure, increase TG, increase estrone, cause gallstones, ele- identical progesterone has been shown to have cancer vate liver enzymes, lower growth hormones, increase pro- protective effects.8 Despite the foreboding results for the thrombic events, increase carbohydrate cravings and inter- WHI study, most researchers still agree that women should rupt tryptophan metabolism and consequently serotonin not hesitate to use hormone replacement therapy for treatmetabolism.5,6 When the same estrogens are given via the ing peri-menopause and menopausal symptoms.9 Howev15

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March 2016 CE — The Hormone Surge

March/April 2016

er, unless the differences between synthetic and bioidentical hormones are known, one may erroneously think that all hormones put patients at risk for the health problems indicated in the WHI study.

experienced when taking progesterone include increased appetite, weight gain, fluid retention, irritability, depression, decreased energy, acne, nausea, insomnia and spasm of the coronary arteries.11 Natural progesterone has been shown to decrease the risk for developing breast cancer. A Synthetic hormones are created in the laboratory to mimic study looked at 80,000 post-menopausal women over eight the molecular structure of the body’s natural hormones.9 years using different kinds of HRT.12 It found that women Synthetic hormones, however, were created slightly differwho used estrogen in combination with synthetic progestin ently from our natural hormones in order to produce a more had a 69 percent increased risk of developing breast canpotent effect by binding to the receptors for a longer period cer when compared to women who never took HRT.12 of time and taking a longer time to be metabolized, if they Women who used bio-identical progesterone in combinaare metabolized at all.9 Bio-identical hormones, like syntion with estrogen had no increased risk in developing thetic hormones, are made in the laboratory; however, they breast cancer compared to women that did not use HRT are the exact chemical structure as the hormones produced and also had a decreased risk in developing breast cancer in the body.8 Bio-identical hormones have been around for compared to the women that used progestin. a very long time, in fact, longer than synthetic hormones. In the late 1930s and early 1940s, a young physical chemistry Conclusion: graduate student by the name of Russell Marker devised a While research is still lacking as to the benefits of bioway to convert a chemical compound found in Mexican wild identical hormones in HRT, the studies available suggest a yams, disogenin, into progesterone with the exact same much greater benefit from bio-identical hormones commolecular structure as the progesterone produced in a pared with synthetic hormones, as well as a reduced woman’s ovaries.8 It wasn’t long before pharmaceutical amount of detrimental side effects. It makes sense to use companies discovered that this first bio-identical progesterhormone replacement products that are molecularly identione could be chemically altered to create synthetic variacal in structure to those that are naturally produced in hutions, which unlike natural substances, could be patented. man bodies. While it is still important to assess a patient Unfortunately, even the slightest variations in the chemical risk vs. benefits of being on HRT, as it would be before structure have led to side effects that are unfavorable and starting any patient on any new medication regimen, it have given hormone replacement therapy a bad name. seems safe to say bio-identical hormones may become a As previously discussed, unlike chemically altered synthetic mainstay treatment for HRT. hormones, bio-identical hormones contain the same molecReferences: ular structure as those produced naturally by the body. As a result, the body recognizes these hormones and interacts 1. KM Brett, Y Chong, E Pamuk, JH Madans. Hormone Rewith them the same way it would interact with the hormones placement Therapy: Knowledge and use in the United produced naturally by the body in the first place. Synthetic States. Center for Disease Control and Prevention 2006. hormones on the other hand, have chemically altered 2. Salpeter, S., et al., “Bayesian meta-analysis of hormone shapes, which are not recognized by the body. Therefore, therapy and mortality in younger postmenopausal womthey are not metabolized efficiently in the body and interen,” Amer Jour Med 2009; 22(11):1016-22. fere with the normal ebb and flow of hormonal function, 3. Rossouw, J., et al., “Risks and benefits of estrogen plus potentially leading to detrimental side effects.9 progestin in healthy postmenopausal women: Principal In a study from 2013, researchers estimated that over the results from the Women’s Health Initiative randomized past decade, between 18,600 to 91,600 post-menopausal controlled trial,” JAMA 2002; 288(3):321-33. women ages 50-59 years old who had a hysterectomy may 4. Sarrel, P., et al., “The mortality toll of estrogen avoidhave died prematurely because they did not take bio4 ance: An analysis of excess deaths among hysterectoidentical estrogen. A meta-analysis from 27 published mized women aged 50 to 59 years,” Amer Jour Public studies showed a 28 percent reduction in mortality and imHealth 2013; July 18. proved quality of life in menopausal women under the age of 60 who used bio-identical hormone replacement thera5. Murkes, D., et al., “Effects of percutaneous estradiol-oral py.10 progesterone versus oral conjugated equine estrogensSynthetic progesterone is called progestin. Progestin does medroxyprogesterone acetate on breast cell proliferation not produce the same actions as natural progesterone. 11 and bel-2 protein in healthy women,” Fertil Steril 2011; Side effects experienced when taking progestin that are not 95(3):1188-91.

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March 2016 CE — The Hormone Surge

March/April 2016

6. M Canonico, E Oger, G Plu-Bureau, et al. Hormone therthetic versions in BHRT? Post Graduate Medicine 2009. apy and venous thromboembolism among postmeno10. Fournier, A., et al., “Unequal risks for breast cancer aspausal women: impact of the route of estrogen adminsociated with different hormone replacement therapies: istration and progestins: The ESTHER study: for the Esresults from the E3N cohort study,” Breast Cancer Res trogen and Thromboembolism Risk (ESTHER) Study Treat 2008; 107(1):103-11.

Group. Circulation 2007:115;840-45.

7. Porsch, J., et al., “Estrogen-progestin replacement thera- 11. Wood, C., et al., “Transcriptional profiles of progesterone effects in the postmenopausal breast,” Breast Canpy and breast cancer risk: the Women’s Health Study cer Res Treat 2009; 114(2):233-42.

(U.S.),” Cancer Causes Control 2002; 13(9):847-54.

12. Fournier, A., et al., “Breast cancer risk in relation to different types of hormone replacement therapy in the E3N -EPIC cohort,” Int Jour Cancer 2005; 114(3):448-54.

8. Gonadal steroids and body composition, strength, and sexual function in men. N Engl J Med. 2013 Sep 12;369 (11):1011-22.

9. Kent Holtorf M.D. The Bioidentical Hormone Debate: Are 13. Conjugated estrogens and breast cancer risk. CamBioidentical Hormones (estradiol, estriol and progesterpagnoli C, Ambroggio S, Biglia N, Sismondi P Gynecol one) safer or more efficacious than commonly used synEndocrinol. 1999 Dec; 13 Suppl 6():13-9.

March 2016 — The Hormone Surge: Bio-identical vs. Synthetic Hormones and Their Role in Current Therapy 1. What estrogen is the most potent estrogen?

A. Estriol (E1) B. Estradiol (E2) C. Estrone (E3) D. Bi-Est (E1/E2)

6. What estrogen selectively activates alpha in a ratio of 5:1, which leads to increased cell proliferation?

A. Estradiol (E2) B. Estrone (E3) C. Bi-Est (E1/E2) D. Estriol (E1)

2. What hormone down regulates the number of estrogen receptors in the endometrium and increases the rate of conversion of estradiol to less active estrogens?

A. Estrone B. Testosterone C. Progesterone D. DHEA

7. The route of estrogen delivery to patients is very important. Which delivery route can lead to increased blood pressure, increased TG, elevated liver enzyme, etc.?

A. Transdermal B. Subcutaneous C. Oral D. Intramuscular

3. Which hormones are produced in the lab and produce a more potent effect by binding to the receptors for a longer period of time and taking a longer time to be metabolized?

A. Bio-identical hormones B. Synthetic hormones C. Both bio-identical and synthetic hormones D. Neither bio-identical or synthetic hormones

8. Which of the following are side effects associated with the production of less sex hormones?

A. Weight gain B. Hair growth C. Increased libido D. Increased energy 9. What happens to a person’s sex hormones as they increase in age?

A. They increase B. They decrease C. They stay the same D. Some increase and others decrease

4. Which study was published in 2002 and revealed an increased risk of breast cancer, coronary heart disease and stroke due to synthetic hormone use in post-menopause women?

A. Women’s Health Initiative B. Women’s Health and Aging Study C. Women’s Hormone and Health Study D. Hormone Initiative

10. What hormone targets the uterus, the breasts and the brain?

A. Estrogen 5. Which of the following products were NOT used in the B. Testosterone WHI Study?

C. Progesterone A. Prempro D. DHEA B. Bio-Identical Hormones C. Provera D. Premarin 17

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March 2016 CE — The Hormone Surge

March/April 2016

This activity is a FREE service to members of the Kentucky Pharmacists Association.

The fee for non-members is $30. Mail completed forms to: KPERF, 96 C. Michael Davenport Blvd., Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile.

Expiration Date: March 2, 2019 Successful Completion: Score of 80% will result in 1.5 contact hours or .15 CEU. Participants who score less than 80% will be notified and permitted one re-examination.

TECHNICIANS ANSWER SHEET. March 2016 — The Hormone Surge: Bio-identical vs. Synthetic Hormones and Their Role in Current Therapy (1.5 contact hours) Universal Activity # 0143-0000-16-003-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D

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

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

Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet.

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

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Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet.

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April 2016 CE — Therapeutics for Pet Aggression

March/April 2016

Part 2. Therapeutics For Pet Aggression, Housesoiling, Seizures and Other Behavior Disorders That are Referred to Retail Pharmacies — What the Pharmacist Needs KPERF offers all CE to Know articles to By: Rachael Bilitera, PharmD candidate; Ivana Catriona Rosieka, PharmD candidate; Megan Petersona, RPh; Sara L Bennettb, DVM, MS, DACVB; Inder Sehgala, DVM, Ph.D.

members online at www.kphanet.org

a Marshall University School of Pharmacy, Huntington, W.Virg. b Veterinary Behavior Consultant, Evansville, Ind. There are no financial relationships that could be perceived as real or apparent conflicts of interest.

Universal Activity # 0143-0000-16-004-H01-P&T 1.5 Contact Hours (0.15 CEU) Goals: To assist pharmacists in understanding signs, diagnoses and prescriptive treatment options of pet aggression, compulsive disorders, housesoiling, hyperkinesis, anorexia, cognitive dysfunction and seizures.

Objectives At the conclusion of this Knowledge-based article, the reader should be able to: 1. Compare the time course of common prescriptive agents and agent combinations used to reduce aggression in dogs and cats; 2. Distinguish similarities and differences between dog/cat and human compulsive disorders; 3. Identify the most common undesirable behavioral conditions in cats and the prescriptive therapies that are commonly prescribed to improve these behaviors; 4. Recognize the canine condition that may be successfully treated with a veterinary prescription for methylphenidate; 5. Summarize the conditions which may necessitate the prescriptive use of mirtazapine in dogs and cats; 6. Point out significant drug interaction concerns associated with the use of selegiline to treat cognitive dysfunction syndrome in aged dogs; and 7. Evaluate both advantages and disadvantages of phenobarbital, potassium bromide, zonisamide and levetiracetam for a case of epilepsy in a dog.

This Continuing Education (CE) article focuses on medications prescribed for the therapy of:

function and seizures must often be treated for the remaining life of the pet.

The majority of pharmacologic options for the treatment of these conditions or seizures in pets involve four major families of psychotropic drugs: Barbiturates, Benzodiazepines, Tricyclic Antidepressants (TCAs) and Selective Serotonin Reuptake Inhibitors (SSRIs). In addition, Monoamine Oxidase Inhibitors (MAOIs), Serotonin (5-HT) agonists, Presynaptic alpha (2)-receptor antagonists and CNS stimulants are prescribed for select conditions. All of these agents are prescribed extralabel (i.e., off-label) by veteriThe first four of these conditions are behavior disorders, narians for dogs and cats with the exceptions of fluoxetine and they are treated with the goal of reducing anxiety and facilitating behavior management and medication through a and clomipramine, which are approved for treatment of behavioral conditions in dogs and, selegiline, which is apfinite time period of therapy. Anorexia may be treated with the human antidepressant mirtazapine, while cognitive dys- proved for pituitary dependent hyperadrenocorticism and 1.

2.

3.

4.

5.

6.

7.

Aggression Compulsive disorders (CD) Housesoiling Hyperkinesis Anorexia Cognitive dysfunction syndrome of dogs and cats Seizure disorders

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April 2016 CE — Therapeutics for Pet Aggression

March/April 2016

cognitive dysfunction in dogs (Plumb, 2015).

amitriptyline (Elavil®) or clomipramine, can sometimes be observed within five to seven days from the initial dose, As discussed in this CE, Table 1 compares doses and indiwith greater efficacy occurring over time, usually over a cations for agents in dogs vs. humans along with selected period of four to six weeks as observed with SSRIs. Treatadverse effects. The referring veterinarian should be conment for a minimum of four to six months is recommended sulted for additional information on drug dosing, therapeutic to improve problem behavior (AAFP, 2004). The overall responses, adverse effects and administration difficulties length of pharmacologic treatment associated with a beconcerning individual pets. Table 2 shows dosing and indihavior problem is very individual and depends greatly on cations for common CNS agents in the cat. Pharmacists the ability of the owner to address environmental concerns should be aware that dosing of most behavioral medicaand implement behavior modification. tions in dogs and cats is higher on a quantity per body weight basis than comparative dosing in humans; thereBuspirone (Buspar®) and SSRIs can be effective in cases fore, medium-to-large dogs may be prescribed larger doses of some inter-cat aggression, such as status-related agof these drugs than many people. gression in which one cat is consistently aggressive to a victim(s) in the absence of outside threatening circumstanc1. Aggression es or social signals. The victim cat also might be treated Aggression, often the result of fear, is a common behavior- with buspirone which may increase assertiveness, while al complaint for both dog and cat owners. Other motivathe aggressor cat may be treated with an SSRI to reduce tions such as territorial defense, conflict or confrontation aggressive outbursts (Overall, 2004). It should be noted with an owner, possessiveness, pain or irritability or playthat increased friendliness has been a reported side effect related aggression, also can occur. As with other presenta- of buspirone in cats, as well as increased aggression in the tions of fear or anxiety, these behavior problems often are victim cat during inter-cat aggression (Crowell-Davis and addressed through both behavior modification and pharma- Murray, 2006). cotherapy to reduce the underlying motivation for the ag2. Compulsive disorders gression, fear, anxiety and social stress. A multiple month course of either an SSRI – often fluoxetine (Prozac®) or a Dogs, cats and people can suffer from compulsive disorTCA such as clomipramine (Anafranil®) – may be preders (CD) and all may be treated with SSRIs or TCAs; howscribed to a pharmacy. Fear-related aggression is frequent- ever, the presentations and thought processing behind CDs ly treated with fluoxetine. Therapy will occur over a course in dogs, cats and people are not homologous. In humans, of months and the pharmacist should emphasize complithis disorder is characterized by intrusive thoughts or obance to the owner since adhering to the daily administration sessions that are recurrent and persistent, resulting in the is correlated with improvement in dogs (Pineda et al., person performing repeated or stereotyped behaviors.

2014). Benzodiazepines are generally considered to be These lead to extreme stress and often only temporary reinappropriate for the at-home treatment of aggression belief from the obsessive thoughts (Barahona-Corrêa, 2015). cause they may reduce the normal repression of aggresAt this time, it cannot be concluded that pets experience sive behavior, often as a result of behavioral disinhibition the same obsessions, but frequent, repetitive behaviors (although there are some situational uses that might be (locomotory, grooming, ingestive, hallucinatory) often are considered appropriate, such as during veterinary visits considered to fall into the category of compulsive disorder with appropriate safety precautions in place).

(Merckvetmanual.com, 2015b). These can be goal directed behaviors such as tail chasing or locomotor behaviors such Clonidine (Catapres®) is a prescriptive option that may be as circling, or even self-directed such as with acral lick dercombined with SSRIs for canine fear and territorial aggresmatitis or flank sucking (Landsberg, 2013). SSRIs, such as sions (Landsberg et al., 2013). Trazodone (Desyrel®) also fluoxetine or sertraline (Zoloft®), and TCAs, specifically may be prescribed in limited circumstances such as the clomipramine (Seksel and Lindeman, 2001), often are eftreatment of inter-dog aggression and impulse control disfective for reducing these compulsive behaviors. Amitriptyorders (Landsberg et al., 2013). line may be prescribed because of its lower cost, but it is Pharmacologic treatment for aggression in cats often is more likely associated with adverse effects and poorer effiimplemented by use of fluoxetine, paroxetine (Paxil®) or cacy due to its limited specificity for serotonin (Landsberg, clomipramine. Although the effects of SSRIs can some2013). times be detected within the first week, the full effects may 3. Housesoiling take up to four to six weeks so the dispensing pharmacist should emphasize to the client the need for compliance The most common behavior condition in cats that leads during this time. The anti-anxiety benefits of TCAs, such as owners to seek behavioral therapy is undesirable toileting 20

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April 2016 CE — Therapeutics for Pet Aggression and urine marking/spraying, which are collectively referred to as housesoiling” (Landsberg, 2013). Urine marking is associated with anxiety and/or territorial motivation, and many cats that urine mark will require more than non-pharmacologic behavioral techniques (Merckvetmanual.com, 2015a).

Urine marking or spraying is typically a small volume of urine deposited on usually a vertical surface, often near doors, windows or objects of social significance and sometimes includes the owner’s belongings. It is observed frequently in sexually intact cats and can be greatly reduced by neutering. Buspirone, fluoxetine or clomipramine all have shown to reduce behavioral urine marking in cats in the veterinary literature. Alprazolam (Xanax®) or other benzodiazepines also can be useful for more immediate treatment of social anxiety and urine spraying in cats (Landsberg, 2013).

4. Hyperkinesis

March/April 2016

Table 2. Cat CNS drug doses, common indications and comments.

Drug

Dose

Indications in cats

Comments

Phenobarbital

1 – 3 mg/kg q12h for seizures; 2-3 mg/kg

Seizure control

A common referral from a veterinarian to a local pharmacy; develop ataxia, cats show expected sedation, lethargy, polyphagia, and polydipsia/polyuria

Alprazolam

0.02 -0.1 mg/kg q8-12h

Anxiety, social stress associated with urine marking, phobias

Longer acting than diazepam

Diazepam

0.2-0.5 mg/kg prn up to tid

Anxiety, urine marking

Amitriptyline

0.5 – 1 mg/kg q12 -24h or 5-10 mg per cat qd

Anxiety, pruritus, adjunctive treatment for lower urinary tract disease

Clomipramine

0.25-1 mg/kg/day

Anxiety, social stress associated with urine marking

Fluoxetine/ Paroxetine

0.5 – 1.0 mg/kg qd

Anxiety, aggression, compulsive disorders, urine marking

Used to stimulate appetite; risk for fatal hepatic lipidosis with oral dosing A popular request for a compounding pharmacy to reformulate, less expensive than many others Cats may demonstrate greater anticholinergic effects and sedation than dogs May be a request for a compounding pharmacy to reformulate; liquid form may be easier to give to some cats

Buspirone

0.5 -1 mg/kg q12h -24h

Social stress associated with urine marking or inter-cat aggression in the home

Muscle relaxant or sedative effects and it is not associated with withdrawal or abuse; has a wide margin of safety May be sedating

Hyperkinesis or hyperexcitability disorder is a rare condition in dogs characterized by over3.75 mg twice Appetite stimulant, activity, panting, poor attention Mirtazapine weekly antiemetic; span, lack of trainability, agincluding with gression and failure to calm chronic renal failure, down in neutral environments cancer chemotherapy, (Landsberg et al., 2013). It is pancreatitis similar to attention deficit hyperactivity disorder (ADHD) in humans. Hyperkinetic dogs people and in pets. It is used as an appetite stimulant for may be treated successfully with a CNS stimulant and in animals with anorexia, such as that which accompanies these circumstances, a pharmacist may receive a veterichronic renal disease or cancer chemotherapy (Plumb, nary prescription for methylphenidate (Ritalin®). The drug 2015). Mirtazapine is also an anti-emetic. It should be used acts paradoxically to produce a calming effect in these judiciously in dogs and cats already on an SSRI or TCA for dogs, as it does in humans (Landsberg et al., 2013). other behavior related problems to avoid serotonin syn5. Anorexia

drome or toxicity (Landsberg, et al., 2013).

Mirtazapine (Remeron®) is a human antidepressant which may elevate norepinephrine and serotonin (Yin et al., 2014). Mirtazapine has been found to increase appetite in

6. Cognitive dysfunction syndrome Cognitive dysfunction syndrome (CDS) is a recognized syndrome of aged dogs and cats that is characterized by a 21

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April 2016 CE — Therapeutics for Pet Aggression

March/April 2016

Quick Reference for pet dosages and indications Table 1. Comparative dosing, indications and time to effect for CNS agents in dogs The Table below shows comparative dosing between dogs and humans for behavior and seizure medications used dogs.

Human indications may not be the same as dogs. CD, cognitive dysfunction.

Drug Oral Dog Potential Person dose Conditions in Time for Significant potential dose in mg/ dose for and condition dogs expected undesirable effects in kg 25 kg dog effects in dogs dogs Phenobarbital 1 – 5 mg/kg 100 mg 50-100 mg 2-3 Anticonvulsant 2 weeks or Sedation, restlessness, PO q12h as q12h; 200 times/day as an more hyper-excitation, ataxia, an anticonvul- mg/day anticonvulsant; polydipsia, polyuria, sant; 2-3 mg/ 30-120 mg/day increased appetite kg prn for sedation Alprazolam

0.02 to 0.1 mg/kg prn to q6h

1.0 mg q6h; 5 mg /day

0.75 to 4.0 mg per day for transient anxiety and anxiety disorder

Situational anxiety, separation anxiety, storm phobia

1-2 hours

Sedation, increased appetite, ataxia; behavioral disinhibition; could be expensive to give frequently

Diazepam

0.5-2.2 mg/kg prn (q4-6h) separation anxiety

50 mg prn

2-10 mg bid–qid for anxiety

1-2 hours

As alprazolam; less expensive

Amitriptyline

1-4 mg/kg q12h

50 mg q12h; 100 mg/day

75 mg q24h for depression

Separation anxiety or other situational fears or phobias seizures.

Anxiety

2-4 weeks or longer

Clomipramine

1-2 mg/kg up to 4 mg/kg, q12h

50 mg q12h; 100 mg/day

100 mg/day maintenance for depression, OCD or panic disorder

2-4 weeks or longer

Clonidine

0.01 – 0.05 mg/kg up to bid

0.2 mg per event; 0.4 mg/day

0.1 mg bid; 0.2 mg/day

Trazodone

2 -3 mg/kg prn to q8h

50 mg q8h; 150 mg/day

150 mg/day

Anxiety, including separation anxiety; CD noise phobia Adjunct with SSRIs or buspirone for canine separation anxiety, noise and storm phobias.

Adjunct for anxiety with an SSRI, TCA or BZD

Vomiting and diarrhea, hyperexcitability or sedation. anticholinergic symptoms: mydriasis, reduced lacrimation, salivation, urine retention, constipation

Fluoxetine

1-2 mg/kg q24h anxiety, including separation anxiety 0.5 – 2 mg/kg q24h anxiety, 1-3 mg/kg q24h CD

40 mg q24h

Human for panic disorder 20-60 mg PO day

40 mg q24h for CD

40-60 q24h for OCD

Paroxetine

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1.5 – 2 hours

Vomiting, dry mouth, constipation, sedation, hypotension

hours up to 2 weeks

Sedation, lethargy, ataxia, increased anxiety

Anxiety, aggression, CD

4-6 weeks for maximal efficacy

Lethargy, changes in appetite and vomiting or diarrhea

Anxiety, aggression, CD

4-6 weeks

lethargy, anorexia, vomiting, diarrhea, constipation, anxiety

THE KENTUCKY PHARMACIST

April 2016 CE — Therapeutics for Pet Aggression

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Quick Reference for pet dosages and indications Table 1. Comparative dosing, indications and time to effect for CNS agents in dogs Continued Drug

Oral Dog dose in mg/kg

Potential dose for 25 kg dog

Person dose and condition

Conditions in dogs

Selegiline

0.5-1 mg/kg q24h

25 mg q24h

10 mg q24h for Parkinson’s Disease

Cognitive dysfunction syndrome

Buspirone

0.5-2 mg/kg q8-12h

30 mg q812h (60-90 mg/ day)

15 mg/day initial dose for generalized anxiety

Methylphenidate

0.5 – 2.0 mg/kg q12h

20 mg q12h; 40 mg/day

Mirtazapine

As an appetite stimulant or antiemetic 3.75 mg for dogs < 7 kg, qd; 7.5 mg for dogs 7-14 kg, qd; 15 mg for dogs 14-25 kg, qd; 30 mg for dogs >25 kg 2-8 (initially 5) mg/kg q12h

15 mg q24h

10 – 60 mg/ day for children over 6 years 15–45 mg q24h for depression

20 mg/kg q8h

500 mg q8h; 1500 mg/day

Zonisamide

Levetiracetam

100 mg q12h (200 mg total/ day)

200-400 mg/ day

Time for expected effects in dogs 4 weeks to 3 months

Significant potential undesirable effects in dogs

General anxiety, urine marking, social stress associated with inter-cat aggression

1-4 weeks

Uncommonly some sedation, increased friendliness, aggression

Hyperkinesis

1-3 days

Increased heart and respiratory rates, anorexia, tremors

Appetite stimulation (chronic renal disease cancer); anti-emesis

Less than 90 minutes

Uncommon at doses administered but tremor, tachycardia, fever, dyspnea, hyperactivity (serotonin syndrome)

Refractory epilepsy

1-2 months

(Jieyun, Song, Lei, Xu, & Chen, 2014)

Vomiting, diarrhea, anorexia, restlessness, repetitive movements, lethargy, salivation

Sedation, ataxia, anorexia

(Von Klopmann, Rambeck, & Tipold, 2007)

500 mg 2 Refractory 2 months Sedation, ataxia times a day for epilepsy epilepsy and seizures.

Doses obtained from (Plumb, 2015); (Hsu, 2013); (Drugs.com, 2015); CD = compulsive disorder; all dosing is per os.

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April 2016 CE — Therapeutics for Pet Aggression

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gradual decline in learned behaviors, spatial awareness, social interactions, housetraining and sleep patterns (Salvin et al., 2010). The clinical signs are summarized by the acronym DISHA for disorientation, interaction changes, sleep/ wake disturbances, housesoiling and activity changes (Osella et al., 2007). This neurodegenerative condition is progressive and shares some common features with agerelated pathologies in humans and with Alzheimer’s disease (Osella et al., 2007). The prevalence of canine CDS is an estimated 14.2 percent of dogs over eight years of age, yet the disease has historically been undertreated due to the owners’ views of their dogs’ symptoms are an unalterable part of aging (Salvin et al., 2010). It has only been more recently recognized as an age-related behavioral condition in cats, in which the incidence could be as high as 50 percent in cats over 15 years of age (Landsberg, 2013). Several clinical features of CDS can be improved through treatment with the MAOI, selegiline (Eldepryl®). Selegiline is the only FDA-approved drug for canine CDS and is sold under the veterinary brand “Anipryl®.” Selegiline use in cats is less documented and would fall under extralabel administration. Reported adverse effects (in dogs) are vomiting, diarrhea and changes in the normal behavior patterns.

Owners should be counseled to observe and report medication safety concerns to their veterinarian since these may necessitate a dose reduction (Plumb, 2015).

7. Seizure disorders

Because selegiline is a MAOI, it has significant drug interactions that both the client and pharmacist should be aware. One would be the combination of selegiline with tramadol (Ultram®), which is a popular opioid in dogs. Tramadol and other opioids also inhibit serotonin reuptake, albeit to a lesser degree than SSRIs and TCAs. Therefore, the addition of tramadol with MAOIs, such as selegiline (Barann, et al., 2015), could lead to serotonin syndrome and should be avoided. In addition to tramadol, selegiline also will have potential adverse interactions with the antiparasitic MAOI amitraz (Mitaban®), the antidepressant buproprion (Wellbutrin®), SSRIs and TCAs that could lead to serotonin syndrome.

Potassium bromide (KBr) is an inexpensive therapeutic option for dogs, and in some instances, cats, with primary idiopathic epilepsy. KBr will be referred by a veterinarian to a compounding pharmacy quite frequently. One disadvantage of KBr for the therapy of epilepsy is that it takes three to four months to achieve seizure control, compared with phenobarbital which has more rapid benefits (Plumb, 2015).

The barbiturate phenobarbital is commonly used as an anticonvulsant and is the drug of choice for dog and cat epilepsies (Plumb, 2015). It is a common prescriptive referral from a veterinarian to a local pharmacy, especially in the form of an elixir. Phenobarbital requires approximately two weeks to reach steady-state plasma concentrations, with subsequent dose adjustments based on seizure control and measurements of phenobarbital blood levels (Plumb, 2015). Dogs occasionally develop tolerance to phenobarbital and lose adequate seizure control and this tolerance may require dose increases. The dose of phenobarbital in dogs and cats will appear high to pharmacists. In a survey by the Oregon State Veterinary Medical Association in 2012, a veterinarian reported that a pharmacist inappropriately reduced an epileptic dog’s phenobarbital dosage believing the dosage was too high. The dog’s seizures returned, could not be controlled and led to euthanasia of the pet (AVMA.org, 2015). Pharmacy personnel should recognize that clients can expect their dog to be sedate initially with any anti-seizure medication as the pet adjusts to the therapy. Dogs also will commonly display effects such as ataxia, polydipsia, polyuria and polyphagia leading to weight gain; (Merckvetmanual.com, 2015c). The client should be counseled that these effects will decrease within the first few weeks.

Zonisamide (Zonegran®) is a sulfonamide anticonvulsant that has seen recent use in veterinary medicine as a second-line drug in dogs. Zonisamide is either administered as an adjunct with phenobarbital to improve seizure control or as monotherapy for clients whose pets have medication As an aside to this discussion of selegiline, a similar drug resistant epilepsy. It is also an attractive option for clients interaction concern exists with co-administration of SSRIs who seek to avoid the adverse effects of phenobarbital, as or TCAs plus tramadol; however, human data indicates zonisamide is well tolerated and considered safe in dogs these agents can be safely combined (Park et al., 2014).

(Von Klopmann et al., 2007). The owner may notice their And this combination can likely be extended to most pets dog is transiently sedated, ataxic and/or lacks their usual provided judicious monitoring of doses for both medications appetite. Zonisamide’s mechanism of action is unknown (tramadol and SSRIs/TCAs) is considered. Pharmacists but it may block neuronal cation channels. The pharmacy should always educate their clients to monitor pets for leth- personnel should be aware that clients who are accusargy, ataxia and vomiting within one to two hours after giv- tomed to the relatively inexpensive costs of KBr or phenoing an SSRI or TCA, if the pet is also on tramadol. barbital may be surprised at the greater cost of zonisamide

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April 2016 CE — Therapeutics for Pet Aggression (Plumb, 2015) if they have not been previously informed of the difference. Therapy for one to two months may be necessary in order to determine whether seizure control is adequate.

Levetiracetam (Keppra®), an antiepileptic and anti-anxiety drug for people, also has become a popular alternative for treatment of dogs with seizures that are resistant to phenobarbital and/or KBr. The popularity of levetiracetam has increased since it became available as a generic. As with zonisamide, it can be employed as a monotherapy or as an adjunct with phenobarbital or KBr. Clients may be forewarned that, as with several other human anti-epileptic agents, a “honeymoon” effect often occurs in which a period of high efficacy may be followed in four to eight months by the development of tolerance (Plumb, 2015). The adverse effect profile for levetiracetam is excellent and sedation is uncommon.

However, one disadvantage that a pet owner should be made aware of is a three-times daily dosing schedule (Volk et al., 2008) and, even as a generic, the cost of levetiracetam treatment is greater than phenobarbital.

Summary Pet behavior disorders and seizures are very disquieting to their owners and the successful use of pharmacologic agents can therefore benefit both pets and owners. Pharmacists who possess knowledge about both the disease condition in pets and the effects of the drugs can provide reassuring counseling on drug use and safety. Aggression in dogs and cats can be treated with SSRI or TCAs, but typically not with benzodiazepines. Compulsive disorders also are treated with SSRIs or the TCA, clomipramine. Owners should be made aware that the full effect of SSRIs or TCAs in behavioral management may not be achieved for three to four weeks or longer; however, some effects could be noted as early as the first week. The underlying anxiety or social stress generally at the root of housesoiling (urine marking and toileting concerns) by cats can be treated with SSRIs, TCAs, as well as with buspirone, or even a benzodiazepine. Mirtazapine is a tetracyclic molecule that in part antagonizes pre-synaptic alpha (2) receptors promoting increased norepinephrine and serotonin release in the CNS. It is used in pets for medically-related anorexia and as an antiemetic. MAOIs inhibit neurotransmitter oxidation sparing dopamine, norepinephrine and epinephrine.

In veterinary medicine, the most commonly prescribed MAOI, selegiline, is used to treat cognitive dysfunction syndrome.

Seizure disorders can be treated with phenobarbital, KBr or more recently, zonisamide or levetiracetam.

Adverse effects that are most relevant to clients during counseling are listed in Table 1, and include anorexia, vomiting and diarrhea for SSRIs, TCAs and selegiline, with additional anticholinergic effects with TCAs. Sedation and ataxia are to

March/April 2016 be expected with use of phenobarbital, the benzodiazepines and zonisamide. Pharmacist and pharmacy technicians should freely consult with the referring veterinarian to exchange ideas such as compounding that may enhance chances for successful therapy or to inquire about any concerns or questions that they or their clients have about a pet prescription.

References AAFP; The American Association of Feline Practitioners.

(2004). Feline Behavior Guidelines. Retrieved from Catvets.com: http://www.catvets.com/public/PDFs/ PracticeGuidelines/FelineBehaviorGLS.pdf Accessed Nov. 5, 2015.

AVMA.org. (2015). Retrieved from https://www.avma.org/ News/JAVMANews/Pages/140901a.aspx Accessed Nov. 5, 2015.

Barann, M., Stamer, U. M., Lyutenska, M., Stüber, F., Bönisch, H., & Urban, B. (2015). Effects of Opioids on Human Serotonin Transporters. Naunyn Schmiedebergs Arch Pharmacol., 388(1): 43-9.

Barahona-Corrêa J.B., Camacho M., Castro-Rodrigues P., Costa R., Oliveira-Maia A.J. (2015) From Thought to Action: How the Interplay Between Neuroscience and Phenomenology Changed Our Understanding of Obsessive-Compulsive Disorder. Front Psychol. 6:1798.

Crowell-Davis, S., Murray, T. (2006) Veterinary Psychopharmacology, First ed., Blackwell Pub., Ltd. Oxford, UK. Drugs.com. (2015). Retrieved from http://www.drugs.com/ Accessed Nov. 5, 2015.

Hsu, W. H. (2013). Handbook of Veterinary Pharmacology, 2nd ed. 2013. Seoul. Republic of Korea.: Shinilbooks.

Yin, J., Song, J., Lei, Y., Xu, X., Chen, J. (2014). Prokinetic effects of mirtazapine on gastrointestinal transit. Am J Physiol Gastrointest Liver Physiol. 306(9): G796-801.

Landsberg, G., Hunthausen, W., Ackerman, L. (2013) Behavior Problems of the Dog and Cat. (2013) 3rd Ed., Elsevier, Edinburgh UK. Merckvetmanual.com. (2015a). Retrieved from http:// www.merckvetmanual.com/mvm/behavior/ normal_social_behavior_and_behavioral_problems _of_domestic_animals/behavioral_problems_of_cats.html? qt=buspirone&alt=sh Accessed Nov. 5, 2015 Merckvetmanual.com. (2015b). Retrieved from http:// www.merckvetmanual.com/mvm/behavior/normal_social_ behavior_and_behavioral_problems_of_domestic_animals/ behavioral_problems_of_dogs.html?qt=aggression&alt=sh Accessed Nov. 5, 2015.

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Merckvetmanual.com. (2015c). Retrieved from http:// www.merckvetmanual.com/mvm/pharmacology/ systemic_pharmacotherapeutics_of_the_nervous_system/ maintenance_anticonvulsant_or_antiepileptic_therapy.html? qt=epilepsy&alt=sh Accessed November 5, 2015

in dogs. Vet J., 199(3): 387-91.

Plumb, D. C. (2015). Plumb’s Veterinary Drug Handbook Eighth Edition. Stockholm, WI.: John Wiley & Sons, Inc.

Seksel, K., & Lindeman, M. J. (2001). Use of clomipramine in treatment of obsessive-compulsive disorder, separation anxieOsella, M.C., Re, G., Odore, R., Girardi, C., Badino, P., Barty and noise phobia in dogs: a preliminary, clinical study. Aust bero, R., Bergamasco, L. (2007) Canine cognitive dysfunction Vet J., 79: 252-6. syndrome: Prevalence, clinical signs and treatment with a neuroprotective nutraceutical. App Animal Behav Sci. 105(4): Salvina, H.E., McGreevya, P.D., Sachdevb, P.S., Valenzuelab, M.J. (2010) Under diagnosis of canine cognitive dysfunc297-310. tion: A cross-sectional survey of older companion dogs. Vet J Overall, K.l. (2004) Paradigms for pharmacologic use as a 184(3): 277-281. treatment component in feline behavioral medicine. J Feline Volk, H. A., Matiasek, L.A., Feliu-Pascual, A.L., Platt, S.R., Med Surgery. 6(1): 29-42.

Chandler, K.E. (2008). The efficacy and tolerability of lePark, S. H., Wackernah, R. C., & Stimmel, G. L. (2014). Serovetiracetam in pharmacoresistant epileptic dogs. Vet Jrl. tonin syndrome: is it a reason to avoid the use of tramadol 176:310-319. with antidepressants? J Pharm Pract., 27(1): 71-8.

Von Klopmann, T., Rambeck, B., & Tipold, A. (2007). ProPineda, S., Anzola, B., Olivares, A., & Ibanez, M. (2014). spective study of zonisamide therapy for refractory idiopathic Fluoxetine combined with clorazepate dipotassium and beepilepsy in dogs. Jrl Sm Anim Pract., 48(3): 134-138. haviour modification for treatment of anxiety-related disorders

April 2016 — Part 2. Therapeutics For Pet Aggression, Housesoiling, Seizures and Other Behavior Disorders That are Referred to Retail Pharmacies — What the Pharmacist Needs to Know 1.When aggression in dogs is treated with pharmacotherapy, common agents such as fluoxetine or clomipramine generally require a time period of __________ for optimal improvement.

A. Minutes B. Hours C. Days D. Months 2. Which of the following drugs would not generally be considered appropriate for home-treatment of aggression in a dog because it disinhibits behavior?

A. Fluoxetine B. Benzodiazepines C. Clomipramine D. Clonidine 3. A cat owner presents your pharmacy with a prescription for paroxetine for their in-door cat named “Harmony.” Harmony is being treated for what is termed “redirected aggression,” in which she sees a feral outdoor cat through a window, seems to interpret this cat as an invader but then hisses at the owners when they are nearby. Which of the following is an important counseling point for the use of paroxetine in this case?

A. This agent will take full effect in four to six days.

B. This agent needs to be administered consistently for the entire prescribed time period.

C. This agent prevents fleas and ticks.

D. This agent is specifically used only for aggression in cats.

4. Compulsive disorder in dogs can be treated with a prescription for SSRIs or TCAs. Which of the agents below would be more likely to be associated with adverse effects and poorer efficacy due to its more limited specificity for serotonin?

A. Fluoxetine B. Sertraline C. Amitriptyline D. Clomipramine 5. Dogs, cats and people can suffer from compulsive disorders (CD); however, it is not known if dogs and cats have ___________.

A. Frequent behaviors B. Repetitive behaviors C. Obsessive thoughts D. Goal-directed behaviors 6. Buspirone, fluoxetine or clomipramine each have been shown to improve the most common behavior in cats that leads owners to seek therapy. Which of the choices below lists this behavioral condition?

A. Hyperkinesis B. Coughing up hairballs on furniture C. Housesoiling D. Roaming

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April 2016 CE — Therapeutics for Pet Aggression

March/April 2016

7. Your pharmacy receives a veterinary prescription for methylphenidate (Ritalin®) for a five month old, male Cocker Spaniel-mixed breed dog named Jupiter. This CNS stimulant has most likely been prescribed for the therapy of what uncommon condition in dogs?

A. Hyperkinesis B. Seizures C. Housesoiling D. Cardiomyopathy

10. Which of the following medications could have drug interaction with selegiline that could precipitate serotonin syndrome in a dog receiving selegiline for CDS? A. Fluoxetine B. Clomipramine C. Amitraz D. All of the above could interact with selegiline leading to excessive serotonergic CNS stimulation.

8. Sumo is an 11 year-old, male domestic short hair cat with chronic renal failure. Besides eating a veterinarydispensed prescription diet formulated for renal disease, he receives oral benazepril and human recombinant erythropoietin injections. Today, Sumo’s veterinarian has written a prescription for mirtazapine, which the owner presents to your pharmacy. What is the most likely adverse condition that may be improved with mirtazapine?

A. Renal-failure related anorexia B. Renal-failure related hypertension C. Renal-failure related dehydration D. Renal-failure related microalbuminuria

11. Which of the following is an advantage of the sulfonamide anticonvulsant Zonisamide (Zonegran)?

A. After just one to three days of therapy, a determination can be made on whether or not zonisamide has adequately controlled seizures.

B. This agent is well tolerated and considered safe.

C. Sedation is not a side effect of Zonisamide.

D. Zonisamide is significantly lower in cost compared to KBr or phenobarbital.

12. A dog owner presents your pharmacy with a prescription for levetiracetam (Keppra®), for their Patterdale Terrier named "Suzy." Suzy is new to this medication and is being treated for refractory epilepsy.

9. Dogs and cats receive monoamine oxidase The owner would like to know what to expect from this inhibitors (MAOI) relatively infrequently compared with new treatment. Which of the following is an important humans; however, there are instances in which a pet counseling point assuming Suzy will be taking may receive a MAOI. The most common over-thelevetiracetam for a chronic time period? counter use of an MAOI is with the anti-parasitic agent A. Sedation is a major side effect of Levetiracetam and amitraz, which is included in some flea/tick should be monitored. preventatives. The most common prescriptive use of B. The cost of this agent is much lower than other options an MAOI is for the therapy of cognitive dysfunction such as phenobarbital. syndrome (CDS) and this MAOI is _____________.

C. A "honeymoon" effect often occurs in which a period of A. Isocarboxazid (Marplan®) high efficacy may be followed in four to eight months by B. Selegiline (Emsam®) the development of tolerance.

C. Phenelzine (Nardil®) D. Levetiracetam is not effective for refractory epilepsy D. Tranylcypromine (Parnate®) and should be discontinued.

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

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April 2016 CE — Therapeutics for Pet Aggression

March/April 2016

This activity is a FREE service to members of the Kentucky Pharmacists Association.

The fee for non-members is $30. Mail completed forms to: KPERF, 96 C. Michael Davenport Blvd., Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile.

Expiration Date: March 2, 2019 Successful Completion: Score of 80% will result in 1.5 contact hours or .15 CEU. Participants who score less than 80% will be notified and permitted one re-examination.

TECHNICIANS ANSWER SHEET. April 2016 — Part 2. Therapeutics For Pet Aggression, Housesoiling, Seizures and Other Behavior Disorders That are Referred to Retail Pharmacies — What the Pharmacist Needs to Know (1.5 contact hours) Universal Activity # 0143-0000-16-004-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D

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

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

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

Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet.

Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party.

Signature ____________________________________________Completion Date___________________________

Personal NABP eProfile ID #_____________________________ Birthdate ____________(MM/DD) PHARMACISTS ANSWER SHEET April 2016 — Part 2. Therapeutics For Pet Aggression, Housesoiling, Seizures and Other Behavior Disorders That are Referred to Retail Pharmacies — What the Pharmacist Needs to Know (1.5 contact hours) Universal Activity # 0143-0000-16-004-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D

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

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

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

Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet.

Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party.

Signature ____________________________________________Completion Date___________________________

Personal 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 will not be accepted.

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KPERF CE Article Guidelines

March/April 2016

Have an idea for a continuing education article? WRITE IT! Continuing Education Article Guidelines

The following broad guidelines should guide an author  to completing a continuing education article for publication in The Kentucky Pharmacist.   

 

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

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

 When submitting the article, you also will be asked Articles are generally written so that they are pertito fill out a financial disclosure statement to identify nent to both pharmacists and pharmacy techniany financial considerations connected to your articians. If the subject matter absolutely is not perticle. nent to technicians, that needs to be stated clearly Articles should address topics designed to narrow at the beginning of the article. gaps between actual practice and ideal practice in Article should begin with the goal or goals of the pharmacy. Please see the KPhA website overall program – usually a few sentences. (www.kphanet.org) under the Education link to see Include 3 to 5 objectives using SMART and meas- previously published articles.

urable verbs. 

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

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

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

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138th KPhA Annual Meeting & Convention

March/April 2016

Registration is open at www.kphanet.org Schedule coming soon!

HOST HOTEL INFORMATION Deadline for OUR KPhA discounted group rate of $138 is Friday, May 6, 2016.

Louisville Marriott Downtown, 280 W. Jefferson Street, Louisville, KY 40202 Visit https://resweb.passkey.com/Resweb.do?mode=welcome_ei_new&eventID=12589935 to make your reservations today! Or call 502-627-5045 / 1-877-901-6632

The Kentucky Pharmacist is online!

Go to www.kphanet.org, click on Communications and then on The Kentucky Pharmacist link.

Would you rather receive the journal electronically?

Email ssisco@kphanet.org to be placed on the Green list for electronic delivery.

Once the journal is published, you will receive an email with a link to the online version.

Are you connected to YOUR KPhA? Join us online!

Facebook.com/KyPharmAssoc Facebook.com/KPhANewPractitioners @KyPharmAssoc @KPhAGrassroots

KPhA Company Page

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KPhA Pharmacy Emergency Preparedness

March/April 2016

Itâ&#x20AC;&#x2122;s 2016 and pharmacist, pharmacy technician and student pharmacist recruitment is underway for the Kentucky Pharmacists Association emergency preparedness program! Pharmacy professionals play a critical part in responding to emergency events such as a natural disaster or infectious disease outbreak. Mass dispensing of medications protects the public and saves lives. In addition, Kentucky has one of two free standing mobile pharmacies in the country to fill maintenance medications during an emergency response.

There are multiple ways to sign up as a volunteer. You may do so on the KPhA website or through an eNews, completing a volunteer form below or simply sending an email directly to Leah Tolliver at ltolliver@kphanet.org.

Please join the emergency preparedness program! We need all of you!

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

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

KPhA Pharmacy Emergency Preparedness Initiative Interest Form

Name: ______________________

Status (Pharmacist, Technician, Other): ___________________

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

KPhA Remembers KPhA desires to honor members who are no longer with us.

Please keep KPhA informed by sending this information to eramey@kphanet.org .

Deceased members for each year will be honored permanently at the KPhA office.

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THE KENTUCKY PHARMACIST

KPhA New and Returning Members

March/April 2016

KPhA Welcomes New and Renewing Members January-February 2016 Ann Abbott Louisville

William R Broughton Shepherdsville

David E Collins Mayfield

Gregory Aldridge Eddyville

Elois Broughton Shepherdsville

David M Conyer Paducah

Karen Altsman Prospect

Clyde E Brown Mayfield

William A Conyers, III Glasgow

Doug Antle Louisville

Peggy Brown Winchester

Karen Cornelius Harrogate, Tenn.

Maryann Awosika Cold Spring

Amy Brown Greenup

Chad Corum Manchester

Nathan J K Bales Frankfort

Amanda Burton Danville

Terry Lee Coyle Campbellsville

Stephanie P Bargo Lexington

Donell N Busroe Harlan

Helen L Danser Tyner

Cathy Barker Flatwoods

Amber Dale Cann Louisville

Amy Davis Paris

Jason S Beals Louisville

Mark A Capps Burkesville

David M DeCuir La Grange

Mary E Beimesch Hebron

Israel Cardenas Louisville

Sherry DeCuir La Grange

Danny Bentley Russell

Shelia Ann Carrico Lawrenceburg

Eldon Depew London

Stephen L Blanford Louisville

Aimee Chambers Somerset

Emily R. Distler Louisville

Gregory F Blank Edgewood

Brian Cheek Louisville

Holly Divine Versailles

Charles Boggs Dandridge, Tenn.

Janie Cheek Louisville

Walter J Doll Lexington

Virginia Lynn Bohmer Cincinnati, Ohio

Carolyn Chou Louisville

Debbie Duckworth Versailles

Victoria M Bond Louisville

Carrie Christofield Ft Mitchell

John R Eastridge Campbellsville

Jeremy Bowling Manchester

David Thomas Clarke Lexington

Catherine Elmes Sarasota, Fla.

Erika Branham Versailles

Peter P Cohron Henderson

Paul Elmes Sarasota, Fla.

Jackson Mac Bray, Jr. Frankfort

Bonnie K Collins Paris

Joe Elmes Louisville

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MEMBERSHIP MATTERS: To YOU, To YOUR Patients To YOUR Profession!

Kay Collins Embrey Brandenburg Tony Esterly La Grange Lauren Esterly La Grange Rebecca Farney Fort Thomas William J Farrell, Jr. Ft. Mitchell David Figg Beaver Dam Matthew J Foltz Villa Hills John Martin Fuller Versailles Lynn Fuller Versailles Bernard J Fussenegger, Sr. Louisville Darrel Gentry Central City John Gentry Central City Elizabeth K. Gentry Central City

THE KENTUCKY PHARMACIST

KPhA New and Returning Members

March/April 2016

Brenda Gladson Winchester

Jolinda Ann Henry Lexington

Christopher Killmeier Louisville

Jenna Marie Noetzel Lexington

Amy L Glaser Alexandria

Tashena Hill Marion

John Knoop Louisville

Karl Andrew Tucker O'Dell Ashland

Robert Goforth Somerset

Larry Hill Williamsburg

David Hein Kramp Elmwood Place, Ohio

Peter J Orzali, Jr. Cold Spring

Lisa Goodlett Springfield

James W Hinkle Heidrick

Kevin Lamping Lexington

Lauren Beth Otis Owingsville

Stephen W Goodlett Lexington

Kristina Hinkle Heidrick

Morris Lloyd, Jr. Louisville

Staci Overby Paducah

Charles L. Gore Russell Springs

Dana N. Ho Louisville

Julie Losch Bowling Green

Julie A Owen Louisville

Cynthia J Gray La Grange

Janet Hodge Louisville

Philip Losch Bowling Green

Jared Scott Padgett Hartford

Nelson D Gray Barbourville

Susan Hogsten Flatwoods

Craig Martin Georgetown

Beth Parks Coralville, Iowa

Bernard J. Gregorowicz Louisville

Barry W Horne Danville

Tom Mattingly Olive Hill

Duane W. Parsons, Jr. Richmond

William M Grise Richmond

O'Shea Hudspeth Lexington

Okey Mbadike Louisville

Himati Patel Louisville

Gina Guarino Louisville

Tawnya Hunt Greenup

Brittany Kidwell McIntyre Bardstown

Mike Patrick Booneville

Dale Gunkel Madisonville

Jane Katherine Ingram West Liberty

Charles McQuillan Florence

George Patterson Gilbertsville

Julie Hagan Paducah

Mamie Ivey McKee

Pam Montgomery Lawrenceburg

Charles David Peterson Rineyville

Brandon Hale Murray

Kyla James Clarksville, Tenn.

Ronald Moreland Falmouth

Anne Policastri Georgetown

Tammy Hanson Burlington

Paul E Jardina Louisville

Jerry B. Morris Louisville

Bruce D Polly Lexington

Deborah A Harden Campbellsville

Amanda Jett Louisville

Patrick Murphy Louisville

Vicky Pulliam Bardstown

David Harris Mayfield

H. Dale Johnson Corbin

Jerri Murphy Louisville

Leanne Pullins Richmond

Dale Heise Harrodsburg

David Tyler Justice Prospect

Burnice Napier Hazard

Sarah Elizabeth Raake Palmyra, Ind.

Marla Helton Frenchburg

Robert Craig Kidwell Crestwood

LeAnne Nieters Louisville

Nancy Paine Rath Louisville Christi Ratliff Pikeville

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

Clay Rhodes Crestwood

THE KENTUCKY PHARMACIST

KPhA New and Returning Members

March/April 2016

Jill Rhodes Crestwood

Roberta Sloan Lexington

Brittany A Taylor Bardstown

Rob Warford Louisville

Lauren Elizabeth Riney Springfield

Richard Slone, Jr. Lexington

Alexis Thompson Paris

Glenn L Watson Crestwood

Laura Ann Roberts Albany

Sheel Slone Lexington

Mykel Tidwell Mayfield

Brian M. Wesselman Florence

Patricia D Robinson Frankfort

Justin Smith Williamsburg

Michael Traylor Princeton

Sandy Wethington Liberty

Scott Ross Hopkinsville

Vance Smith Harrodsburg

Tiffany Trombley Quicy

Beverly White Williamsburg

Thomas Russell Independence

Cathy Spencer Louisville

John Cody Turpin Harrogate, Tenn.

Nina Crossley Whitehouse Lexington

Wanda Salyer Flat Gap

R James Spencer Beaver Dam

Terry Vest Russell

Paul Williams Hardinsburg

Larry Schaefer Madisonville

Nancy Stanton Holmes Mill

Nancy Walker Cynthiana

Kerri Woods Hamilton, N.Y.

Jim Scott Earlington

Robert W. Stone Glasgow

Rachel Wall Frankfort

Grady A Wright Georgetown

Scotty Sears La Grange

Paula Ann Straub Louisville

Amanda Ward Louisa

Dan P Yeager Lexington

Shruti Sharma Louisville

Meghan Tarter Russell Springs

Rodney Ward Louisa

Jane Yeager Lexington

Know someone who should be on this list?

Ask them to join YOU in supporting OUR KPhA! KPhA Government Affairs Contribution Name: _______________________________Pharmacy: _____________________________

Email: ______________________________________________________________ Address: _____________________________________________________________ City: ___________________________________________ State: _________ Zip: ____________ Phone: ________________ Fax: __--_______________ E-Mail: _____________________________ Contribution Amount: $_________ Check ____ (make checks payable to KPhA Government Affairs)

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

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Naloxone Training

March/April 2016

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

Donate online to the Kentucky Pharmacists Political Advocacy Council!

Go to www.kphanet.org and click on the Advocacy tab for more information about KPPAC and the donation form.

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Pharmacy Law Brief

March/April 2016

Pharmacy Law Brief: Potential Liability for Defamation Author: Peter P. Cohron, B.S.Pharm., J.D., practicing pharmacist and attorney, Henderson, Ky. Question: I hit a rough patch in my relationship with a longstanding patient, and now he is going all around town saying very bad things about me and my competence as a pharmacist. Can you review the law related to defamation so I can begin to figure out whether this fellow, now a former patient, has crossed the line?

Response: Defamation is a false statement made to others that creates or gives a negative and/or derogatory impression of a person, business or other entity. It can be either libel (a printed statement) or slander (a spoken statement).

Defamatory statements in Kentucky are actionable. To establish a claim for defamation, the following elements must exist: (1) defamatory language, (2) about the plaintiff, (3) which is published and (4) which causes injury to reputation. Stringer v. Wal-Mart Stores, Inc., 151 S.W.3d 781, 793 (Ky. 2004).

The defamatory statement must be patently untrue. This includes a “false light” statement, which is technically true but still designed to give a negative connotation. However, opinion or statements interpreted as opinions by reasonable persons are not defamatory. “The pharmacy has been cited by the Health Department several times for rodents” is defamatory if untrue but “The worst pharmacy in town” is not.

The pharmacist may sue for defamation per se, where the statement implies a person’s inability or unfitness for his work. Statements are considered defamatory per se if they “tend to expose the plaintiff to public hatred, ridicule, contempt or disgrace or to induce an evil opinion of him in the minds of right-thinking people, and to deprive him of their friendship, intercourse and society.” CMI, Inc. v. Intoximeters, Inc., 918 F. Supp. 1068, 1083 (W.D. Ky. 1995).

Submit Questions: jfink@uky.edu Disclaimer: The information in this column is intended for educational use and to stimulate professional discussion among colleagues. It should not be construed as legal advice. There is no way such a brief discussion of an issue or topic for educational or discussion purposes can adequately and fully address the multifaceted and often complex issues that arise in the course of professional practice. It is always the best advice for a pharmacist to seek counsel from an attorney who can become thoroughly familiar with the intricacies of a specific situation, and render advice in accordance with the full information.

police keep an eye on him as he sells drugs with no prescription.” “He is a drug addict himself.”

The damage suffered by the pharmacist above may be easily determined by loss of business. When the public relies on the defamatory statement and takes its business elsewhere, compensable damages are accounted through the loss of income. However, other damages may be assessed if people simply shun or refuse to associate with the pharmacist. If she can no longer go comfortably to church, or to her favorite restaurant, a jury may calculate damages to compensate her for her loss of society. Finally, where the person engaging in the defamation knows his statements are false and yet intentionally makes the statements, punitive damages may also be assessed.

The alleged defamer has some defenses against the charge of defamation. Among these, a true statement, courts have ruled, is not defamatory. Nor is a statement spoken through privilege, though an action may follow against the third party if that person breaks the privilege. As mentioned above, if the person makes the statement “in my opinion” the statements become opinion and are not conA claim for defamation per se creates a legal presumption sidered defamation. Finally, and most often cited, if the of both malice and damages. “Therefore, damages are pre- claim for damages cannot be attributed to the defamatory sumed and the defamed person may recover without alle- statements, they were not defamatory. gation or proof of special damage.” Disabled American VetLast, before filing a lawsuit, the pharmacist above needs to erans, Dept. of Kentucky, Inc. v. Crabb, 182 S.W.3d 541, keep in mind that Kentucky courts have traditionally and 547 (Ky. App. 2005). As the person in the question above is historically not favored plaintiffs. Such lawsuits in the Comreferencing the pharmacist’s competence, this is a proper monwealth are difficult to win. Still, a pharmacist must course of action. weigh her future reputation and income against this history Examples of statements that would fall under defamation and make a choice whether to pursue the matter in the per se: “He sells meth out the back door to children.” “The courts.

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Bowl of Hygeia

March/April 2016

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Pharmacy Policy Issues

March/April 2016

PHARMACY POLICY ISSUES: CONFIDENTIALITY AND SUPPLYING MEDICATIONS FOR LAWFUL EXECUTIONS Author: Carleton S. Ellis is a second professional year PharmD student at the University of Kentucky College of Pharmacy. A native of Louisa, Ky., he completed his pre-professional coursework at Morehead State University.

Issue: In the ongoing controversy over the involvement of health professionals in capital punishment, pharmacies are becoming increasingly scrutinized. Should the name of a compounding pharmacy providing the drugs for lethal injection remain confidential?

Discussion: In the U.S., 19 states and the District of Columbia have abolished the death penalty; this leaves 31 states (including Kentucky) with the legal authority to execute prisoners.1 Since 1976, when the Supreme Court repealed a four-year ban on capital punishment, the vast majority – almost 90 percent – of these executions have been carried out via lethal injection.2 While the procedures vary from state to state, the most common protocols involve a three drug combination of sodium thiopental, pancuronium bromide and potassium chloride administered sequentially and in that order. This strategy serves to anesthetize and paralyze the prisoner before stopping the heart.3

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.

months after the December ruling, in May 2015, a law was passed in Texas which exempts the names of suppliers of drugs used for public execution from being published. 9

There has been much debate surrounding the morality and ethics of capital punishment. One group with a clear stance is the manufacturers of the drugs used for lethal injection.

In early 2011, Hospira, Inc. (the sole US manufacturer of sodium thiopental) stopped producing the drug citing, “[the company] could not prevent the drug from being diverted to departments of corrections for use in capital punishment procedures.”4

Texas is not the only state dealing with this challenge. In Ohio, a similar law which maintains the privacy of compounding pharmacies supplying drugs for lethal injection became effective in March 2015. The state scrambled to put together the bill, expecting they could make a deal with a compounding pharmacy; however, it turns out that none were willing to do business. As of October 2015, the state was reaching out to the FDA to contend for the right to pur10 With a shortage of the drugs necessary for lethal injection, chase the necessary drugs from foreign sources. states such as Texas – the national leader in executions While Kentucky has only executed three prisoners since per year – have turned to compounding pharmacies to sup- 1976 (the most recent two being by lethal injection), the ply them with appropriate drugs.5 Earlier this year, the In- possibility remains of the state buying drugs for lethal injecternational Academy of Compounding Pharmacists pub- tion from a compounding pharmacy. If you are the owner of lished a statement in which it discouraged members from a compounding pharmacy, would you be willing to supply participating in legally authorized executions.6 However, drugs for lethal injection? Should the names of these comthere are known cases in which compounding pharmacies pounding pharmacies be released to the public? These have supplied state governments with drugs to be used for questions may seem immaterial now, but this is an issue lethal injection. In the event that this occurs, are the com- that Kentucky pharmacists may have to confront in the pounding pharmacies entitled to confidentiality? near future.

All public records are accessible for inspection by any perReferences son – and this includes government sales contracts. In December 2014, a Texas district court ordered the names of 1) Duggan J, Hammel P, Stoddard M. Hours of suspense, emotion lead up to a landmark vote for legislators on the compounding pharmacies supplying the drugs for lethal repealing death penalty [Internet]. Omaha.com. 2015 injection to be made publicly available claiming that they 7 [cited 2015 Oct 26]. Available from: http:// fell under the category of public records. One compoundwww.omaha.com/news/legislature/live-coverage-fate-of ing pharmacy which supplied the drugs to the state had -death-penalty-in-nebraska-hinges-on/ previously had its name leaked to the press and was met 8 article_32726c27-0ef4-5415-9d07-f90f08707602.html. with a “firestorm” according to the pharmacy owner. A few 38

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March/April 2016

Pharmacy Policy Issues 2) Death Penalty Information Center. Facts about the Death Penalty [Internet]. deathpenaltyinfo.org. 2015 [cited 2015 Oct 26]. Available from: http:// www.deathpenaltyinfo.org/documents/FactSheet.pdf.

Press_Release_Compounding_fo.pdf? hhSearchTerms=%22lethal+and+injection%22.

6) International Academy of Compounding Pharmacists.

IACP ADOPTS POSITION ON COMPOUNDING OF LETHAL INJECTION DRUGS [Internet]. 2015. Available from: http://c.ymcdn.com/sites/www.iacprx.org/ resource/resmgr/Media/

10) Johnson A. Pharmacies avoid execution trade [Internet]. The Columbus Dispatch. 2015 [cited 2015 Oct 26]. Available from: http://www.dispatch.com/ content/stories/local/2015/10/16/pharmacies-avoidexecution-trade.html.

7) Langford T. Court Tells TDCJ to Name Lethal Injection Drug Suppliers [Internet]. The Texas Tribune. 2014 3) Romanelli F, Whisman T, Fink JL. Issues surrounding [cited 2015 Oct 28]. Available from: http:// lethal injection as a means of capital punishment. Pharwww.texastribune.org/2014/12/11/tdcj-cant-keep-lethalmacotherapy. 2008 Dec;28(12):1429-36. doi: 10.1592/ injection-drug-supplier-secr/. phco.28.12.1429. Review. PubMed PMID: 19025423.

8) Solomon D, Solomon D. What Running Out of Pento4) McGreal C. Lethal injection drug production ends in the barbital Means for Texas [Internet]. Texas Monthly.

US [Internet]. The Guardian. 2011 [cited 2015 Oct 28].

2013 [cited 2015 Oct 28]. Available from: http:// Available from: http://www.theguardian.com/ www.texasmonthly.com/the-daily-post/what-running-out world/2011/jan/23/lethal-injection-sodium-thiopental-of-pentobarbital-means-for-texas/. hospira.

9) Solomon D. The FDA Confiscated a Supply of Execu5) Berman M. Texas finds more lethal injection drugs after tion Drugs Texas Is Thought to Have Imported Illegally all [Internet]. Washington Post. 2015 [cited 2015 Oct [Internet]. Texas Monthly. 2015 [cited 2015 Oct 28].

27]. Available from: https://www.washingtonpost.com/ Available from: http://www.texasmonthly.com/the-dailynews/post-nation/wp/2015/03/25/texas-finds-morepost/the-fda-confiscated-a-supply-of-execution-drugslethal-injection-drugs-after-all/. texas-is-thought-to-have-imported-illegally/.

Kentucky Pharmacists Political Advocacy Contribution Form Name: _________________________________ Pharmacy: ___________________________ Address: _______________________ City: ________________ State: _____ Zip: ________ Phone: ________________ Fax: __--_______________ E-Mail: __________________________________ Contribution Amount: $_________ Check ____ (make checks payable to KPPAC)

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

CONTRIBUTION LIMITS The primary, runoff primary and general elections are separate elections. The maximum contribution from a PAC to a candidate or slate of candidates is $1,000 per election.

Individuals may contribute no more than $1,500 per year to all PACs in the aggregate.

In-kind contributions are subject to the same limits as monetary contributions.

Cash Contributions: $50 per contributor, per election.

Contributions by 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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March/April 2016

Pharmacists Mutual

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Cardinal Health

March/April 2016

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THE KENTUCKY PHARMACIST

KPhA Board of Directors/Staff

March/April 2016

KPhA BOARD OF DIRECTORS

HOUSE OF DELEGATES

Bob Oakley, Louisville Boakley@BHSI.com

Chair

Chris Harlow, Louisville cpharlow@gmail.com

Chris Clifton, Villa Hills chrisclifton@hotmail.com

President

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

Trish Freeman trish.freeman@uky.edu

President-Elect

KPERF ADVISORY COUNCIL

Brooke Hudspeth, Lexington brooke.hudspeth@kroger.com

Secretary

Christen S Bruening cmschenkenfelder@gmail.com

Chris Palutis, Lexington chris@candcrx.com

Treasurer

Matt Carrico, Louisville matt@boonevilledrugs.com

Duane Parsons, Richmond dandlparsons@roadrunner.com

Past President Representative

Matt Carrico, Louisville* matt@boonevilledrugs.com

Mary Thacker, Louisville mary.thacker@att.net

Chad Corum pharmdky21@gmail.com

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

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

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

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

Directors

Kevin Mercer kevin.mercer@uky.edu

Speaker of the House

Sullivan University Student Representative

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

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

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50 Years Ago/Frequently Called and Contacted

March/April 2016

50 Years Ago at KPhA BOARD OF PHARMACY MEETS IN LEXINGTON Members of the Kentucky Board of Pharmacy met recently in Lexington for the purpose of reaching decisions on some of the problems currently confronting the Board.

Among the items discussed were: Rules and Regulations conforming to the Pharmacy Bill, Fee for Permit to operate a Pharmacy, Renewal Fees, Budget for the Board of Pharmacy, Employment of an Executive Secretary, Employment of an additional Inspector, Employment of an additional girl in the office.

President Golden listed several types of committees he deemed necessary and named the Chairman of each. Among the committees listed were the COMMITTEE ON PERSONNEL, RECIPROCITY AND PUBLIC RELATIONS — Jerome A. Budde, Chairman; BUDGET COMMITTEE — Vernon C. Stubblefield, Jr., Chairman; COMMITTEE ON LEGISLATION AND REGULATIONS — Coleman Friedman, Chairman.

Applications for the position of Executive Secretary of the Kentucky Board of Pharmacy and Drug Inspector for the Kentucky Board of Pharmacy are found on the opposite page.

- From The Kentucky Pharmacist, April 1966, Volume XXIX, Number 4.

Frequently Called and Contacted Kentucky Pharmacists Association 96 C. Michael Davenport Blvd.

Frankfort, KY 40601 (502) 227-2303 www.kphanet.org Kentucky Board of Pharmacy State Office Building Annex, Ste. 300 125 Holmes Street Frankfort, KY 40601 (502) 564-7910 www.pharmacy.ky.gov Pharmacy Technician Certification Board (PTCB) 2215 Constitution Avenue Washington, DC 20037-2985 (800) 363-8012 www.ptcb.org

Kentucky Society of Health-System Pharmacists P.O. Box 4961 Louisville, KY 40204 (502) 456-1851 x2 (502) 456-1821 (fax) www.kshp.org info@kshp.org American Pharmacists Association (APhA) 2215 Constitution Avenue NW Washington, DC 20037-2985 (800) 237-2742 www.aphanet.org

National Community Pharmacists Association (NCPA) 100 Daingerfield Road Alexandria, VA 22314 (703) 683-8200 info@ncpanet.org Drug Information Center Sullivan University College of Pharmacy 2100 Gardiner Lane Louisville, KY 40205 (502) 413-8638 www.sullivan.edu Kentucky Regional Poison Center (800) 222-1222

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

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March/April 2016

THE

Kentucky PHARMACIST 96 C. Michael Davenport Blvd.

Frankfort, KY 40601

Show your Pharmacist Pride with a KPhA Roamey Window Cling ($5) or your own personalized Roamey ($25)!

All proceeds benefit the KPhA Building Fund

Louisville Marriott Downtown

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

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