The Kentucky Pharmacist Vol. 11, No. 3

THE KENTUCKY PHARMACIST Vol. 11, No. 3 May/June 2016 News & Informat ion for Members of the Kentucky Pharmacists Ass ociation

Guardian of the Profession in Frankfort: 2016 Legislative Wrapup Registration and schedule online at www.kphanet.org

Table of Contents

May/June 2016 June 2016 CE — Adult Immunization Schedule June Pharmacist/Pharmacy Tech Quiz Answer Sheet KPERF CE Article Guidelines The Kentucky Pharmacist Online KPhA Emergency Preparedness KPhA New and Returning Members Pharmacy Law Brief 138th KPhA Annual Meeting & Convention 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 138th KPhA Annual Meeting & Convention From your Executive Director The Campaign for Kentucky’s Pharmacy Future APSC 2016 Kentucky Legislative Pharmacy Summary May 2016 CE — Beers Criteria May Pharmacist/Pharmacy Tech Quiz Answer Sheet Naloxone Certification Training

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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

May/June 2016

PRESIDENT’S PERSPECTIVE Chris Clifton KPhA President 2015-2016

pacted negatively. At the same time, KPhA also worked to promote and enhance the profession where needed. I would like to thank the KPhA staff, and all of those members that spent long days and nights during the legislative session to help steer our profession through the muddy waters. I am so proud of all the work that was done and completed during the session.

I think the legislative session itself would have made any year successful, but we also decided to change headquarters and move into a new building this past December. We I can’t believe that my tendefinitely have decided to take the road less traveled this ure as President of this past year at KPhA and I am proud of the work and the degreat Association is drawcisions that our Board of Directors have made with the full ing to a close. I am not support of the House of Delegates. I would like to thank all sure how I expected it to be or if anything went as comof those members and individuals that have already donatpletely planned, but I have enjoyed representing the proed to The Campaign for Kentucky Pharmacy’s Future. fession I love, and I am glad to see that Kentucky has so We are a fourth of the way there to achieve our goal of $1 many wonderful pharmacists doing great things for this million, and I want to encourage you to pledge in whatever state, the country and most importantly their patients. amount you can at www.kphanet.org/?

When we started this journey last June, my vision was to page=buildingcampaign . Below is a list of identified giving UNITE this profession as one to rally around provider sta- opportunities for OUR campaign! No donation is too small, tus and broaden this profession’s practice. Being UNITED and every donation will be recognized in a Book of Honor as one gives us a stronger, more focused voice when call- at KPhA and KPERF headquarters. ing for change or preventing damage. We are all pharma YOU are invited to join the Campaign for Kentucky cists, whether it is in the community, the hospital, long term Pharmacy’s Future to assure our collective success as care, academia, clinical, managed care, etc. We may praca member of the Committee of 100 Pharmacy tice differently and have different wants and needs, but we Founders. Donations or pledges at this level start at all have the same underlying principles: To take care of the $5,000 and are payable in whole or in part over the patient and do what is best for his or her wants and needs. next 5 years.

And it is with that core element that we will always be  AND, you can be a member of this Committee by helpUNITED together. And I would ask that every pharmacist ing KPhA and KPERF BUILD a Wall of Excellence or remember this, when advocating for their profession and a Wall of Presidential Leadership. Donations or their passions. We continue to stay strong and firm on our pledges at this level start at $10,000 and are payable message for H.R. 592 and S. 314 in Congress, with all of in whole or in part over the next 5 years. our Kentucky Representatives on board and only our two U.S. Senators remaining to be persuaded. Let’s work to gether to get this done by year’s end and prove to the country that our state is strong and UNITED in supporting and advocating pharmacist provider status by all of our Kentucky Senators and Representatives. On the state level, I was proud to see our profession and other state asso-  ciations UNITE to help in the passage of several state pieces of legislation, most notably SB 117. SB 117 is our long awaited update to our MAC bill passed in 2012, which provides transparency to PBMs, requires them to be separately licensed and regulated by the state Department of Insurance and requires PBMs to update a MAC list and individu ally notify every contracted pharmacy when there is an appeal granted on a drug. With more than 19 bills introduced during this legislative session, KPhA monitored each and every one of them to make sure YOUR practice wasn’t im3

OR, YOU are invited to join the Campaign for Kentucky Pharmacy’s Future by helping to lay a Cornerstone. Donations or pledges at this level start at $3,000 and are payable in whole or in part over the next 3 years.

OR, YOU are invited to join the Campaign for Kentucky Pharmacy’s Future as a Pharmacy Builder.

Donations or pledges here are at the $1,000 level and can be commemorated with one of the History of Pharmacy prints dedicated to the person of your choice.

OR, you can purchase a KPhA Roamey Window cling for $5.

Continued on Page 5 THE KENTUCKY PHARMACIST

Joel Thornbury for House of Representatives

May/June 2016

Paid for by Joel Thornbury for House of Representatives

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THE KENTUCKY PHARMACIST

138th KPhA Annual Meeting & Convention

May/June 2016 installation of new officers and directors, engagement with vendors and exhibitors and especially the overall promotion of pharmacy. I encourage all pharmacists to attend in order to learn and share ideas for a better profession of tomorrow.

Continued from Page 3 

Join the 2020 Club ($20 a month through 2020) or give a gift of any amount.

With your help we can get to that magical number of $1 million! Wouldn’t you want to look back and say I helped pave the way for Kentucky’s Pharmacy Future? I know I do.

Well, there it is my last journal article. I would like to thank everyone that believed in me and supported me this past year and more. I feel very lucky to have been very blessed with a wonderful family, community and professional family.

I will always be there to support OUR KPhA and I hope to see each and every one of you along the way. Thank you and God Bless.

I hope to see everyone this June 2-5 at the Louisville Marriott Downtown for the 138th KPhA Annual Meeting & Convention. As always there will be great CE, a wonderful time for fellowship, recognition of peers with our annual awards,

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

Thursday, June 2, 2016 KPERF Golf Scramble 10:30 am Registration 11:00 am Shotgun start Friday, June 3, 2016 7 am Registration Opens 7:30 am-9:30 am Opening Breakfast/KPhA Annual Membership Meeting and Opening House of Delegates 9:00 am – 10:00 am CE: DSCSA: Debunking the Myths 9:00 am – 10:00 am Pharmacy Practice Accreditation (NonCE) 10:10 – 11:10 am CE: Why Would We Give Syringes to People Who Inject Drugs?

– Greg Lee, Kentucky DPH 10:10 – 11:10 am CE: Diabetes Update – Brooke Hudspeth 11:25-12:45 pm KPhA Awards Luncheon 1:00 – 2:30 CE: USP 795, 797, and 800: How Do I Comply with the Updated Guidelines? – Tyler Stevens, Michelle DeLuca Fraley, Barb Jolly 1:00-2:30 CE: Implementing Collaborative Care Agreements to Advance Pharmacy Practice and Improve Access to Care – Cassy Beyerle & Holly Divine 2:40 -3:40 CE: Financial Planning for Young Pharmacy Professionals – Bruce Lafferre 2:40 -3:40 CE: What Pharmacists Should know about Weapons of Mass Destruction – Leah Tolliver 3:50-5:20 pm CE: NASPA/NMA 2016 KPhA Student Pharmacist Self-Care Championship 3:50-5:20 pm “Improving Patient Care While Making More Money” Union Springs Workshop (Non CE) 5:30 pm-7:30 pm Opening of Hall of Exhibits Saturday, June 4, 2016 7:00 am Registration/Continental Breakfast 7:00 am Reference Committee

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CE: 2016 Kentucky Pharmacy Law Update – Ralph Bouvette 9:30 am to 11 am Hall of Exhibits Open 9:30 am to 11 am Academy of Consultant Pharmacists Business Meeting 11 am to noon CE: Professional Socialization of the Next Generation of Pharmacists – Holly Byrnes, PharmD BCPS; Anne Policastri, PharmD, MBA, FKSHP; Sarah Smith, PharmD, BCPS 11 am to noon CE: I’m Just As Nervous As a Cat: Treatment Options for Anxiety and Insomnia – Melinda Joyce Noon College Update and Preceptor Recognition Luncheon Technician Lunch/Academy meeting 1:00-2:30 pm CE: New Drugs: How do they stack up? – Trish Freeman 2:40: 3:40 pm CE: Mobile Health and Remote Monitoring in the Pharmacy – Joey Mattingly 2:40: 3:40 pm CE: Human Papillomavirus (HPV): What’s in it for Patients?

– Clark Kebodeaux 3:45 pm-5:30 pm House of Delegates Closing Session 6 pm President’s Reception 7 pm Ray Wirth Banquet (stick around after for networking with colleagues) Sunday, June 5, 2016 7 am Continental Breakfast/Social networking 8 am-4 pm CE: APhA Diabetes Certification – Brooke Hudspeth *Additional registration required 8 am-11 am CE: Substance Abuse Prevention/ Combating Drug Abuse in Your Community: Train the Trainer - Laurel Taylor 11:15 am-12:45 pm CE: Medical Marijuana Policy Town Hall featuring Kari Franson, University of Colorado School of Pharmacy

THE KENTUCKY PHARMACIST

From Your Executive Director

MESSAGE FROM YOUR

EXECUTIVE DIRECTOR In Greek, it is καλωσόρισμα while in German we may be greeted by willkommen or by benvenuto from our Italian friends. Others may greet us with bienvenida in Spanish, bienvenue in French or a kind welkom in Dutch. However, we say or receive it — we always enjoy a warm and embracing Welcome! That is truly how OUR KPhA feels about our new headquarters for the Association and for the profession: WELCOME — this is your professional home and pharmacy headquarters, a pinnacle for the Association today and for many years to come. The doors belong to and are always open to our members. Hopefully, you have already or will be able to make a trip soon to see it for yourself.

When reflecting upon my upbringing, one of my fondest memories is how my mother, Lillian, would welcome visitors to our home. As a very young child, I can recall when an occasional “hobo” would happen upon our property, given our close proximity to the Southern Railway. Mom would provide him with a quick meal (outside at the picnic table of course), and he would be on his way (I suppose yesterday’s hobos are a variant of today’s homeless.). Moreover, our home was often the tutoring lab for neighborhood children as Mom would answer questions and guide children other than her biological own with their overnight assignments. And, when family and other guests arrived in our home, they were always welcomed with warmth and a friendly, “What can I get you to drink?” According to the Elementary Latin Dictionary, the word hospitality derives from the Latin hospes, meaning "host," "guest" or "stranger". By metonymy “Hospital” in Latin refers to a guest’s lodging or an inn. Hence, we have the derivative for our English words of host, hospitality, hotel, hospice and hostel. My mother wasn’t rich or famous or socially prominent. Yet she touched other’s lives without needing to be on a grand stage. She accomplished this by welcoming others, by being kind to them, and by going out of her way for them. These are my fond memories of growing up here in Kentucky.

As President Clifton notes in his article, the quest of having pharmacists recognized as integral providers for patient care continues, and we look forward to witnessing that welcoming mat being extended by Congress, CMS and other payers.

Along these lines, a review in the Annals of Internal Medicine1 recently synthesized current data related to the involvement of pharmacist-led interventions in helping patients manage their chronic disease states. The review concludes, in part, “Pharmacist-led chronic disease management was associated with effects similar to those of usual care for re-

May/June 2016

Robert “Bob” McFalls

source utilization and may improve physiologic goal attainment. Further research is needed…”

If patient outcomes are to be improved in Kentucky, with medically underserved areas in urban and rural counties alike, we must continue the push to advance the hospes role of the pharmacist in addressing health interventions. Since it started in 2008, the Gallup-Healthways Well-Being Index® has examined the comparative well-being of citizens throughout the 50 states along with the District of Columbia.

Its latest report, “The State of American Well-Being: 2015 State Well-Being Rankings”2 revealed that Kentuckians have consistently reported low well-being year after year. In fact, West Virginia and Kentucky have been the lowest and second lowest well-being states in the country, respectively, since the Index started. The Gallup-Healthways Well-Being Index uses a holistic definition of well-being and self-reported data from individuals to measure the elements that matter most to well-being: purpose, social, financial, community and physical. Previous Gallup and Healthways research shows that high well-being closely relates to key health outcomes such as lower rates of healthcare utilization, workplace absenteeism and workplace performance, change in obesity status and new onset disease burden.

I recently read an interesting article in the Australian Pharmacist from Catherine Waterman in which she explores the world of grey nomads and the health challenges they carry with them on their migratory journeys around Australia (“Risky nomads coming to a pharmacy near you”, 10/1/15).3 Grey nomads are well known across Australia as elders who travel to iconic sites to avoid the extreme weather conditions.

Some are facing end-of-life conditions, so they go on the road to enjoy the life they have left with their partners who are well enough to do the driving. But, as Ms. Waterman notes, they may be risking their lives due to a lack of education about their health and required medications. Access to one’s pharmacist and to the knowledge that s/he has is critical on any journey if life, consistent with the “Code of Ethics for Pharmacists” (as adopted by APhA on 10/27/94) in “… assist(ing) individuals in making the best use of medications.” Indeed, hospitality may require our direct action and interventions.

The Code and its principles remind us that pharmacists have their own covenantal relationship with their patients, meaning “…that a pharmacist has moral obligations in response to the gift of trust received from society. In return for this gift, a pharmacist promises to help individuals achieve optimum benefit from their medications, to be committed to their welfare, and to maintain their trust.” I can think of no better 6

THE KENTUCKY PHARMACIST

The Campaign for Kentucky’s Pharmacy Future

May/June 2016

affirming description of the pharmacist as a bearer of professional hospitality in helping patients help themselves to have the healthiest life possible.

1.

2.

“Pharmacist-led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared with Usual Care”, Annals of

3.

Internal Medicine, Greer, et.al, doi 10.7326/M15-3058, published 26 April 2016.

The latest index can be accessed at http://info.healthways.com/ hubfs/Well-Being_Index/2015_Data/GallupHealthways_State_of_American_WellBeing_2015_State_Rankings.pdf?t=1456266714360.

The article was accessed and can be viewed at http:// www.psa.org.au/download/ap/apoct15/cover-story.pdf.

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

Donors to the campaign as of May 16, 2016                      

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Jeff Arnold Ray Bishop Fred Carrico Matt Carrico Jessika Chinn J. Leon & Margaret Claywell David Dubrock Brian Fingerson Matt Foltz Robert Goforth Cynthia Gray George & Burnetta Hammons JCAP Don & Vicki Kupper Phil & Julie Losch Bob Oakley Chris & Consuelo Palutis Duane Parsons Richard & Zena Slone Leah Tolliver Sam Willett Mary Ann & Michael Wyant

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APSC

May/June 2016

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THE KENTUCKY PHARMACIST

2016 Kentucky General Assembly Pharmacy Summary

May/June 2016

Session Summary Regarding Pharmacy Legislation 2016 KENTUCKY GENERAL ASSEMBLY A Member Update from OUR Kentucky Pharmacists Association The Guardian of the Profession

KPhA gratefully acknowledges the engagement of members throughout the Commonwealth who made legislative advocacy a personal priority during the 2016 legislative session. KPhA Members were united in your resolve to make a difference by conducting regular telephone calls and engaging in one-on-one conversations with your state senators and representatives. From President Chris Clifton, the Government Affairs Committee, Chair Richard Slone, OUR KPhA Board of Directors, Executive Director Bob McFalls & Staff: Thank You for your due diligence and commitment. Your advocacy efforts make a difference!

journed. The exceptions are those bills that contained an emergency clause or those that included a specific effective date.

Pharmacy Benefit Managers (PBMs): The number one legislative priority of OUR KPhA and the pharmacy community was achieved when Governor Bevin signed SB 117 on April 9. The bill, sponsored by Senator Max Wise (RCampbellsville) and shepherded through the House by Representative Jeff Greer (D-Brandenburg) and Rep. Tommy Thompson (D-Owensboro), provides additional transparency regarding the operations of pharmacy benefit managers (PBMs) including a requirement that PBMs be separately licensed by and subject to regulation by the state Department of Insurance. The bill requires PBMs to maintain and regularly update a comprehensive Maximum Allowable Cost (MAC) list and also changes the way the companies develop MAC pricing and how they determine reimbursement. The legislation revises the current MAC law to make the requirements of an appeals process, including the timeline for PBMs to respond to appeals, a statutory requirement instead of a contract provision between pharmacies and PBMs. It also requires PBMs to individually notify all contracted pharmacies when an appeal is granted so that pharmacies can reverse and resubmit claims in order to be properly reimbursed. If a PBM denies an appeal, it would have to give the pharmacy the source where the drug could be purchased from a wholesaler licensed by the Kentucky Board of Pharmacy.

KPhA acknowledges and thanks our advocacy partners for this session: American Pharmacy Cooperative, Inc., American Pharmacy Services Cooperative, EPIC Pharmacies, Inc., KIPA, Kentucky Retail Federation, National Association of Chain Drug Stores and the National Community Pharmacists Association.

Pharmacy issues were in the forefront throughout the 2016 Kentucky General Assembly. Legislative proposals affecting the practice of pharmacy as well as those specifically impacting retail pharmacies were among the bills introduced and debated up until the closing hours of the session. When the session ended on April 15, Kentucky’s pharmacy community had reason to celebrate. A bill initiated by the group to require additional oversight of pharmacy benefit managers (PBMs) and more transparency regarding their operations had won approval. KPhA’s advocacy efforts on behalf of its members also were successful in helping to win passage of legislation dealing with other third-party payers, in preventing major limitations on use of Kentucky’s generic substitution law and in significantly changing a bill exempting certain administrative activities from the practice of pharmacy.

The following narrative summary highlights some of the key issues affecting KPhA members that were considered during the 2016 Session. The electronic version of the summary includes links to the legislature’s website so you can easily access additional information on specific bills including the full text of the legislation as it was introduced along with changes made or proposed as bills moved through the process.

Other Reimbursement Appeals: The legislature also approved SB 20 to establish an appeals process within the Cabinet for Health and Family Services to resolve disputes between a provider and a Medicaid managed care organization (MCO). The bill requires the cabinet to promulgate administrative regulations within 120 days to implement an external independent third-party review of disputed claims after a provider has exhausted the MCO’s internal appeals process. It also allows for an appeal of any final decision rendered by the third-party review to the administrative hearing tribunal within the Cabinet. The bill contained an emergency clause so it took effect on April 8 when it was signed by the governor.

Most bills that were enacted during the 2016 Session will take effect in mid-July, 90 days after the legislature ad-

Provider Notice of Contract Changes: Beginning on Jan. 1, 2017, insurers and managed care organizations (MCOs) 9

THE KENTUCKY PHARMACIST

2016 Kentucky General Assembly Pharmacy Summary that want to make changes in the terms and conditions of the contracts they have with providers will have new rules to follow. Senate Bill 18 was introduced by Senator Ralph Alvarado (R-Winchester) and requires insurers and MCOs to give providers advance notice of material changes in contract terms and conditions, including a description of the change and its effective date. Under terms of the bill, material changes include not only reimbursement changes but also revisions to provider network requirements and inclusion in any new or modified insurance products. Notice of contract changes are required to be sent in orangecolored envelopes that bear the words, "ATTENTION! CONTRACT AMENDMENT ENCLOSED!", in at least 14point, boldface type. The bill also requires the insurer to provide a clean copy of the contract incorporating the changes if three or more significant changes are made within a 12-month period if the provider requests the new document. The bill will become law this summer without the governor’s signature.

May/June 2016

companies from requiring their plan subscribers to use mail order pharmacies if retail pharmacies agreed to accept the same financial terms and conditions as the mail order pharmacy in order to participate in the network. Although several senators expressed concern about insurers and PBMs directing business to mail order pharmacies in which they had a financial interest, no additional consideration was given the bill after it was referred to the Senate Appropriations and Revenue Committee.

Representative Cluster Howard (D-Jackson) also introduced a bill to prohibit an insurer from requiring the use of a mail order pharmacy but HB 226 would have allowed for differential co-pays or co-insurance. The bill was not considered in the House Banking and Insurance Committee.

Administrative Activities in Pharmacies: At the time of its introduction, supporters of HB 527 described it as an economic development bill needed to allow Onco360 to put its headquarters in Louisville, but KPhA and its pharmacy affiliates quickly recognized that the bill would significantly Biosimilars: House Speaker Pro Tem Jody Richards (Daffect the practice of pharmacy in Kentucky. The original Bowling Green), at the request of KPhA and its pharmacy bill proposed a special class of pharmacy — a restricted affiliates, sponsored an amendment to SB 134 that was distribution pharmacy — that would have been allowed to added in the House and concurred in by the Senate before perform a number of tasks with little oversight by the state the bill won final approval. The change ensures that the Board of Pharmacy. In response to concerns raised by the prescriber notification requirement in the bill would be met pharmacy community, significant changes were made and if a phone call, fax or electronic communication was made the enacted version of the bill exempts certain administrato the prescriber or his office personnel. The bill, spontive activities from the practice of pharmacy and allows any sored by Senator Ralph Alvarado (R-Winchester), requires pharmacy to engage in these administrative functions that the automatic substitution of FDA-approved interchangeacould be done either within or outside the pharmacy. These ble biosimilars but requires notice to the prescriber about tasks include billing patients, entering patient insurance what product was dispensed except when the prescription information, opening faxes and setting up patient profiles. indicates “do not substitute.”

The final version of HB 527 that was signed by the governor on April 13 also updates the statutory definition of Specialty Drugs: Representative Jeff Greer (DBrandenburg) attempted to address the growing problem “prescription drug orders” to include those orders issued for community pharmacy resulting from the widespread but through protocols authorized by the state Board. inconsistent classification of “specialty drugs” by pharmacy Tamper-resistant Opioids: Although the bill’s sponsor, benefit managers (PBMs) and the insurance companies Representative Addia Wuchner (R-Burlington), agreed to they represent. make a major change to address concerns raised by the Insurers and PBMs continue to put medications on a spepharmacy community, the Senate did not act on HB 330 cialty drug list without any clear criteria which limits the before the session ended. The House-passed version of ability of retail pharmacies to dispense these drugs to their the bill would have made an exception to Kentucky’s generic drug law by requiring a pharmacist to get written or patients. House Bill 458 proposed to define specialty drugs to include only those that have special handling inverbal consent from a prescriber to dispense a non-abuse structions or patient education required by the drug manu- deterrent opioid when the prescriber writes for a tamperfacturer that could not be done in a retail pharmacy or resistant drug. those that the Federal Drug Administration (FDA) has put Board of Pharmacy Initiatives: Two bills introduced at on a restricted distribution list. The bill easily cleared the the request of the Kentucky Board of Pharmacy failed to House but was not considered in the Senate. win final approval during this year’s session. House Bill Mail Order Mandates: Another provision of Greer’s HB 398, introduced by Representative Mary Lou Marzian (DLouisville), would require new pharmacy technicians to un458 that cleared the House would have barred insurance 10

THE KENTUCKY PHARMACIST

2016 Kentucky General Assembly Pharmacy Summary dergo an FBI and Kentucky State Police fingerprint-based criminal background check, starting April 1, 2017. The bill cleared the House and advanced in the Senate where an amendment was adopted adding the provisions of another Board initiative (HB 437) to establish licensing standards for “outsourcing” facilities that compound drugs without a patient-specific prescription and to require licensing of medical gas wholesalers. The House did not act on the Senate changes so the bill died.

HME Licensing: Responsibility for licensing providers of home medical equipment will move from the Board of Pharmacy to a newly-created Board of Durable Medical Equipment Suppliers with the passage of HB 562. Unless home medical equipment or supplies are provided through a separate legal entity, pharmacies are not required to obtain a HME license.

Synthetic Drugs: House Bill 4 was approved to increase the penalties for trafficking in and possession of synthetic drugs. The bill was amended in the Senate to reschedule hydrocodone combination products as Schedule II drugs and to add two fentanyl derivatives to the list of Schedule I drugs. The Senate language also preserved the prescriptive authority of optometrists and advanced practice registered nurses to write for hydrocodone combination products. The House approved the Senate changes and the bill was delivered to Governor Bevin on April 15. He signed it on April 27.

The General Assembly also approved HCR 187 urging the federal government to screen all inbound shipments to the United States to help identify and intercept illegal synthetic drugs and chemicals.

May/June 2016

Medical Malpractice Reform: Litigation regarding medical malpractice was the topic addressed by four bills introduced this year, but none of them were enacted. One of the bills introduced in the House proposed a mandatory mediation system prior to a lawsuit being filed (HB 344) while HB 554 would have set standards for the conduct of medical malpractice lawsuits. Senate Bill 6 reintroduced the concept of medical review panels to prescreen medical malpractice claims and SB 31 proposed to make expressions of sympathy and similar statements inadmissible as evidence of liability in medical malpractice cases.

Medicaid Expansion: House Bill 6 passed the House requiring the state to expand its Medicaid program to the full extent permitted by federal law, but the measure died in the Senate Health and Welfare Committee.

Limits on Co-Pays and Co-Insurance: Bills were introduced in both chambers to require insurers to offer health benefit plans that offer a lower cost-sharing structure for prescription drugs covered by the plan, but neither Senate Bill 268 nor HB 321 passed.

Mandated Benefits: Senate Bill 193, dubbed Noah’s Law, was enacted this year to add amino-based elemental formulas to the list of therapeutic foods that insurers offer drug coverage as part of their health plans, as well as the state’s Medicaid program, are required to cover. A provision of SB 18 also requires treatment of mitochondrial disease by therapeutic food, formulas and supplements under health plans that provide prescription drug coverage.

Limited Access to Criminal Records: House Bill 40 won legislative approval this year to clear the criminal record of those convicted of 60-plus specific felony crimes including Continuation of Therapy: Senator Ray Jones (D-Pikeville) several drug-related offenses and is set to become law this introduced SB 123 to permit a pharmacist to dispense con- summer. The original bill that cleared the House would tinuation of therapy without a refill order under limited cirhave required expungement of most non-violent felony concumstances, but the bill died without a hearing. victions five years after an offender completed his sentence or probation. In addition, it would have permitted a judge to “Sharps” Disposal: Legislation requiring local health demask the records regarding multiple felony convictions. partments to develop recommendations to encourage the proper disposal of needles fell victim to controversy over The bill was significantly changed when it was considered needle exchange programs after an amendment was addin the Senate, but the final version still will restrict access to ed to HB 160 requiring the programs to have a one-to-one the records regarding past criminal behavior. The enacted exchange rate. The bill died in the House after the Senate provisions allow an ex-offender to file a petition with the amendment was added. court to vacate his conviction of one of 61 felony crimes five years after he has completed his sentence or probaMedical Marijuana: Although HB 584 and SB 263 were filed to legalize the sale and use of medical marijuana, tion. The prosecutor must be notified of the petition and there was less discussion of the issue during the 2016 Ses- given the opportunity to comment. If the petition is granted, sion than occurred last year. Neither bill saw action nor did the public record of the crime will disappear. The final bill SB 304 calling for the creation of a task force to craft legis- also allows the expungement of multiple misdemeanor conlation for consideration in 2017 to authorize the use of mari- victions rather than the single offense that is permitted unjuana for palliative and end-of-life care. der current law.

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THE KENTUCKY PHARMACIST

The Campaign for Kentucky’s Pharmacy Future

May/June 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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THE KENTUCKY PHARMACIST

May 2016 CE — Beers Criteria

May/June 2016

Beers Criteria: The 2015 Update By: Brian Garcia, PharmD Candidate – University of Kentucky; Zara Risoldi Cochrane, PharmD, MS, FASCP – Creighton University; Sarah M. Lawrence, PharmD, MA, CGP - PharMerica The authors declare no financial relationships that could be perceived as real or apparent conflicts of interest.

Universal Activity # 0143-0000-16-005-H05-P&T 1.0 Contact Hour (0.1 CEU)

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

Goal: Clinicians should be aware of medications that are potentially inappropriate in older adults, the rationale involved in making that determination and what alternatives may exist.

Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: 1. Recognize which medications and classes of medications are included in the Beers Criteria; 2. Explain which medications have been added or removed from the latest Beers update, and the rationale behind these changes; and 3. Suggest alternative therapy recommendations to prescribers to reduce the use of potentially inappropriate medications. special populations of older adults, including palliative and hospice care patients. These patients have different care goals, and should be treated accordingly.

Introduction The Beers Criteria, originally written in 1991 by geriatrician Mark Beers, MD, is the longest running and most comprehensive list of potentially inappropriate medications (PIMs) for older adults. The Beers Criteria is intended as a guideline for clinical knowledge and practice for most patients over 65 years of age in ambulatory, acute and institutional settings. In its initial incarnation, this document was intended as a prescribing guideline for nursing home patients.

Since 2011, the American Geriatrics Society has maintained and published the Criteria, and has updated it twice.

The original update was published in 2012, and a second update was published in October 2015.1

Another limitation relates to the care of very old (80+) patients. Most clinical trials exclude patients over 80 years of age, and there is very little data on the use of medications in this age range. When recommending medications for this age class, clinicians should consider further research for evidence specific to that age group as well as their own expert opinion or clinical experience. The Beers Criteria does not issue recommendations specific to this population.

The Beers Criteria is only beneficial to the patient if used appropriately; clinicians should not use its recommendations as absolute prescribing guidelines. Medications discussed in the Beers Criteria are only potentially inappropriate for use in older adults. When making a recommendation or decision to utilize a medication on the list, clinicians should take care to review the reason that the medication was considered potentially inappropriate, and what the strength of that recommendation is.

Use of PIMs has been associated with poor health outcomes in patients over the age of 65, including increased rates of confusion, falls and mortality.2 Avoidance or judicious use of PIMs may decrease these adverse effects in this age group and improve medication safety. The 2015 Beers Criteria update is the output of a 13-member interdisciplinary expert panel, which utilized a modified Delphi process to build consensus among expert panelists.

Appropriate Use & Limitations of the Beers Criteria 5 One limitation to the Beers Criteria is that clinicians do not fully understand its purpose and scope. The Beers Criteria is intended to serve as a reference, is not completely comprehensive and should not be treated as a contraindication to the use of any medication. In order to make recommendations that are applicable to the entire geriatric population, guidance must remain non-specific and allow for clinical judgment based on patient-specific factors. The recommendations in the Beers Criteria may not be applicable for

It may be helpful to think of the Beers Criteria as a warning light, which should serve as a starting point to analyze the patient’s medical needs in depth before making a decision, rather than treating it as a list of medications that are universally inappropriate.

PIMs may be appropriate for some older adults, when used with appropriate caution. Careful evaluation can mean the difference between keeping a patient on an appropriate regimen, and the patient suffering by not being allowed a medication simply because it was on the list. Insurance

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May 2016 CE — Beers Criteria

May/June 2016

companies have instituted some barriers to filling Beers alertness and increase fall risk. The expert panel provided a Criteria medications for the older adult population. Again, strong recommendation to avoid meclizine based on modthe criteria should serve as a signal to stop and think about erate level evidence. the appropriateness of the medication, and should not be Avoid implemented as a “hard stop” or “do not fill list.” Pharmalonger cists who feel the benefits outweigh the risks of a Beers than 8 medication and encounter insurance blocks should take weeks further steps to get the medication approved for the patient. unless for Proton use in Strong High Level Pump Changes in the 2015 Version high risk Recommendation of Evidence Inhibitors patients The 2015 Beers Criteria update added drugs to the list and (chronic removed some drugs. The update provided new guidance steroid or for medication recommendations based on renal function NSAID and for managing drug-drug interactions. Another change use) this year is the creation of two new publications. The first is Proton Pump Inhibitors (PPIs) were added to the list of a “how to” guide focusing on appropriate use of the Beers PIMs for multiple reasons, including the increased risk of Criteria and its application to the geriatric population. The Clostridium difficile infection, as well as increased rate of second publication identifies potential alternative medications and recommendations for certain high risk PIMs. Each bone mineral density loss and an increased risk of fracrecommendation includes the level of evidence supporting tures. The committee noted that their benefit may outweigh the risk for short courses of therapy, but chronic use for duthe recommendation (low, moderate, high) as well as the strength of recommendation (strong or weak). A recommen- rations longer than eight weeks should be avoided. An exception may be appropriate in the case of high risk patients, dation may have a low level of evidence, but still merit a strong recommendation based on the severity of the poten- including patients on chronic steroids or NSAIDs. tial adverse effect of that medication.

PPIs reduce levels of gastric acid produced by the stomach, which decreases the body’s defense mechanism against C. Medications Added to the Beers Criteria in 2015 diff and other infections. This results in an increased likeliTwo medications and one class of medication were added hood of infection, especially with administration for longer to the Beers Criteria in the 2015 update. These medicathan eight weeks and/or with co-administration of broad tions, which include desmopressin, meclizine and proton spectrum antibiotics that disrupt normal microbiota.6,7 pump inhibitors, may be inappropriate in older adults.

Studies have shown that long term administration of PPIs, Moderate Strong especially at higher doses, increases the risk of bone minDesmopressin Avoid Level of Recommendation eral density loss and fractures because of impaired absorpEvidence tion and metabolism of calcium, along with other vitamins Desmopressin should be avoided for treatment of nocturia and minerals.8 The expert panel provided a strong recomor nocturnal polyuria. Desmopressin carries a high risk for mendation to avoid scheduled, long term (> 8 weeks) use of hyponatremia. Desmopressin decreases the excretion of PPIs in low risk patients, with a high quality level of eviwater, without altering sodium excretion. Due to the body’s dence. natural volume-regulating mechanisms, higher levels of sodium are excreted in the urine, causing hyponatremia. The Cautions added to the list with respect to disease state expert panel provided a strong recommendation to avoid Four classes of medications have been added to the Beers this medication based on moderate level evidence.

Criteria in the 2015 update, with respect to disease state.

These medications, including 1st and 2nd generation antipsychotics, additional CNS stimulants and non-hypnotic benzodiazepines are potentially inappropriate in patients in correMeclizine, a first generation antihistamine with anticholinersponding disease states. The guidelines also have clarified gic side effects, was added to the list of first generation antispecifications for Sliding Scale Insulin. histamines that are considered to be potentially inappropri1st/2nd Avoid in Strong Moderate ate. Meclizine and other first generation antihistamines Generation patients Recommendation Level of have anticholinergic effects such as dry mouth, dry eyes, Antipsychotics with Evidence constipation and urinary retention. They may also decrease Delirium Meclizine

Avoid

Strong Recommendation

Moderate Level of Evidence

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May 2016 CE — Beers Criteria While the 2012 version of the Beers Criteria cautioned against the use of conventional (first generation) and atypical (second generation) antipsychotics to treat behavioral symptoms of patients with dementia, the 2015 update extended that caution to include patients with delirium. Use of antipsychotics may, in fact, worsen delirium.

May/June 2016 and should be avoided unless other medications are not appropriate for the patient. The committee provided a strong recommendation to avoid this class of medications in this patient group with a moderate level of evidence.

Other Noteworthy Changes to PIMs Eszopiclone/ Zaleplon/ Zolpidem

In general, use of both conventional and atypical antipsychotics increases the risk of cerebrovascular accident (stroke) and mortality in persons with dementia.9 These agents also are associated with cognitive impairment, electrolyte imbalances and increased fall risk. CMS and state surveyors closely scrutinize the use of antipsychotic medications in older adults with dementia who reside in long term care facilities. Because of this, antipsychotics only should be considered for behavioral symptoms of dementia or delirium when other interventions have failed and the patient is a threat to self or others.

Avoid

Strong Recommendation

Moderate Level of Evidence

While the 2012 Beers Criteria recommended only short term (less than 90 days) use of non-benzodiazepine hypnotics, the 2015 update now recommends complete avoidance of this class, which includes eszopiclone, zaleplon and zolpidem. These agents have a similar adverse event profile to benzodiazepines and cause ataxia, impaired psychomotor function and syncope. This increases the risk of falls or fractures, especially in patients with a history of falls. Additionally, these medications often provide minimal The FDA cautions against the use of antipsychotics in patients with electrolyte imbalances such as hypokalemia and improvement in sleep latency and duration for older patients. These medications should be avoided unless safer hypomagnesemia. These agents are associated with increasing the QT interval, thereby increasing a patient’s risk alternatives are not available. If these medications must be used, clinicians should consider decreasing the dosage of of cardiovascular events.10 Use should be avoided except for treatment of patients with schizophrenia or bipolar disor- other CNS-active medications. der. Short term use as anti-emetic therapy during chemoModerate Sliding Scale Strong therapy can be considered. The expert panel provided a Avoid Level of Insulin Recommendation strong recommendation to avoid this class of medications Evidence with the stated comorbidities based on moderate level eviThe recommendation to avoid sliding scale insulin (SSI) dence. usage was retained from the 2012 Beers Criteria, but further clarified. Sliding scale insulin should be avoided based Avoid in Moderate on a moderate quality of evidence and at a strong recomArmodafinil/ patients Strong Level of Modafinil with Recommendation mendation. The use of SSI carries a higher risk of hypoglyEvidence Insomnia cemia without improvement in hyperglycemia, regardless of care setting. The 2015 update defines sliding scale insulin Both armodafinil and modafinil have been added to the list as the “sole use of short- or rapid-acting insulins to manage of CNS stimulants that should be avoided in patients with or avoid hyperglycemia in absence of basal or long-acting insomnia. These medications can have a negative effect on insulin” and “does not apply to titration of basal insulin or elderly patients who suffer from insomnia, which may be use of additional short- or rapid-acting insulin in conjunction related to their approximate 15 hour half-life.11, 12 The exwith scheduled insulin (i.e. correction insulin).” This recompert panel provided a strong recommendation to avoid mendation is particularly critical for older adults residing in these medications based on a moderate level of evidence. long term care facilities. Because SSI may compromise the Avoid in health of the frail elderly patient, long term care facilities patients Moderate that persist in using it as routine treatment for diabetes may Strong Opioids with a Level of experience problems from state surveyors and other reguRecommendation history of Evidence latory agencies.13 falls Removal of Drugs from the Beers Criteria Opioids should be avoided in patients with a history of falls Loratadine, an antihistamine, has been removed from the or fractures except for those with recent fracture or joint replacement. Similar to other CNS-active drugs like benzo- list of strong anticholinergic medications, and is no longer diazepines and hypnotics, opioids have an increased risk of considered a potentially inappropriate medication. ataxia and other symptoms noted in the previous section Previously, anti-arrhythmic drugs (class 1a, 1c and III) were 15

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May 2016 CE — Beers Criteria Table A – Dosage Adjustment Based on Renal Function Creatinine Clearance (ml/min)

<80 <60 <50 30-50

<30

Medication Levetiracetam

Reduce Dose

Gabapentin Pregabalin

Reduce Dose Reduce Dose

Cimetidine Famotidine

Reduce Dose

Nizatidine Ranitidine

Reduce Dose Reduce Dose Reduce Dose

Edoxaban Rivaroxaban

Reduce Dose*

Amiloride Dabigatran

Avoid

Reduce Dose

Fondaparinux

Avoid Avoid

Probenacid

Avoid

Spironolactone

Avoid

Triamterene

Avoid Avoid (Weak Recommendation) Reduce dose (Weak Recommendation) Avoid (Weak Recommendation-GI side effects) Reduce Dose Reduce dose - monitor for adverse effects

Tramadol ER Tramadol IR Duloxetine Enoxaparin Colchicine

<25

Recommendation

Apixaban

Avoid*

*does not match manufacturer recommendation on the list of medications to avoid for first line treatment of atrial fibrillation. This recommendation has been removed, because new evidence and guidelines suggest that rhythm control can have outcomes as good as or better than rate control.14 It is important to note that some anti-arrhythmic drugs still are considered PIMs and should be avoided:  

May/June 2016 stipation has been removed as drug-disease, drugsyndrome category because it is common across the age spectrum and not predominantly specific to older adults.

Because constipation can be caused or exacerbated by medication use, prescribers and pharmacists should continue to monitor patients taking such medications.

The 2012 Beers Criteria suggested avoidance of inhaled anticholinergic agents such as tiotropium in male patients with lower urinary tract symptoms and/or benign prostatic hyperplasia (BPH). These agents were thought to decrease urinary flow and lead to urinary retention. In the 2015 update, there is no recommendation to avoid inhaled anticholinergic agents in patients with lower urinary tract symptoms or BPH. This is presumably because of their low systemic absorption profile.

In the 2012 list, the anti-infective nitrofurantoin was considered a PIM in patients with a creatinine clearance (CrCl) less than 60ml/min, but studies have now shown nitrofurantoin to be relatively safe and effective for patients with CrCl of at least 30ml/min. It should still be avoided as longterm suppressive therapy because of the possibility of irreversible pulmonary fibrosis, liver toxicity and peripheral neuropathy.

Reference information for dosage adjustment based on renal function This is a new category added to the Beers Criteria and is designed to serve as a reference point when starting and maintaining patients with kidney dysfunction on new therapies. Refer to Table 6 in the 2015 AGS Beers Criteria for the complete analysis.15 Recommendations to avoid specific drugs or reduce the dose are made with a strong recommendation and moderate quality of evidence. These recommendations are summarized in Table A. Reference information for drug-drug interactions

This is a new category added to the Beers Criteria 2015 update. It is designed to serve as a reference point when starting and maintaining patients on PIMs that may interact with and worsen adverse effects of current medications. All Amiodarone (Class III) - avoid except in patients with recommendations in this category carry a moderate or high heart failure or substantial left ventricular hypertrophy quality of evidence. Table B depicts the offending drug or Dronedarone (Class III) - avoid in patients with perma- class and the interaction risks. nent atrial fibrillation or severe/recent decompensated Alternative Medications16 heart failure



Disopyramide (Class 1a) - avoid, due to strong anticholinergic effects



Digoxin - avoid as first line treatment for patients with atrial fibrillation or heart failure, and limit daily doses to < 0.125 mg or less

Although included in the 2012 Beers Criteria, chronic con-

An additional article was published as a tool for clinicians to use along with the 2015 Beers Criteria. This article contains recommendations for medications that may be used in lieu of a potentially inappropriate medication. It is important to note that these recommendations are based on consensusbased data, and do not have the same level of evidence as 16

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May 2016 CE — Beers Criteria

May/June 2016

Table B – Drug-Drug Interactions Initial Drug/Class

Interacting Drug/ Class Amiloride/ triamterene

Increased risk of…

Recommendation

Hyperkalemia

Other anticholinergic drugs

Cognitive decline

Avoid routine use – reserve for patients with hypokalemia while on ACEIs Avoid /minimize total number of anticholinergic drugs

> 2 other CNSactive drugs

Falls and fractures

NSAIDs

Peptic Ulcer Disease GI bleeds

Lithium

ACEIs Loop diuretics

Lithium toxicity

Peripheral Alpha-1 blockers

Loop diuretics

Theophylline

Cimetidine

Urinary incontinence in older women Theophylline toxicity

Warfarin

Amiodarone Warfarin

ACEIs

Anticholinergic drugs Antidepressants (TCAs and SSRIs) Antipsychotics Benzodiazepines and non-BZD hypnotics Opioids Corticosteroids (PO/IV)

Allergic symptoms

Parkinson’s disease

High Risk Medication

Bleeding

First Generation Antihistamines

Dopamine agonists (e.g.

Benztropine & Trihexyphenidyl)

Alternative Therapy 1. Intranasal saline 2. 2nd gen antihistamines (fexofenadine, loratadine, cetirizine) 3. Intranasal steroids (fluticasone, etc.)

Carbidopa/ levodopa

the Beers Criteria. The most useful recommendations are listed in Tables C through G. Conclusion Pharmacists have an important role in the care of the older

Avoid – if steroids are required, provide GI protection Avoid – monitor lithium concentrations Avoid in older women

References

1. Hulisz D. Updated Beers Criteria: A more comprehensive guide to medication safety in older adults. American Avoid Pharmacists Association Avoid when Website. http:// possible – monitor www.pharmacist.com/updated INR -beers-criteria-morecomprehensive-guide-medication-safety-older-adults.

November 1, 2015. Accessed January 8, 2016.

Table C – Anticholinergic Medications Indication

Avoid using > 3 CNS-active drugs, minimize total amount

adult patient. Knowledge of the Beers Criteria and its appropriate use can help pharmacists make good recommendations for the initiation, monitoring and modification of older adults’ medication regimens. Pharmacists can serve as a resource to prescribers who care for older adults, and to older adults who may purchase PIMs over-the-counter.

Pharmacy technicians can help with monitoring for appropriate medication use in older adults, and report any changes in a patient’s status or medication habits to the pharmacist for further investigation and action.

2. Fick DM, Mion LC, Beers MH et al. (2008). Health outcomes associated with potentially inappropriate medication use in older adults. Res Nurs Health; 31:42-51.

3. Davidoff AJ, Miller GE, Sarpong EM et al. Prevalence of potentially inappropriate medication use in older adults using the 2012 Beers Criteria. J Am Geriatr Soc 2015; 63:486-500.

4. Fox C, Smith T, Maidment I et al.(2014). Effect of medications with anti-cholinergic properties on cognitive function, delirium, physical function and mortality: A systematic review. Age Ageing; 43:604-615.

5. Steinman, M., Beizer, J., Dubeau, C., Laird, R., Lundebjerg, N., & Mulhausen, P. (2015). How to Use the American Geriatrics Society 2015 Beers Criteria-A Guide for Patients, Clinicians, Health Systems, and Payors. Journal of the American Geriatrics Society J Am Geriatr Soc.

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May 2016 CE — Beers Criteria

May/June 2016

Table D – Cardiovascular Medications Indication

Hypertension

Atrial Fibrillation

Hypertension

High Risk Medication

Indication

Alternative Therapy

Guanabenz, Guanfacine, Methyldopa

Thiazide diuretics, ACEIs, ARBs, long -acting DHP CCBs Blacks: Thiazides or CCBs only Heart failure, Diabetes, CKD patients: ACEIs or ARBs preferred

Disopyramide

Rate Control: non-DHP CCB (diltiazem); beta-blocker Rhythm control: dofetilide, flecainide, propafenone

Nifedipine (immediate release)

Table F – Endocrine System – Active Drugs

Depression Neuropathic Pain

High Risk Medication Tricyclic antidepressants Tricyclic antidepressants

Epilepsy

Barbiturates

Insomnia

Eszopiclone, Zaleplon, Zolpidem

Alternative Therapy

Hormone Replacement

Estrogens with or without progestins (oral or patch) including conjugated estrogen, esterified estrogen, estradiol or estropipate

Dyspareunia/ Vulvovaginitis: vaginal estrogen formulations Vasomotor Symptoms: SSRI, SNRI, gabapentin

Type 2 Diabetes

Long Acting Sulfonylureas (glyburide and chlorpropamide)

Short-acting sulfonylureas (glipizide, etc.) and metformin

Thyroid Replacement

Desiccated thyroid

Levothyroxine

Table G – Pain Medications Indication

Amlodipine or other long acting non-DHP CCB

Acute mild or moderate pain

Table E – Central Nervous System – Active Drugs Indication

High Risk Medication

Alternative Therapy SSRI (excluding paroxetine), SNRI, Bupropion SNRI, gabapentin, topical capsaicin, pregabalin, topical lidocaine patch Any new anticonvulsants, especially lamotrigine and levetiracetam No pharmacological therapy, Consider positive sleep hygiene

Mild or Moderate Chronic pain

High Risk Medication Skeletal muscle relaxants (carisoprodol, cyclobenzaprine, methocarbamol, etc.)

Indomethacin, ketorolac (PO & IV)

Alternative Therapy 1.

2.

1.

2.

Acetaminophen Ibuprofen, naproxen (if no HF and GFR >30ml/min administered with PPI) Acetaminophen Ibuprofen, naproxen (if no HF and GFR >30ml/min administered with PPI)

9. Trifiro, G., Spina, E., & Gambassi, G. (2008). Use of antipsychotics in elderly patients with dementia: Do atypical and conventional agents have a similar safety profile? Pharmacological Research, 1-12.

10. Shulman, M., Miller, A., Misher, J., & Tentler, A. (2014).

Managing cardiovascular disease risk in patients treated with antipsychotics: A multidisciplinary approach. Journal of Multidisciplinary Healthcare JMDH, 489-489.

6. Biswal, S. (2014). Proton pump inhibitors and risk for Clostridium difficile associated diarrhea. Biomed J Biomedical Journal, 178-178.

11. Nuvigil® [package insert]. Teva Pharmaceuticals, Inc., North Wales, PA; 2015.

7. Mcfarland, L. (2008) Antibiotic-associated diarrhea: Epi- 12. Provigil® [package insert]. Teva Pharmaceuticals, Inc., North Wales, PA; 2015. demiology, trends and treatment. Future Microbiology,563-578.

13. State Operations Manual: Appendix PP-Guidance to Surveyors for Long Term Care Facilities (Revision 133) 8. Ito, T., & Jensen, R. (2010). Association of Long-Term https://www.cms.gov/Regulations-and Guidance/ Proton Pump Inhibitor Therapy with Bone Fractures and Guidance/Manuals/downloads/ Effects on Absorption of Calcium, Vitamin B12, Iron, som107ap_pp_guidelines_ltcf.pdf. Published: 2015 Feb and Magnesium.Current Gastroenterology Reports Curr 6; accessed: 2015 Jan 6 Gastroenterol Rep,448-457.

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May 2016 CE — Beers Criteria

May/June 2016

14. Waldo, A.(2015). Rate Control versus Rhythm Control ety J Am Geriatr Soc, 616-631. in Atrial Fibrillation: Lessons Learned from Clinical Tri16. Hanlon, J., Semla, T., & Schmader, K. (2015). Alternaals of Atrial Fibrillation. Progress in Cardiovascular Distive Medications for Medications in the Use of Higheases, 168-176.

Risk Medications in the Elderly and Potentially Harmful 15. American Geriatrics Society Updated Beers Criteria for Drug-Disease Interactions in the Elderly Quality Potentially Inappropriate Medication Use in Older Measures. Journal of the American Geriatrics Society J Adults. (2012). Journal of the American Geriatrics SociAm Geriatr Soc.

May 2016 — Beers Criteria: The 2015 Update 1. The Beers Criteria addresses medications that are related to poor health outcomes in older adults.

Pharmacists and prescribers should use this information in what way?

A. To prevent patients from ever taking these medications B. As a reference to determine if the medication is appropriate for the patient C. To restrict access to these medications in long-term care facilities D. As a comprehensive list containing all medications that may be inappropriate for the elderly

5. A majority of anti-arrhythmic drugs have been removed from Beers Criteria because new evidence and guidelines suggest that “rhythm control can have outcomes as good as or better than rate control.” Which of the following medications is still considered a Potentially Inappropriate Medication despite this new wording?

A. Procainamide B. Sotalol C. Disopyramide D. Flecainide

2. First-generation antihistamines (e.g. meclizine) post a potential danger to geriatric patients for what reason?

A. First-generation antihistamines cause short-term paranoia and can lead to dementia.

B. First-generation antihistamines decrease renal function and increase sodium levels in the body.

C. First-generation antihistamines block muscarinic receptors which decreases alertness and increases the risk of falls.

D. None of the above, first-generation antihistamines should be considered first-line therapy for all patients.

6. Which of the following medications are considered potentially inappropriate in the geriatric population with a Creatinine Clearance <60ml/min?

A. Triamterene B. Ibuprofen C. Gabapentin D. Apixaban

7. Which of the following is an appropriate alternative to first generation antihistamines for geriatric patients suffering from seasonal allergies?

A. Intranasal saline 3. Which of the following classes of medications can lead B. Second generation antihistamines (fexofenadine, to both an increased risk of Clostridium difficile loratadine, cetirizine) infections, as well as increase the rate of bone mineral C. Intranasal steroids (fluticasone) density loss and the risk of fractures?

D. All of the above are appropriate A. Proton-pump inhibitors because they directly inhibit bacterial growth and increase the activity of osteoclasts 8. Which of the following medications should be avoided B. Proton-pump inhibitors because they create a more in older adult patients with Parkinson’s disease? favorable environment for opportunistic infections and A. Carbidopa/Levodopa decrease absorption of nutrients B. Benztropine C. Atypical antipsychotics because they decrease gastric C. Tryhexyphenidyl secretions and decrease mental alertness D. B and C D. Opioids because they decrease gut motility and cause ataxia 9. Which of the following medications should be avoided for treatment of type 2 diabetes in an older adult?

4. Sliding Scale Insulin carries an increased risk of A. Metformin hypoglycemia without improvement in hyperglycemia.

B. Glyburide Which of the following correctly defines sliding scale C. Glipizide insulin?

D. Insulin A. Using a long-acting insulin at night and adjusting meal time insulin based on carbohydrate intake 10. ACE Inhibitors may increase levels of what B. An IV insulin drip monitored in the ICU electrolyte when co-administered with Amiloride or C. The titration of basal insulin in addition to predetermined Triamterene? meal-time doses A. Phosphate D. The sole use of short or rapid acting insulin in the B. Potassium absence of basal or long-acting insulin C. Amylase D. Serum Creatinine 19

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May 2016 CE — Beers Criteria

May/June 2016

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Naloxone Certification Training

May/June 2016

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June 2016 CE — Adult Immunization Schedule

May/June 2016

CDC Recommended Adult Immunization Schedule By: Sarah Schroer, PharmD Candidate – University of Kentucky; Sarah M. Lawrence, PharmD, MA, CGP – PharMerica There are no financial relationships that could be perceived as real or apparent conflicts of interest.

Universal Activity # 0143-0000-16-006-H01-P&T 1 Contact Hour (0.1 CEU) Goal: To provide clinicians with an overview of the current CDC Adult Immunization Schedule with a focus on available vaccines, their recommended indications and schedules and the disease states they protect against.

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Objectives At the conclusion of this Knowledge-based article, the reader should be able to: 1. Discuss background information about each infection for which a vaccine has been recommended in the adult population; 2. Determine whether a patient is a candidate for vaccine therapy; and 3. Identify important recent changes to the CDC Adult Immunization Schedule.

Introduction The recommended immunization schedules for persons living in the United States are reviewed and approved by the Advisory Committee on Immunization Practices (ACIP) annually. They also are approved by the American College of Physicians (ACP), the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse-Midwives (ACNM).

The Centers for Disease Control (CDC) has published its updated 2016 immunization schedule recommendations for both pediatric and adult populations, effective Feb. 1, 2016. The 2016 update includes several major and minor changes.1 Vaccines Hepatitis A2, 3

Adult Indications      



Men who have sex with men Illicit drug users (injection and non-injection) Persons with occupational risk for infection Persons with chronic liver disease Persons who receive clotting factor concentrates Persons traveling to or working in countries with high or intermediate endemicity of hepatitis A Unvaccinated persons anticipating close personal contact with an international adoptee within the first 60 days after arrival in the U.S. from a country with high or intermediate endemicity of hepatitis A

Hepatitis A Licensed Products

Adult Schedules

HAVRIX

2 dose schedule: 0 months 6-12 months

VAQTA

2 dose schedule: 0 months 6-18 months

TWINRIX (combined hepatitis A and hepatitis B)

3 dose schedule: 0 months 1 month 6 months 4 dose schedule: 0 days 7 days 21-30 days 12 months

Hepatitis A is a highly contagious liver Source: Recommended Adult Immunization Schedule – United States - 2016 infection caused by the Hepatitis A virus (HAV). It is generally transmitted by the fecal-oral appetite, nausea, vomiting, abdominal pain, dark urine, clay route through person-to-person contact or by consumption -colored bowel movements, elevated liver enzymes and of contaminated food or water. Infected individuals are the jaundice. Symptoms generally last less than 2 months, and most infectious 1-2 weeks before the onset of clinical signs treatment is simply supportive care. However, some individand symptoms, when the concentration of the HAV is high- uals, particularly young children, are asymptomatic. Once a est in their stool and serum. Signs and symptoms of HAV person has been infected with HAV, antibodies against the infection present abruptly and include fever, fatigue, loss of virus form and protect from future HAV infections. Accord22

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June 2016 CE — Adult Immunization Schedule ing to the CDC, Hepatitis A rates in the United States have declined by 95 percent since the Hepatitis A vaccine first became available in 1995.

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Hepatitis B4 Hepatitis B is a liver infection caused by the Hepatitis B virus (HBV). It is transmitted when blood, semen or another body fluid from a person infected with the Hepatitis B virus enters the body of someone who is not infected. This can happen through sexual contact, sharing needles or syringes or from mother to baby at birth. Hepatitis B infections can be either acute or chronic. The risk for chronic infection is related to a person’s age at infection. According to the CDC, about 90 percent of infected infants and 25-50 percent of infected children 1-5 years old will become chronically infected, compared to 2-6 percent of newly-infected adults. Signs and symptoms of HBV infection present similarly to that of Hepatitis A infection and include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored bowel movements, elevated liver enzymes and jaundice. However, the presence of signs and symptoms of HBV infections will vary. Most children under 5 years old and newly infected immunosuppressed adults are asymptomatic, while 30-50 percent of persons 5 years and older have symptoms. Treatment for acute HBV infections is supportive in nature. Treatment for chronic HBV infections includes antiviral medications and regular monitoring to prevent liver damage and hepatocellular carcinoma.

Human Papillomavirus5

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May/June 2016

Adult Indications Sexually active persons not in a long-term, mutually monogamous relationship (e.g., > 1 sex partner during the previous 6 months) Persons seeking evaluation or treatment for an STD Current or recent injection drug users Men who have sex with men Health care and public safety workers at risk for exposure to blood or other infectious body fluids Unvaccinated adults < 60 years old with diabetes as soon as feasible after diagnosis (discretion of clinicians if ≥ 60 years old) Persons with ESRD (including those receiving dialysis), HIV infection and/or chronic liver disease Susceptible sex partners or household contacts of hepatitis B surface antigen-positive persons Residents and staff of facilities for developmentally disabled persons Travelers to regions with intermediate or high rates of endemic HBV infection All other persons seeking protection from HBP infection*

Hepatitis B Licensed Products Hepatitis B Only: RECOMBIVAX HB ENGERIX-B

Combined HAV and HBV: TWINRIX

Combined hepatitis B, diphtheria, tetanus, acellular pertussis adsorbed, and inactivated polio virus):

Adult Schedules 3 dose series: 0 months 1 month 6 months (minimum of 4 months after dose 1 and 2 months after dose 2) Adults receiving hemodialysis or with other immunocompromising conditions should receive a higher dose of a single antigen vaccine than other indications 3 dose schedule: 0 months 1 month 6 months 4 dose schedule: 0 days 7 days 21-30 days 12 months

Not for use in adults.

Only for use in infants to 10 years old.

PEDIARIX

Human papillomavirus (HPV) is a very  common virus that infects epithelial cells.

Over 120 types of HPV have been identiSource: Recommended Adult Immunization Schedule – United States - 2016 fied and are distinguished by unique *Acknowledgment of a specific risk factor is not a requirement for hepatitis B numbers. HPV is best known to cause vaccination warts in locations ranging from hands and feet to mucosal membranes such as genitals, mouth These types are considered high-risk and can cause canand throat. While most HPV infections are asymptomatic cers of the anus, cervix, penis, vulva, vagina and oropharand resolve on their own, certain types can lead to cancer. ynx. According to the CDC, an estimated 17,600 women

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and 9,300 men are from previous vacHuman papillomavirus (HPV) diagnosed with a cancinations against or Adult Indications Licensed Products Adult Schedules cer caused by HPV illnesses from the flu.

CERVARIX (2vHPV) 3 dose series: each year. In the pre- Unvaccinated females If a person encounages 13 through 26 0 months vious immunization ters an influenza 1-2 months schedule published virus that has 6 months by the CDC, both a evolved enough that Unvaccinated females GARDASIL (4vHPV) ages 13 through 26 GARDASIL 9 bivalent and quadritheir immune system Unvaccinated males ages (9vHPV) valent vaccination does not recognize 13 through 21, may were listed. Now, the it, they can get the still vaccinate through schedule has been flu again. The other 26 years updated to include a type of change ocUnvaccinated males ages 22 through 26 who nine-valent human curs in influenza A have sex with men or papillomavirus vacviruses but is far less who are cine (9vHPV) as an common. It is called immunocompromised option for both males “antigenic shift.” This Source: Recommended Adult Immunization Schedule – United States 2016 and females indicated is a more sudden for HPV vaccination. and dramatic change The 9vHPV (brand name Gardasil 9) protects against HPV in the virus, resulting in new hemagglutinin and/or new 16 and 18, which cause about 66 percent of HPV-related neuraminidase proteins on the surface of the virus. Anticancers, as well as five additional HPV-types which acgenic shifts generally emerge from animal populations and count for about 15 percent of cervical cancers, as well as are so different from their subtype counterparts in humans two additional types (HPV 6 and 11) which cause anogeni- that most people have little to no protection against the tal warts. It has the same recommendations as the quadri- new virus. valent vaccine in previous immunization schedule updates. Standard influenza vaccines are either trivalent or quadrivalent. Trivalent vaccines include coverage of influenza A (H1N1), A (H3N2) and an influenza B virus strain. QuadriInfluenza, commonly known as “the flu,” is a contagious valent vaccines have the same coverage with the addition disease caused by the influenza virus. There are three of protection against another influenza B virus strain. A types of influenza viruses: A, B and C. Influenza A and B yearly influenza vaccination is recommended because the are the two types that most commonly spread through the vaccine changes every year in response to the virus conpopulation and cause seasonal flu epidemics each year. stantly changing and evolving. Extensive research is done Influenza A viruses are divided into subtypes. Influenza A to predict the most likely influenza strains to be circulating subtypes are based on two surface proteins of the virus: during peak season, and these strains are what the yearly hemagglutinin (H) and neuraminidase (N). H and N are influenza vaccine is developed to protect against. It takes further divided into subtypes and identified by the addition about 2 weeks from the time of administration for the influof a number. There are 18 hemagglutinin subtypes (H1 enza vaccines to become effective. This is due to the time through H18) and 11 neuraminidase subtypes (N1 through it takes for antibodies to the virus to develop after vaccine N11). The influenza A subtypes which cause the flu in hu- administration. mans are influenza A (H1N1) and influenza A (H3N2). RaThe flu is a respiratory illness that can range from mild to ther than being broken down into subtypes, influenza B is severe. Symptoms can include fever, cough, sore throat, divided into lineages and strains. The influenza B viruses runny or stuffy nose, muscle or body aches, headaches currently circulating belong to one of two lineages: B/ and fatigue. The onset of symptoms from the flu are usualYamagata and B/Victoria. ly sudden, and can last anywhere from a few days to 2 The influenza viruses are constantly changing. The most weeks. Complications of the flu include pneumonia, broncommon type of change seen in influenza viruses is called chitis and sinus and ear infections. These complications “antigenic drift.” This refers to small genetic changes in the can lead to flu-related deaths. The flu also can exacerbate virus that happen naturally as it replicates. These seeming- pre-existing disease states such as asthma and heart failly minor genetic changes accumulate over time and result ure. While anyone can get the flu, young children, pregin viruses that have genetic material unique enough that nant women and persons 65 years of age and older are at the body’s immune system may not recognize the virus a higher risk of developing serious complications from it.

Influenza6

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Influenza Vaccine Type

Trade Name

Age Indications

Inactivated influenza vaccine, quadrivalent (IIV4), standard dose

Fluarix Quadrivalent FluLaval Quadrivalent Fluzone Quadrivalent Fluzone Intradermal Afluria Fluvirin Fluzone Flucelvax

≥ 3 yrs ≥ 3 yrs varies based on dose 18-64 years ≥ 9 yrs; 18-64 yrs via jet injector* ≥ 4 yrs ≥ 6 mos ≥ 18 yrs

Fluzone High-Dose

≥ 65 yrs

Flublok

≥ 18 yrs

FluMist Quadrivalent (intranasal)

2-49 yrs

Inactivated influenza vaccine, trivalent (IIV3), standard dose Inactivated influenza vaccine, cell-culture-based (ccIIV3), standard dose Inactivated influenza vaccine, trivalent (IIV3), high dose Recombinant influenza vaccine, trivalent (RIV3), standard dose Live attenuated influenza vaccine, quadrivalent (LAIV4)

Source: Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2015-2016 Influenza season. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm#Tab.

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*Afluria has been approved for IM injection via a needle-free jet injector for persons aged 18-64 years All influenza vaccines are made with egg protein except RIV3, which may be administered to any patient ≥ 18 years with a known egg allergy.

LAIV4 is contraindicated in pregnant women, immunosuppressed adults and any adults who have taken influenza antiviral medications within the previous 48 hours. Additionally, the use of these antiviral drugs should be avoided for 14 days after vaccination.

Routine annual influenza vaccination is recommended for all persons aged ≥ 6 months who do not have contraindications. Adults are recommended to receive just one influenza vaccine per year. If possible, health care providers should begin offering vaccination by October and continue to do so as long as influenza viruses are circulating. Above is a list of currently available vaccine types, brand names and ages each is approved to be administered to from the 2015-2016 season. They are all administered as intramuscular (IM) injections unless otherwise indicated. For adults and older children, the recommended site for IM vaccination is the deltoid muscle.

rash appears. Additional complications that can occur from measles include ear infections, pneumonia, bronchitis and diarrhea. Rare but more serious complications of measles include acute encephalitis (which can result in permanent brain damage), seizures and death from respiratory and neurologic complications.

Mumps8:

Mumps is a viral illness caused by a paramyxovirus. It is spread by direct contact with respiratory secretions, saliva or fomites. Signs and symptoms of mumps include pain, tenderness and swelling of one or both parotid salivary glands in the cheek and jaw area. Swelling generally peaks in 1 to 3 Measles, Mumps, Rubella days but may last as long as 10 days. According to the CDC, 7 3-10 percent of adolescent and adult males suffering from Measles (Rubeola) : mumps also have inflammation of one or both testicles. AlMeasles is an extremely contagious acute viral respiratory ternatively, mumps infection can present with only nonspeillness, spread by direct contact with infectious droplets or by cific or primarily respiratory symptoms, or it may be asympairborne particles from an infected person breathing, cough- tomatic. Rare but serious complications of mumps include ing or sneezing. It is characterized by fever, cough, conjunc- pancreatitis, deafness, meningitis and encephalitis. tivitis and inflammation of the upper respiratory tract at onRubella (German Measles)9: set. Koplik spots (white lesions on the inside of the cheeks indicative of measles) also appear early in the infection Rubella is a viral illness generally presenting as a mild infeccourse. Roughly 14 days after exposure to the measles vition that lasts 2-3 days. It is spread by contact with respiratorus, a red blotchy rash appears, spreading from the head to ry secretions from an infected person coughing or sneezing. the trunk to the lower extremities. Patients are generally con- Signs and symptoms of rubella include a low-grade fever sidered contagious from 4 days before to 4 days after the and a rash that starts on the face and spreads to the rest of 25

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June 2016 CE — Adult Immunization Schedule the body. About half of the individuals who get rubella are asymptomatic. However, according to the CDC there is at least a 20 percent chance of birth defects if rubella is acquired by a pregnant woman early in pregnancy. These birth defects include deafness, cataracts, heart defects, mental retardation and liver and spleen damage.

Meningococcal Disease Meningococcal disease is caused by the bacteria Neisseria meningitidis. Twelve types of N. meningitidis have been identified and are commonly referred to as serogroups. Serogroups A, B, C, W and Y (specifically B, C and Y in the United States)

May/June 2016 Measles, Mumps, Rubella

Adult Indications All unvaccinated adults born in 1957 or later Students in postsecondary educational institutions Persons who work in a health care facility Persons who plan to travel internationally

Adult Schedules One time dose

Licensed products M-M-R II

2 dose series: 0 days 28 days (minimum)

Source: Recommended Adult Immunization Schedule – United States - 2016

*MMR vaccine is contraindicated in pregnancy and immunocompromised patients. Pregnant women without evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy prior to discharge from the health care facility.

Meningococcal Disease

Adult Indications

Licensed Products

Adult Schedules

Serogroup B Young adults aged 16 through 23 years (preferably 16 through 18) Persons at risk for developing meningococcal disease because of an outbreak attributed to menB Persons with anatomical or functional asplenia or persistent complement component deficiency Microbiologists routinely exposed to N. meningitidis

TRUMENBA (menB)

3 dose series: 0, 2, 6 months Currently no revaccination recommended

BEXSERO (menB)

2 dose series: 0, 1 month (minimum) Currently no revaccination recommended

Serogroups A, C, W, Y Persons with anatomical or functional asplenia or persistent complement component deficiency Microbiologists routinely exposed to N. meningitidis Persons at risk for developing meningococcal disease because of an outbreak attributed to men A, C, W or Y Persons who travel to or live in countries where meningococcal disease is hyperendemic or epidemic Military recruits First-year college students ≤ 21 years old who live in residence halls (if no meningococcal vaccine received since their 16th birthday)

MENACTRA (men A, C, W, Y) MENOMUNE (men A, C, W, Y) MENVEO (men A, C, W, Y)

One time dose All indications except anatomical or functional asplenia or persistent complement component deficiencies 2 dose series (for asplenia and complement deficiency only) 0, 2 months (minimum) Revaccinate every 5 years for: Asplenia or complement deficiency Microbiologists routinely exposed Persons who continue to travel or live in countries where meningococcal disease is hyperendemic or epidemic

Source: Recommended Adult Immunization Schedule – United States - 2016

most commonly cause meningococcal disease. Neisseria meningitidis is spread from person to person by exchanging respiratory and throat secretions (mucus or saliva) during close or lengthy contact, including living in the same

household. Additionally, some individuals can be carriers of the bacteria. Illness from N. meningitidis can be very serious. It can lead to meningitis, bacteremia and septicemia, all of which can be fatal. Symptoms of meningitis include 26

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sudden onset of fever, headache, stiff neck, nausea, vomiting, photophobia and altered mental status. Symptoms of bacteremia include fatigue, vomiting, cold hands and feet, cold chills, rapid breathing, diarrhea and severe aches or pain in the muscles, joints, chest or abdomen. Populations at an increased risk of developing meningococcal disease include infants under 1 year old, persons 16 through 23 years old and persons with impaired immune systems.10 Until recently, only vaccines protecting against serogroups A, C, W and Y were available.

Vaccine

Meningococcal Serogroup B (menB): According to the National Meningitis Association, outbreaks of serogroup B meningococcal disease occurred on four college campuses from March 2013 to June 2015. These outbreaks resulted in two deaths, one student needing both feet amputated and several other students suffering from long-term neurological effects such as memory loss, difficulty retaining information and difficulty concentrating. Two menB vaccines have recently been FDA-approved and added to the immunization schedule. They are recommended routinely for individuals 10 years and older who are at increased risk for serogroup B meningococcal infections.11 The first menB vaccine is Trumenba, and it is given as 3 doses on a schedule of 0, 2 and 6 months. The second menB vaccine is Bexsero, which is given as 2 doses administered at least 1 month apart.12

There are two pneumococcal vaccines. The pneumococcal conjugate vaccine (PCV13, brand name Prevnar 13) protects against 13 types of pneumococcal bacteria. The pneumococcal polysaccharide vaccine (PPSV23, brand name Pneumovax) protects against 23 types of pneumococcal bacteria. The updated recommendation released by the CDC is in regards to the amount of time recommended between the two pneumococcal vaccines when both are indicated in an immunocompetent patient 65 years or greater. The previous recommendation was to administer

PCV13 (Prevnar 13)

Age ≥ 19 years Cochlear implants Cerebrospinal fluid (CSF) leaks Functional or anatomic asplenia Immunocompromised state Age ≥ 65 years All individuals if no previous vaccination

PPSV23 (Pneumovax)

Age 19-64 years Alcoholism Chronic heart, liver or lung disease Cigarette smoking Diabetes Cochlear implants CSF leaks Functional or anatomic asplenia Revaccinate ≥ 5 years after first dose Immunocompromised state Revaccinate ≥ 5 years after first dose Age ≥ 65 years All individuals regardless of previous vaccination No revaccinations required

Source: Recommended Adult Immunization Schedule – United States - 2016

 If both pneumococcal vaccines are indicated, administer PCV13 first and administer PPSV23 a minimum of 1 year later, EXCEPT: — If both pneumococcal vaccines are indicated for cochlear implants, CSF leaks, asplenia or immunocompromised states, administer PCV13 first and administer PPSV23 a minimum of 8 weeks later. The interval between PPSV23 doses should be at least 5 years.

Pneumococcal Disease13 Pneumococcal disease is an infection caused by Streptococcus pneumoniae bacteria. The bacteria are spread person-to-person by direct contact with respiratory secretions such as saliva or mucus. Some individuals, especially children, can be asymptomatic carriers of the bacteria. Infections from Streptococcus pneumoniae can cause a variety of illnesses including ear infections, sinus infections, pneumonia, meningitis and bacteremia. Certain populations are at an increased risk for pneumococcal disease, including children under 2 years old, adults 65 years and older and both children and young adults who are immunocompromised.

Pneumococcal Disease Indication

the PCV13 first, followed by the PPSV23 six to 12 months later. The new 2016 immunization schedule recommends administering the PCV13 first then waiting at least one year before administering the PPSV23.

Tetanus, Diptheria, Pertussis Tetanus15: Tetanus is a non-contagious disease caused by a toxin produced by the bacteria Clostridium tetani. C. tetani usually enters the body through a wound. On average, there is an incubation period of about 8 days before signs and symptoms of infection are seen. However, the closer to the central nervous system the infection site is, the shorter the incubation period and the higher the risk of death. There are three clinical forms of tetanus. The first is local tetanus, which is characterized by patients having persistent contraction of muscles in the area of the injury. Local tetanus 27

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may persist for weeks before Tetanus, Diptheria, Pertussis gradually subsiding. The secAdult Indications Adult Schedules Licensed Products ond form is cephalic tetanus, Pregnant women during One dose of Tdap during Adult Products: which is when C. tetani is preeach pregnancy each pregnancy (preferably TENIVAC (Td) sent in the flora of the middle (preferably 27-36 during 27-36 weeks’ BOOSTRIX (Tdap) ear, or following injuries to the weeks gestation) gestation) regardless of ADACEL (Tdap) head. Cephalic tetanus is charinterval since prior Td or Td generic acterized by involvement of Tdap vaccination Td booster every 10 years, Pediatric Products: cranial nerves, especially in the Persons aged ≥ 11 years DAPTACEL who do not have substitute for Tdap one face. The third form is generalINFANRIX contraindications time ized tetanus, which accounts PEDIARIX Adults with an unknown or Begin or complete 3-dose for about 80 percent of reportPENTACEL incomplete history of series (below) including 1 ed tetanus cases. Generalized KINRIX completing a 3-dose Tdap dose, then Td tetanus is characterized by a primary vaccination booster every 10 years: series 0, 1, 6-12 months tightening of the muscles startSource: Recommended Adult Immunization Schedule – United States - 2016 ing with the jaw (“lockjaw”), continuing to the neck and eventually spreading to the abdomen. Other symptoms of course. During the first stage, which lasts 7-10 days on avgeneralized tetanus include difficulty breathing and swalerage, symptoms resemble that of the common cold or othlowing, fever, sweating, hypertension and rapid heart rate. er minor respiratory tract infection. Symptoms include runSpasms last for several minutes at a time and may contin- ny nose, low-grade fever and occasional mild coughing. ue for 3-4 weeks. Complete recovery can potentially take During the second clinical stage, which can last up to 10 months and involves prolonged hospitalization. weeks, a person develops sudden, violent fits of coughing and the characteristic “whooping” sound at the end of each 16 Diphtheria : coughing fit. These fits occur most frequently at night, and Diphtheria is a contagious disease caused by a toxin proare associated with vomiting and exhaustion when they duced by the bacteria Corynebacterium diphtheria. It can end. The third stage is thought of as a gradual recovery, affect almost any mucous membrane. C. diphtheria is com- when the whooping cough fits gradually start to taper off monly spread person-to-person by contact with respiratory and cease completely. The average length of the third clinisecretions. It also is known to rarely be spread by contact cal stage is 7-10 days. with the skin lesions of infected persons, or by contact with 17, 18 clothes and objects that touched infected skin lesions. Clin- Varicella ically, diphtheria illnesses are classified based on what part Varicella is a highly contagious disease caused by the variof the body the disease is located in. This includes anterior cella zoster virus (VZV), a member of the herpesvirus nasal, pharyngeal and tonsillar, laryngeal, cutaneous, ocu- group. It can be spread through the air when an infected lar and genital. The most common site of infection is the individual coughs or sneezes. It also can be spread by pharynx and tonsils. Pharyngeal and tonsillar diphtheria touching or breathing in aerosolized virus from varicella causes sore throat, anorexia, low-grade fever and ultimate- lesions. VZV has the ability to cause a primary infection, ly pharyngitis. Within 2-3 days of symptom onset, a bluish- remain latent in the body, then reactivate and cause a secwhite pseudomembrane forms and spreads. Bleeding ocondary infection. The primary infection of VZV, varicella, is curs if removal of this pseudomembrane is attempted. better known as the chickenpox. The secondary infection of From this point in the infection, some patients will recover VZV, herpes zoster, is better known as shingles and will be without treatment and others may develop severe disease discussed in a subsequent section. that can result in death.

The main signs of a primary varicella infection (chickenpox) Pertussis17: are a fever accompanied by a generalized, itchy rash that Pertussis, commonly known as whooping cough, is a highly quickly progresses from macules to papules to vesicular lesions before crusting. The rash generally lasts 2-3 days. contagious respiratory illness caused by the bacteria BorAdults infected with varicella may have a fever and feel ill 1 detella pertussis. It is spread person-to-person by contact with respiratory secretions of an infected individual, such as -2 days prior to the onset of the rash. The most common complications from varicella are bacterial infections of the those spread from coughing and sneezing. Pertussis is skin and soft tissue in children and pneumonia in adults. generally thought of as having three stages in its clinical 28

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June 2016 CE — Adult Immunization Schedule Breakthrough varicella is a much less severe case of varicella, defined as happening more than 42 days after varicella vaccination.

In general, patients experiencing breakthrough varicella will have less chance of a fever, fewer and less severe lesions and a shorter duration of illness. According to the CDC, breakthrough varicella occurs in -30 percent of persons vaccinated with one dose of the varicella vaccine, and it appears to occur less frequently in persons vaccinated with two doses of the varicella vaccine.

May/June 2016 Herpes Zoster19

Varicella

Herpes zoster, also known as shingles, is All adults without evidence of VARIVAX 2 dose series caused by reactivaimmunity to varicella 0 weeks tion of the varicellaPersons who have close 4 weeks later contact with (minimum) zoster virus (VZV). immunocompromised Anyone who has sufpatients or family members fered from a primary Persons at high risk for varicella infection exposure or transmission (better known as (teachers, child care chickenpox) or who employees, residents/staff of institutional facilities, has received the varicollege students, military cella vaccine can depersonnel, those living in velop herpes zoster. households with children, The majority of peononpregnant women of ple who develop herchildbearing age, international travelers) pes zoster only develSource: Recommended Adult Immunization Schedule – United States - 2016 op it once in their life*Varicella vaccine is contraindicated in pregnancy and immunocompromised time, but more reactipatients. Pregnant women without evidence of immunity should receive the vations of VZV are varicella vaccine upon completion or termination of pregnancy prior to possible. Herpes zosdischarge from the health care facility. ter presents as a rash Herpes Zoster that is generally painAdult Indications Licensed Products Adult Schedules ful, itchy or tingly.

These symptoms, as All adults aged ≥ 60 years ZOSTAVAX One time dose well as headache, regardless of whether they report a prior photophobia and maepisode of herpes laise can actually prezoster cede the rash onset Source: Recommended Adult Immunization Schedule – United States - 2016 by days to weeks. The *Herpes zoster vaccine is contraindicated in pregnancy and rash develops into immunocompromised patients clusters of clear vesicles. New vesicles continue to form over 3-5 days and proImmunization Schedule gressively dry and crust, healing in 2-4 weeks. Permanent 2016 Major Updates1 pigmentation changes and scarring can be seen after the rash resolves. The rash most commonly develops in one or 1. The nine-valent HPV vaccine (9vHPV, Gardasil 9) two adjacent dermatomes, appearing in a strip along one was added to the immunization schedule as an side of the body’s trunk area. option for males and females aged 13 through 26.

The most common complication of herpes zoster is 2. Two serogroup B meningococcal disease (menB) postherpetic neuralgia (PHN), a persistent pain where the vaccines were added to the immunization schedule rash once was. PHN usually lasts for weeks or months, but with appropriate indications. can last up to many years. Older adults have a higher risk 3. The interval between the two pneumococcal of PHN as well as an increased risk for more severe and vaccines, PCV13 (Prevnar 13) and PPSV23 prolonged PHN. Additional complications of herpes zoster (Pneumovax), was extended from “6 to 12 months” include ophthalmic involvement, bacterial superinfection of to “at least one year” for patients in whom both are the lesions, cranial and peripheral nerve palsies and viscerindicated. Exceptions to this include patients with al involvement (meningoencephalitis, pneumonitis, hepatiimmunocompromising conditions, asplenia, CSF leak tis, acute retinal necrosis). Immunocompromised individuals or cochlear implant, for whom the interval should be are at a higher risk of developing more severe, more wideat least 8 weeks. spread and longer lasting rash. They are also at a higher risk of post-shingles complications from herpes zoster.

Adult Indications

Licensed Products

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Adult Schedules

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June 2016 CE — Adult Immunization Schedule Conclusion Since their discovery, vaccines have been crucial in preventing disease epidemics in the United States. Pharmacists and pharmacy technicians are arguably the most accessible healthcare personnel to patients. This puts them in a prime position to identify patients who are indicated for certain vaccines. Pharmacists can provide recommendations and counseling to those vaccine-appropriate patients.

Advocating for the vaccines in the CDC Adult Immunization Schedule, including spreading information about their safety and efficacy, will help us continue to prevent city, state and nation-wide disease epidemics. For more information, or to access various forms of the full Adult Immunization Schedule online, please visit: http://www.cdc.gov/vaccines/ schedules/hcp/adult.html.

References 1. Recommended Adult Immunization Schedule – United States - 2016. (2016, Feb. 1). Retrieved from http:// www.cdc.gov/vaccines/schedules/downloads/adult/ adult-schedule.pdf

May/June 2016 8. Mumps. (2015, May 29). Retrieved from http:// www.cdc.gov/mumps/ 9. Rubella (German Measles, Three-Day Measles).

(2011, April 29). Retrieved from http://www.cdc.gov/ rubella/ 10. Meningococcal Disease. (2014, April 1). Retrieved from http://www.cdc.gov/meningococcal/ 11. Serogroup B Meningococcal Disease. (2015). Retrieved from http://www.nmaus.org/disease-preventioninformation/serogroup-b-meningococcal-disease/ 12. Serogroup B Meningococcal (MenB) VIS. (2015, Aug. 14). Retrieved from http://www.cdc.gov/vaccines/hcp/ vis/vis-statements/mening-serogroup.html 13. Pneumococcal Disease. (2015, June 10). Retrieved from http://www.cdc.gov/pneumococcal/about/ index.html 14. Chapter 21: Tetanus. (2015, July 16). Retrieved from http://www.cdc.gov/vaccines/pubs/pinkbook/ tetanus.html

2. Viral Hepatitis – Hepatitis A Information. (2015, Aug. 27). Retrieved from http://www.cdc.gov/hepatitis/hav/

15. Chapter 7: Diphtheria. (2015, May 15). Retrieved from http://www.cdc.gov/vaccines/pubs/pinkbook/dip.html

3. Nelson, N.P., Murphy, T.V. (2015, July 10). Chapter 3: Infectious Diseases Related to Travel – Hepatitis A. Retrieved from http://wwwnc.cdc.gov/travel/ yellowbook/2016/infectious-diseases-related-to-travel/ hepatitis-a

16. Pertussis (Whooping Cough). (2016, Aug. 31). Retrieved from http://www.cdc.gov/pertussis/

4. Viral Hepatitis – Hepatitis B Information. (2015, May 31). Retrieved from http://www.cdc.gov/hepatitis/hbv/

17. Chapter 22: Varicella. (2015, Aug. 11). Retrieved from http://www.cdc.gov/vaccines/pubs/pinkbook/ varicella.html

18. Chickenpox (Varicella). (2011, Nov. 16). Retrieved from http://www.cdc.gov/chickenpox/hcp/clinical5. HPV Vaccine Information for Clinicians. (2015, Novemoverview.html ber). Retrieved from http://www.cdc.gov/hpv/hcp/need19. Shingles (Herpes Zoster). (2014, May 1). Retrieved to-know.pdf from http://www.cdc.gov/shingles/hcp/index.html Adult 6. Influenza (Flu). (2016, Feb. 19). Retrieved from http:// Immunization Schedule. (2016, Feb. 18). Retrieved www.cdc.gov/flu/ from http://www.cdc.gov/vaccines/schedules/hcp/ adult.html 7. Measles (Rubeola). (2015, Feb. 13). Retrieved from http://www.cdc.gov/measles/

Clarification In our February CE Part 1., Central nervous system (CNS) modulating drugs for pet fear and anxiety related behaviors that are referred to retail pharmacies-what the pharmacist needs to know, on page 23, we referred to an idiosyncratic, potentially fatal liver toxicity associated with oral benzodiazepine administration to cats as lipidosis; however, this toxicity appears on histology as necrosis instead. We regret any confusion this may have caused.

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THE KENTUCKY PHARMACIST

June 2016 CE — Adult Immunization Schedule

May/June 2016

June 2016 — CDC Recommended Adult Immunization Schedule 1. Dark urine, clay-colored bowel movements and jaundice are all characteristic symptoms of what vaccine-preventable infection(s)?

A. Measles B. Influenza C. Hepatitis A and B D. Pneumococcal Disease

6. The most common complication of Herpes Zoster (“shingles”) is: A. Bacterial superinfection of the lesions.

B. Pneumonitis.

C. Postherpetic neuralgia.

D. Hepatitis.

2. Which of the following influenza vaccines is only recommended for patients ≥ 65 years of age?

A. Inactivated influenza vaccine, trivalent (IIV3), standard dose B. Inactivated influenza vaccine, quadrivalent (IIV4), high dose C. Recombinant influenza vaccine, trivalent (RIV3), standard dose D. Live attenuated influenza vaccine, quadrivalent (LAIV4) 3. What vaccine preventable disease is characterized by swelling of one or both parotid salivary glands in the cheek and jaw area?

A. Mumps B. Diphtheria C. Meningococcal disease D. Tetanus 4. PPSV23 (Pneumovax) is indicated in patients aged 19-64 years with all of the following health conditions except: A. Cigarette smoking.

B. Diabetes.

C. Alcoholism.

D. Hyperlipidemia.

5. For males ≥ 11 years old with no contraindications and documentation of a completed primary series, on what schedule should vaccination for tetanus, diphtheria and pertussis be received?

A. Td booster every 5 years, substituting for Tdap one time B. Td booster every 10 years, substituting for Tdap one time C. Td booster every 15 years, substituting for Tdap one time D. Tdap booster every 5 years, substituting for Td one time

7. The major 2016 updates to the CDC Adult Immunization Schedule include all of the following except: A. Injection drug users being added to the adult indications for vaccination against Hepatitis A. B. The interval between the two pneumococcal vaccines, when both are indicated, being extended for certain patient populations.

C. The addition of two serogroup B meningococcal disease vaccines to the schedule.

D. The addition of a nine-valent HPV vaccine to the schedule.

8. Kolpik spots (white lesions on the inside of the cheeks) and a rash that progressively spreads from the head, to the trunk, to the lower extremities is indicative of what disease?

A. Pneumococcal disease B. Measles C. Human Papilloma Virus D. Pertussis 9. Which is the correct schedule for the Herpes Zoster vaccine?

A. One time dose B. First dose at 0 months, second dose a minimum of 1 month later C. First dose at 0 months, second dose a minimum of 3 months later D. First dose at 0 months, second dose at 3 months, third dose a minimum of 12 months later 10. Which vaccine-preventable disease is characterized by three stages, where stage 1 resembles a common cold, stage 2 consists of violent fits of coughing which happen mainly at night and are associated with vomiting and extreme exhaustion and stage 3 is a gradual recovery?

A. Herpes Zoster B. Rubella C. Diphtheria D. Pertussis

Send potential continuing education topics to Scott Sisco at ssisco@kphanet.org 31

THE KENTUCKY PHARMACIST

June 2016 CE — Adult Immunization Schedule

May/June 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: May 11, 2019 Successful Completion: Score of 80% will result in 1 contact hour or .1 CEU. Participants who score less than 80% will be notified and permitted one re-examination.

TECHNICIANS ANSWER SHEET. June 2016 — CDC Recommended Adult Immunization Schedule (1 contact hour) Universal Activity # 0143-0000-16-006-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.

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 June 2016 — CDC Recommended Adult Immunization Schedule (1 contact hour) Universal Activity # 0143-0000-16-006-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

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.

THE KENTUCKY PHARMACIST

KPERF CE Article Guidelines

May/June 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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THE KENTUCKY PHARMACIST

The Kentucky Pharmacist Online

May/June 2016

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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THE KENTUCKY PHARMACIST

KPhA Pharmacy Emergency Preparedness

May/June 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, completing a volunteer form below or simply sending an email directly to Leah Tolliver at ltolliver@kphanet.org.

Come see us in the Exhibit Hall at the 138th KPhA Annual Meeting & Convention June 2-5, 2016!

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

May/June 2016

KPhA Welcomes New and Renewing Members March-April 2016 Frankie Abner Barbourville

Cindy Ann Biecker Edgewood

Mike Cayce Hopkinsville

John Adams Lebanon

Danny Biliter Richmond

John C Cerrito Louisville

Elaine Adams Crestwood

Stefani Brinn Billington Murray

Andraya Clark Rineyville

Sandra Foster Anderson Monticello

Raymond J Bishop Louisville

Chris Clifton Villa Hills

Karen M Arlinghaus Ft. Wright

Michael Trent Blacketer Louisville

Katy Clifton Villa Hills

Glenn Timothy Armstrong Mount Washington

Renee' B. Blair London

Sharon Clouse Glasgow

Michael J Arnold Wilder

Kenneth M Boggs Hazard

Joseph Collins Middlesboro

Steven Dawson McDowell

William M Ashby Canton

Michael P Bordes Williamsburg

Mildred Cook Tyner

Amy Delcourt Greenup

James D Ball Elizabethtown

Michael Branstetter Glasgow

Edward E Crews Winchester

Hedwig Devine Georgetown

Christopher Lee Barker Morehead

Larry K Bright Campbellsville

Heather Fronk Crump Flemingsburg

Dave Dickerson Morehead

Barbara Batsel White Plains

Angela Rene Brunemann Union

James C Cummins Hopkinsville

Melanie Dicks Lexington

Harold C Beck Benton

Billy P Burton Newburgh, Ind.

Jeffrey W Danhauer Owensboro

Steve Doom Elizabethtown

Morgan Beck Madisonville

Quint C Butler Munfordville

Alan Daniels Georgetown

Elisha Dougherty Benton

Daniel Beebe Cincinnati, Ohio

John Garland Byassee Clinton

Heather L Daniels Hazard

Melissa Marie Dowling Park Hills

B. Michael Beller Poca, W.Virg.

Douglas Bradley Carr Hopkinsville

Joey Darling Wheelersburg, Ohio

William DuBois Cincinnati, Ohio

Michael Berger Henderson

Matt Carrico Louisville

Martin Davenport Murray

Jane Dunbar-Suwalski Longmont, Colo.

Mike Berry Maysville

James Fred Carrico Louisville

Judith E Davenport Louisville

Gerald Durr Crescent Springs

Marguerite D Bertram Albany

Daniel Kyle Carver Alexandria

Sharon Davidson East Bernstadt

Michael Eastridge Lebanon

36

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

THE KENTUCKY PHARMACIST

KPhA New and Returning Members

May/June 2016

Kevin Emberton Edmonton

April Dawn Golden Corbin

Joseph Stephen Hays Smiths Grove

Megan Kramer Cedar Crest, N.M.

David O. Eubank Columbia

Shirley A Good Hopkinsville

J Gregg Henry Greenville

Darren Lacefield Bowling Green

John B Evans Eddyville

Ben W Gower Henderson

James Eric Hicks Whitesburg

Jane Lacefield Bowling Green

Nikita M Evans South Shore

William Gravely Glasgow

Stephen Hill Stanford

Thomas Lawrence Carlisle

Brooke Feltner London

Monte J Gross Stanton

Cassandra Hobbs Louisville

Michelle Loos Covington

Lindsay A. Ferrell Owingsville

Jill Elizabeth Grutza Maysville

Brooke Hudspeth Lexington

Andrew Losch Louisville

Jaime Janielle Fields Hindman

Ryan Haggard Richmond

Ronald Huening Cincinnati, Ohio

Claire W. Love Lexington

Joseph L Fink Lexington

Carolyn Loy Hale Columbia

Jennifer Ihrig Hebron

Robert T Lucas Flatwoods

Maureen Fink Lexington

Tina Hall Greenup

John Inabnitt Somerset

James William Marshall Leitchfield

Celeste C Flick Crestview Hills

James Hammond Argillite

Joseph K. Johnson Campbellsville

Joseph Mashni Florence

Clarence Alan Francis Mayslick

George Hammons Barbourville

Barbara L Jolly Louisville

Kelly Maston Woodburn

Suzanne Marie Francis Florence

Catherine Hanna Lexington

Melinda Joyce Bowling Green

Sunni Mauk Paducah

Cathy N Francisco Pikeville

Chris Harlow Louisville

Clark Kebodeaux Lexington

John B McClanahan Ashland

Kristen Fugate-Oliver Krypton

Matthew Harman Dublin, Ohio

Angela Parrett Kennedy Simpsonville

Tera Mcintosh Midway

Dana Fuller Lexington

Clara J Hartgrove Martin

Krista Kennedy Simpsonville

Sandra Lee Mckone Louisville

Johnathan Fuller Beaver Dam

Jimmi Hatton-Kolpek Lexington

Ann J Keown Scottsville

Charles McQuillan Florence

Susan Gage Maineville, Ohio

Julie Hawkins Pewee Valley

Brian K. Key Pineville

Lynita Mcwaters Paducah

Thomas P Glover Providence

Melodie Hawkins Mt Sterling

Scott King Hazard

Mark Meador Scottsville

KPhA Honorary Life Members Ralph Bouvette, Leon Claywell, R. David Cobb, Gloria Doughty, Kenneth Roberts, Ann Amerson Mazone 37

THE KENTUCKY PHARMACIST

KPhA New and Returning Members

May/June 2016

Laurie Meeks Lexington

Kathy O'Dell Ashland

Doug Russell Louisville

Kelly M Smith Lexington

Anne Megibben Louisville

David Wayne O'Quinn West Liberty

Melody Ryan Lexington

Lisa Smith Dry Ridge

Daniel Meier Edgewood

Jeffrey Osman Lexington

Jessica L Salmons Hazard

John Spencer Richmond

Erica Nicole Melton Mayfield

Darren W. Parks Louisville

Denise Schickling Crescent Springs

Scott Stephens Cynthiana

Linda Menner Henderson

Paul Richard Patrick Lexington

Mohammed Shailuddin Brentwood, Tenn.

Sally J Stiltner Berea

John D Milam Lexington

Risa D Perry Almo

Mohammon Shajiudoin Radcliff

Pam Stith Danville

Kelly Mink Lancaster

Michael Pipkin Gilbertsville

Anna L Sharp Campbellsville

Veronica G Stith Vine Grove

Bernardine Miracle Whitesburg

Steve Pollock Prospect

Kent L Shearer Albany

Jacquelyn Strickland Hopkinsville

Pamela Moore Campbellsville

Larry Powell Richmond

Steve Sheldon Bowling Green

David Bradley Stultz Greenup

Tonya Gail Moses Danville

Elizabeth A. Prather Florence

Catherine l Shely Morehead

Misty M Stutz Crestwood

Benjamin Patrick Mudd Lebanon

Timothy Quillen Greenup

Frances Sherrill Paducah

J. Eddie Sutton London

Theresa L Mullins Hindman

Sarah T. Raines Owensboro

Amanda Louis Shimfessel Lexington

Stephanie Taylor Corbin

Mary Beth Murley Bowling Green

Myra S Ray Smiths Grove

John Simkins Somerset

Neil Taylor McDaniels

Shelley Elane Nall Lexington

Ronald R. Renfrow Bowling Green

Alan Simon Prospect

Gene Thompson Lexington

Constance Nally Louisville

Felix G. Reynolds Lancaster

Patti Sizemore-Mink London

Francis Britton Thompson London

Erica Christine Neff Florence

Betty Ritchie Jeff

Richard K. Slone Hindman

Judy B Thompson Argillite

John F. Nie Independence

Alyson Claywell Roby Bardstown

Zena Slone Hindman

Angela DeFosset Tracy Louisville

Mark Nybo Crescent Springs

Thomas Runge Union

Robert Anthony Smith Ashland

Steven Gregory Treadway Elizabethtown

http://www.kphanet.org/?page=buildingcampaign 38

THE KENTUCKY PHARMACIST

KPhA New and Returning Members

May/June 2016

Clifford P Tsuboi Lexington

Joseph L Wagner Louisville

Rodney Whittington Princeton

Reginald David Woolf South Fulton, Tenn.

Michael Tucker Louisville

Earnest J. Watts Cornettsville

Gary Wientjes Morehead

Whitney Wright Dixon

Jason Underwood Shelbyville

Donald Eugene Webb Middlesboro

Jack Wikas Cold Spring

Michael B Wyant Finchville

Wendy Marie Underwood Horse Cave

Tonya Westmoreland Lowmansville

Carol Wills Lexington

Scott Yates Auburn

William Wagers Berea

Karen White Lewisburg

James Blake WIseman Benton

Jeanne Zeis Covington

Know someone who should be on this list?

Ask them to join YOU in supporting OUR KPhA! 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, 96 C Michael Davenport Blvd., Frankfort, KY 40601

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

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

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

Cash Contributions: $50 per contributor, per election.

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

(This information is in accordance with KRS 121. 150)

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THE KENTUCKY PHARMACIST

Pharmacy Law Brief

May/June 2016

Pharmacy Law Brief: Naturopathic Physicians Author: Joseph L. Fink III, B.S.Pharm., J.D., Professor of Pharmacy Law and Policy and Kentucky Pharmacists Association Professor of Leadership, Department of Pharmacy Practice and Science, UK College of Pharmacy Question: We have recently had a practitioner relocate to our community who is an “N.D.” What is that person’s scope of professional practice, and how should the pharmacist interact with such a practitioner?

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

Response: That individual apparently holds the degree Doctor of Naturopathy. This is a philosophy or school of thought in approaching disorders of the human body parallel to several others. Allopathic medicine, whose practitioners hold the M.D. degree, and osteopathic medicine, D.O. degree holders, are two other approaches. A further one of mostly historical interest is homeopathic medicine, although the Homeopathic Pharmacopoeia of the United States for additional experience as do, say, holders of the M.D. or continues to be recognized in the Federal Food, Drug and D.O. degree these days.

Cosmetic Act as one of the three official compendia.

Each state has a specific scope of practice defined by the Naturopathy emphasizes a holistic approach to restoring law in that jurisdiction, e.g., some states permit prescribing health with use of non-invasive measures. It generally of federal legend medications and some even authorize avoids surgery and use of medications. Natural self-healing performing surgical procedures. At this writing the Comis emphasized. The holistic health movement in the U.S. monwealth of Kentucky has no licensure statute addressing that began during the 1970s focused interest on this apnaturopathy and establishing a legal scope of practice for proach to health and health care. such practitioners. For pharmacists it is important to bear in The scope of practice for a naturopath varies widely from mind that a prescription must be issued in the scope of the jurisdiction to jurisdiction. Treatment modalities commonly practitioner’s license: encountered with naturopathy include nutritional and herbal KRS 315.010(23) "Prescription drug order" means medicine, lifestyle advice and counseling, selected homeoan original or new order from a practitioner for pathic remedies and remedial massage. Many naturopaths drugs, drug-related devices or treatment for a huoppose use of immunizations based on the historical roots man or animal, including orders issued through of the specialty. collaborative care agreements. Lawful prescriptions There are seven schools of naturopathy with membership result from a valid practitioner-patient relationship, in the Association of Accredited Naturopathic Medical Colare intended to address a legitimate medical need, leges, with five of those in the U.S. and two in Canada. and fall within the prescribing practitioner's scope of professional practice; (emphasis added).

Currently, 17 states, four Canadian provinces, the District of Columbia and the US territories of Puerto Rico and the US As a final note, it is important to differentiate the N.D. deVirgin Islands all have licensing laws for naturopathic physi- gree holder from one whose academic degree is D.N.P. cians. In these states and provinces, naturopaths are re- That last abbreviation reflects holders of advanced profesquired to graduate from a four-year, residential naturopathic sional degrees in nursing, Doctor of Nursing Practice, not medical school and pass a board examination (NPLEX) in naturopathy. As such, holders of the D.N.P. degree may be order to receive a license. Typically, holders of the N.D. licensed under statutes applicable to the nursing profession degree do not complete post-graduate residency training to practice as an Advanced Practice Registered Nurse.

The Campaign for Kentucky’s Pharmacy Future: The Next 50 Years http://www.kphanet.org/?page=buildingcampaign 40

THE KENTUCKY PHARMACIST

138th KPhA Annual Meeting & Convention

May/June 2016

Education

Register online at www.kphanet.org

Recognition Networking

41

THE KENTUCKY PHARMACIST

Pharmacy Policy Issues

May/June 2016

PHARMACY POLICY ISSUES: “RIGHT TO TRY” LAWS Author: Erica Krantz is a third professional year student at the University of Kentucky College of Pharmacy. A native of Williamston, Mich., she earned a B.S. in Physiology degree at Michigan State University prior to enrolling at UK. Issue: I’ve heard in the popular media about a new legislative development in some states related to use of medications called “Right to Try” laws. What is that initiative, and does it have any implications for pharmacists?

Discussion: The “Right-to-Try” laws, currently enacted in 24 states, are written with the goal of helping terminally ill patients have access to investigational drugs that may be life-saving.1 These laws, which would provide access to drug products approved by the U.S. Food and Drug Administration (FDA) for Phase I clinical studies, have been debated as helpful versus harmful due to their stark contrast to the traditional approach using the Investigational New Drug (IND) application which is approved by the FDA.

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.

gational drug because it is their personal right to try. 5 This would allow patients opportunity when they have no options and don’t qualify for the clinical trial. 6 In the eyes of those supporting the legislation, the FDA’s “compassionate use program” is a long and drawn out process that still presents barriers to access. Even if approved through the clinical trial program, the terminally ill state that the investigational medications are not received in a timely manner. 7 Right-to-Try only allows access to medications that have passed basic safety testing (Phase I).8 The Right-to-Try laws are worded to protect the referring prescriber from adverse action by a licensing board.9 Should the patient pass away, a further provision guards the patient’s heirs by not requiring them to pay back the medical Turning to related activities in the Kentucky General As- fees. 9 These guidelines help protect the physician and sembly, Senate Bill 139 was introduced by Republican families making it more likely for their participation in Sen. C.B. Embry Jr. in the Senate on Feb. 10, 2015 and trying to help the patient receive the medication. referred to the Health & Welfare Committee on February Opposition to the Legislation 12. There was no decision regarding this legislation during the 2015 legislative session.5 This bill would have allowed Looking at Phase I trial drugs as unproven treatment mo“use of experimental treatments for terminal illnesses.” 5 dalities, their use makes individuals, prescribers and the The new provision would have been added to KRS Chapter FDA cautious regarding the legislation. More harm than 217 and would have changed the law to “permit eligible good could come from use of these drugs. Phase I trials patients to use investigational drugs, biological products, or only contain a small handful of people and are designed to devices for a terminal illness; establish the conditions for only show the safety in these few people; efficaciousness use of such experimental treatments; prohibit sanctions of has not been established at this stage of the process. 10 health care providers; clarify the duties of health care insur- Elizabeth Weeks Leonard outlines the opposition, saying, ers regarding experimental treatments; prohibit certain ac- “There are several assumptions that would be required for tions by state officials; provide immunity for use and recom- the Right-to-Try laws to be effective: Drug companies mendation of experimental treatments.”5 would willingly provide their pre-approved products to dying patients; patients would willingly pay for the drugs; and Support of the Legislation doctors would willingly prescribe the drugs.”3 Another arguThe argument runs this way: The Right-to-Try laws provide ment is the questions surrounding where the lines are to be terminally ill patients with the opportunity to use an investi- drawn between those who are terminally ill and others who The Right-to-Try movement is supported by the Goldwater Institute, a conservative Arizona-based organization which has a drafted proposed state legislation to facilitate terminally ill patients’ access to investigational drugs which have secured Phase I FDA approval.2 The desire for more accessibility to experimental drugs dates back to the 1980’s during the AIDS crisis leading to the FDA’s “compassionate use” program.3 The request for more opportunities for individual decision making surfaced again in the public realm during 2008 when the U.S. Supreme Court declined to hear the case of Abigail Alliance for Better Access to Developmental Drugs v. Von Eschenbach.4 This case led the FDA to expand the “compassionate use” exception.3

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THE KENTUCKY PHARMACIST

May/June 2016

Pharmacy Policy Issues are chronically ill? Once terminally ill patients have access to unproven drugs, will the chronically ill request them too because they have a right to their own decision making?

Those opposing the legislation believe that allowing unproven drugs to be used will negatively affect the drug companies and the FDA approval process. Why would someone join the drug company’s trial and potentially risk getting the placebo? If everyone had access to the real drug, there would be no information for the FDA to use to determine if this drug can be approved for marketing.

Overall, the FDA system could potentially be damaged with this law.3 Those opposing the legislation also say that the FDA “compassionate use” application only takes about 45 minutes to complete. In the 2012 Fiscal year, 974 of the 977 “compassionate use” requests were granted.11 This allows for the drug product approval process to be still controlled by the FDA while also allowing the terminally ill access to the drug.12

the Public's Health. The Journal of Law, Medicine & Ethics, 269-279.

4. Abigail Alliance for Better Access to Developmental Drugs v. Von Eschenbach. 495 F.3d 695 (D.C. Cir 2008), cert. denied 552 U.S. 1159 (2008).

5. Legislative Record Online (15RS). Retrieved Dec. 18, 2015, from http://www.lrc.ky.gov/record/15RS/ SB139.htm.

6. Olsen, D. (2015, November 10). Dying Should Have 'Right to Try' New Treatments. Retrieved Dec. 29, 2015, from http://time.com/4091290/right-to-try/.

7. Dresser, R. (2015). “Right to Try” Laws: The Gap between Experts and Advocates. Hastings Center Report, 9-10. Retrieved Dec. 29, 2015, from http:// www.ncbi.nlm.nih.gov/pubmed/25944200.

8. Right to Try Model Legislation. Retrieved Jan. 1, 2016, Irrespective of position supported, more information should from http://www.khi.org/assets/uploads/news/13359/ be collected to make a decision on the legislation being goldwater_institute_right_to_try_model_legislation.pdf. proposed in Kentucky. While both sides of the argument 9. SB139. Retrieved Dec. 17, 2015, from http:// pose good supporting arguments, the problem boils down www.lrc.ky.gov/record/15RS/SB139/bill.pdf. to this – how are the terminally ill going to get access to medications? Whether it is through new FDA approval pro- 10. Rubin, R. (2015, Oct. 3). Experts critical of America's cesses or individual state laws, focus should be placed on right-to-try drug laws. The Lancet, 1325-1326. trying to change laws to help the terminally ill receive availRetrieved Dec. 18, 2015, from able treatment in a timely manner. While a legislative prohttp://www.ncbi.nlm.nih.gov/pubmed/26460764. posal has been advanced in Kentucky, the U.S. House of 11. Tsakopoulos, A., Han, J., Nodler, N., & Russo, V. Representatives was presented with the Right to Try Act of (2015, Nov.) The Right to Try: An Overview of Efforts 2015 sponsored by Rep. Matt Salmon of Arizona and in to Obtain Expedited Access to Unapproved Treatment July 2015 Referred to the Subcommittee on Crime, Terrorfor the Terminally Ill. Food and Drug Law Journal. 70ism, Homeland Security, and Investigations.13 4:617-641.

References: 12. Bateman-House, A., Kimberly, L., Redman, B., Dubler, 1. About Right to Try. Retrieved Dec. 20, 2015, from N., & Caplan, A. (2015, September 29). Right-to-Try http://righttotry.org/about-right-to-try/.

Laws: Hope, Hype, and Unintended Consequences.

Annals of Internal Medicine 163:796-798. Retrieved 2. Monir, M. (2015, February 19). States move to give Dec. 18, 2015, from terminally ill 'right-to-try' drugs. Retrieved Dec. 22, http://annals.org/article.aspx?articleid=2443961.

2015, from http://www.usatoday.com/story/news/ nation/2015 /02/19/ right-to-try-state-legislationterminally-ill-patients/23667229/.

3. Leonard, E. (2009). Right to Experimental Treatment: FDA New Drug Approval, Constitutional Rights, and

13. H.R.3012 - 114th Congress (2015-2016): Right to Try Act of 2015. (July 15, 2015). Retrieved Dec. 29, 2015, from https://www.congress.gov/bill/114th-congress/ house-bill/3012/text.

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Pharmacists Mutual

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Cardinal Health

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KPhA Board of Directors/Staff

May/June 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

May/June 2016

50 Years Ago at KPhA KENTUCKY PHARMACIST IS NOMINEE FOR APHA PRESIDENT-ELECT George W. Grider, of Danville, Kentucky and B. Samuel Rogers of Jacksonville, Florida are candidates for the presidency of the American Pharmaceutical Association for 1967-68. Their selection was announced at the final session of the 113th annual meeting of the American Pharmaceutical Association in Dallas.

EDITOR’S NOTE: Grider went on to win the election.

- From The Kentucky Pharmacist, May 1966, Volume XXIX, Number 5.

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

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