The Kentucky Pharmacist Vol. 12, No. 3 by Kentucky Pharmacists Association

THE KENTUCKY PHARMACIST Vol. 12, No. 3 May/June 2017 News & Informat ion for Members of the Kentucky Pharmacists Ass ociation

SOLD! Former KPhA headquarters sold to Independence Bank

The Campaign for Kentuckyâ&#x20AC;&#x2122;s Pharmacy Future

Make your donation online at http://www.kypharmacyfuture.net/

Table of Contents

May/June 2017 The Kentucky Pharmacist Online Naloxone Certification Training KPhA Emergency Preparedness CE Article Guidelines Campaign for Kentucky’s Pharmacy Future June 2017 CE — Hypoglycemia in Diabetes June Pharmacist/Pharmacy Tech Quiz Answer Sheet The Kentucky Pharmacist Online KPhA New and Returning Members Pharmacy Policy Issues Pharmacy Law Brief Pharmacists Mutual Cardinal Health KPhA Board of Directors/KPERF Board of Directors 50 Years Ago/Frequently Called and Contacted/KPhA Staff

Table of Contents Table of Contents— Oath— Mission Statement President’s Perspective Campaign for Kentucky’s Pharmacy Future 139th KPhA Annual Meeting and Convention Message from your Interim Executive Director KPhA Welcomes Jody Jaggers APSC 2017 Kentucky Legislative Session Summary What is KPPAC? 2017 KPERF Golf Scramble May 2017 CE — Look-alike/Sound alike Drug Errors May Pharmacist/Pharmacy Tech Quiz Answer Sheet Pharmacy Time Capsules

2 3 4 5 6 7 8 9 13 14 15 18 19

20 21 22 24 25 26 34 35 36 38 42 44 45 46 47

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

Kentucky Pharmacists Association Vision — We are a unified pharmacy profession empowered to maximize patient and public health as fully integrated members of the healthcare team. Mission — The mission of KPhA is to advocate for and advance the profession through an engaged membership.

Editorial Office: © Copyright 2017 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: Sam Willett 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.

THE KENTUCKY PHARMACIST

President’s Perspective

May/June 2017

PRESIDENT’S PERSPECTIVE Trish Freeman

cally, ACPE Standard 2.3 requires that the graduate is able to design prevention, intervention, and educational strategies for individuals and communities to manage chronic disease and improve health and wellness. Similarly, Standard 2.4 requires that the graduate is able to describe how population-based care influences patient-centered care and the development of practice guidelines and evidence-based best practices.

KPhA President 2016-2017

OUR KPhA has long advocated for and supported the role of Kentucky pharmacists in public health. First, through our initial advocacy related to immunization authority over 13 years ago and more recently through our partnership with the Kentucky Department for Public Health (KDPH) in Pharmacists as Public Health Partners emergency preparedness. In 2015, we were instrumental in Every day, pharmacists across the Commonwealth and the securing authority for pharmacists to play a role in public nation impact the health of individual patients. In doing so, health and harm reduction by expanding access to naloxthey also improve the collective health of their communities. one in our pharmacies. As a result of SB 192 (2015), speThere is no better example of pharmacists’ impact in public cially certified pharmacists can initiate the dispensing of health than our contribution to preventive medicine through naloxone via a physician protocol. To date, over 1,700 pharmacists have been trained and are certified to play this vaccination. Since 2004, when Kentucky pharmacists gained authority to administer adult immunizations via pre- important role in public health. scriber-approved protocols, pharmacists have safely and Most recently, KPhA has partnered with KDPH to utilize the efficiently vaccinated thousands of patients across the state’s mobile pharmacy in harm reduction activities. Since state. the initiative began last December, the mobile pharmacy has been deployed to 10 local health departments across the state, providing access to naloxone and HIV and Hepatitis C testing. At these events, pharmacist and student pharmacist volunteers provide education on the use of naloxone as rescue therapy to prevent opioid overdose deaths and dispense naloxone from the mobile pharmacy. Four hundred individuals have received opioid overdose prevention education and 389 prescriptions of naloxone have been dispensed. Time will tell how expanded access The Accreditation Council for Pharmacy Education (ACPE) to naloxone as a result of pharmacist intervention can realso recognized the valuable role pharmacists can play and duce opioid overdose deaths across the Commonwealth. included public health focused standards in the most recent accreditation standards for schools of pharmacy. 2 SpecifiAs the most accessible healthcare providers, pharmacists are poised to advance our role as partners in public health. The Centers for Disease Control and Prevention recognized that the legions of pharmacists across the nation are an untapped resource and made recent efforts to raise awareness of the opportunities for state public health officials to partner with pharmacists to improve outcomes in patients with chronic disease.1

Continued on Page 7

The Campaign for Kentucky’s Pharmacy Future 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.kypharmacyfuture.net/ or call 502-227-2303. 3

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Campaign for Kentucky’s Pharmacy Future

May/June 2017

The Campaign for Kentucky’s Pharmacy Future

Make your donation online at http://www.kypharmacyfuture.net/

Donors to the campaign as of May 1, 2017                      

Anonymous Jeff Arnold Ray Bishop Lanny Branstetter William R. Brown Fred Carrico Matt Carrico Jessika Chinn J. Leon & Margaret Claywell Chris & Katy Clifton Marshall Davis David Dubrock Paul Easley Ashley Eschenbach Brian Fingerson Renie & Joseph L. Fink III Matt Foltz Andrew & Virginia France Trish Freeman Robert Goforth Cynthia Gray George & Burnetta Hammons

                    

Christopher Harlow JCAP KPhA First District Don & Vicki Kupper Phil & Julie Losch Claire Love Joe Mashni Bob Oakley Chris & Consuelo Palutis Duane Parsons Ron & Lisa Poole Richard Ross Richard & Zena Slone Kelly Smith Jo Anne Taheri Leah Tolliver Jason Wallace Sam Willett Lewis & Kim Wilkerson Jacob & Carol Wishnia Michael & Mary Ann Wyant

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139th KPhA Annual Meeting and Convention

May/June 2017

Reserve your room today!

Tentative Schedule (Subject to Change)

Griffin Gate Marriott Resort and Spa is the host hotel for the 139th KPhA Annual Meeting & Convention. Book your room now at a reduced rate of $139/night for single and double occupancy. Overnight accommodations can be made online through a link at http://www.kphanet.org/?page=AnnualMeeting, or by calling 1-800-266-9432 before May 31, 2017 to receive the group rate. The group name is Ky Pharmacist Association Annual Meeting 2017.

Friday, June 23, 2017 7 pm Ray Wirth Banquet (stick around after for 7 am Registration Opens networking with colleagues) 7:30 -9:30 am Opening Breakfast/KPhA Annual Membership Sunday, June 25, 2017 Meeting and Opening House of Delegates 8:30 am Breakfast/Non-CE Learning Presentation (Novo Nordisk) 9:00 – 10:00 am CE: An Ounce of Prevention: An Opioid Misuse 9:45 -11:45 am CE: Protocol-authorized Smoking Cessation: What's a Pharmacist to do? – Melody Ryan Reduction Strategy– Douglas Oyler 10:10 – 11:10 am CE: A Culture of Patient Safety - Don McGuire 11:25-12:45 pm KPhA Awards Luncheon 1:00 – 2:00 pm CE: Expanding the Role of Pharmacists = Expanding Patient Access to Care – Tom Menighan, APhA Executive VP/CEO 2:10 -3:40 pm CE: Senate Bill 101: Impact on Pharmacy Practice– Clark Kebodeaux 3:50-5:20 pm CE: NASPA/NMA 2016 KPhA Student Pharmacist Self-Care Championship 5:30 pm-7:30 pm Opening of Hall of Exhibits Saturday, June 24, 2017 7:00 am Registration/Continental Breakfast 7:00 am Reference Committee 8-9:30 am CE: 2017 Kentucky Pharmacy Law Update – Ralph Bouvette 9:30 to 11 am Hall of Exhibits Open 11 am to noon CE: Preceptor Development: Let’s all Speak the Same Language – Pharmacist Patient Care Process – Anne Policastri & Misti Stutz 11 am to noon CE: Exploring the New Terrain of New & Emerging Diabetes Medications - Lourdes Cross Noon College Update and Preceptor Recognition Luncheon Noon 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: Shaping the Workforce of Tomorrow: Preparing Technicians for Advanced Roles - Ashley Mattingly & Sarah Lawrence 2:40: 3:40 pm CE: The Expanding Role of Pharmacists In Opioid Addiction Treatment: Long-Acting Injectables – Emily Blaiklock 3:45 -5:30 pm House of Delegates Closing Session 6 pm President’s Reception

2017 KPERF Golf Scramble June 22, 2017

Registration: 11:30 a.m. Noon Shotgun start

Griffin Gate Marriott Resort Golf Course Assemble your team now! Register online at www.kphanet.org.

THE KENTUCKY PHARMACIST

Message from Your Interim Executive Director

May/June 2017

MESSAGE FROM YOUR

INTERIM EXECUTIVE DIRECTOR

Sam Willett I’m Sam Willett, RPh, and have served on the KPhA Board of Directors for 11 years and am now serving as your interim executive director of KPhA. When our previous Executive Director, Bob McFalls, submitted his resignation, the board asked me to fill the position as interim until we could hire a new executive director. I accepted the challenge and a challenge it has been! I live in Mayfield, which is 259 miles from Frankfort, but the reward to that challenge is that I am staying with my daughter in Louisville through the week and get to see my grandchildren daily. As a retail pharmacist of 40 years and pharmacy owner for 22 years, an office job presents its own challenges and rewards. First I had to become a lobbyist and learn the political process. With the tutelage of a group called “pharmacy partners,” especially Shannon Stiglitz and Ralph Bouvette, I have been able to participate and contribute in that process. I have had to learn how to be the director of a professional association that affects the livelihood of members and non-members of our KPhA. It has been a much less daunting task due to the wonderful staff we have at KPhA and the help of current KPhA President Trish Freeman and our board of directors.

jobs, but take it upon ourselves. Accentuate the positives in your job and remove the negatives. Are we drifting or paddling in our involvement with our profession. Do we drift, thinking that someone else will take care of the problems that we face or do we paddle by getting involved with our local, state and/or national associations? OUR KPhA offers many opportunities to be engaged in your state association. Members can volunteer for any of the committees, run for office or volunteer to help with the planning of the annual meeting or the legislative conference. Attending the annual meeting or legislative conference is another way to get involved and also network with your peers. If you feel that you are drifting now, get involved and feel the satisfaction of paddling in your state association.

Are we drifting or paddling in political involvement. Again it is so easy to drift in the area of politics. Many of our current economic issues are going to have to be settled politically. Start paddling by contacting your state and federal representatives and senators. As the saying goes, the squeaky As a dear friend and mentor of mine told me, we as pharmawheel gets oiled! Donate to the Kentucky Pharmacist Politicists must adapt, make do and overcome and I succumb to cal Advocacy Council (KPPAC) and Government Affairs this saying many times during a day. As I meet the daily Fund. OUR KPhA is paddling in the political arena. Our lobchallenges of this office, I offer some challenges to our byists and our Executive Director, who is also a lobbyist, members and non-members to consider. spend many hours at the capitol during the legislative sesIf you aren’t paddling, you’re drifting. This is a powerful sion. Many hours are spent by these people studying bills statement by Erik Van Alstine, a speaker and writer whose that affect the profession and work to make sure that those mission is to promote transformation in people and organibills will not adversely affect the profession. We are not alzations around the world. My question to you: Are you pad- ways successful in getting all the bills passed that we want dling or drifting? during the legislative session and will start to work soon after the session is over for the next legislative session. Has your daily job got you drifting or paddling, and if we are drifting how do we get to where we are paddling. Yes, it’s OUR KPhA is paddling into the future with its capital cameasy to drift, get up, go to work, go home and not be inpaign for a new office building. We closed on the sale of our volved. One way to make the changes to where we are pad- previous building on April 28 and now direct our attention on dling, we can continue to educate ourselves, become profi- buying the office building at 96 C. Michael Davenport Blvd., cient in certain disease states. After getting proficiency in Frankfort, where we are currently located. It is our goal to one such disease state, tackle another. The satisfaction of raise $1,000,000 in our capital campaign to buy the building being able to help people with a disease state that you have and to pay for the modifications and technological advances now become proficient in may make you feel like you are needed. A packet was sent in April to all members and each paddling in a job that before maybe you were just drifting. donation will be greatly appreciated. Our website at KPhAnWe shouldn’t rely on others to provide satisfaction in our et.org allows for donations to be made on line by clicking on 6

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KPhA Welcomes Dr. Jody Jaggers “The Campaign for Kentucky’s Pharmacy Future.” In closing, I would like to thank everyone who has helped me in meeting the challenges of this office. It has been a rewarding event in my life, and I have made a lot of new friends in the process. The KPhA board has hopes to be

May/June 2017 able to announce the new Executive Director at our annual meeting June 22-25 at the Griffin Gate Marriott Resort & Spa in Lexington. I hope that we have a record attendance at the meeting and our members can meet the new Executive Director at that time.

KPhA Welcomes Dr. Jody Jaggers to staff We are pleased to announce that Dr. Josiah (Jody) Jaggers joined KPhA on May 1, 2017 as Director of Pharmacy Emergency Preparedness. Jody graduated from WKU with a BS in chemistry in 2000 and then attended UK College of Pharmacy, graduating with a Doctor of Pharmacy degree in 2005. He has more than 12-years' experience in community pharmacy practice and currently lives in Versailles with his wife, Shanna and their two children. “I look forward to working closely with the Department of Public Health in utilizing the Mobile Pharmacy to serve the citizens of our great Commonwealth!” Jody will oversee the KPhA Pharmacy Emergency Preparedness Program, as well as other public health initiatives. His email address is jjaggers@kphanet.org.

viewed him or herself as a public health partner and looked for opportunities to engage with local health departments to improve public health, imagine the collective impact we could have! KPhA stands ready to support you in this important role moving forward.

Continued from Page 3

The KPhA Board of Directors recently approved a 5-year strategic plan to guide the association’s efforts.3 The strateReferences gic plan has four strategic focus areas: Engage, Support, Advance and Advocate. Specifically, Focus Area 3 calls for 1. Centers for Disease Control and Prevention. A PROGRAM GUIDE FOR PUBLIC HEALTH: Partnering with us to Advance pharmacy practice to improve patient and Pharmacists in the Prevention and Control of Chronic public health with Goal 3 calling for us to Advance the Diseases. https://www.cdc.gov/dhdsp/programs/spha/ recognition of pharmacists as public health providers. We docs/pharmacist_guide.pdf hope to do this by establishing new strategic partnerships with KDPH to advance public health goals. Other objectives 2. Accreditation Council for Pharmacy Education. ACunder Goal 3 include promoting the immunization registry CREDITATION STANDARDS AND KEY ELEMENTS to immunizing pharmacists and encouraging its use to asFOR THE PROFESSIONAL PROGRAM IN PHARMAsess and document the immunizations provided by pharCY LEADING TO THE DOCTOR OF PHARMACY DEmacists, and supporting current public health initiatives inGREE. https://www.acpe-accredit.org/pdf/ cluding emergency preparedness and opioid overdose preStandards2016FINAL.pdf vention. 3. KPhA 2016-2020 Strategic Plan. https://c.ymcdn.com/ I encourage each of you to reflect on what you can do to sites/kphanet.site.ym.com/resource/resmgr/ strategic_plan/KPhA_Strategic_Plan_2016-202.pdf impact public health in your community. If every pharmacist 7

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APSC

May/June 2017

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2017 KPhA Kentucky General Assembly Summary

May/June 2017

2017 KPhA Kentucky General Assembly Session Summary You may have heard legislators and Governor Matt Bevin touting the 2017 legislative session as the most productive one in decades. The impact of this session’s policy changes will develop over time, but no one can deny that this session was chocked full of action. During the 2017 Kentucky General Assembly, with a Republican-controlled House and Senate, more bills were passed in a 30-day session than in any “short” session since the legislature began meeting in annual sessions in 2001. In fact, the number of bills set to become law as a result of this session’s action — a total of 188 — actually exceed the number passed in many 60-day sessions that are held in evennumbered years.

April, 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 it moved through the process. You also can access this information through the Legislative Research Commission Website at www.lrc.ky.gov, under the 2017 Legislative Record link. Immunizations: This year, KPhA’s top legislative priority was changing the law to give pharmacists increased authority to administer CDC-recommended vaccinations via protocol beginning at age nine, and it passed. Current Kentucky law allows pharmacists to administer only the flu vaccine to children starting at age nine and this change brings all other age-appropriate vaccinations in line with the flu vaccine. Senate Bill 101, sponsored by Senate Health and Welfare Chair Julie Raque Adams (R-Louisville), easily passed both chambers and was signed by Governor Bevin.

Republicans in the General Assembly have been waiting for the opportunity to pass long-held GOP priorities, and they took legislative action to ensure these priorities passed. These included bills making Kentucky a “right-towork” state, repealing the state’s prevailing wage law and allowing the establishment of charter schools. The state’s continuing drug abuse problem drove legislative action on a number of fronts including new statutory limits on prescriptions for Schedule II drugs written for acute pain and increased penalties for drug trafficking.

Consolidation of Prescription and Refills: Freshman Senator Stephen Meredith (R-Leitchfield) successfully shepherded through SB 205 that will allow a pharmacist in his or her professional judgment to consolidate a prescription for a non-controlled maintenance medication written with refills into no more than a 90-day supply. A pharmacist The pharmacy community had another successful legislacan currently consolidate prescription medication for a 30tive session with the passage of legislation expanding the day supply with two refills, but they must contact the preauthority of pharmacists to allow them to administer all age- scriber before making such a change. Senate Bill 205 appropriate vaccinations to anyone beginning at age nine. simply removes the requirement that a pharmacist call the Legislation also passed allowing pharmacists to consolidate prescriber. The legislation will take effect 90 days after the a prescription for a maintenance medication with refills for General Assembly adjourned. up to a 90-day supply. And legislation creating medical rePrescriptive Authority—PA/APRNs: Prior to the start of view panels passed in the 2017 session as well. The goal session, physician assistants made a presentation to the of the legislation is to reduce frivolous medical malpractice Interim Joint Committee on Licensing and Occupations claims and pharmacists are included in the legislation. when they asked the General Assembly to give them the KPhA acknowledges and thanks our advocacy partners for authority to prescribe controlled substances. Members of this session: American Pharmacy Cooperative, Inc., Ameri- the committee expressed concerns about giving any addican Pharmacy Services Cooperative, EPIC Pharmacies, tional health care providers the authority to prescribe conInc., KIPA, Kentucky Retail Federation, National Associatrolled substances given Kentucky’s drug abuse problem. tion of Chain Drug Stores and the National Community This was the sentiment that ruled the day in the end as the Pharmacists Association. legislature didn’t grant a hearing to either HB 19 or SB 55, both of which would have given physician assistants the The following narrative summary is arranged by issue area authority to prescribe controlled substances, but the bills and highlights some of the key issues that were considered were markedly different. during the 2017 Session. The electronic version of our 2017 Session Summary, which was emailed to members in The bill that was most problematic for the pharmacy com9

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2017 KPhA Kentucky General Assembly Summary

more than the pharmacy would be reimbursed from all payment sources. In some instances, a patient’s co-pay may be more than the actual cost of the prescription drug, or in other words, the patient could have paid less money if they paid cash for the prescription. Rowland did not hear the bill in his committee, but it is expected that he will have informational hearings about HB 336 in the interim.

munity was SB 55 as it would have given physician assistants the ability to dispense controlled substances. Even though those advocating for SB 55 said that they would make a change removing the dispensing language, the bill never got a hearing and, therefore, was never amended. In contrast, HB 19 would have only allowed physician assistants to prescribe controlled substances. The bill would have removed language prohibiting physician assistants from dispensing, but it didn’t give them specific authority to dispense.

Drug Abuse: The General Assembly and Governor Bevin are concerned about the drug abuse epidemic that has taken over Kentucky. Out of this concern, there were several bills filed trying to address the opioid abuse problem plaguing Kentucky.

Another bill would have eased some of the restrictions on nurse practitioners authority to prescribe controlled substances. Senate Bill 158 would have removed the requirement that nurse practitioners enter into collaborative care agreements with physicians in order to dispense controlled substances. Instead, it would have required a nurse practitioner to obtain a controlled substance registration certificate from the U.S. Drug Enforcement Agency. The bill was referred to the Senate Licensing, Occupations and Administrative Regulations Committee where it died. Mail Order/ Specialty Drugs: For the last couple of years, independent pharmacies have raised concerns about health insurance companies requiring patients to fill prescriptions through mail order pharmacies and the overclassification of costly medications as “specialty drugs,” that they then require patients to get through specialty pharmacies. In the 2016 legislative session, then House Banking and Insurance Committee Chair Jeff Greer (DBrandenburg) sponsored HB 458 that would have prohibited insurance companies from requiring patients to get prescription drugs through mail order pharmacies and limited the universe of specialty drugs to only those requiring special handling and patient education by the drug manufacturer and those on a limited distribution list developed by the U.S. Food and Drug Administration. The bill did include the condition that pharmacies must accept the same financial terms and conditions as the mail order pharmacy. This legislation easily passed the House, but died in the Senate after concerns were raised about costs to Medicaid and others. During the 2017 session, Greer was no longer House Banking and Insurance Committee chair, but he still filed HB 365 that would have only addressed the mail order pharmacy issues. The bill was similar to the 2016 legislation, except that it did not include the specialty drug restrictions. It was assigned to the House Health and Family Services Committee where it did not receive a hearing. Co-pay Limits: Newly appointed House Banking and Insurance Committee Chair Bart Rowland (R-Tompkinsville) filed HB 336 that would limit a patient’s co-pay to be no

May/June 2017

Enhanced Drug Trafficking Penalties: Legislators were faced with a new, more deadly street drug causing increased numbers of overdoses and they filed legislation to try and address fentanyl and more deadly fentanyl derivatives. Senator John Schickel (R-Union) filed SB 14 that would have increased drug trafficking penalties for any amount of heroin. It was amended in the House to include the provisions of HB 333, including making fentanyl derivatives a Schedule I drug and adding penalties for trafficking in fentanyl, carfentanyl and heroin. House Bill 333 included other provisions that are discussed below and it passed in the last two days of the session and was signed by the governor on April 11. Controlled Substance Prescribing Limits: Several bills were filed to limit the amount of opioids one can prescribe for acute pain, but HB 333, sponsored by Representative Kim Moser (R-Taylor Mill) was the one that passed. It limits prescriptions for Scheduled II controlled substances for acute pain to a three-day supply. The limits have exemptions for major trauma or surgery, end-of-life care, cancer or, if in the professional judgement of the prescriber, more is necessary. KPhA and its partners convinced the sponsor to include language that for a pharmacist filling a prescription for more than a three-day supply, these prescriptions are presumed valid and therefore don’t conflict with the Drug Enforcement Agency’s rules on corresponding responsibility. Senate Bill 14 was amended to include all the provisions of HB 333 but it failed to pass the House since the Senate passed HB 333. House Bill 193 and SB 193 would have limited prescription for opioids to seven days for treating acute pain and HB 381 would have limited opioid prescriptions to three days, like HB 333. Scheduling of Controlled Substances: Two bills passed that impact the scheduling of drugs as controlled substances in Kentucky. House Bill 158 requires Kentucky’s controlled substance scheduling to be in line with the federal scheduling of controlled substances. The bill was amended in the House to add language allowing Kentucky to have a

THE KENTUCKY PHARMACIST

2017 KPhA Kentucky General Assembly Summary

May/June 2017

stricter schedule of controlled substances. Also, HB 333 allows the Office of Drug Control policy to request for drugs to be scheduled by the Cabinet for Health and Family Services. Both bills passed and were signed into law by Governor Bevin.

to be put in KASPER, but that provision was amended after concerns were raised by hospital advocates. A companion measure was filed in the Senate (SB 192) but it never received a committee hearing.

Senator Julie Raque Adams (R-Louisville) filed SB 191 that would have required pharmacists to document the dispensTamper Resistant: House Health and Family Services Chair Addia Wuchner (R-Florence) once again filed legisla- ing of naloxone in KASPER. The bill never received a hearing in the committee Adams chairs. Proponents argued that tion requiring health insurance plans to cover tamperthey need to know where naloxone is being dispensed in resistant opioids. Wuchner has tried for several years to order to identify community hotspots of drug abuse. pass such legislation and this year the bill suffered the same fate as in previous years and did not pass. When HB Opioid Tax: Representative James Kay (D-Versailles) filed 308 was originally filed, it included a requirement for phar- HB 467 that would have placed a one-cent-per-dose tax on macists to notify the prescribers if they were substituting a opioids with the proceeds going to support drug treatment non-tamper resistant opioid for a tamper-resistant opioid. services and drug abuse education programs. The tax After conversations with KPhA representatives and Rep. would be assessed at the wholesale level and on mail orDanny Bentley (R-Russell), Wuchner later agreed to reder pharmacies. The bill did not receive a hearing in commove this language and also changed the bill to only enmittee. courage insurance companies to cover abuse deterrent Board of Pharmacy Legislative Package: The Kentucky opioids. House Bill 308 was amended in the Senate to allow anyone to dispense naloxone under a standing order Board of Pharmacy (KBOP) saw some success in the 2017 legislative session with its legislative agenda. Once again, from a prescriber. The bill passed the Senate Health and KBOP asked the General Assembly to pass two bills — Welfare Committee, but failed to get a vote on the floor of one requiring separate licensure of outsourcers, third-party the Senate in the final two days of the session. logistics providers and medical gas wholesalers and anothEnhanced Controlled Substance Monitoring: The Gen- er bill requiring pharmacy technicians to undergo criminal eral Assembly clearly believes that Kentucky’s prescription background checks. Senator Ralph Alvarado (Rdrug monitoring system (KASPER) isn’t being used to its Winchester) filed SB 111 that would create separate licensfullest potential, and that is why they passed two bills this es for outsourcers, third-party logistics providers and medisession expanding the amount of information contained in cal gas wholesalers, but it was Representative Danny BentKASPER. Senate Bill 32 requires the Administrative Office ley’s (R-Russell) version — HB 364 — that was ultimately of the Courts to provide the last five years of Class A misenacted. The bill was amended twice, first in the House to demeanor and felony drug conviction data to the Cabinet allow the KBOP to establish a donated drug repository profor Health and Family Services (CHFS). CHFS will then put gram and again in the Senate, to require virtual wholesalthis information into KASPER for prescribers to consider ers and distributors to be licensed. But the KBOP’s other when writing prescriptions for controlled substances to a legislative priority, requiring pharmacy technicians to underpatient who may have a drug abuse problem. Senate Bill go an FBI and a state police criminal background checks, 32 passed both chambers with only two legislators voting was not enacted into law (HB 301). The Senate argued that “no.” legislative action was not necessary and the board could take this action by administrative regulation. It also was Another measure that will add information into the KASPER likely not acted upon because it created a new fee to cover system also passed the General Assembly without much the costs of the background check and legislators are not opposition. House Bill 314 was sponsored by Representaquick to add new fees to Kentuckians or a subset of Kentive Danny Bentley (R-Russell), the only pharmacist in the tuckians. General Assembly. The bill requires positive toxicology screenings from possible drug overdoses in emergency Tort Reform: Tort reform advocates can claim the 2017 rooms to be included in KASPER. The bill requires emerlegislative session as a success, even though they didn’t gency room dispensing of controlled substances to be rec- get everything they wanted. But they can certainly celeorded in KASPER as well. The legislation was a priority for brate given that they were successful in passing SB 4 the Cabinet for Health and Family Services, in order to stop which requires someone filing a medical malpractice lawthose addicted to opioids from going to multiple emergency suit to first have the case reviewed by a panel of medical rooms to get controlled substances. Originally, HB 314 re- experts. It was a priority for the Senate to pass SB 4, quired all hospital administrations of controlled substances where it passed the first week of session, and its sponsor, 11

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2017 KPhA Kentucky General Assembly Summary Senator Ralph Alvarado (R-Winchester), thought it was a priority for the House as well. The bill lost steam in the House as some of the newly elected members started to raise concerns. After it passed the Senate by a vote of 2313 with two Republicans voting against the measure, the House took its time taking up the legislation and when it did, it passed 51-45.

country from foreign countries be tested for safety by the U.S. Food and Drug Administration. There has been discussion at the national level to allow the importation of drugs from other countries, because drugs cost less in places such as Europe than they do here. The resolution was adopted by the House on the last day of the session.

Basically it creates a panel of medical experts to review a claim of malpractice before it formally goes into the court system. The idea is to try and weed out frivolous lawsuits from legitimate instances of malpractice. Pharmacists are included, meaning any case against them would first go in front of a medical review panel as well. If the panel hasn’t completed its work in nine months, then the plaintiff can go straight to court without the final opinion of the medical review panel. This was a change that was made in the House along with a change that made it permissible, not mandatory, for the findings of the medical review panel to be admissible. The legislation was signed by the governor after passing both chambers. Other priorities for tort reform advocates didn’t make it across the finish line. The General Assembly failed to adopt SB 18 that would have made findings of medical accrediting or credentialing organizations privileged and, therefore, not subject to discovery in medical malpractice lawsuits. Senate Bill 18 also was sponsored by Alvarado and it passed the Senate, but the House did not take up the legislation. Senate Bill 85 would have prohibited expressions of sympathy from being introduced in medical malpractice cases and it never received a hearing in committee. Imported Drugs: Representative Jason Nemes (RLouisville) filed a simple resolution (HR 213) encouraging the U.S. Congress to require all drugs imported into the

May/June 2017

Medical Marijuana: While other states have legalized the sale of marijuana or at a minimum, allowed patients access to medical marijuana, Kentucky has only taken baby steps towards allowing its use in any form. There were several bills filed in the 2017 session on the issue. Senator Perry Clark (D-Louisville) has been a long-time champion of medical marijuana and legalization of marijuana. He filed separate bills on each topic, neither of which passed (SB 57 and SB 76). Senator Morgan McGarvey (D-Louisville) filed SB 243 that would have allowed physicians to recommend and dispense the use of cannabidiol and create a legislative task force to study compassionate use of medical marijuana, but it failed to get a committee hearing. Finally, newlyelected Representative John Sims (D-Flemingsburg) filed HB 411 that would have allowed for the use of medical marijuana, but it didn’t receive a committee hearing either. The General Assembly did pass legislation that would make any FDA-approved cannabidiol legal for use in Kentucky, once one is available (HB 333). Tobacco Cessation Coverage: The General Assembly passed legislation requiring health insurance plans and Medicaid to cover smoking session therapies approved by the federal government. Senate Bill 89 would require payment of such therapies as Chantix and other prescription medications shown to help patients quit smoking. The bill easily passed both chambers and was signed by the governor.

Join the Committee of 100! Each contributor who pledges at least $5,000 over the next 5 years will be counted among the Committee of 100. Add your name to the list today by calling 502-227-2303 or log on to http://www.kypharmacyfuture.net/ Contributions are tax deductible. 12

THE KENTUCKY PHARMACIST

What is KPPAC?

May/June 2017

What is KPPAC? FAQs for the Kentucky Pharmacists Political Advocacy Council What is KPPAC?

vious PBM transparency bill in 2016.

KPPAC is the Kentucky Pharmacists Political Advocacy Council. We are a PAC that represents the interests of Kentucky pharmacists that provides donations to our state legislators. These donations allow us to develop lasting relationships with our legislators and strengthen our lines of communication when our profession needs a strong voice regarding up-and-coming legislation. Our current political system is set-up in a “pay to play” environment, and our profession requires an active PAC to ensure the interests of our profession are well served.

What are KPPAC’s focuses for 2017 and the future?

Who is a part of KPPAC? KPPAC represents ALL Kentucky pharmacists, and our shareholders are those individuals who contribute to KPPAC’s fund. KPPAC has a board of directors composed of a chair of the board and five board members. The board meets to discuss input from our shareholders and develop strategies to address specific legislative interests of the profession of pharmacy. Who serves on the KPPAC board of directors?

Currently, KPPAC has been focused on legislation that will lower the patient age for immunizations by pharmacists, an anti-mandatory mail order bill and a specialty drug bill. What is the difference between KPPAC and KPhA’s Government Affairs Committee (GAC)? KPhA’s Government Affairs Committee (GAC) and KPPAC work in concert with each other to forward legislation benefiting our profession. The GAC is a part of KPhA; their function is to prioritize an annual legislative agenda and develop strategies to achieve success in Frankfort. KPPAC uses its established relationships with legislators to assist in the implementation of the GAC’s strategic plan. Quick note about donations: Both GAC and KPPAC operate through member donations. GAC donations can come from individuals AND/OR companies, and these donations help pay for lobbyists. PACs in Kentucky must be registered through the Kentucky Registry of Election Finance and abide by its Elections Finance rules. Therefore KPPAC donations can only come from individuals and those funds go to sponsor individual legislators campaign bids.

Matthew Carrico serves as the chair of the board for KPPAC, and currently our directors include: Cindy Stowe, Ethan Klein, Leon Claywell, Richard Sloan and Robert Goforth. Any shareholder who donates $1,500 to KPPAC is eligible to serve as a director. Our board of directors is composed of leaders that donate both their time and money How can I donate or be involved? to forward the profession of pharmacy and is open for those KPPAC accepts donations through both online donations shareholders interested in serving on the KPPAC board. and checks. To donate online, go to www.kphanet.org; a link to KPPAC can be found under the ‘Advocacy’ tab. How long has KPPAC been around? Checks can be made out to “KPPAC” and mailed to 96 C. KPPAC was established in 2008 with Leon Claywell serving Michael Davenport Blvd. Frankfort, KY 40601. as the first chair. We were established to help augment To let your voice be heard or become more involved, KPhA’s voice of Kentucky pharmacists to our legislators. please reach out to anyone on the KPPAC board or any What accomplishments has KPPAC achieved recently? member of the GAC. The board is always looking for those with insight on moving our profession forward. Also, if you In the last five years, KPPAC has assisted KPhA and other have a relationship with a legislator, please let us know and state pharmacy organizations in passing 11 bills into law. help us arrange a meeting with them. There are political KPPAC worked with KPhA and others to help find bipartifund raising events during the year, and we would like to san sponsors and co-sponsors to enact pro-pharmacy legbring KPPAC members if it is in their district. islation. Notable legislation includes the PBM audit bill in 2012, the PBM transparency bill (the first one in the nation) Lastly, if you would like to serve on our Board of Directors, in 2013, the oral chemotherapy parity bill in 2014, the colplease let us know by contacting Angela Gibson via email laborative care bill in 2015 and a bill strengthening our pre- at agibson@kphanet.org. 13

THE KENTUCKY PHARMACIST

2017 KPERF Golf Scramble

May/June 2017

To kick off the 139th KPhA Annual Meeting & Convention, join us for the

KPERF GOLF SCRAMBLE Griffin Gate Marriott Resort Golf Course on June 22, 2017! Scramble begins at Noon EDT SHOTGUN START Griffin Gate Marriott Resort Golf Club, 1800 Newtown Pike, Lexington, KY 40511 Donâ&#x20AC;&#x2122;t miss this opportunity to support the Kentucky Pharmacy Education & Research Foundation and KPhA and join friends, new and old, for an afternoon of fun and networking. Prizes will be awarded and beverages will be available on course. Two drink tickets per golfer are included in the registration fee.

The Kentucky Pharmacy Education & Research Foundation (KPERF) is the tax-exempt charitable foundation formed by the Kentucky Pharmacists Association. Entry Fee:

Individual $100

Team

Hole Sponsor

$400

REGISTRATION DEADLINE JUNE 15, 2017!

$150 ONE ENTRY FORM PER TEAM PLEASE

Team Name: _______________________________________ $400 Team

Player 1_________________________

Player 2__________________________

Player 3_________________________

Player 4__________________________

PLEASE MAKE CHECKS PAYABLE TO KPERF and SUBMIT PAYMENT TO: KPERF Golf Scramble, 96 C Michael Davenport Blvd., Frankfort, KY 40601

OR Individual:_________________________

Individual:_________________________

$100

Hole Sponsor:____________________________________________________ $150

(Text for Sign)

To pay by credit card, go to www.kphanet.org and register online, or call 502-227-2303

TOTAL $_____________

Are you connected to YOUR KPhA? Join us online! Facebook.com/KyPharmAssoc Facebook.com/ KPhA Company Page @KyPharmAssoc @KPhAGrassroots

THE KENTUCKY PHARMACIST

May 2017 CE â&#x20AC;&#x201D; LASA Drug Errors

May/June 2017

Look-alike/Sound-alike (LASA) Drug Errors: An Ongoing Dilemma By: Jacob Hall, Pharm. D Candidate, Sullivan University College of Pharmacy & Angela Tracy, RPh, LDE, BCGP, Patient Care Specialist, Kroger Pharmacy The authors declare no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-0000-17-005-H05-P&T 1 Contact Hours (0.1 CEU) Expires 4/24/2020

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

Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: 1. 2. 3. 4.

Analyze medication errors among children under 6 years old; Identify a sensitive group of patients that can be affected by LASA drugs and give a specific example; Evaluate the use of the Tallman lettering system for LASA drugs; and Compare and contrast the ways in which outpatient pharmacies can help to prevent LASA errors in the patient population and in the workplace setting.

As professionals in the pharmacy setting, there is one phone call we all dread from a patient. It was a busy day, things were happening out of the ordinary, a technician called in and to top it all off, we had filled a medication incorrectly for someone. A medication error is probably the worst nightmare that a pharmacist could have. Errors occur every day ranging from no complications, to mild discomfort, to severe illness and death. A pharmacistâ&#x20AC;&#x2122;s first priority is ensuring the safety of every patient that comes to the pharmacy. A delicate group of patients that we interact with everyday are children. Medication errors of inappropriate drug or dosage often can be more serious in children than in adults. The expertise of pharmacists, along with tools to assess the complexity of prescribing and dispensing medications, can help to eliminate potential errors in the pharmacy setting.

mated the degree of potential harm that might occur if a patient received an erroneous drug and the degree of potential harm from not receiving the intended drug therapy. There were three main categories in which the study used to relay potential harm to the patient. First, there were substitutions that represented high risk or harm from receiving the wrong drug (eg, received methadone instead of methylphenidate). Second, there were substitutions that represented high risk for harm based on not receiving the intended drug (eg, did not receive furosemide but received fosinopril). Third, there were substitutions that represented high harm from receiving the wrong drug and high harm for not receiving the intended drug (eg, did not receive albuterol but received labetalol).1 These efforts have shown that further investigation needs to be done to help prioritize pediatric LASA errors. We as pharmacists need to continue to be prospective and not retrospective in addressing these As we discussed, one of the more sensitive groups of patients that we hope to prevent errors in is children. Not only critical issues in outpatient pharmacies. do they rely on us to provide accurate and precise dosing So what are some of the prospective techniques we as proof their medications, they also rely on the caregiver to adfessionals in the pharmacy setting can take in order to enminister the medication accurately and on time each day. sure the best possible patient safety for all of our patients? Nearly 700,000 children under 6 years old experienced an Since 2008, ISMP has maintained a list of drug name pairs out-of-hospital medication error between 2002 and 2012. and trios with recommended, bolded tall man (uppercase) Of these, one in every four children was under 1 year old. letters to help draw attention to the dissimilarities in lookAlthough 94 percent of these errors did not require medical alike drug names. The list includes mostly generic-generic treatment, the medication errors accounted for 25 deaths drug name pairs, although a few brand-brand or brandand 1,900 critical care admissions, according to the study.1 generic name pairs are included. The US Food and Drug In a study conducted at The Medical University of South Carolina, 3,550 drug pairs were established as Look-alike/ Sound-alike (LASA) drugs. Using a modified three round Delphi survey method, 38 participating pediatricians esti-

Administration (FDA) list of drug names with recommended tall man letters was initiated in 2001 with the agencyâ&#x20AC;&#x2122;s Name Differentiation Project.2 Here is a list with brief details on some of the other most common ways pharmacies can 15

THE KENTUCKY PHARMACIST

May 2017 CE — LASA Drug Errors

May/June 2017

improve the ongoing dilemma of LASA drug therapies. Let us  look at what we can tell patients. 

Throw out ALL expired medications and medications that they are NOT presently taking. Throwing out medications that they are not currently taking will minimize the risk of taking any expired and/or wrong medications.



Know when your medication(s) expire(s). Write down the date the prescription expires if your patient cannot legibly read it on the bottle. The pharmacy has electronic records of all prescriptions dispensed and you can give the patient a correct expiration date.



Never exchange the colored caps or switch manufacturer boxes of your eye or ear drops. This may lead to the improper dosing or administration of the wrong medication which could lead to very harmful side effects.

Separate medications. Make sure that all pharmacy staff knows about the importance of keeping LASA medications on separate shelves or in separate bays in the pharmacy. This will help reduce the chance of picking up the wrong medication during hectic periods in the pharmacy.

Image courtesy of CIAP Health

Image courtesy of www.nyee.edu



Educate staff. Pharmacists should identify that LASA errors do exist and should educate staff on the potential of LASA drug errors in their personal setting. When errors do occur, the pharmacist should make sure that a non-punitive system is in place so that reporting errors is commonplace. Also, the information should be shared among other retailers and pharmacies of the same chain so that these sites can offer awareness and education to their staff.



If you have to confirm a prescription, CALL! Sometimes we wonder in the pharmacy setting how a physician got through school with the terrible handwriting they display on a prescription. If there is any question about the drug name, strength, dosage or directions, call the physician who wrote the prescription. It may irritate the patients a little because they have to wait for confirmation from the physician, but let your patients know that their safety is your number one concern.

If using visual aids, be sure to wear them while reading your prescription label or drug bottle. Always tell patient to make sure to read prescription label and auxiliary information with visual aids in a well-lit room.



Do not store LASA drugs together. Instruct patients to place drugs in different areas of the home. If the drugs look or sound alike, be sure to place them on separate For prescriptions given via the phone for drugs that might shelves or in separate cabinets if possible. have a LASA issue, make sure you repeat the information back to the caller, spell the drug name and ask for an indica Make sure patient is aware LASA drugs exist. Educate your patients about drugs that look alike and sound tion as to why the patient is taking the medication. Ask the alike and that there is the potential for medication errors person who called the prescription in for their name, so that the same person can be spoken with directly in case of any with these medications. issues that might come up while filling the prescription. Here are several tips that pharmacists and their staff can  Reporting Results. Reporting is a key component of take in order to help mitigate the potential for unintentional understanding LASA errors and communicating epidemimedication errors when it comes to look-alike, sound-alike ological trends on near misses. National reporting webmedications in the pharmacy. 16

THE KENTUCKY PHARMACIST

May 2017 CE — LASA Drug Errors

May/June 2017

sites exist for errors and near misses in which the reporter is kept confidential. It is important to let pharmacy staffs know that they will not be punished for reporting an error. Many times, staff members try to hide the error in fear of suspension or dismissal from the company. The fact is we all make mistakes and if you hide them, no one else can learn from the error. We as healthcare professionals need to relay that hiding an error could potentially result in even more harm to the patient. 

ISMP’s guidelines for LASA medications.2 By trying to implement these safety measures through discussions with both our patients and pharmacy staff, we hope that the pharmacy profession will continue to lead the way in improving patient-centered care. References

1. Basco WT, Garner SS, Ebeling M, Freeland KD, Hulsey TC, Simpson K. Evaluating the Potential of Look-Alike, Sound-Alike Drug Substitution Errors in Children. Acad Employ Technology. Many pharmacies across the counPediatr. 2016; 16:183-191. try have implemented the electronic prescription systems which have helped in reducing many of the errors from the 2. ISMP. Survey on LASA drug name pairs: Who knows physician’s standpoint. More implementation needs to be what’s on your list and the best ways to prevent mix-ups? done at the pharmacy level like providing automatic flags ISMP Medication Safety Alert! Acute Care Edition. 2009 or notifications on prescriptions that qualify under the May 21; 14:1-3.

May 2017 — Look-alike/Sound-alike (LASA) Drug Errors: An Ongoing Dilemma 1. How many children have experienced a medication error between the years 2002 and 2012? A. 70,000 B. 7,000 C. 700,000 D. None of the above

6. It is best to hold someone accountable for a medication error through punishment and possible termination. A. True B. False 7. Who should you report a medication error to? A. Patient B. Co-workers C. Other pharmacies in the area or within the same company D. All of the above

2. Which of the following is NOT a category in which the study of medication errors among children was divided? A. Harm/risk based on not receiving the intended drug B. Harm/risk based on receiving the wrong drug C. Harm/risk based on receiving no drug therapy D. Harm/risk based on receiving wrong drug and not receiving intended drug

8. What is the purpose of reporting errors to national databases? A. To identify trends and near misses so that other pharmacies may be prospective and catch the mistake before it happens B. To make sure certain technicians and pharmacists can never find a job C. To show who has the least amount of errors among all pharmacies D. None of the above

3. Which labeling technique has been used since 2008 by ISMP to reduce errors with look-alike sound-alike medications? A. smallMan lettering B. broadMan lettering C. wideMan lettering D. tallMan lettering 4. It is proper to dispose of medications that you may not know the date on which it was dispensed, or if you are no longer taking it. A. True B. False 5. Which of the following would increase your chance of having a medication error as a patient? A. Keeping medications on different shelves or cabinets in your home B. Changing caps and boxes of different eye and ear drops you may take C. Wearing glasses while administering medications D. Administering medication in a well-lit room

9. What advancement in technology has been used to reduce medication errors from the physician to the pharmacy? A. Hand-writing all prescriptions B. Digital timestamps for prescriptions C. Electronic prescription delivery through software programs D. Allowing more than one controlled substance per blank in the state of Kentucky 10. Safety with look-alike and sound-alike medications helps to alleviate stress among which population? A. Patient B. Pharmacist C. Physician D. All of the above

THE KENTUCKY PHARMACIST

May 2017 CE — LASA Drug Errors

May/June 2017

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: April 24, 2020 Successful Completion: Score of 80% will result in 1.0 contact hour or .1 CEUs. Participants who score less than 80% will be notified and permitted one re-examination. TECHNICIANS ANSWER SHEET. May 2017 — Look-alike/Sound-alike (LASA) Drug Errors: An Ongoing Dilemma (1.0 contact hour) Universal Activity # 0143-0000-17-005-H05-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 6. A B

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 May 2017 — Look-alike/Sound-alike (LASA) Drug Errors: An Ongoing Dilemma (1.0 contact hour) Universal Activity # 0143-0000-17-005-H05-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 6. A B

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.

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

THE KENTUCKY PHARMACIST

Pharmacy Time Capsules

May/June 2017

Pharmacy Time Capsules 2017 (Second Quarter) 1992 

Oncologic pharmacy recognized as a specialty by BPS.



Pharmacy sales in the US totaled approximately $77.8 billion dollars. This expanded to almost $154 billion in 2002.

1967 

Drug Intelligence, later retitled to Drug Intelligence and Clinical Pharmacy and more recently Annals of Pharmacotherapy, inaugurated by editor and founder Donald Francke.

1942 

American Society of Hospital Pharmacists (ASHP), now the American Society of Health-System Pharmacists, formed with 153 charter members.

1892 

Formation of the Utah Pharmacists Association By: Dennis B. Worthen, PhD, Cincinnati, OH One of a series contributed by the American Institute of the History of Pharmacy, a unique non-profit society dedicated to assuring that the contributions of your profession endure as a part of America's history. Membership offers the satisfaction of helping continue this work on behalf of pharmacy, and brings five or more historical publications to your door each year. To learn more, check out: www.aihp.org

Save the date! 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. 19

THE KENTUCKY PHARMACIST

The Kentucky Pharmacist Online

May/June 2017

NEW in 2017! Two of the six editions of

The Kentucky Pharmacist will be published online only. To access the online version, go to www.kphanet.org, click on Communications and then on The Kentucky Pharmacist link. Continuing Education articles are available to KPhA Members electronically under the Education tab on the KPERF CE Articles page (log-in required).

The March/April and November/December editions will be electronic only.

Would you rather receive all of the journals electronically? Email ssisco@kphanet.org to be placed on the KPhA Green List for electronic delivery. Once the journal is published online, you will receive an email with a link to the online version. Contact Scott Sisco at ssisco@kphanet.org or call the KPhA Headquarters at 502-227-2303 with questions.

THE KENTUCKY PHARMACIST

KPERF Naloxone Certification Training

May/June 2017

KPERF Naloxone Certification Training The online training program can be found at the following link on the KPhA website: http://www.kphanet.org/?page=NaloxoneCert2015 The cost of the training is $5 for KPhA members, and $10 for nonKPhA members. After successfully completing the course, credit will be applied to your CPE Monitor Profile and you will be emailed a certificate of completion. Contact Scott Sisco at sisco@kphanet.org or 502-227-2303 with questions.

THE KENTUCKY PHARMACIST

KPhA Pharmacy Emergency Preparedness

May/June 2017

Volunteer Volunteer Volunteer Pharmacist, pharmacy technician and student pharmacist recruitment is still 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. You may sign up as a volunteer on the KPhA website, completing a volunteer form below or simply sending an email directly to jjaggers@kphanet.org. Please join the emergency preparedness program and help to recruit other volunteers! We need all of you! For more information on how you can be involved in the KPhA Pharmacy Emergency Preparedness Initiative, contact KPhA at 502-227-2303 or by email at jjaggers@kphanet.org.

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

KPhA Pharmacy Emergency Preparedness Volunteer Form Name: __________________

____

Status (Pharmacist, Technician, Student): ___________________

Mailing Address: ________________________________________City: __________________ State: _________ Zip: ___________ Email: _______________________________________ Phone: ________________________ County:

_______

T-Shirt size: ______________

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 KPhA via email at jjaggers@kphanet.org, fax to 502-227-2258 or mail at KPhA, 96 C Michael Davenport Blvd., Frankfort, KY 40601.

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

THE KENTUCKY PHARMACIST

Campaign for Kentucky’s Pharmacy Future

May/June 2017

The Campaign for Kentucky’s Pharmacy Future Donation Levels for KPhA and KPERF Building Fund Campaign Diamond Bowl of Hygeia Platinum Bowl of Hygeia Gold Bowl of Hygeia Silver Bowl of Hygeia Bronze Bowl of Hygeia E.M. Josey Memorial Cornerstones Builders Brick Layers

$100,000+ $75,000-$99,999 $50,000-$74,999 $25,000-$49,999 $10,000-$24,999 $5,000-$9,999 $2,500-$4,999 $1,000-$2,499 $1-$999

Pledges can be paid over 5 years. Gifts made to KPERF are tax deductible to the extent allowable by law. http://www.kypharmacyfuture.net/ or call 502-227-2303

Send potential continuing education topics to Scott Sisco at ssisco@kphanet.org 23

THE KENTUCKY PHARMACIST

Continuing Education Article Guidelines

May/June 2017

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.  



Include a quiz over the material. Usually between 10 to 12 multiple choice questions. Articles are reviewed for commercial bias, etc. by at least one (normally two) pharmacist reviewers.

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



Articles are generally written so that they are pertinent to both pharmacists and pharmacy technicians. If the subject matter absolutely is not pertinent to technicians, that needs to be stated clearly at the beginning of the article.

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



Articles should address topics designed to narrow gaps between actual practice and ideal practice in pharmacy. Please see the KPhA website (www.kphanet.org) under the Education link to see previously published articles.



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.



Article should begin with the goal or goals of the overall program – usually a few sentences.



Include 3 to 5 objectives using SMART and measurable verbs.



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

THE KENTUCKY PHARMACIST

Campaign for Kentucky’s Pharmacy Future

May/June 2017

The Campaign for Kentucky’s Pharmacy Future

Online donations accepted at kypharmacyfuture.net Donations to the KPERF/KPhA Building Fund are tax deductible! 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 kypharmacyfuture.net or call 502-227-2303.

Memorialize your Donation through the History of Pharmacy in Print Program! Pick out your print and we will display the framed print, along with a plaque with the recognition you request, in the KPhA Headquarters building. All donations of $1,000 or more are eligible.

THE KENTUCKY PHARMACIST

June 2017 CE — Hypoglycemia in Diabetes

May/June 2017

An Overview of Hypoglycemia in Diabetes By: Radhika Patel, PharmD., PGY-1 Pharmacy Resident, Baptist Health Louisville; Krista Best, PharmD., BCPS There are no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-0000-17-006-H01-P&T 1.0 Contact Hour (0.1 CEUs) Expires 4/30/2020 Goal: To educate pharmacists about hypoglycemia including risk factors, signs/symptoms and both preventative and treatment strategies. Learning Objectives At the conclusion of this Knowledge-based article, the reader should be able to: 1. 2. 3. 4.

Understand the basic pathophysiology of hypoglycemia in adults with diabetes (P); Recognize the common risk factors of hypoglycemia in adults with diabetes (P&T); Identify the signs/symptoms of hypoglycemia (P&T); and, Select an appropriate intervention to prevent and effectively treat a hypoglycemic event (P).

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

toms of hypoglycemia and selection of treatment regimens with minimal or no risks of hypoglycemia, health care proDiabetes mellitus is a metabolic disorder of insulin secrefessionals can effectively prevent hypoglycemic events and tion, action or both resulting in abnormally high blood gluavoid long-term complications. This article will include a cose levels.1 According to American Diabetes Association review of the classification of hypoglycemia, its risk factors, (ADA) Statistics About Diabetes, nearly 30 million people or clinical presentation, prevention and treatment. 9 percent of the population in the United States have diabeDefinition of Hypoglycemia tes, and about 1.4 million Americans are diagnosed with 2 diabetes every year. It is predicted that one in three Ameri- The broad definition of hypoglycemia was described by can adults will have diabetes in 2050.3 In 2012, diabetes Whipple in 1938, which also is known as Whipple’s triad: was the seventh leading cause of death in the United lower plasma glucose concentration, symptoms associated States and accounted for $245 billion total costs.4 Diabetes with it and rapid symptom relief when plasma glucose conis a prevalent chronic disease. When diabetes is poorly centration is corrected.9 controlled, it is often associated with microvascular and Generally, in the clinical setting a plasma glucose level of ≤ macrovascular complications (cardiovascular diseases, 70 mg/dL has been used to define hypoglycemia, based on nephropathy, retinopathy, neuropathy, etc.). Various large the ADA guideline’s recommendation.7 However, it is difficlinical trials such as The Diabetes Control and Complicacult to assign a precise value due to the inter-patient variations Trial (DCCT) and UK Prospective Diabetes Study (UKPDS) have demonstrated tight glycemic control reduces bility in glycemic threshold. For example, patients with uncontrolled diabetes tend to have a higher value for glycemic diabetes complications.5,6 While the benefit of tight blood glucose control is evident, hypoglycemia or low blood sugar threshold at which they develop hypoglycemic symptoms. It is a common complication associated with glucose-lowering is commonly accepted that there are variable glycemic thresholds in response to hypoglycemia; the ADA and the therapy in patients with diabetes, and hypoglycemia can limit long-term maintenance of normal blood sugar levels or Endocrine Society has defined hypoglycemia in patients with diabetes non-numerically as “all episodes of an abnoreuglycemia. When episodes of hypoglycemia are severe, that expose the prolonged or recurrent it can lead to poor quality of life, in- mally low plasma glucose concentration 10 7 individual to a potential harm.” A 2005 report by a creased complications and mortality. In 2011, there were workgroup of the ADA and the Endocrine society has clasapproximately 282,000 emergency department visits for 2 hypoglycemia in adults with diabetes. With the utilization of sified hypoglycemia as pseudo-hypoglycemia, probable or newer glucose-lowering therapies, rates of severe hypogly- documented symptomatic hypoglycemia,10asymptomatic cemia remains unchanged to date.8 Clearly, there is a need hypoglycemia and severe hypoglycemia. for establishing effective control measures to tackle this With the continuous advancement in treatment options of complication. Through early recognition of signs and symp- diabetes, it is important to recognize and understand the Introduction

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Table 1: Classification of Hypoglycemia frequency of hypoglycemia as well as Level Glycemic Criteria Description overcome the most Level 1: Glucose alert ≤ 70 mg/dL (3.9 mmol/L) Sufficiently low for treatment with important barriers to value fast-acting carbohydrate and glycemic control in dose adjustment of glucosediabetic patients. lowering therapy Thus, the InternaLevel 2: Clinically < 54 mg/dL (3.0 mmol/L) Sufficiently low to indicate tional Hypoglycemia significant hypoglycemia serious, clinically important Study Group reclashypoglycemia sified hypoglycemia Level 3: Severe No specific glucose threshold Hypoglycemia associated with with the agreement hypoglycemia severe cognitive impairment of both the ADA and requiring external assistance for recovery European Associa11 tion. The Interna*Adopted from International Hypoglycaemia Study Group. Diabetes Care. 2017;40(1):155–157. tional Hypoglycemia Study Group classified hypoglycemia into three different brain utilizes greater than 50 percent of whole-body glulevels: glucose alert value (≤70 mg/dL), clinically significant cose.13,14 Under normal conditions, the brain cannot synhypoglycemia (<54 mg/dL) and severe hypoglycemia (no thesize glucose or store it for more than a few minutes; 11 specific glucose threshold) as shown in Table 1. The defi- thus, the brain requires continuous supply of glucose from nition of severe hypoglycemia remains same. Severe hypo- circulation. When blood glucose levels fall below the norglycemia is an episode where the mental state of a patient mal range, several physiological defense mechanisms get is so disturbed that they are unable to self-treat. The key activated in order to protect brain function and to limit the differentiating feature of severe hypoglycemia is a require- effects of hypoglycemia.14 (Figure 1) The first defense ment of assistance from another person.9,11,12 mechanism includes marked reduction in pancreatic β-cell insulin secretion as glucose levels drop but remain within Pathophysiology of Hypoglycemia the physiologic range (≥ 80 mg/dL). The second defense Glucose is the metabolic fuel source for the brain. The mechanism includes rise in pancreatic α-cell glucagon secretion as glucose levels

Figure 1: Normal physiological and behavioral defenses against hypoglycemia in humans.

*Adopted from Cryer PE. Diabetes. 2008;57 (12):3169-76.

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June 2017 CE â&#x20AC;&#x201D; Hypoglycemia in Diabetes Figure 2: Glycemic thresholds for secretion of counter-regulatory hormones and the onset of changes in hypoglycemic symptoms in response to hypoglycemia in non-diabetic subjects.

May/June 2017 hypoglycemia in T2DM. However, as patients progress into absolute insulin deficiency and Î˛-cell failure (long-standing T2DM), these patients can exhibit glucose counterregulatory defects similar to T1DM patients.10,17 Complications of Hypoglycemia

*Adopted from Yun JS, Ko SH. Korean J Intern Med. 2015;30(1):6-16. drop just below the physiologic range. The third defense mechanism includes an increase in epinephrine secretion specifically when there is deficiency in glucagon secretion. The last defense mechanism occurs during prolonged hypoglycemia causing an increase in cortisol and growth hormone secretion.13-17 Plasma glucose levels will continue to decline if these defensive mechanisms fail to halt the hypoglycemic episode. The secretion of counter-regulatory hormones and the onset of cognitive and physiological changes occur at specific blood glucose thresholds in non-diabetic individuals (Figure 2).15, 16 Both physiological defensive mechanisms and subjective recognition of behavioral changes in hypoglycemia play an essential role in the restoration of euglycemia.

Hypoglycemia may cause serious complications such as stroke, myocardial infarction, acute cardiac failure and ventricular arrhythmias.9 In the ADVANCE and ACCORD trials, severe hypoglycemia was associated with a significantly higher risk of major cardiovascular events as well as all-cause mortality.20,21 It is reported in EURODIAB IDDM complication study that severe hypoglycemia in T1DM patients is associated with a prolonged QTc interval, leading, cardiac arrhythmias and deaths.22 In addition, when severe hypoglycemia is profound and prolonged, it increases risk of permanent neurologic deficits such as hemiparesis, memory impairment, decreased thinking capabilities and can ultimately result in brain death or coma.9 Risk Factors of Hypoglycemia There are a number of factors that increase the risk of hypoglycemia in patients with diabetes. Most of these are related to three situations: insulin excess, decreased glucose availability and defective glucose counter-regulatory mechanisms.17,18,23 Risk factors that are not associated with these three situations include: age, female gender, African American race, renal impairment, low health literacy and lower socioeconomic status.20 It is reported that elderly patients (aged > 60 years) with T1DM have twice the risk of hypoglycemia compared to young patients.17

Insulin excess results from exogenous insulin or insulin secretagogues such as sulfonylurea which trigger insulin release. Among commonly used sulfonylureas, those with longer duration of action, such as glyburide, are more freThere are differences in the efficiency of the hypoglycemic quently associated with hypoglycemia. A meta-analysis of 21 reaction in patients with Type 1 diabetes mellitus (T1DM) and Type 2 diabetes mellitus (T2DM). In patients with T1DM, studies comparing glyburide with other anti-diabetic medicaas glucose levels fall, glucagon secretion does not increase, tions, including insulin, revealed a 83 percent higher risk of hypoglycemia with glyburide compared with other sulfonylucausing a defect in the second defense against developing reas, while the risk of hypoglycemia was 52 percent higher hypoglycemia. T1DM patients become critically dependent on the third defense i.e., increased epinephrine secretion. A when compared with those taking other insulin secreta24 prospective study compared T1DM patients with and without gogues. Relative risk of hypoglycemia among other anti7,25 epinephrine response and found a 25 fold increase in risk of diabetic agents is listed in Table 2. severe hypoglycemia in those without an epinephrine reReduced glucose availability can occur from either desponse. 17,18 Hypoglycemia unawareness also can develop creased exogenous glucose intake (e.g., missed meals or due to diminished epinephrine secretion, causing reduced overnight fast) or through decreased endogenous glucose autonomic, sympathetic and adrenomedullary responses.19 production (e.g., usually after alcohol ingestion). Alcohol inIn T2DM patients, these physiological defensive mechahibits gluconeogenesis and can result in hepatic glycogen nisms are mostly intact during the early course of the depletion and hypoglycemia, especially if there is limited disease. This could be the reason for lower incidences of food consumption.18

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Table 2: Relative risk of hypoglycemia among currently available anti-diabetic agents7,25 Anti-diabetic Agents

Relative Risk of Hypoglycemia

Metformin

GLP-1R agonists SGLT-2 inhibitors DPP-4 inhibitors Thiazolidinediones α-glucosidase inhibitors Colesevelam

+ + + + + +

Bromocriptine Sulfonylurea

+ +++

Meglitinides

Insulin (especially with short acting or premixed)

++++

Pramlintide + DPP-4= dipeptidyl peptidase-4, GLP-1= glucagon-like peptide-1 receptor, SGLT-2= sodium glucose cotransporter-2 +, minimal hypoglycemia; ++, infrequent hypoglycemia, +++, occasional hypoglycemia; ++++, frequent hypoglycemia Table 3: Signs and Symptoms of Hypoglycemia 18 Adrenergic Symptoms     

Palpitations Anxiousness Tremors Irritability Pallor

Cholinergic Symptoms   

Neuroglycopenic Symptoms    

Sweating Hunger Paresthesia

  

Risk factors related to defective glucose counter-regulatory mechanisms include: insulin deficiency, history of severe hypoglycemia and aggressive glycemic therapy or goals.18 Strict glycemic control has been shown to be associated with an increased risk of hypoglycemia.17,18 Although the benefits of stringent A1C goals have been demonstrated, the results of the ACCORD, ADVANCE and Veterans Affairs Diabetes Trial support the less stringent A1C goals for all patients. The most recent guidelines issued by the American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) and the ADA also recommend individualized A1C goals for all patients in order to achieve optimal benefit in terms of efficacy and risk.7,25 Signs and Symptoms of Hypoglycemia Hypoglycemia can cause three distinct types of neurogenic symptoms: adrenergic, cholinergic and neuroglycopenic symptoms, as listed in Table 3.18 All of these neurogenic symptoms are caused by reduced plasma glucose concentration and lead to activation of central nervous systemmediated autonomic nervous system responses. Among all

Confusion Difficulty speaking Blurred vision Decreased sensations of warmth, weakness and fatigue Behavioral changes Seizures Coma

neurogenic symptoms, neuroglycopenic symptoms are usually recognized by others. These signs and symptoms of hypoglycemia can be mild, moderate or severe, depending on how low the glucose falls and a variety of other factors. Manifestations of hypoglycemia may vary from person to person and can even vary within the same patient on different occasions. Because the symptoms of hypoglycemia are nonspecific and relatively insensitive, many episodes go unrecognized. The patient may not notice any symptoms/ signs of hypoglycemia, even though these are apparent to others. Older adults tend to have more neuroglycopenic symptoms than autonomic symptoms (i.e., adrenergic or cholinergic), and thus, tend to have delayed recognition.18 Some medications may make symptoms of hypoglycemia difficult to recognize. Beta-blockers are known to mask adrenergic symptoms of hypoglycemia (tremors, palpitations, anxiousness, etc.). Many T1DM and T2DM patients are using beta-blockers for treatment of cardiovascular diseases. Thus, it is important to educate diabetic patients who are using beta-blockers about the cholinergic

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symptoms of hypoglycemia (sweating and hunger) instead of adrenergic symptoms.27

Table 4: Oral Hypoglycemia Treatments18,19,28 3-4 glucose tablets

Prevention of Hypoglycemia

1 serving of glucose gel 4 oz (120 mL or ½ cup) of pure juice or soda (nondiet drink) 8 oz (240 mL or 1 cup) of nonfat milk 4-5 saltine crackers 4 teaspoons of table sugar 1 tablespoon of honey 5-6 jellybeans

In order to prevent the development of hypoglycemia, a number of approaches have demonstrated efficacy including: patient education, careful glucose monitoring, reevaluation of A1C goals, appropriate medication selection and adjustment and diet and exercise modification.10 Patient education about hypoglycemia should include signs and symptoms, potential complications and treatment using oral carbohydrates or glucagon. In addition, patients should be educated on other precipitating factors such as alcohol ingestion, incorrect timing or doses of diabetes medications and skipped meals. It is important to discuss with patients how their diabetes medications work and how to minimize hypoglycemia.10 Patients should be encouraged to document episodes of hypoglycemia and to contact their provider if they have unexpected or more-frequent episodes. Appropriate self-monitoring of blood glucose (SMBG) is one of the most effective ways of defining blood glucose trends and detecting asymptomatic hypoglycemia. The 2017 ADA diabetes guidelines recommend frequent SMBG testing at least 3-4 times daily prior to meals and snacks for patient using multiple daily injections of insulin or on intensive insulin regimens.7 For most healthy patients using insulin ADA recommends pre-prandial SMBG targets of 80 to 130 mg/dL, whereas postprandial glucose levels measured 1 to 2 hours after a meal should be less than 180 mg/ dL.7

formulation to minimize episodes of hypoglycemia. For example, the use of rapid-acting insulin analogue (e.g., lispro or aspart) in place of regular insulin or the use of longacting insulin (e.g., glargine or detemir) rather than intermediate-acting insulin (e.g., NPH) may reduce the frequency of hypoglycemia. For patients with oral anti-diabetic agents, especially sulfonylureas and meglitinides, substitution to a different class of diabetes medications such as metformin, GLP-1 agonists, DPP-4 inhibitors or SGLT-2 inhibitors may be warranted to prevent further hypoglycemic episodes.10,18,28

Diet and exercise modifications have a role in preventing hypoglycemia. Patients with diabetes must be educated about their carbohydrates intake and how these carbohydrates affect their glucose. Patients taking long-acting secretagogues alone (e.g., glyburide) or in combination with other agents for diabetes, and fixed insulin regimens should be counseled to follow a regular and predictable meal plan to prevent hypoglycemic episodes. Moreover, for A reasonable HbA1c goal of less than 7 percent is targeted patients taking insulin who develop exercise-induced for most of healthy patients with diabetes. More stringent hypoglycemia, it is prudent to provide education about how HbA1c goal of less than 6.5 percent might be reasonable to adjust their insulin doses as well as carbohydrates intake for patients with longer life expectancies and without signifi- on the days of planned exercise. These patients must be cant hypoglycemia or adverse treatment effects.7 Less instructed to monitor blood glucose levels before and after stringent HbA1c goal of less than 8 percent may be appro- exercise; pre-exercise carbohydrate rich snacks can be priate for patients with a history of severe hypoglycemia, consumed if blood glucose levels are less than 100 mg/ advanced complications or who are encountering difficulty dL.7,10,18 with control of their HbA1c. To prevent hypoglycemia, patient specific HbA1c goals should be determined by provid- Treatment of Hypoglycemia ers specifically for patients with hypoglycemia unawareThe goals for effective treatment of hypoglycemia include ness and recurrent hypoglycemic episodes. These patients quick detection of a hypoglycemic episode and increase in may benefit from enrollment in blood glucose awareness the blood glucose to a safe level through appropriate training programs which provide important information intervention. Most patients with asymptomatic or mild to about how to recognize early signs and symptoms of hypomoderate symptomatic episodes of hypoglycemia and who glycemia and manage them effectively in order to prevent are conscious can be self-treated effectively by the hospital admission.10 consumption of 15 grams of oral carbohydrates.7,18,19,28 The SMBG provides trends in blood glucose levels, and this “rule of 15” is preferably used to prevent overtreatment and data can be used to make adjustments in insulin dose or rebound hyperglycemia. This rule involves confirming 30

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June 2017 CE â&#x20AC;&#x201D; Hypoglycemia in Diabetes

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hypoglycemia by self-testing blood glucose, consumption of 15 grams of fast-acting carbohydrates (Table 4), followed by a recheck of blood glucose level 15 minutes after a carbohydrate consumption to ensure that the glucose level is greater than 70 mg/dL.7, 18,28,29 If the blood glucose remains below the desired goal, then another 15 grams of carbohydrate should be ingested and blood glucose tested again 15 minutes later. Generally, 5 grams of carbohydrate will increase the plasma glucose concentration by about 15 mg/dL.28 Once the hypoglycemic episode is resolved, the patient should have their usual meal or snack to prevent another episode. In patients who have severe hypoglycemia and still have consciousness, use of 20 grams carbohydrates instead of 15 grams is recommended.28,29 It is important to choose appropriate sources of oral carbohydrates and avoid items with added fat since it may delay glucose absorption and prolong hypoglycemic episode.7 Thus, patients should be counseled to avoid treating hypoglycemia with certain candies such as peanut butter cups and chocolate. Additionally, it would be wise to advise avoidance of hard candy such as butterscotch in case the patients were to lose consciousness. Patients should be certain that their beverage of choice during a hypoglycemic episode does contain carbohydrates and is not an artificially sweetened beverage i.e. diet drink or squeeze water flavor. Patients who develop hypoglycemia as a result of taking Îą-glucosidase inhibitors such as acarbose must be treated with simple oral glucose (e.g., corn syrup, glucose tablets/gel or honey) instead of sucrose (e.g., table sugar or soft drinks) since the hydrolysis of sucrose to glucose and fructose is inhibited by acarbose.30 Parenteral treatment of hypoglycemia is warranted when a patient loses consciousness and is unwilling or unable to consume oral carbohydrates or when a patient presents with sulfonylurea-induced prolonged hypoglycemia. Two types of parenteral treatment are currently available including dextrose and glucagon.7,28,29,31 Intravenous glucose is administered as dextrose 25 grams over 1-3 minutes, and it is preferred for hospitalized patients with severe hypoglycemia and intravenous access.32 Glucagon is commonly utilized for ambulatory patients with severe hypoglycemia since it does not require intravenous access and can be easily administered by a family member or caregiver in an emergency situation. Glucagon is a naturally occurring hormone that is secreted by the pancreas. Its physiologic actions are mediated by the liver in order to maintain glucose levels through glycogenolysis (breakdown of glycogen) and gluconeogenesis (generation of glucose).17,31 The usual recommended dose of glucagon is 1 mg (1 mL), given subcutaneously or intramuscularly in the 31

buttocks, thigh or arm.33 It is available as an emergency kit which contains a powder for reconstitution and a diluent.33 Patients who have history of severe hypoglycemic episodes or are prone to severe hypoglycemia should have emergency kit readily available and their family members and/or caregivers should be instructed on the dosage and administration technique of the glucagon. If the patient does not respond within 15 minutes of first glucagon (1 mg) administration, another dose should be given. 28,29 After the patient regains consciousness and is able to swallow, oral carbohydrates should be given to restore liver glycogen and prevent further episodes of hypoglycemia. In patients with recurrent severe hypoglycemia, after attaining normal blood glucose levels, future adjustments in pharmacologic treatment as well as re-evaluation of HbA1c goals may be warranted. Conclusion Hypoglycemia is a common and significant complication of diabetes. It is a rate limiting factor in achieving glycemic goals. Prevention of hypoglycemia is vital. The key factors to prevent hypoglycemia are patient education, careful glucose monitoring, reevaluation of A1C goals, appropriate medication selection and adjustment and diet and exercise modification. Early recognition and appropriate treatment of hypoglycemia is essential to preventing progression to life threatening complications like seizure or coma. Common signs of hypoglycemia include diaphoresis, pallor, increased heart rate (tachycardia) and slight elevation in systolic blood. The patient, family and caregivers should be educated on appropriate management of a hypoglycemic episode. They should be able to differentiate mild-to-moderate hypoglycemic episodes from severe hypoglycemic episodes and treat it appropriately with oral carbohydrate using rule of 15 or glucagon, respectively. It is important for patients to learn strategies to minimize their risk of hypoglycemia. All patients with diabetes should understand the risk factors, signs and symptoms of hypoglycemia and appropriate treatment of hypoglycemia. Finally, with a basic understanding of these principles, a collaborative foundation can be built to institute strategies for hypoglycemia risk minimization between patients, caregivers and healthcare providers. References: 1. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2013;36 Suppl 1:S67-74. 2. American Diabetes Association. Statistics about diabe-

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tes. Available at: http://www.diabetes.org/diabetesbasics/statistics/?referrer=https://www.google.com/. Accessed May 23, 2016.

treatment modalities. Diabetes Care. 2005;28:29482961.

14. Cryer PE. The barrier of hypoglycemia in diabetes. 3. Boyle JP, Thompson TJ, Gregg EW, Barker LE, WilliamDiabetes. 2008;57(12):3169-76. son DF. Projection of the year 2050 burden of diabetes 15. Cryer PE, Axelrod L, Grossman AB, et al. Evaluation in the US adult population: dynamic modeling of inciand management of adult hypoglycemic disorders: an dence, mortality, and prediabetes prevalence. Popul Endocrine Society Clinical Practice Guideline. J Clin Health Metr. 2010;8:29. Endocrinol Metab. 2009;94(3):709-28. 4. National Diabetes Statistics Report. 2014. Available at: 16. Yun JS, Ko SH. Avoiding or coping with severe hypoglyhttps://www.cdc.gov/diabetes/pubs/statsreport14/ cemia in patients with type 2 diabetes. Korean J Intern national-diabetes-report-web.pdf. Accessed April 1, Med. 2015;30(1):6-16. 2017. 17. Chelliah A, Burge MR. Hypoglycaemia in elderly patients 5. The effect of intensive treatment of diabetes on the with diabetes mellitus: causes and strategies for prevendevelopment and progression of long-term complication. Drugs Aging. 2004;21(8):511-30. tions in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N 18. Cryer PE, Davis SN, Shamoon H. Hypoglycemia in diabetes. Diabetes Care. 2003;26(6):1901-1912. Engl J Med. 1993;329(14):977-86. 6. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352(9131):854-65. 7.

9. 10.

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19. Cryer PE. Minimizing Hypoglycemia in Diabetes. Diabetes Care. 2015;38(8):1583-91.

20. Calles-escandón J, Lovato LC, Simons-morton DG, et al. Effect of intensive compared with standard glycemia treatment strategies on mortality by baseline subgroup American Diabetes Association. Standards of Medical characteristics: the Action to Control Cardiovascular Care in Diabetes – 2017. Diabetes Care. 2017;40(1):S1Risk in Diabetes (ACCORD) trial. Diabetes Care. 138. 2010;33(4):721-7. Lipska KJ, Yao X, Herrin J, et al. Trends in Drug Utilization, Glycemic Control, and Rates of Severe Hypoglyce- 21. Patel A, Macmahon S, Chalmers J, et al. Intensive blood glucose control and vascular outcomes in patients with mia, 2006-2013. Diabetes Care. 2017;40(4):468-475. type 2 diabetes. N Engl J Med. 2008;358(24):2560-72. Amiel SA, Dixon T, Mann R, Jameson K. Hypoglycaemia in Type 2 diabetes. Diabet Med. 2008;25(3):245-54. 22. Snell-bergeon JK, Wadwa RP. Hypoglycemia, diabetes, and cardiovascular disease. Diabetes Technol Ther. Seaquist ER, Anderson J, Childs B, et al. Hypoglycemia 2012;14 Suppl 1:S51-8. and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society. Diabe- 23. Cryer PE. Hypoglycemia: still the limiting factor in the glycemic management of diabetes. Endocr Pract. tes Care. 2013;36(5):1384-95. 2008;14(6):750-6. International Hypoglycaemia Study Group. Glucose con24. Gangji AS, Cukierman T, Gerstein HC, Goldsmith CH, centrations of less than 3.0 mmol/L (54 mg/dL) should Clase CM. A systematic review and meta-analysis of be reported in clinical trials: a joint position statement of hypoglycemia and cardiovascular events: a comparison the American Diabetes Association and the European of glyburide with other secretagogues and with insulin. Association for the Study of Diabetes. Diabetes Care. Diabetes Care. 2007;30(2):389-94. 2017;40(1):155–157.

12. Boyle PJ, Schwartz NS, Shah SD, Clutter WE, Cryer PE. Plasma glucose concentrations at the onset of hypoglycemic symptoms in patients with poorly controlled diabetes and in nondiabetics. N Engl J Med. 1988;318 (23):1487-92.

25. Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the american association of clinical endocrinologists and american college of endocrinology on the comprehensive type 2 diabetes management algorithm - 2016 executive summary. Endocr Pract. 2016;22(1):84-113.

13. Zammitt NN, Frier BM. Hypoglycemia in type 2 diabetes: 26. Mitrakou A, Ryan C, Veneman T, et al. Hierarchy of glypathophysiology, frequency, and effects of different

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cemic thresholds for counterregulatory hormone secretion, symptoms, and cerebral dysfunction. Am J Physiol. 1991;260(1 Pt 1):E67-74.

2011. Available at: http://www.accessdata.fda.gov/ drugsatfda_docs/label/2011/020482s024lbl.pdf. Accessed Oct. 15, 2016.

27. White JR. The contribution of medications to hypoglycemia unawareness. Diabetes Spectrum. 2007;20 (2):77-80.

31. Pearson T. Glucagon as a treatment of severe hypoglycemia: safe and efficacious but underutilized. Diabetes Educ. 2008;34(1):128-34.

28. Gabriely I, Shamoon H. Hypoglycemia in diabetes: common, often unrecognized. Cleve Clin J Med. 2004;71(4):335-42.

32. Dextrose. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://0-online.lexi.com.library.acaweb.org/lco/action/ doc/retrieve/docid/patch_f/6724. Accessed Oct.15, 2016.

29. Childs BP, Grothe JM, Greenleaf PJ. Strategies to limit the effect of hypoglycemia on diabetes control: identify33. Glucagon [prescribing information]. Indianapolis, IN: Eli ing and reducing the risks. Clin Diabetes. 2012;30(1). Lilly and Company LLC; September 2012. Available at: 30. Precose (acarbose) [prescribing information]. Wayne, http://pi.lilly.com/us/rglucagon-pi.pdf. Accessed Oct. NJ: Bayer Healthcare Pharmaceuticals Inc; March 15, 2016.

June 2017 — An Overview of Hypoglycemia in Diabetes 1. According to 2017 American Diabetes Association (ADA) Standards of Medical Care in Diabetes, which of the following glucose alert value is used to define hypoglycemia in patients with diabetes? A. ≤ 70 mg/dL B. ≤ 80 mg/dL C. ≤ 90 mg/dL

6. Which of the following are cholinergic symptoms of hypoglycemia? A. Sweating and hunger B. Palpitations and tremors C. Irritability and anxiousness 7. Neuroglycopenic symptoms of hypoglycemia include: I.Confusion II.Seizures III.Pallor A. I & II B. II & III C. I, II, & III

2. Which of the following are physiological defense mechanisms to limit the effects of hypoglycemia? A. Increase in insulin secretion B. Increase in glucagon release C. Decrease in epinephrine secretion D. None of the above 3. Which of the following factors are associated with increased risk of hypoglycemia in patients with diabetes? I.Insulin excess II.Decreased glucose availability III.Defective glucose counter-regulatory mechanisms A. I & II B. II & III C. I, II, & III

8. For most healthy patients with diabetes, the American Diabetes Association current recommendation for pre-prandial blood glucose level is: A. 70 – 130 mg/dL. B. 80 – 130 mg/dL. C. < 110 mg/dL. 9. The best choice of treatment for a conscious patient with diabetes experiencing hypoglycemia is: A. 4 oz of 1% milk. B. 4 oz of diet soda. C. 3 to 4 glucose tablets.

4. Which of the following anti-diabetic agent has the lowest risk of hypoglycemia? A. Insulin B. Sulfonylureas C. DPP-4 inhibitors

10. The “rule of 15” approach to treating hypoglycemia refers to: A. A 15-minute wait between glucagon injections. B. 15 gram of simple carbohydrates every 15 minutes. C. Blood glucose increases of 15 mg/dL every 15 minutes.

5. Alcohol intake increases the risk of hypoglycemia through which of the following mechanisms? A. Increased hepatic glycogen production B. Decreased endogenous glucose production C. Defective glucose counter-regulatory mechanisms 33

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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: April 30, 2020 Successful Completion: Score of 80% will result in 1.0 contact hour or .1 CEUs. Participants who score less than 80% will be notified and permitted one re-examination. TECHNICIANS ANSWER SHEET. June 2017 — An Overview of Hypoglycemia in Diabetes (1.0 contact hour) Universal Activity # 0143-0000-17-006-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C 3. A B C 5. A B C 2. A B C D 4. A B C 6. A B C

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KPhA New and Returning Members

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KPhA Welcomes New and Renewing Members March-April 2017 Frankie Abner Barbourville

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To YOU, To YOUR Patients To YOUR Profession!

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Terry Lee Coyle Campbellsville

Kristen Fugate-Oliver Krypton

Chris Harlow Louisville

Susan Bostic Russell Springs

Heather Daniels Hazard

Dana Fuller Lexington

Matthew Harman Dublin, Ohio

James Bowman Elizabethtown

Martin Davenport Murray

Bernard Fussenegger Louisville

Julie Hawkins Pewee Valley

Michael Branstetter Glasgow

Judith Davenport Louisville

Roy Gentry Monterey, Tenn.

Joseph Hays Smiths Grove

William Broughton Shepherdsville

Melanie Dicks Lexington

April Golden Corbin

Dale Heise Harrodsburg

Elois Broughton Shepherdsville

Holly Divine Versailles

Shirley Good Hopkinsville

Marla Helton Frenchburg

Clyde Brown Mayfield

Debbie Duckworth Versailles

Gina Guarino Louisville

Amanda Helton Pathfork

Angela Brunemann Union

Jane Dunbar-Suwalski Longmont, Colo.

Rodney Haddix Lexington

Jennifer Higgins Barbourville

MEMBERSHIP MATTERS:

THE KENTUCKY PHARMACIST

KPhA New and Returning Members

May/June 2017

Stephen Hill Stanford

Daniel Meier Edgewood

Charles Peterson Rineyville

Misty Stutz Crestwood

Kristina Hinkle Heidrick

Erica Melton Mayfield

Steve Pollock Prospect

Terrisa Sutherland Bimble

James Hinkle Heidrick

Pamela Moore Campbellsville

Nancy Rath Louisville

Stephanie Taylor Corbin

Janet Hodge Louisville

Kristy Moore McDowell

Myra Ray Smiths Grove

Amy Thompson Lexington

Susan Hogsten Flatwoods

Benjamin Mudd Lebanon

Felix Reynolds Lancaster

Mykel Tidwell Mayfield

Brooke Hudspeth Lexington

Theresa Mullins Hindman

Wanda Salyer Flat Gap

Steven Treadway Elizabethtown

Ronald Huening Cincinnati, Ohio

Beth Murley Bowling Green

Kent Shearer Albany

Michael Tucker Louisville

Kyla James Clarksville, Tenn.

Jerri Murphy Louisville

Steve Sheldon Bowling Green

Evin Vann Glasgow

Joseph Johnson Lebanon

Patrick Murphy Louisville

Alan Simon Prospect

Terry Vest Russell

Robert Craig Kidwell Crestwood

Shelley Nall Lexington

Zena Slone Hindman

Amanda Ward Louisa

Scott King Hazard

Burnice Napier Hazard

Richard Slone Hindman

Rodney Ward Louisa

Jane Lacefield Bowling Green

Carol Neel Louisville

Kelly Smith Lexington

Donald Webb Middlesboro

Darren Lacefield Bowling Green

Victor Nwosu Prospect

Cory Smith Barbourville

Rebecca Webb Shepherdsville

Michelle Loos Covington

Mark Nybo Crescent Springs

Jordan Smith Louisville

Jack Wikas Alexandria

James Marshall Leitchfield

Jeffrey Osman Lexington

R James Spencer Beaver Dam

Samuel Willett Mayfield

John McClanahan Ashland

Lauren Otis Owingsville

John Spencer Richmond

Carol Wills Lexington

Tera McIntosh Midway

Julie Owen Louisville

Cathy Spencer Louisville

Patricia Ann Woolum Barbourville

Anne Megibben Louisville

Susan Lynne Peak Simpsonville

Sally Stiltner Berea

Joseph Wright Louisville

Veronica Stith Vine Grove

Scott Yates Auburn

Brooke Strong Barbourville

Paula Yother Barbourville

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

THE KENTUCKY PHARMACIST

Pharmacy Policy Issues

May/June 2017

PHARMACY POLICY ISSUES:

Academic Preparation to Pursue a Pharmacy Degree Author: Erica Krantz is a fourth professional year student at the University of Kentucky College of Pharmacy. A native of Williamston, Mich., she earned a Bachelor of Science degree in physiology at Michigan State University prior to enrolling at UK. Issue: I know some students enter pharmacy school after completing two years of pre-pharmacy work, some do three and some complete a bachelor’s degree before entering. What are the pros and cons of these approaches? chemistry, organic chemistry, Discussion: Planning out courses Have an Idea? as a pre-pharmacy student, the human anatomy, math and a few This column is designed to aspiring pharmacist must decide non-science classes.7 Currently, the address timely and practical either to complete the minimum list of mandatory coursework differs issues of interest to pharmacists, required coursework or earn a from school to school. The Accredipharmacy interns and pharmacy bachelor’s degree prior to applying for tation Council for Pharmacy Educatechnicians with the goal being to admission to pharmacy school. A tion (ACPE) standards are encourage thought, reflection and pre-pharmacy student weighs the published to help advance exchange among practitioners. pros and cons of a degree and pharmacy academics. The ACPE Suggestions regarding topics for currently the decision is up to him or 2016 standards highlight the need consideration are welcome. Please her. In 2016, nine colleges of for students who are professional, send them to jfink@uky.edu. pharmacy require completion of a have problem-solving and critical bachelor’s degree before entering.1 thinking capabilities and are able to 8 More schools are starting to follow this trend and require a express empathy. When debating making a bachelor’s bachelor’s degree prior to beginning pharmacy school. 2,3 degree required, the ACPE standards should be taken into This begs the question: should a bachelor’s degree be consideration. required for admission? Current pharmacy schools that require baccalaureate Education of pharmacists began as apprenticeships. A person worked next to an established pharmacist to learn the trade.4 Moving education into a college setting began in 1821 at the Philadelphia College of Pharmacy.4 Upon graduation, students would be awarded a Graduate in Pharmacy (PhG) degree. A Pharmaceutical Chemist (PhC) degree would be awarded for an additional year of study and a Doctor of Pharmacy (PharD) would be given with even further education. Then in the 1940’s, the American Council on Education recommended pharmacy school be extended to a six year program. Most schools decided to create a Bachelor of Science in Pharmacy (BSPharm) program leading to a five-year professional degree.4,5 Some programs offered a Doctor of Pharmacy (PharmD), a program that focused more on teaching pharmacy students the clinical pharmacy role. In 1992, the American Association of Colleges of Pharmacy (AACP), voted to move toward requiring all pharmacy schools to offer PharmD degrees.6 The PharmD program requires a minimum of two academic years or the equivalent collegelevel coursework before admission into PharmD programs.

degrees for enrollment include University of Southern California, California Northstate University, University of California-San Diego, California Health Sciences University, Keck Graduate Institute, The Ohio State University, University of Saint Joseph, Touro University and Touro College.1,9,10 Other schools’ websites, such as University of Minnesota and Oregon State University, state that preference will be given to students with an undergraduate degree.11,12 The University of Michigan College of Pharmacy Class of 2016 had 68 of the total 78 students (87 percent) in the class earn a bachelor’s degree prior to entering the PharmD program.13 At the University of Kentucky College of Pharmacy the Classes of 2016 to 2019 on average have half of the students entering the program with a baccalaureate degree.14 The Advantages

Requiring a bachelor’s degree, means that the students entering the profession will be older and most likely have had more exposure to personal and professional development prior to entering pharmacy school.15 Due to an older age, the maturity level of the students will likely be Each school has a set list of prerequisite courses that must higher. By earning a prior degree, pharmacy schools can be completed prior to entering pharmacy school. Most ensure that students are entering with a broader schools require pre-pharmacy coursework in biology, educational foundation. With students entering with more 38

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Pharmacy Policy Issues science credits, pharmacy schools can focus the content of their curricula more on clinical pharmacy and reducing the redundancy of basic science classwork during the PharmD degree program.2 By requiring a bachelor’s degree prior to pharmacy school admission, there will be consistency of standardized preparation.15 Applying consistency to pharmacy school performance, multiple studies have assessed the correlation between professional grades and years of undergraduate education completed. Students with degrees have been shown to perform better academically than students who did not get a degree.16-19 McCall’s study determined that having a Bachelor of Science degree or advanced college coursework significantly increased the first year pharmacy GPA and cumulative GPA. It also was determined that the advanced coursework at the undergraduate level is tied to less academic delay or suspension.18 The Disadvantages While there are advantages to obtaining a bachelor’s degree prior to entering pharmacy school, there also are disadvantages that must be considered. A bachelor’s degree takes longer meaning that not only will the student be paying for an extra year or two of tuition, the student also foregoes the salary that could have been earned graduating from pharmacy school earlier.2 The cost of undergraduate tuition continues to increase. From 2014 to 2015, college tuition across the nation was raised between 2 percent to 7 percent.20 Being required to complete a bachelor’s degree prior to starting pharmacy school, a student would be required to take general education classes for graduation, like music appreciation, which have little application to the practice of pharmacy. A survey of academic pharmacy administrators concluded that the only social sciences they thought were necessary for inclusion in pre-professional studies were English composition and public speaking. 21 Another study determined that obtaining a Bachelor of Science degree had no significant correlation with passing the North American Pharmacist Licensure Examination (NAPLEX).22

May/June 2017 The Argus Commission is a committee within the American Association of Colleges of Pharmacy that considers major national, health-related initiatives and publishes yearly reports. In the 2011-12 Report titled “Cultivating ‘Habits of Mind’ in the Scholarly Pharmacy Clinician,” the Commission made the recommendation that, “specification of pre-pharmacy prerequisites be minimized in favor of the use of better assessment tools and that preference in admissions be given to pre-pharmacy experiences that develop an inquisitive mind in our entering students.”23 End Note Pharmacists have come a long way from apprenticeship as the approach to entering the profession. Responses to a survey sent out to 102 deans of colleges/schools of pharmacy were evenly divided over the ideal length of undergraduate coursework.21 While there is no consensus on content or length of the pre-professional requirements, thought should be put into unifying requirements. This is a topic certainly deserving of discussion and not only by those in the hallowed halls of academe. This is an issue with profession-wide implications. And those nuances may become even more personal if the long term trend of pharmacists’ offspring following them into the profession continues. Citations 1. American Association of Colleges of Pharmacy. (2016). 2015-2016 Summary of Pre-Professional Course Requirements by Pharmacy Degree Institution. 2. Gleason, B. L., Siracuse, M. V., Moniri, N. H., Birnie, C. R., Okamoto, C. T., & Crouch, M. A. (2013). Evolution of pre-professional pharmacy curricula. Am J Pharm Educ. 77(5), 95. 3. Gleason, B. L., Siracuse, M. V., Moniri, N. H., Birnie, C. R., Okamoto, C. T., & Crouch, M. A. (2013). Evolution of pre-professional pharmacy curricula. Am J Pharm Educ. 77(5), 95.

4. Fink III, JL. (2012) Pharmacy: A Brief History of the Obtaining the best and brightest incoming pharmacy class Profession. The Student Doctor Network, is a focus of college of pharmacy admissions. By requiring http://studentdoctor.net/2012/01/pharmacy-a-briefa bachelor’s degree prior to admission when other schools history-of-the-profession/ (Jan) 2012. still only require a set amount of pre-requisites, the schools without that higher standard fear that they no longer will be 5. Fink III, JL, (2007). Viewpoint: A matter of degree: Let's competitive; those school might hold the concept that they get it right. Drug Topics. 2007(Mar 5);151:64. are no longer receiving the top applicants.2 While there is 6. Archived Policy from 1980-2011 of the American Assoan argument that older students are more mature, the ciation of Colleges of Pharmacy House of Delegates counter argument is that professional development is (2011) Retrieved Nov. 17, 2016, from: taught throughout pharmacy school and professional extrahttp://www.aacp.org/governance/HOD/Documents/ curricular activities. 39

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Pharmacy Policy Issues

May/June 2017

AACP%20ARCHIVED%20POLICY%201980-2011.pdf 7. Pre-Pharmacy School Prerequisites. American Association of Colleges of Pharmacy. Retrieved Nov. 15, 2016, from http://www.aacp.org/resources/student/ pharmacyforyou/admissions/admissionrequirements/ Pages/PharmDSchoolInformation.aspx 8. Accreditation Council for Pharmacy Education. Standards 2016. Retrieved Nov. 15, 2016, from https://www.acpe-accredit.org/pdf/ Standards2016FINAL.pdf. 9. Doctor of Pharmacy Admissions. (n.d.). Retrieved Nov. 16, 2016, from http://www.pharmacy.ohio-state.edu/ future-students/doctor-pharmacy-admissions 10. University of Southern California. (n.d.). Retrieved Nov. 16, 2016, from https://pharmacyschool.usc.edu/ programs/pharmd/pharmdprogram/admission/ requirements/ 11. Pharm. D. Frequently Asked Questions. (2016). Retrieved Nov. 16, 2016, from http://pharmacy.oregonstate.edu/pharm-d-frequentlyasked-questions 12. Prerequisites. (n.d.). Retrieved Nov.15, 2016, from https://www.pharmacy.umn.edu/degrees-programs/ doctor-pharmacy/admissions/prerequisites 13. U-M College of Pharmacy Guide for Prospective & Incoming Students. (n.d.) Retrieved Nov. 15, 2016 from https://pharmacy.umich.edu/guide-prospective-andincoming-pharmacy-students 14. Black EP. Personal communication, Nov. 16, 2016. 15. Harrell, K. (2015). Has The Time Come for a Bachelor’s Degree Prerequisite to Pharmacy School? Am J Pharm

Educ. 79(8). 16. Chisholm, M. A. (2001). Students’ performance throughout the professional curriculum and the influence of achieving a prior degree. Am J Pharm Educ. 65(4), 350. 17. Renzi, S. E., Krzeminski, M. A., Sauberan, M. M., Brazeau, D. A., & Brazeau, G. A. (2007). Pre-pharmacy years in college and academic performance in a professional program. Am J Pharm Educ. 71(4), 69. 18. Houglum JE, Aparasu RR, Delfinis TM. Predictors of academic success and failure in a pharmacy professional program. Am J Pharm Educ. 2005;69 (3):Article 43. 19. McCall KL, Allen DD, Fike DS. Predictors of academic success in a doctor of pharmacy program. Am J Pharm Educ. 2006;70(5): Article 106. 20. Clark, K. (2015, Nov. 4). College Board Says Tuition Rose Faster than Inflation Again This Year. Retrieved Nov. 17, 2016, from http://time.com/money/4098683/ college-board-tuition-cost-rose-inflation-2015/. 21. Broedel-Zaugg, K., Buring, S. M., Shankar, N., Soltis, R., Stamatakis, M. K., Zaiken, K., & Bradberry, J. C. (2008). Academic pharmacy administrators' perceptions of core requirements for entry into professional pharmacy programs. Am J Pharm Educ. 72(3), 52. 22. McCall, Kenneth L., et al. "Preadmission predictors of PharmD graduates' performance on the NAPLEX." Am J Pharm Educ. 71.1 (2007): 05. 23. Speedie, M. K., Baldwin, J. N., Carter, R. A., Raehl, C. L., Yanchick, V. A., & Maine, L. L. (2012). Cultivating ‘habits of mind’ in the scholarly pharmacy clinician: report of the 2011-12 Argus Commission. Am J Pharm Educ. 76(6), S3.

KPhA Government Affairs Contribution Name: _______________________________Pharmacy: _____________________________

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

Mail to: Kentucky Pharmacists Association, 96 C Michael Davenport Blvd., Frankfort, KY 40601

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139th KPhA Annual Meeting & Convention

May/June 2017

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Pharmacy Law Brief

May/June 2017

Pharmacy Law Brief: Medical Orders for Scope of Treatment (MOST) Documents

Author: Joseph L. Fink III, B.S. Pharm., J.D., Professor of Pharmacy Law and Policy and KPhA Professor of Leadership, Department of Pharmacy Practice and Science, UK College of Pharmacy Question: I’ve heard that there is something new in Kentucky related to a patient expressing wishes or preferences for end-of-life care, sort of like a Living Will or Durable Power of Attorney for Health Care. But as I understand it, this new thing is a form with check boxes that a patient completes to document his or her desires. I’ve even had a patient ask me about that in the context of caring for a loved one. What is that?

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: Pharmacists likely are familiar with legal documents such as a Living Will, a Durable Power of Attorney for Health Care or medical surrogate designation. Hopefully, each and every pharmacist has completed those The form is official once a physician has explained the varidocuments. That certainly should be done when first preous alternatives to the patient, the decisions have been paring or updating one’s Last Will and Testament. made and the form is signed by the physician along with The new item referred to in the question above is known as the patient. Medical Orders for Scope of Treatment (MOST). A MOST Often such a form will be completed when the patient enForm can go a long way toward assuring that a patient’s ters a health care facility such as a hospital, nursing home wishes about end-of-life care with modalities including nuor hospice residential facility, or when the patient enrolls for trition, hydration and use of medications are known, comhospice services to be provided at home. If the patient municated and followed. changes locations, say hospital to extended care facility, Being knowledgeable about the MOST Form and its role is the form is to travel with him or her but note that it must be important to the pharmacist for two reasons – first, for per- the original version completed by the patient, not a photosonal and family decision-making, and second, for educat- copy. The patient can make changes in the preferences ing patients about their options. recorded on the form at any time just as the patient can A MOST Form can help the patient to maintain control over cancel or void the form at any time. The wishes recorded in the form are to be reviewed annually. health care being administered and received at the end of life. For example, similar to a Do Not Resuscitate (DNR) request or order, the MOST Form communicates to emergency responders and other health care professionals whether to initiate cardiopulmonary resuscitation. But a MOST Form can go further; it can document other important, even critical, information regarding the patient’s preferences at the end of life.

What are some differences between the MOST Form and other somewhat similar approaches? Compared to a Do Not Resuscitate, the MOST Form encompasses more information such as preferences for life-sustaining initiatives in addition to CPR. The MOST Form will address options such as intubation, antibiotic use and application of feeding tubes.

Authorized in more than 30 states, the MOST Form is designed to be prominent and visible in what may be a voluminous patient chart. The Kentucky form has been designed to have a bright red portion in a prominent location and to be printed on pink paper so it is visible in the patient’s chart. Faxed copies or photocopies are neither valid nor acceptable.

The MOST Form is not a substitute for a properly prepared Living Will and Durable Power of Attorney for Health Care. Taken together, these two documents provide more detailed information than does a MOST Form. It has become common practice for a client visiting an attorney for preparation of a Last Will and Testament to be asked about completing a Living Will and Durable Power of Attorney for The MOST Form must be completed and executed with the Health Care during the same session; considering all such assistance of a physician or other health care professional. documents at the same time is highly recommended. Note, 42

THE KENTUCKY PHARMACIST

May/June 2017

Pharmacy Law Brief however, that completion of a MOST Form requires a discussion with one’s physician, an individual typically not present when the Last Will and Testament, Living Will and Durable Power of Attorney documents are being considered, drafted and signed.

311.629, or the responsible party in accordance with KRS 311.631. Once initial medical treatment is begun and the risks and benefits of further therapy are clear, your treatment wishes may change. Your medical care and this form can be changed to reflect your new wishes at any time. However, no form can address all the medical treatment decisions that may need to be made. An advance directive, such as a Kentucky Health Care Power of Attorney, is recommended for all capable adults, regardless of their health status. An advance directive allows you to document in detail your future health care instructions or name a surrogate to speak for you if you are unable to speak for yourself, or both. If there are conflicting directions between an enforceable Living Will and a MOST Form, the provisions of the living will shall prevail.

Alternatively, a patient who has been diagnosed with a terminal illness, an advanced chronic progressive disease or a condition that requires care in a health care institution may need a MOST Form in addition to the other traditional health care advance directives. A Living Will or a Durable Power of Attorney for Health Care may not be sufficient to forestall CPR in a patient who desires not to have such rigorous measures pursued. Some make the distinction that only patients facing lifethreating conditions will find completion of a MOST Form appropriate. For most individuals, a Living Will, designed to document one’s decisions about health care, and a Durable Power of Attorney for Health Care, used to designate someone else to make those decisions if needed, will provide the full protection and peace of mind one would like to have.

If the patient is travelling out of state it is a good idea to take the form along. Although it may not comply with legal requirements in another state to be considered legally binding, it may well prove to be an effective means of communicating one’s preferences to health professionals in another jurisdiction. And while discussing other states, it The Hospice of the Bluegrass points out that “in order to be should be pointed out that what is known in Kentucky as an enforceable physician order, the MOST Form must be Medical Orders for Scope of Treatment (MOST) may have signed by a physician.” However, that organization goes on another name elsewhere. For example, in West Virginia to point out that “any medical professional with adequate this document is known as POST – Physician Orders for knowledge to have an informed conversation regarding a Scope of Treatment. patient’s current medical condition, prognosis, treatment The Kentucky MOST Form is available online from the options, goals, values and preferences for medical care in Kentucky Board of Medical Licensure website at the future, can have the MOST conversation and complete http://kbml.ky.gov/board/Documents/MOST%20Form.pdf. the form.” Information prominently located at the top of the reverse side of the form document provides important information about the role of the MOST Form:

Sources of Further Information: 



Information for patient, surrogate or responsible party of patient named on this form



The MOST Form is always voluntary and is usually for persons with advanced illness. MOST records your  wishes for medical treatment in your current state of health. The provision of nutrition and fluids, even if medically administered, is a basic human right and  authorization to deny or withdraw shall be limited to the patient, the surrogate in accordance with KRS

Hospice of the Bluegrass. Medical Orders for Scope of Treatment (MOST): Frequently Asked Questions. Frequently Asked Questions for Health Care Providers, Lexington, KY (undated). Available at http://www.hospicebg.org/MOST. KRS 311.6225. Available at www.lrc.ky.gov/statutes/ statute.aspx?id=44035. National POLST Paradigm. Physician Orders for LifeSustaining Treatment Paradigm. Available at www.polst.org.

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May/June 2017

Pharmacists Mutual

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Cardinal Health

May/June 2017

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KPhA Board of Directors/KPERF Board of Directors

KPhA BOARD OF DIRECTORS

May/June 2017

HOUSE OF DELEGATES

Chris Clifton, Villa Hills chrisclifton@hotmail.com

Chair

Lance Murphy, Louisville lancemurphy84@gmail.com

Speaker of the House

Trish Freeman, Lexington trish.freeman@uky.edu

President

Amanda Jett, Louisville ajett@sullivan.edu

Chris Harlow, Louisville cpharlow@gmail.com

President-Elect

KPERF BOARD OF DIRECTORS

Brooke Hudspeth, Lexington brooke.hudspeth@kroger.com

Vice Speaker of the House

Chair

Secretary

Duane Parsons, Richmond dandlparsons@roadrunner.com

Secretary

Chris Palutis, Lexington chris@candcrx.com

Treasurer

Clark Kebodeaux, Lexington clark.kebodeaux@uky.edu

Treasurer

Jessika Chinn, Beaver Dam jessikachilton@ymail.com

Past President Representative

Chris Palutis, Lexington chris@candcrx.com

KPhA President

Directors

Trish Freeman, Lexington trish.freeman@uky.edu

Matt Carrico, Louisville* matt@boonevilledrugs.com

Paul Easley, Louisville rpeasley@bellsouth.net

Kevin Chen, Lexington kevin.chen@uky.edu

University of Kentucky Student Representative

Melinda Joyce, Bowling Green MBJoyce@chc.net

Chad Corum, Manchester pharmdky21@gmail.com

Bob Oakley, Louisville Boakley@BHSI.com

Matt Foltz, Villa Hills mfoltz@gomedcare.com

Kelly Smith, Lexington ksmit1@email.uky.edu

Cathy Hance, Louisville cathy@compoundcarerx.com

KPERF ADVISORY COUNCIL Christen S Bruening, Cincinnati, Ohio cmschenkenfelder@gmail.com

Cassy Hobbs, Louisville cbeyerle01@gmail.com Katherine Keeney, Louisville kkeene6675@my.sullivan.edu

Sullivan University Student Representative

Chris Killmeier, Louisville cdkillmeier@hotmail.com Jeff Mills, Louisville jeff.mills@nortonhealthcare.org Richard Slone, Hindman richardkslone@msn.com Sam Willett, Mayfield** willettsam@bellsouth.net *At-Large Member to Executive Committee ** On Leave from Board while serving as Interim Executive Director

Matt Carrico, Louisville matt@boonevilledrugs.com Kim Croley, Corbin kscroley@yahoo.com Kimberly Daugherty, Louisville kdaugherty@sullivan.edu Mary Thacker, Louisville mary.thacker@att.net

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

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50 Years Ago/Frequently Called and Contacted/KPhA Staff

May/June 2017

50 Years Ago at KPhA SUNDAY SALES SUIT DISMISSED A suit designed to halt the operation of business on Sunday in Kenton County has been dismissed in Kenton Circuit Court. The suit was filed against several companies last August which conduct business on Sunday. Included among the defendants were Scanlon Drug Store, Superx Drug Stores, and Elsmere Drug Store. Judge William Dunn, in denying the motion, made reference to a decision by the Kentucky Court of Appeals handed down fifty years ago in a case tried in Kenton County. Seventy-five stores in Campbell County are still awaiting trial on charges of opening on Sunday. - From The Kentucky Pharmacist, May 1967, Volume XXX, 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 Kentucky Regional Poison Center (800) 222-1222

Pharmacy Technician Certification Board (PTCB) 2215 Constitution Avenue Washington, DC 20037-2985 (800) 363-8012 www.ptcb.org

American Pharmacists Association (APhA) 2215 Constitution Avenue NW Washington, DC 20037-2985 (800) 237-2742 www.aphanet.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

National Community Pharmacists Association (NCPA) 100 Daingerfield Road Alexandria, VA 22314 (703) 683-8200 info@ncpanet.org

KPhA Staff

Drug Information Center SUCOP 2100 Gardiner Lane Louisville, KY 40205 (502) 413-8638 www.sullivan.edu

Sam Willett, RPh Interim Executive Director swillett@kphanet.org Scott Sisco, MA Director of Communications & Continuing Education ssisco@kphanet.org

KPhA Remembers

Angela Gibson Director of Membership & Administrative Services agibson@kphanet.org

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.

Jody Jaggers, PharmD Director of Pharmacy Emergency Preparedness jjaggers@kphanet.org Elizabeth Ramey Receptionist/Office Assistant eramey@kphanet.org

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May/June 2017

THE

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

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