The Kentucky Pharmacist Vol. 8 No. 4

Y K C U T N E K E H T T S I C A M PHAR Vol. 8, No. 4 July 2013

MEMBERSHIP MATTERS! To YOU! To YOUR Patients!

To YOUR Profession!

2013-14-KPhA President Duane Parsons with his wife, Linda.

Below: Introducing Roamey, the KPhA Gnome

News & Information for Members of the Kentucky Pharmacists Association

Table of Contents

July 2013

Table of Contents Table of Contents— Oath— Mission Statement President’s Perspective 135th KPhA Annual Meeting Message from Your Executive Director 2013 KPERF Golf Scramble 2013 KPhA House of Delegates Report Images of the 135th KPhA Annual Meeting Relevance and Relationships Review KPhA Emergency Preparedness Pharmacy’s Future: Student Participation at KPhA Annual Meeting Saving the Bowl of Hygeia July 2013 CE: Pediatric OTC July Pharmacist/Pharmacy Tech Quiz

2 3 4 7 8 9 10 12 13 14 15 16 30

August 2013 CE: COPD and CVD August Pharmacist/Pharmacy Tech Quiz Senior Care Corner KPhA New and Returning Members KPhA Government Affairs/Pharmacy Health Screenings Cardinal Health Sponsors/Exhibitors of the 135th KPhA Annual Meeting New Directors of the KPhA Board of Directors Pharmacy Law Brief Technician Review Pharmacy Policy Issues Pharmacists Mutual APSC KPhA Board of Directors 50 Years Ago/Frequently Called and Contacted

31 38 39 40 42 43 44 46 48 49 50 52 53 54 55

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

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

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

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

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

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

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

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

Editorial Office:

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.

© Copyright 2013 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.

Editorial, advertising and executive offices at 1228 US 127 South, Frankfort, KY 40601. Phone 502.227.2303 Fax 502.227.2258. Email ssisco@kphanet.org.

Website http://www.kphanet.org.

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President’s Perspective

PRESIDENT’S PERSPECTIVE Duane W. Parsons KPhA President 2013-2014

July 2013 promote the profession of pharmacy, enhance the practice standards of the profession and demonstrate the value of pharmacists’ services within the health care system. That’s a very lofty and honorable mission statement. Over the years, we’ve done a great job of promoting the profession and enhancing practice standards. We have always struggled with demonstrating the value of our services, NOT with our patients. We have, however, not done a good job of demonstrating the value of our services within the healthcare system in order to attain provider status.

There are various reasons this has not happened to date.

A primary reason, I believe, is that we are not a very unified profession. Pharmacy has many diverse pathways down which we travel. That leads to different issues that are relevant to different segments within the profession. What’s important to some seems to have less relevancy to others.

We need to change that mindset. If it’s important to the profession in any area, it needs to be important to the proIt’s a very humbling experience to be standing at this podifession overall. We need to be unified in our approach. um as YOUR president. I’m so very honored. I would like to That’s where KPhA can play a vital role. We need to be the thank each of our members and our Board for their faith in unifying leader for all issues that face the profession no bestowing this honor on me. I’d also like to thank Bob and matter from which pathway they arise. There are very disour hard-working staff, Kelli, Scott, Leah and Nancy for tinct advantages in speaking as a consolidated, unified their support to our Board and to our profession. Special group representing large numbers with an even louder thanks to my family for allowing me to serve you. Thanks to voice. our sponsors and supporters and to the University of Kentucky College of Pharmacy and Sullivan University College That’s exactly why MEMBERSHIP MATTERS. It matters to YOU. It matters to YOUR patients. It matters to YOUR proof Pharmacy for all the support they provide as well. fession.

I had the very valuable opportunity with Bob to attend the annual meeting of the National Alliance of State Pharmacy Let’s focus on what matters to YOU. For YOU, membership provides: Associations (NASPA) in April. The primary conversation

Adapted from President Parsons’s address at the Ray Wirth Banquet at the 135th KPhA Annual Meeting, June 8, 2013 in Louisville, KY

for the meeting was the leadership responsibility for incom ing presidents for each state association and the role of  each Board they served. One of the topics that really intrigued both Bob and me was the Four Sights of the Board:  1.) Oversight, making sure the Board is true to its mission.

2.) Insight, asking the questions that are important.

Networking with Colleagues Access to State and National Resources on Pharmacy Related Issues



Special Programs and Pricing on Insurance and Financial Services specifically designed for Pharmacists through Pharmacists Mutual Companies



Special Pricing on Quality Improvement Programs to meet the needs of Pharmacists offered by Pharmacy Quality Commitment

3.) Foresight, looking at trends in the profession.

4.) Hindsight, evaluating what has been done in the past.

Legislative and Regulatory Advocacy

Foresight was particularly of importance. How do we get to where we want to go?

Many of the sideline conversations we had with other state  associations centered on that. We heard a primary concern  from almost all state associations of how to work through membership issues while trying to establish the relevancy  of our profession.

Special discounts from Dell, Hertz and others Free CE for members Programs like Immunization Training for Pharmacists

Continued on Page 6

The mission of the Kentucky Pharmacists Association is to

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THE KENTUCKY PHARMACIST

135th KPhA Annual Meeting

July 2013

2013 KPhA Professional Awards

Leon Claywell, Bardstown, Bowl of Hygeia Award sponsored by the American Pharmacists Association Foundation and the National Alliance of State Pharmacy Associations with support from Boehringer Ingelheim. Pictured with outgoing KPhA Chair Lewis Wilkerson, outgoing President Kimberly Croley and Amy Nicholas, Associate Director, Health Economics and Outcomes Research at Boehringer Ingelheim.

Catherine Hanna, Lexington, KPhA Distinguished Service Award

Trish Freeman, Lexington, KPhA Pharmacist of the Year

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135th KPhA Annual Meeting

July 2013 KPhA Professional Promotion Award Julie N. Burris, Louisville Walgreens Corporation, Buddy McCaffery, District Manager, accepted for Walgreens.

Buddy Wheeler, Lexington, KPhA Excellence in Innovation Award sponsored by Upsher-Smith Laboratories, Inc.

Brooke Hudspeth, Lexington, KPhA Distinguished Young Pharmacist of the Year, sponsored by Pharmacists Mutual Insurance. Bruce Lafferre presented for Pharmacists Mutual.

Leslie Lochner and Robin Lillpop, Louisville, KPhA Technician of the Year

Representative Jeff Greer (D-Brandenburg), KPhA Meritorious Service Award. KPhA Member Jonathan Van Lahr assisted in the presentation.

Raymond Float, Danville (second from right), Cardinal Health Generation Rx Award. KPhA Executive Director Robert McFalls, President Duane Parsons, Todd Wright, Cardinal Health Retail Sales Manager and David Kelly, Cardinal Health Pharmacy Business Consultant presented the award.

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President’s Perspective

July 2013 We can serve as ambassadors in our own areas to help recruit and retain members.

Continued from Page 6

We can actively promote KPhA membership to other members of our profession.

which allow members to enhance services offered 

Opportunities to be engaged in making a difference with your colleagues

If we are to attain provider status and expand patient access to pharmacists’ services and receive reimbursement How can each of us be engaged? Engagement doesn’t for these services, we all need to be engaged. We need to necessarily mean that you need to serve on our Board, strengthen our membership numbers in order to speak with although we should all give consideration to that. There are a much louder voice. We need to present a more unified various ways that we can all serve our profession through appearance within our profession.

KPhA that are less time consuming. Not all have the time That will be a primary role as I serve as your President in for a Board level commitment. We CAN, however, be enthe upcoming year. Many of you will see Bob and me in gaged in other ways. your workplaces throughout the coming year. We’ll be acWe can help draft legislative priorities that affect us by tively promoting membership benefits and membership serving on a committee such as our Government Affairs services as we travel. We challenge each of you to be Committee. more actively engaged in this role and to get others actively engaged. And, if you look close enough and follow us on We can serve as members of other committees as well. social media, you will be seeing our new KPhA MemberSome of those are Organizational Affairs, Professional/ ship Matters friend, Roamey the KPhA Gnome!

Public Affairs, New Practitioners, or Membership Engagement.

We can be engaged in work groups such as Health Information Technology (HIT) or Emergency Preparedness when called upon.

We can serve as mentors to other members of the profession to help them understand the importance of becoming KPhA members and getting involved themselves.

Introducing!

Roamey the KPhA Gnome!

We can educate our legislators to help them understand how important and valuable our services are to their constituents.

Membership Matters

We can engage in grassroots efforts involving issues that affect our profession.

We can educate our patients on how important and beneficial our services are to their personal health.

The Kentucky Pharmacist is

Roamey, the KPhA Gnome, visits Wheeler Pharmacy in Lexington

online!

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

President Duane Parsons accompanied Roamey on a tour of several Lexington pharmacies in July. Watch the KPhA Facebook page and the KPhA Website for the adventures of Roamey and Duane.

Would you rather receive the journal electronically?

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

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

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From Your Executive Director

July 2013

MESSAGE FROM YOUR

EXECUTIVE DIRECTOR Robert “Bob” McFalls I hope and trust that your Summer is going really well. as an Association that represents and informs others From our perspective, it has been a great Summer thus far. about the myriad ways that YOU help YOUR patients To all who attended and supported KPhA’s 135th Annual with their healthcare needs.

Meeting & Convention in Louisville, I want to thank you for  YOUR active membership helps promote the visibility your engagement and participation. We especially want to of the profession as well as YOUR KPhA’s involvement thank all of our sponsors and exhibitors for your participain pharmacy and related health issues throughout Kention and financial support. By all accounts, it was a great tucky and on a national level. meeting that was filled with informative CE, recognition of  YOUR profession is strengthened through the collecpharmacists and pharmacy technicians with great peer tive power of being united in YOUR KPhA to advance awards and presentations, engaged networking opportunithe role of pharmacy with other health professions, the ties and a golf scramble that refused to be rained out. media and the general public.

Along these lines, be sure to mark your calendar and save the date for 2014 when the 136th KPhA Annual Meeting  YOUR concerns matter — YOUR KPhA brings pharand Convention will be held on June 5-8, 2014 at the Marmacists and partners together to advance legislative riott Griffin Gate in Lexington! priorities and to safeguard the profession from unfair or Another exciting development at this year’s Annual Meeting unnecessary regulations and actions. was the appearance of, uh…, a new little colleague, sup YOUR financial support matters. Membership dues are porter and almost humanoid creature. Gartenzwerg! the lifeblood for YOUR KPhA, providing the Association Through the pages of this edition of The Kentucky Pharmawith the flexibility of being able to use funds where they cist, you are being introduced to Roamey, the KPhA Memare most needed in terms of addressing urgent legislabership Matters Gnome. Roamey began his journey with tive issues and other critical priorities.

KPhA in Louisville at the Annual Meeting and will be traveling throughout the Commonwealth in the coming days,  YOUR active engagement as a grassroots advocate months and years. Not all that different from “GNOME” — matters. Whether you talk with an elected official, write that desktop environment and graphical user interface that a letter or speak at a community forum, YOUR efforts runs on top of a computer operating system — Roamey’s are making a difference. intention is to serve YOU by promoting the profession of pharmacy and membership engagement with YOUR KPhA.  YOU matter — and YOUR involvement is making a difference as evidenced by our legislative successes Roamey the KPhA Gnome’s heartfelt message is simple for the profession during the past two state legislative but incredibly powerful: sessions.

Membership Matters: Thank YOU for being an active member and participant in To YOU! To YOUR Patients! To YOUR Profession! the KPhA Family. We hope that you will welcome Roamey, When you engage with KPhA, YOUR voice matters as an the KPhA Gnome, and support his efforts in spreading the active member. You add the power of YOUR voice to admessage that MEMBERSHIP MATTERS with YOUR KPhA! vance the profession of pharmacy with your peers in terms P.S. Did you know that there are currently an estimated 25 of other engaged pharmacists and pharmacy technicians million garden gnomes in Germany, but that there is only who are working in all practice settings. one Roamey, the KPhA Gnome? Hmmm. Or could there be  YOUR membership helps YOUR KPhA to be stronger more?

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2013 KPERF Golf Scramble

July 2013

2013 KPERF Golf Scramble

Last Place: Jan Gould, Cheryl Gould, Gay Dwyer, Joe Carr

First Place: Duane Parsons, Lewis Wilkerson, Jeff Mills, Joel Thornbury

Second Place: Nevin Goebel, Keith Stinson, Josh Pitts, Eric Pitts

Closest to the Pin: Chris Stewart

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Longest Drive: Kyle Carver

THE KENTUCKY PHARMACIST

2013 House of Delegates

July 2013

2013 Actions of the KPhA House of Delegates Louisville, KY, June 7-9, 2013 Matt Martin , PharmD, 2013 Speaker of the House Cassandra Beyerle, PharmD, 2013 Vice-Speaker and Chair of the Reference Committee Kim Croley, PharmD, CGP, FASCP, FAPhA- 2013 Parliamentarian At the 2013 KPhA House of Delegates, members from on short notice to address an urgent issue. throughout the Commonwealth gathered to discuss, debate 2013.03 Subsection 11.2 (added) and make recommendations to not only shape the organiThis addition addresses indemnification and insurance for zation, but also to push forward our beloved profession.

Board members and it will now be provided for their serOpening Session vice.

The opening session was on Friday morning. Delegates Committee Reports were slated and committee reports presented. Nominations Adoption of the following committee reports: were requested for Vice-Speaker; none were presented.

Therefore, the nomination process was postponed until the final session of the House to allow time for Delegates to make nominations for Vice-Speaker.

  

Public and Professional Affairs Policy Review Government Affairs

Reference Committee

Resolution Adoption The Reference Committee met Saturday morning, bright Submitted by Gloria Doughty, recognizing the efand early to discuss resolutions and make recommendaforts of UK student pharmacists in the packing of tions to the House. The meeting was open to all KPhA memorabilia from the Pharmacy Museum during members and chaired by Vice-Chair Beyerle. The members this time of transition. of the committee were Barry Eadens, Judy Minogue, Lance The House also approved five candidates to be submitted Murphy, Chris Clifton, Joe Carr and Kim Croley to the Governor for consideration for appointment to the (Parliamentarian).

Board of Pharmacy. The five names submitted were: DeboClosing Session rah Brewer (Morgan), Joseph Carr (Daviess), Scott GreenThe closing session took place Saturday afternoon. During well (Jefferson), Christopher Killmeier (Jefferson) and Donthis session, recommendations of the Reference Commitald Kupper (Oldham). tee were discussed and nominations for Vice-Speaker were Two nominations were made for Vice-Speaker: Ethan Klein announced and voted upon. Adoption of committee reports and Barry Eadens. A vote via paper ballots was held, and also took place at the closing session of the House.

Ethan Klein, PharmD, was officially elected and appropriately sworn in as Vice-Speaker of the House of Delegates.

Bylaw Changes The 2013 House of Delegates, once again, was a time for discussion and debate. This is when we decide the next Address ballots for election and the way they will be sent to steps of YOUR KPhA and look forward to more involvemembers. This was changed to solely electronic, unless ment and discussion in the House as we push our profesthe member requests a paper ballot. sion forward. To become more involved, step up, serve on 2013.02 Subsection 6.57 (added) a committee, become a delegate in the House, voice YOUR stance. KPhA is here for YOU! This addition allows Board meetings to be held telephonically or by video conference. This is to address the issue of -The KPhA House of Delegates will meet at the Mid-Year inclement weather or when a Board meeting may be called Conference on Legislative Priorities in November.

2013.01 Subsection 5.51 (amended)

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135th KPhA Annual Meeting

July 2013

Images from Louisville

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THE KENTUCKY PHARMACIST

135th KPhA Annual Meeting

July 2013

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Relevance and Relationships Review

July 2013

RELEVANCE AND RELATIONSHIPS REVIEW Adapted from presentation at House of Delegates Opening Session, June 7, 2013 by outgoing President Kim Croley I know the Agenda says this is a President’s Report, but I will leave the listing of our accomplishments by Your KPhA this year to our Executive Director. There have been many, some small, some large, all well-deserved and all were the result of a group effort.

“pharmacist’ and know that the title comes with respect and even awe of my ability to improve my patients’ quality of life.

I attended my first KPhA convention here in Louisville in June of 1984. This year marks my 29th consecutive annual meeting. Next year as I finish my tenure as Chairman of the Board, it will be my 30th anniversary. I have driven to Frankfort an untold number of times in the last 29 years. I have driven in rain, ice, snow and occasionally sunshine! I have taken my daughter in her carrier to Budget meetings and signed checks while she slept. My children have both spent many nights at home with their father while I was away at meetings representing KPhA. They also got to go to places they probably would not have if I hadn’t been attending yet another meeting.

Relevance and Relationships This was the theme for my second Presidential year. I chose this theme because it embodies everything that pharmacists do. We are not purveyors of drugs; we are providers of healthcare and most importantly, health information about safe, effective medication use. Our patients come to the pharmacy looking for answers; they pick the pharmacy because they believe answers can be found there. More than 186,000 people enter a pharmacy each week and that cannot be by coincidence.

I have spent much of my time this year talking to other pharmacists about the importance of what we do. Pharmacists tend to be humble, introverted, self-effacing individuals that do not draw attention to the wonderful things we do for our patients. We tend to sit on the sidelines and wait for recognition when instead we should be talking to everyone about the positive patient outcomes we affect through our daily work.

We struggle with anything controversial and try to fly under the radar most of the time. If you had told me in November when we had our Legislative Conference that we would be able to affect change and achieve SB 107 which calls for transparency by PBMs, I would have probably told you that was a pipe dream. Everyone told us it could not be done, yet we did. How do we build on this success, what is our next hurdle to jump? In my part of the state, methamphetamine manufacture is a cash cow, much as marijuana production used to be a cash crop. Should the healthcare professional charged with safe, effective medication use revisit again moving pseudoephedrine back to prescription status?

Should we push harder for a pharmacist-only class of drugs which falls in the middle of the current prescription and nonprescription classes? I don’t have any answers; I just have the questions.

Can we unite as pharmacists and quit describing ourselves based on practice site but on our place as the medication experts to achieve provider status under the law? Of all the questions, this one is my most challenging. I don’t care if anyone calls me “doctor”, I just want them to call me

One of our funny stories tells about Rachel staying at friends of mine one evening while I was at a meeting. She was about 4 years old and had her Barbie doll with her.

She asked my friend Darrell to help snap the clothes on the doll because she was struggling with getting them on. Darrell asked Rachel where “Barbie” was going and thought she would say shopping but instead Rachel said “she has to go to a meeting!” Both of my children are active in groups that help other people. Rachel has volunteered hundreds of hours while at UofL helping others, even tutoring at a neighborhood center on 17th street. My son Rob is working on his Eagle Scout project this summer and just finished a week of teaching Bible School at church. I like to believe that my work as a volunteer leader for KPhA has set a good example for my children and for other pharmacists, and I would not trade a minute of it.

As a registrant for this Annual Meeting you each received a ribbon attached to your nametag that says “Membership Matters”  I would declare to you that being a Member of the Pharmacy Profession means YOU Matter. Stand up tall  YOU are a pharmacist!

I want to thank Bob McFalls, Scott Sisco, Kelli Sheets and Nancy Baldwin for their dedicated service to Your KPhA. They have made my job very easy this year. I want to thank Lewis Wilkerson for his leadership and all the members of the Board of Directors for their faithful service. Most of all I want to thank you for the honor and privilege of serving as President of Your KPhA for a second time. It has been my pleasure.

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KPhA Pharmacy Emergency Preparedness

The Emergency Preparedness program is moving along nicely!

Here are the latest accomplishments as well as next steps that will involve all of you around the state: The destruction of Tamiflu Suspension and the transport of the antivirals to a central warehouse for storage has been complete.

July 2013

have it fully operational for deployment by August 15th.

Pharmacy district meetings for the fall are being scheduled. An emergency preparedness program has been approved for 1.25 hours of continuing education that can be provided. KPhA is working with KDPH to possibly have the mobile pharmacy available for touring at the district meetings.

The mobile pharmacy's functionality including water, gener- We are looking for volunteers to coordinate a meeting for ator and utilities is being tested this month. KPhA hopes to eastern and southern Kentucky.

For more information on how you can be involved in the KPhA Pharmacy Emergency Preparedness Initiative, contact Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness at 502-2272303 or by email at ltolliver@kphanet.org. KPhA is a partner with the Kentucky Department of Public Health for emergency preparedness and disaster response.

For more resources, visit YOUR www.kphanet.org and click on Resources—Emergency Preparedness.

KPhA Pharmacy Emergency Preparedness Initiative Interest Form Name: _____________________________________

QS/1 Experience: Yes____ No _____

Status (Pharmacist, Technician, Other): ___________________________ Email: ______________________________ Phone: ___________________________ For Pharmacists: Interest in serving as a volunteer: Yes____ No _____ If yes, please go to KHELPS link on KPhA Website to register (www.kphanet.org under Resources) ____ I would like to serve as pharmacy district coordinator (PDC). PDCs will serve as a point of contact in their respective county and may assist in dispensing activities on the mobile pharmacy if deployed in the event of a disaster.

Please send this information to Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness via email at ltolliver@kphanet.org, fax to 502-227-2258 or mail at KPhA, 1228 US 127 South, Frankfort, KY 40601.

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135th KPhA Annual Meeting

July 2013

PHARMACY’S FUTURE: Student pharmacist involvement

Team CHAOS, winners of the 2013 NASPA-NMA Student Pharmacist Self-Care Championship, Ryan P. Hickson – UK, Mallory Megee – UK, Sharlonda Nunn – Sullivan, Clarissa Morey – Sullivan. Pictured with 2013 Host Brent Simpkins.

(Right) Lance Murphy (Sullivan) and Brooke Herndon (UK), members of Team Reigning Champs, discuss an answer.

Members of Kappa Psi were recognized for their efforts in helping Gloria Doughty and other volunteers pack the contents of the Kentucky Pharmacy Renaissance Museum. The museum’s contents will be stored at KPhA headquarters until a permanent location is established.

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Bowl of Hygeia

July 2013

Saving the Bowl of Hygeia The Bowl of Hygeia has a rich history within pharmacy, and we need to step up and make sure this history continues.

Given that this is an award presented at the state level, the State Pharmacy Associations — including YOUR KPhA — along with NASPA, are working together to help make sure this award we hold so dearly is never at risk of being extinguished. In order to sustain the award, each state association is working to build an endowment sufficient to generate dividends that will fund the program in perpetuity.

The APhA Foundation, a national nonprofit 501 (c) (3), has agreed to be the home of the endowment account, and to date we are almost half way to our goal of $600,000.

Our goal is to raise $5,000 as a collective gift from members of the Kentucky Pharmacists Association. At the 135th KPhA Annual Meeting, 2013 Bowl of Hygeia recipient Leon Claywell pledged to match contributions to the fund from Kentucky up to $5,000.

As of March 2013, we have collected $900.

Won’t you please help by making a contribution? Let’s earn that pledge and make Kentucky proud by dobling our participation!

There are two ways to give: Online at: http://www.aphafoundation.org and choose the Bowl of Hygeia endowment button.

Kentucky will get credit by your address.

Or, you can send your check to: APhA Foundation – Bowl of Hygeia 2215 Constitution Ave., NW Washington, DC 20037-2985

September 16, 2013 University Club of Kentucky

    

Be sure to mark Kentucky on the memo section of your check. Thank you in advance for joining YOUR KPhA in this effort.

Kentucky Pharmacy Law Review at 9 a.m.* Golf Registration begins at 10 a.m.

Lunch available at 11 a.m.

Shotgun Start at Noon Dinner, Awards Ceremony & Auction start at 5:30 p.m.

*This activity is eligible for ACPE credit; see final CPE activity announcement for specific details.

Long-time KPhA Member Gloria Doughty was granted Honorary Membership status by the KPhA House of Delegates at the 135th KPhA Annual Meeting.

Registration available at www.ukalumni.net/pharmgolf2013 15

THE KENTUCKY PHARMACIST

July 2013 CE—Pediatric OTC

July 2013

Pediatric Over-the-Counter Medication Refresher for Pharmacists There are no financial relationships that could be perceived as real or apparent conflicts of interest.

By: Ashley S. Crumby, PharmD, Assistant Clinical Professor, Purdue University and Clinical Pharmacist, Pediatric Infectious Disease, Riley Hospital for Children at IU Health (Indianapolis); Rachel E. Bohard, 2013 PharmD Candidate, Purdue University; and Andrea J. Bittner, 2013 PharmD Candidate, Purdue University.

Original article published by the Indiana Pharmacists Alliance (IPA). This activity may appear in other state pharmacy association journals. Reprinted with permission. Copyright

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

Š 2012 Indiana Pharmacists Alliance.

Universal Activity # 0143-9999-13-007-H01-P&T 1.5 Contact Hours (0.15 CEU) Goal The goals of this article include increasing pharmacist awareness of barriers to appropriate pediatric OTC medication misuse, identifying methods to address these barriers, defining appropriate use of over-the-counter pharmacologic and nonpharmacologic treatment options for pediatric cough and/or cold and identifying situations in which physician referral is appropriate.

Objectives At the conclusion of this article, the reader should be able to: 1. Identify challenges associated with over-the-counter (OTC) medication use in children.* 2. Identify situations in which physician referral is appropriate for pediatric patients with cough/cold and fever symptoms.* 3. Design a treatment plan, including specific counseling points for parents, for a pediatric patient with cough/cold symptoms and/or fever. *Pharmacy Technician Objectives product which was not indicated and involvement of more than two caregivers in the treatment or selection of the Many over-the-counter (OTC) cough and cold product laOTC product.2 Pharmacists can play an important role in bels may contain complex instructions and misleading the selection of appropriate OTC products (nongraphics which may guide caregivers toward administration pharmacologic and pharmacologic) as well as during the of inappropriate products to children. Due to low literary or provision of counseling regarding dosing, adverse effects numeracy skills, some caregivers are at increased risk for and administration techniques. It is essential for pharmainappropriate administration of pediatric OTC products. A cists to be aware of current OTC product labeling as well recent study showed 85 percent of parents in the United as recommendations in order to assist caregivers with the States treat their children with OTC medications prior to selection and use of OTC medications in children. It also is seeking professional care. This makes addressing situabeneficial for pharmacy technicians to understand when a tions in which physician referral is necessary an important pharmacist consultation is appropriate when dealing with role of the pharmacist.1 Misuse of OTC products can be the caregivers of pediatric patients. direct result of incorrect indication, selection of an inappropriate product or incorrect dosing. Although rare, an estiThe Common Cold: A Brief Overview mated 85 percent of pediatric fatalities caused by OTC medications involved inappropriately dosed cough and/or The common cold is typically a self-limited viral infection cold products.2 Factors leading to overdose of these prod- which can be caused by more than 200 viruses. The most ucts included administration of more than two medications common virus seen in children is rhinovirus. On average, containing the same ingredients, inappropriate utilization of most children will experience between six and eight colds measuring devices, use of adult products in situations per year, each lasting between 10 and 14 days per epiwhere pediatric products were indicated, selection of a sode.3 Following onset, cold symptoms tend to peak Introduction:

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THE KENTUCKY PHARMACIST

July 2013 CE—Pediatric OTC

July 2013

around day three or four and begin to diminish on or after day seven.3 These symptoms may include stuffy or runny nose, frequent sneezing, accumulation of mucus in the back of the throat (often referred to as postnasal drip), sore throat, cough and water eyes. Other symptoms such as low -grade fever, decreased appetite and mild head or body aches can also occur.4,5 Mucus production during a cold is common and can be clear, white, yellow or even green in color.4 Historically, caregivers thought the color of the mucus was an indicator of illness severity, but it has been shown that the colors merely represent the body’s production of antibodies and have no significance in determining whether antibiotic therapy is indicated.4 Because the majority of cold cases are viral in nature, antibiotics are often unnecessary and should generally be avoided. Communicating this to caregivers is important and can often prevent unnecessary physician visits. An important rule of thumb to remember is “green snot doesn’t mean squat.”

Bulb syringe with or without saline nasal drops This approach is considered the treatment of choice for nasal symptoms in infants. Nasal bulb syringes can be used to clear the nose every 3 to 4 hours.6 Head elevation Elevating the head of the bed can promote better drainage of the sinus and nasal passages. A large wedge-shaped pillow that raises the upper body by 6 to 8 inches is best if the patient is experiencing significant drainage.9,10 Increased water ingestion Water is considered the best expectorant for children.

Proper hydration thins the mucus which can ease the child’s efforts to expel it and prevent dehydration.

Immune System Support5 The common cold is caused by a viral infection and requires the body’s immune system for proper eradication.

General ways to promote immune system function include:5

Avoiding secondhand smoke or other air pollutants5 Avoiding unnecessary antibiotics5 Antibiotics can breed resistance, thus increasing the chance of becoming ill with antibiotic-resistant infections.

Breastfeeding5 Breast milk contains antibodies which can be passed from mother to child. These antibodies can provide protection against infection even after breastfeeding is stopped.

Increasing fluid intake5 Drinking plenty of fluids during the common cold is important. Healthcare providers should always recommend pediatric-specific fluids such as Pedialyte® because these products contain the proper amount of fluid and electrolytes Non-pharmacologic therapy and can help prevent electrolyte imbalances.

Non-pharmacologic therapy can include a variety of apEating yogurt Active cultures present in certain yogurts and probiotics proaches and should generally be considered “first-line” for symptom relief as well as immune system support durcontain beneficial bacteria which can aid in preventing ing the common cold. Some recommendations include the colds.5 use of humidifiers to improve the environment as well as Yogurts and probiotics containing Lactobacillus acidophilus increasing fluid intake to keep the body well hydrated. Bewith Bifidobacterium animales were shown to reduce both low you will find specific instructions regarding a variety of the incidence and duration of rhinorrhea, cough and fever non-pharmacologic options. symptoms in children 3 to 5 years old.11 Although sufficient efficacy evidence is lacking, the CDC Symptomatic relief6,8 considers Lactobacillus safe for use in children and infants Humidifiers or cool mist vapors but does caution regarding the use of probiotics in patients In general, cold air humidifiers are recommended when on concomitant immunosuppressive therapy. 12 compared to warm air humidifiers due to safety concerns Yogurts containing live active cultures include(but are not with regard to children. Also, regular cleaning of humidifiers limited to): and other treatment products is recommended due to the Yoplait YoPlus, Stonyfield, Dannon Activia.13 increased risk of bacterial growth and mold which may oc- Check labeling on individual products for specific inforcur. If these instruments are not cleaned regularly, they mation. may emit microorganisms into the environment and cause Receiving adequate amounts of sleep serious illness due to pathogen inhalation.8 Adequate sleep promotes immune system function. 14 Rest, increased fluid intake and the use of nonpharmacologic as well as pharmacologic therapy can be used for symptomatic relief during episodes of the common cold.6 These methods will help to alleviate the cold symptoms, but will not shorten the length of illness.6 Although the common cold is typically a self-limiting and mild viral infection, it can sometimes lead to more serious complications including secondary bacterial infections.7 In some instances, physician referral of seriously ill infants and children is necessary, and pharmacists can play a vital role in this referral process due to their increased accessibility and contact with caregivers.

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THE KENTUCKY PHARMACIST

July 2013 CE—Pediatric OTC Agent

July 2013

Dose

Available dosage forms

ADEs

Drug Interactions

Administration

Recommendation

2-6 yo: 6.25 mg q 4-6 h (max 37.5mg/ d)

Solution/syrup/ elixir (typically 12.5mg/5mL)*, orally disintegrating strip, orally disintegrating tablet, caplet, capsule, tablet, gelcaps, fastmelt tablets

Mild: Sedation, dizziness, dry nasal/ pharyngeal mucosa, somnolence; Severe: hypersensitivity (anaphylaxis)

Moderate inhibition of CYP2D6; cumulative effects with concomitant CNS depressants and anticholinergics

With food to avoid GI upset

Consult physician if patient <2 yo; monotherapy not recommended in pediatrics for common cold;3,16,19 combination therapy with decongestant may be beneficial in adolescent patients; chewable tablet contains phenyalanine-caution in phenylketonurics; caution in peptic ulcer disease, urinary obstruction

Antihistamines Diphenhydramine3,15,19,45

6-<12 yo: 12.525 mg q 4-6 h (max 150 mg/d) ≥12 yo: 25-50 mg q 4-6 h (max 300 mg/ d)

Idiosyncratic: paradoxical excitement in young children, nervousness, restlessness

Younger children require more sleep than older children but in general, “adequate sleep” includes at least 10 to 12 hours.14

tion, thus decreasing the amount of mucus and drainage present.15 When compared to first generation antihistamines, the second generation products are not considered to be as beneficial due to reduced anticholinergic properties.

Pharmacologic Therapy Although not always recommended in pediatric patients, various pharmacologic agents can be used to treat the symptoms of the common cold. In general, these options include antihistamines, nasal decongestants, antitussives, expectorants and analgesics. Other therapeutic options include complementary or alternative medicine such as chicken soup, vitamin C, zinc, Echinacea, Airborne Jr® and honey. Below are recommendations for the use of these products in pediatric patients.

A Cochrane systematic review evaluating the use of antihistamines either alone or in combination with a decongestant concluded antihistamine use as monotherapy did not provide any clinically significant effects on general recovery in the course of the common cold in either children or adults.16 First generation antihistamines were associated with a small decrease in sneezing and rhinorrhea, but also were associated with a significantly higher incidence of side effects such as sedation.16

Antihistamines Antihistamines competitively bind, but do not activate the H1 receptor and prevent histamine from binding.15 First generation antihistamines are considered nonselective and provide mostly sedative effects. This class of antihistamines includes diphenhydramine, clemastine and chlorpheniramine.15 Second generation antihistamines are peripherally selective and therefore provide less sedation due to an inability to cross the blood brain barrier. 15 Second generation oral OTC antihistamines include loratidine, fexofenadine and cetirizine.15 First generation antihistamines often are utilized during the common cold because they are associated with anticholinergic properties such as drying of mucus membranes. This association results in a reduction of nasal, lacrimal gland and salivary hypersecre-

Many caregivers expect antihistamines to decrease nasal symptoms because they provide this effect in the setting of allergic rhinitis. The general population does not understand the pathophysiology of allergic rhinitis and the common cold differ greatly. 16, 17 During allergic rhinitis, large amounts of histamine are released in response to an allergen while a common cold uses bradykinin as the major cytokine mediator.16,17 Bradykinin can induce vasodilation and lead to congestion, but this mechanism is unaffected by antihistamines. Sedation of a sick child is the most likely benefit seen with the use of antihistamines although the use of these products for sedative effects alone is not currently recommended.18 Although safety and efficacy data regarding antihistamine

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use in pediatric patients is sparse and somewhat conflicting, the general consensus is that antihistamine use as monotherapy provides no real benefit in terms of nasal symptom relief and should be avoided in pediatric patients.3, 16, 19 Combination therapy including antihistamines and decongestants has been shown to be ineffective in small children, but may provide limited benefit in older children and adults by relieving nasal symptoms such as runny nose and post-nasal drip.3, 16, 17, 19 Nasal decongestants Topical and systemic decongestants produce vasoconstriction in the nasal mucosa, therefore reducing inflammation and swelling while improving ventilation.15 OTC decongestants for oral use can be found in a variety of products and include pseudoephedrine (immediate and sustained release) as well as phenylephrine.15 These oral options have a slower onset of action when compared to topical decongestants, but often are associated with longer decongestive effects and less local irritation.15 Of the oral options, pseudoephedrine is the most frequently used oral decongestant, and although considered safe, has been associated with the potential for increased blood pressure and heart rate.15 Additionally, use of pseudoephedrine in patients with a history of hypertension, vasospasm and/or cardiovascular disease should be avoided due to increased risk for stroke or heart attack.15 Use of pseudoephedrine also should be avoided in the treatment of patients taking monoamine oxidase inhibitors such as linezolid due to the risk of severe hypertensive reactions.15 At this time, insufficient data exist to support the safety and efficacy of phenylephrine as an oral decongestant in any age. However, it is suggested that phenylephrine has minimal effect on blood pressure even when taken at higher than recommended doses, making it seem like a safer alternative to pseudoephedrine.20 Although data is conflicting, phenylephrine is “generally recognized as safe” and may be an appropriate alternative for patients unable to tolerate the adverse effects associated with pseudoephedrine.20

At this time, studies evaluating the safety and/or efficacy of nasal decongestants in pediatric patients have not been completed, making the use of these agents inappropriate in children due to lack of sufficient data.16, 19 Some studies have shown potential benefit, including relief from nasal congestion, from oral or topical nasal decongestants in the adolescent and adult populations, making recommendations for these groups more appropriate.16, 19 Antitussives Cough is one of the most common and troublesome presenting symptoms in children.21 This symptom is not only troublesome for the child but, it also can be one of the most intolerable symptoms for caregivers because it often prevents sick children from getting enough sleep at night.21 The Slone Survey identified that in any given week, about 1 in 10 children in the U.S. receives some form of cough and/ or cold products.22 With these results, it is important to address the high prevalence of medication use in children, especially given the lack of efficacy data and potential for adverse effects.22 Various review articles have helped to characterize the use of cough and/or cold products in children, but evidence to support the effectiveness of the agents in the pediatric population remains inconclusive.23 One agent utilized in the treatment of cough is dextromethorphan. This cough suppressant is used to depress the cough center activity in the medulla and inhibits the reuptake of serotonin in the presynaptic cleft.24 This suppressive action can be harmful because it puts the patient at potential risk for severe respiratory depression and serotonin syndrome.24 These risks are especially dangerous in the pediatric population due to a lack of sufficient data, thus making the use of dextromethorphan for treatment of acute cough an inappropriate recommendation in children.3, 23

Topical antitussive options also are available for use in children to treat the symptoms commonly associated with cough and cold. These products use medicated vapors to relieve symptoms such as cough without causing the systemic side effects (i.e., drowsiness or jittery feelings) that Topical OTC nasal decongestants are an option in patients have been associated with other cough and cold relief unable to take oral medications and include phenylephrine, products.25 One of the most commonly used topical antitusnaphazoline, tetrahydrozoline, oxymetazoline and xylomet- sives is Vicks VapoRub® which includes camphor, eucalypazoline.15 These topical products are extremely effective at tus oil and menthol. Vicks VapoRub® is approved for use in relieving nasal congestion and produce less systemic adchildren 2 years of age and older and can be applied to the verse effects than oral decongestants, but may produce neck and chest up to 3 times per day.26, 27 This product is burning, sneezing, stinging and dryness of the nasal muco- not intended for use in children less than 2 years old due to sa.15 Additionally, prolonged use (>3 to 5 days) can result the camphor component, and also should not be applied in 15 in severe rebound congestion. Patients should be counthe nostrils or under the nose.25-27 Side effects associated seled to discontinue the use of topical decongestants after with the use of Vicks VapoRub® include increased mucus three days and to contact his/her doctor. production, obstruction of small airways and rebound con19

THE KENTUCKY PHARMACIST

July 2013 CE—Pediatric OTC Agent

July 2013

Dose

Available dosage forms

ADEs

Drug Interactions

Administration

Recommendation

<4 yo: 1 mg/kg/ dose q 6 h (max 15 mg/dose)

Syrup, caplet, ER caplet, tablet, ER tablet

Agitation, irritability, hypertension, tremor, dizziness, nervousness, tachycardia, dysrhythmia, anorexia, nausea, vomiting, seizure, insomnia, dystonic reactions, headache

Antacids (other than Al(OH)3; ↓ excretion of pseudoephedrine), sympathomimetics (enhance ADEs; tachycardia, toxicity), SNRIs (enhances tachycardia) cannabinoids (enhances tachycardia)

Oral formulations: water or milk can ↓ GI distress

No studies in children; adolescents and adults may benefit; FDA approved in ages >4 yo for symptomatic relief of nasal congestion associated with the common cold, sinusitis, upper respiratory allergies(ER formulations approved in >12 yo); Do NOT use >72 hours due to risk of rebound congestion (esp. with topical nasal formulation)

Decongestants Pseudoephedrine46,47

4-5 yo: 15 mg q 4-6 h, max 60 mg/24 h 6-12 yo: 30 mg q 46 h, max 120 mg/24 h >12 yo (adolescen ts and adults): IR formulation: 60 mg q 4-6 h, max 240 mg/ day ER formulation: 120 mg q 12 h or 240 mg once daily

gestion.26,27 Another formulation, Vicks BabyRub®, does not include camphor and is regarded as safe for children less than 2 years old when used as directed.28 This product is a combination of petrolatum, aloe extract, eucalyptus oil, lavender oil and rosemary oil. Because it is marketed as “unmedicated,” very little safety and efficacy data is available regarding its use in the pediatric population.26,27

Do not crush ER tablet or capsule

support the efficacy of guaifenesin for acute cough and upper respiratory tract infections.19 Water is considered the safest and most efficacious expectorant for children with an acute cough.30, 31 Little data supports the use of mucolytics or pharmacological expectorants, but it is clearly understood that ample water intake will promote thinning and loosening of the mucus and promote coughing.30, 31

Expectorants

Complementary and Alternative Medicine (CAM)

Expectorants, specifically guaifenesin, are used to reduce the viscosity of respiratory tract fluid secretions and increase sputum volume.29 These actions are thought to improve the efficacy of the cough reflex as well as the action of the ciliary in the trachea and bronchi, making it easier for patients to expel bronchial drainage.29 However, like other cough and cold products, limited evidence is available to

All use of herbal supplementation in children under the age of 2, as well as in pregnancy and lactation, should be done with extreme caution.32 Many CAM therapies are associated with little clinical data regarding efficacy and safety, especially in the pediatric population. Nonpharmacologic therapy is the safest way to manage symptoms of the common cold in pediatric patients, and should 20

THE KENTUCKY PHARMACIST

July 2013 CEâ&#x20AC;&#x201D;Pediatric OTC Agent

July 2013

Dose

Available dosage forms

ADEs

Drug Interactions

Administration

Recommendation

<4 yo: not for OTC use

Tablet, ER capsule, liquid capsule, lozenge, solution/syrup/ suspension, oral disintegrating strip, ER suspension

Confusion, excitement, irritability, nervousness, serotonin syndrome

Antipsychotics, CYP2D6 inhibitors, darunavir, MAO Inhibitors, metoclopramide, peginterfeon alfa-2b, quinidine, selective serontonin reuptake inhibitors, serotonin modulators, tocilizumab

Do not use within 14 days of stopping an MAO inhibitor

No proven efficacy in children.

Antitussives Dextromethorphan48

4-6 yo: Oral: 2.57.5 mg q 4 -8 hrs ER formulation: 15 mg twice daily, max 30 mg/ day 6-12 yo: Oral: 5-10 mg q 4 h OR 15 mg q 6-8 hrs ER formulation: 30 mg twice daily, max 60 mg/ day >12 yo: Oral: 1020 mg q 4 h OR 30 mg q 6-8 h ER formulation: 60 mg twice daily, max 120 mg/ day

Oral Zinc: 33 Oral zinc formulations have demonstrated a dose-related reduction in the duration of the common cold Vitamin C â&#x20AC;&#x201C; Vitamin C is the most commonly used CAM in adults; however, studies in children did not reveal the product associated with the common cold. 3 Vitamin C same reduction when compared to placebo. This lack of should not be used for treatment, but limited evidence sugreduction could be attributed to differences in formulation, gests that prophylactic use may decrease the severity and dosing and frequency of administration. Differences in host duration of symptoms.3 However, excessively high doses of inflammatory responses, virus etiology and susceptibility vitamin C should be avoided as they have been correlated and even the lack of reliable third-party symptom reporting with adverse effects including headaches, intestinal and also could account for the lack of evidence. If oral zinc therurinary complications, kidney stones and significant interacapy is used in the pediatric population, it is important to use tions with anticoagulants.3 be used prior to pharmacologic therapy and CAM.

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July 2013 CE—Pediatric OTC Agent

July 2013

Dose

Available dosage forms

ADEs

Drug Interactions

Administration

Recommendation

6 mos – 2 yo: 2550 mg q 4 h, max 300mg/ day

Caplet, oral granules, syrup, tablet, ER tablet

Dizziness, drowsiness, headache, rash, decreased uric acid levels, nausea, stomach pain, vomiting, kidney stone formation

No known significant drug interactions

Take with a full glass of water; Do not crush, chew, or break tablet

No proven efficacy in children.

Expectorants Guaifenesin49

2-5 yo: 5 -100 mg q 4 h, max 600 mg/day 6-11 yo: 100-200 mg q 4 h, max 1.2 g/day >12 yo: 200-400 mg q 4 h, max 2.4 g/day

a recommended dose and to counsel patients regarding common side effects such as nausea or bad (metallic) taste.

Echinacea:5, 32, 34 This product is believed to act as a nonspecific immune stimulant and is used to stimulate white blood cell function and cell-mediated immunity. It also is reported to have broad-spectrum antimicrobial activity against bacteria, fungi and viruses.32 Root preparations may be effective in lessening the severity of cold symptoms, but clinical data is inconclusive. 5,34 The use of echinacea also can trigger allergic reactions and should be avoided in patients with allergies to ragweed, daisy, aster and chrysanthemum.5, 34 Also, many tinctures have high alcohol concentrations (15-90 percent), which should be considered when evaluating the use of echinacea in pediatric patients. 32 Use for greater than 10 days in any population is not recommended.32 Airborne Jr®35,36- This product is marketed for children ages 4 to 10 as an herbal supplement designed to “boost your immune system to help your body combat germs.”35 The primary ingredients listed are vitamin C (835 percent of the daily recommended value), vitamin E, zinc and manganese.35 This product has not been evaluated by the FDA and has not been proven to be clinically effective for the prevention or treatment of cough or cold.35 Airborne Jr® is

classified as an herbal supplement, holding a similar place in therapy to vitamins with the same ingredients.36 Honey37- Data supporting the effectiveness of honey for the treatment of acute cough in children (minimum age of 12 months) due to upper respiratory infections is limited.37 A review of two trials containing a total of 268 patients, ages 2-18, showed treatment with honey to be potentially superior to treatment with diphenhydramine but these results were consistent with “low to moderate quality evidence.” 37 Chicken Soup – Limited clinically significant data is available with relation to the use of chicken soup for the common cold.3,30 Some individuals believe the hot steam from the soup may help relieve sinus pressure and inflammatory symptoms. This action is similar to the moistening of oral and nasal passage seen with other hot beverages or warm air humidifiers.3, 30 Individuals also like the use of chicken soup during the common cold because it is one of the few non-pharmacologic options that is safe for the pediatric population and is not associated with adverse effects.

Prevention of the Common Cold: Disinfection and Hand Washing In general, viruses often spread via hand-to-hand contact as well as through large-particle aerosolization.34 Avoiding close contact with people who have colds or other upper

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July 2013 CEâ&#x20AC;&#x201D;Pediatric OTC Agent Analgesics and Antipyretics Aspirin50

Acetaminophen51

Dose

Available dosage forms

ADEs

Drug Interactions

Administration

Recommendation

1015mg/ kg/dose Max: 4g/ day 1015mg/ kg/dose every 46 hours

Caplet, tablet, chewable tablet

GI bleeding; platelet inhibition; Reyes syndrome

NSAIDs, anticoagulants, antithrombotics

Caplet, ER caplet, capsule, elixir, gelcap, solution/ suspension/ syrup, suppository, tablet, chewable tablet, oral disintegrating tablet Caplet, capsule, solution injection, suspension, tablet, chewable tablet

GI hepatotoxicity (in case of overdose)

Anticholinergics

Administer with food or full glass of water to minimize GI disturbances Shake suspension well before pouring dose; take with food or milk; report any unusual bleeding or bruising

NEVER use for fever or viral symptoms in children; product is only available as a solid dosage form One concentration 160mg/5mL; drops are no longer available

Cardiovascular edema; drowsiness; GI bleeding or intolerance; platelet inhibition; acute renal failure

GI irritants; can decrease efficacy of some antihypertensives

Administer with food

Only approved for patients >6 months; keep children well hydrated; multiple concentrations (40mg/mL and 100mg/5mL); avoid in patients with renal disease or congenital heart disease; may blunt sings/symptoms of serious infection

Max: 5 doses in 24 hours Ibuprofen52

July 2013

OTC analgesic dose: 410mg/ kg/dose every 68 hours Max: 40mg/ kg/day OTC fever dose: 5-10mg/ kg/dose every 68 hours Max: 40mg/ kg/day

respiratory tract infections (URTIs) can help prevent viral exposure.4 Infected persons are most contagious during the first three days of symptom onset and will likely no longer be contagious by about day seven of illness. 5 Routine disinfection of commonly touched surfaces such as door knobs, sink handles and light switches can decrease the risk of viral spreading.39 This disinfection should be done using an EPA-approved product such as LysolÂŽ to ensure appropriate killing of the virus.39 Proper hand hygiene in both children and adults also may prove beneficial in preventing illness and stopping the spread of the virus.4 Intermittent and frequent hand washing is recommended for all ages and should be done using antibacterial soap or

hand sanitizers containing organic acids such as salicyclic acid. Recent studies have demonstrated increased efficacy at prevention of rhinovirus infection when using organic acid-based when compared to ethanol-based hand sanitizers. This difference is thought to be the product of extended residual activity against rhinovirus seen with organic acid products.39-41 These products can be found over-thecounter and are generally considered safe for use in children.40 Pain and Fever relief One of the leading causes of parental concern with regard to symptoms of illness is fever.38 The common belief chil23

THE KENTUCKY PHARMACIST

July 2013 CE—Pediatric OTC dren must maintain a “normal” temperature leads to the misuse of antipyretics on a daily basis.38 Many parents are not aware of the beneficial effects associated with fever including slowing of bacterial and viral growth which in turn helps the body recover more quickly from an infection.38 Due to this beneficial effect, the primary treatment goal for a febrile child should not be normalization of body temperature but should actually include improvement of the child’s general well-being including adequate fluid intake and prevention of more serious symptoms.38

July 2013 Pain4, 23 Hot/Cold Packs Use cold packs if pain is associated with inflammation and swelling.

Use heating pad if patient is experiencing stiffness or chronic pain.

Distraction

Consider using an enjoyable activity or item such as TV, Another common misconception in the pediatric population board games, ice cream, etc. as a distraction for children in is with regard to the treatment of pain. In previous decades, pain. pain management for infants and children was not consid- Massage/physical therapy ered a significant priority due to the assumption that these Make the child more comfortable and relaxed to positively patients did not experience pain due to an “inadequately contribute to general well-being and allow the body to natudeveloped neuroendocrine system and nerve pathways.”10 rally overcome the acute situation.

However, many clinical studies have since proven the pediatric population may actually be more sensitive and poten- Pharmacologic therapy tially experience more intense pain than adults.10 As a reAcetaminophen sult, effective practices to appropriately manage pain in The current recommendation for pharmacologic treatment children have become standard in the clinical setting, in10 cluding using pain assessment as the fifth vital sign. Like of fever and pain in children is the use of acetaminophen.

In the past, recommendations included the use of aspirin in adults, children can experience pain in a variety of situathese situations, but due to a confirmed association betions including immunizations, acute illness (i.e. otitis metween salicylates and Reyes syndrome in children, aspirin dia), chronic disease, injury and medical procedures, thus making pain management an important part of treatment in is no longer considered a treatment option for this population.42,43 The recommended dose of acetaminophen in chilthis population.10,32 dren is 10 to 15 mg/kg/day every 4 to 6 hours with a maxiTreatment of both fever and pain contain both nonmum dose of 75 mg/kg/day (or 5 doses) in 24 hours.42,43 pharmacologic and pharmacologic options. Safe and effecOTC acetaminophen formulations for children include a tive OTC medication options for the treatment of pain and/ standard liquid concentration of 160mg/5mL as well as or fever include ibuprofen and acetaminophen.42,43 Either chewable tablets and Meltaways®.42-44 The generally acchoice, when used in appropriate doses, may be considceptable safe and effective duration of OTC use is five days ered first line therapy when the patient requires an analgeor less.42,43 Hepatotoxicity is a severe adverse reaction of sic or antipyretic.42,43 acetaminophen use and is seen in situations of supratheraNon-pharmacologic therapy peutic dosing (greater than 15 mg/kg/dose) or in prolonged overdose situations in which appropriate single doses were Fever10, 42 given at intervals shorter than four hours.42 Environmental Control Ibuprofen Adjust room temperature to avoid extremes in heat or cold.

Ibuprofen is another option for fever and pain in the pediatRemove excess clothing and/or use lightweight clothing. ric population and has been associated with a faster onset and duration of action than acetaminophen. However, data Sponge baths with lukewarm water do not currently support a significant difference in safety or Do not use cold water which can induce shivering thus fur- effectiveness between the two agents, making them both ther increasing body temperature. appropriate options in children. 42 Dosing recommendations in children are different for the treatment of fever versus Do not use rubbing alcohol which can be systematically pain. For children greater than 6 months of age, the dose absorbed and cause fume inhalation, both of which have for treatment of fever is 7.5 mg/kg/dose given every 6 hours hazardous CNS side effects (i.e. increased heart rate, with a maximum dose of 30 mg/kg/day. This is slightly difheadaches, dizziness and nausea).

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ferent than the dose for treatment of pain which is 5 to 10 mg/kg/dose given every 6 to 8 hours with a maximum dose of 4 doses in 24 hours.42,43 Dosage forms for ibuprofen in children include liquid preparations in concentrations of 40 mg/mL as well as 100 mg/5 mL.42 The variety of concentrations makes selection of the appropriate product even more important due to the risk of overdose if the wrong product is used. Ibuprofen also is available as a chewable tablet . 45

inconsolable irritability, vomiting/diarrhea, rash, headache or severe pain in throat or ear Fever in an immunocompromised child such as one with cancer, HIV or history of transplant

Swelling or erythema at the site of pain No relief, no improvement, or worsening of pain despite adequate treatment

Putting it all together

Barriers to Appropriate OTC Use in Children

Inappropriate dosing is one of the most important barriers to proper OTC use in children and plays a significant role in OTC-associated fatalities in this population.2 Dosing inOne critically important point to remember in this population structions on these products are often confusing and result is the maintenance of adequate hydration while taking ibuin both overdosing and underdosing situations. Because profen or other non-steroidal anti-inflammatory agents.42 pharmacists are such an accessible healthcare provider, it Although only limited case reports exist, renal insufficiency is important they feel comfortable providing dosing recomhas been directly correlated with the use of ibuprofen as a mendations with regard to use of these products in chilresult of prostaglandin inhibition that ultimately disrupts redren. nal blood flow.42 It is recommended to avoid the use of ibuAnother barrier to appropriate OTC use in children is the profen in children who are dehydrated, have a history of selection of combination products containing the same accardiovascular disease, have preexisting renal disease or 42 tive ingredients. Many caregivers unknowingly administer 2 also are using other nephrotoxic agents.

-3 times the daily recommended amount of medications When to refer10, 19, 43, 46, 47 such as acetaminophen because they are not aware of its In general, non-pharmacologic therapy should be considinclusion in multiple products used in cough and cold. For ered first line for treatment of cough and cold in pediatric this reason, single ingredient products should be recompatients. If pharmacologic therapy is used to alleviate mended in order to avoid an unintentional overdose of any symptoms, it is important for the caregiver to use OTC one ingredient.2 47 medications only for the amount of time recommended. If Selection of an inappropriate product is also a common symptoms persist beyond the recommended amount of barrier to proper OTC use in pediatric patients.2 In some time, the caregiver should be instructed to follow-up with instances, caregivers may select products not indicated for the primary care physician. a child’s symptoms or even substitute adult products when Here are some general situations in which physician refer- pediatric formulations are indicated.2 ral is recommended: Finally, improper utilization of measuring devices also contributes to inappropriate OTC use.2 Although many caregivCough/cold symptoms6, 10, 31 ers are tempted to use household teaspoons and tablePersistent cough >4 weeks31 spoons for medication dosing, these devices are not conChildren <2 years old with cough31 sidered appropriate because the amount of medication deCough indicative of another disease state such as pertuslivered can vary greatly. In these situations, pharmacists sis, croup, bronchiolitis, asthma, GERD10,31 should offer to explain how to use the devices appropriately 6 Symptoms lasting > 10 days or provide measuring tools which will provide the recom10, 43 Pain symptoms mended dose of medication with less difficulty. 2

Fever10, 42, 43 Age > 6 months and temperature ≥103oF Age > 2 months and rectal temperature ≥100.2oF Age 3 to 6 months and temperature ≥101oF No fever relief or improvement despite adequate treatment Development of seizures or unusual drowsiness in addition to looking more “ill” Development of additional symptoms such as stiff neck,

Medication adherence is an important part of medication use in children and can be negatively impacted by a variety of factors including:10 Poor communication between the provider and the caregiver and/or patient.

Lack of understanding regarding the severity of the illness.

Lack of interest regarding taking medication (especially in adolescents).

Poor taste of drug formulations.

Uncertainty or anxiety regarding potential medication relat25

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July 2013

ed adverse effects.

Inconvenient dosage forms and dosing schedules (i.e. administration three or more times daily).

Failure of the caregiver to remember to administer the drugs.

Medication safety is another very important part of mediation use. Administration errors may result from the following scenarios:10 Incorrect or inappropriate medication.

Incorrect or inappropriate dose.

Inappropriate medication administration technique.

Inappropriate dosing instrument.2 Administration of more than two medications containing the same ingredients.2 Two or more caregivers contributing to the treatment and selection of the OTC product.2 To avoid life-threatening events, pharmacists can remind caregivers to keep all medications (OTC and prescription) out of the reach of children. They also should keep all medications in the original bottles or containers with the lids tightly sealed.6 Recognizing and understanding common flaws in the medication-use process can help providers, caregivers and patients create strategies to prevent problems before they arise.10 Clinical Pearls for Pharmacists 1. Not all OTC products are approved for use in children.

The FDA recommends against the use of cough and cold products, such as pseudoephedrine, phenylephrine, diphenhydramine, brompheniramine and chlorpheniramine, in children younger than 2 years of age. 57 Additionally, manufacturers of these products voluntarily changed their labels to state: “do not use in children under 4 years of age.” 57 Paying close attention to product labeling, ingredients and instructions for use allows pharmacists to provide appropriate recommendations and guidance for patients.6 2. Although vitamin C is often used in the adult population for prophylaxis of the common cold, it should not be used as active treatment in adults or children.3 3. Antibiotic therapy is not appropriate for treatment of the common cold in adults and children. Therapy directed toward symptom relief is a more appropriate recommendation.3 4. Antihistamines should not be recommended for the treatment of nasal symptom relief in children. 3,16,19 5. Currently, nasal decongestants are not recommended in children due to limited safety and efficacy data. This drug class should be reserved for adolescent and adult populations.16,19

6. Dextromethorphan is not an appropriate treatment for cough in pediatric children.3 7. Ibuprofen is an appropriate analgesic and/or antipyretic for children greater than 6 months old.6, 42, 43 8. Aspirin should NEVER be given to children due to the rare, but very serious, risk of Reyes syndrome. 6, 42, 43 9. Avoid cough and cold medications with multiple active ingredients. Use single ingredient products to reduce the risk of overdose.48 10. Pharmacists are the most accessible healthcare professionals: it is critical to select the appropriate products based on the individual pediatric patient, screen each patient for potential drug-drug interactions or contraindications, and thoroughly educate caregivers about proper dosing and administration.

References 1. OTC Medicines/Dietary Facts and Figures. Consumer Healthcare Products Association. Available at: http:// www.chpa-info.org/pressroom/ OTC_FactsFigures.aspx. Accessed June 10, 2012.

2. Dart RC, Paul IM, Bond GR, et al. Pediatric Fatalities Associated With Over the Counter (Nonprescription) Cough and Cold Medications. Ann Emerg Med. 2009; 53(4)411-7.

3. Simasek M, Blandino DA. Treatment of the Common Cold. Am Fam Physician. 2007; 75(4):515-520.

4. Centers for Disease Control and Prevention. Get Smart: Know When Antibiotics Work: Common Cold and Runny Nose. Available at http://www.cdc.gov/ getsmart/antibiotic-use/URI/colds.html. Accessed May 14, 2012.

5. National Institutes of Health. MedlinePlus. Common cold. Available at http://www.nlm.nih.gov/medlineplus/ ency/article/000678.htm. Accessed May 14, 2012.

6. Centers for Disease Control and Prevention. Get Smart: Know When Antibiotics Work: Symptom Relief.

Available at http://www.cdc.gov/getsmart/antibiotic-use/ symptom-relief.html.

7. Aguilera L. Pediatric OTC Cough and Cold Product Safety. US Pharm. 2009;34(7):39-41.

8. Humidifier Health. What is the Source of the problem?

Available at http://www.humidifierhealth.org/? go=health. Accessed May 14, 2012.

9. Smith SM, Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database of Systematic Reviews 2008; 1 :CD001831.

10. Nahata MC, Taketomo C. Pediatrics. In: Pharmacotherapy: A Pathophysiologic Approach. 7th ed. DiPiro JT, Talbert RL, Yee GC, et al., eds. New York, NY:

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McGraw-Hill; 2008.

11. Lever GJ, Li S, Mubasher ME, et al. Probiotic effects on cold and influenza-like symptom incidence and duration in children. Pediatrics. 2009 Aug;124(2):e172-9.

12. National Institutes of Health. MedlinePlus Supplements. Lactobacillus. Available at http:// www.nlm.nih.gov/medlineplus/druginfo/ natural/790.html. Accessed July 8, 2012.

13. Tyson A. Yogurt Brands Containing Probiotics.

LiveStrong. Available at http://www.livestrong.com/ article/281319-yogurt-brands-containing-probiotics/.

Accessed July 8, 2012.

14. Sleep for Kids. Children’s Sleep Sheet. Available at http://www.sleepforkids.org/html/sheet.html. Accessed July 8, 2012.

15. May JR, Smith PH. Allergic Rhinitis.

In:Pharmacotherapy: A Pathophysiological Approach.

7th edition. Dipiro JT, Talber RL, Yee GC, eds. New York, NY: McGraw-Hill; 2008.

16. Sutter AI, Lemiengre M, Campbell H, et al. Antihistamines for the common cold. Cochrane Database Syst Rev. 2003;(3):CD001267.

17. What is the Common Cold? New-Medical. Available at http://www.news-medical.net/health/What-is-theCommon-Cold.aspx. Accessed May 14, 2012.

18. Consumer Healthcare Products Association. Statement from CHPA on the voluntary label updates to oral OTC children's cough and cold medicines. www.chpainfo.org/10_07_08_PedCC.aspx. Accessed July 8, 2012.

19. Isbister GK, Prior F, Kilham HA. Restricting cough and cold medicines in children. J Paediatr Child Health.

2012; 48(2): 91-8.

20. Harron RC, Winderstein AG, AmKelvey RP, et al. Efficacy and safety of oral phenylephrine: systematic review and meta-analysis. Ann Pharmacother.

2007;41:381-90.

21. Paul, Ian M. Therapeutic Options for Acute Cough Due to Upper Respiratory Infections in Children. Lung 2012; 19: 41-44.

22. Vernacchio L, Kelly JP, Kaufman DW, et al. Cough and Cold Medication Use by US Children, 1999-2006: Results from the Slone Survey. Pediatrics 2008; 122: e323-e329.

23. Smith SM, Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database of Systematic Reviews 2008; 1 :CD001831.

24. Dextromethorphan. Respiratory Agents. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. St. Louis, MO. Available at: http://

factsandcomparisons.com. Accessed June 7, 2012.

25. VICKS®. VapoRub® Topical Ointment. Available at: http://www.vicks.com/products/vapo-family/vaporubtopical-ointment. Accessed October 2012.

26. OTC cough and cold medication: keeping children safe.

Pharmacist’s Letter/Prescriber’s Letter 2011;27 (1):270105.

27. Vicks Vapo-Rub – How dangerous for children? Child Health Alert. 2009 Feb;27:2.

28. VICKS®. BabyRub® Soothing Ointment. Available at: http://www.vicks.com/products/childrens-medicine/ babyrub-ointment. Accessed October 2012.

29. Guaifenesin. Respiratory Agents. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. St. Louis, MO. Available at: http:// factsandcomparisons.com. Accessed June 7, 2012.

30. Aguilera L. Pediatric OTC Cough and Cold Product Safety. US Pharm. 2009; 34(7):39-41.

31. Cold medicines for kids: What’s the risk? Children’s Health. MayoClinic. Available at: http:// www.mayoclinic.com/health/cold-medicines/CC00083.

Accessed on: July 2012.

32. Echinacea (Echinacea purpurea, Echinacea angustifolia). Natural Products Database. Lexi-Comp Online.

Lexi-Comp, Inc. Hudson, OH. Available at: http:// online.lexi.com/crlonline. Accessed May 15, 2012.

33. Science M, Johnstone J, Roth DE, et al. Zinc for the treatment of the common cold: a systematic review and meta-analysis of randomized controlled trials. CMAJ. 2012. Available at www.cmaj.ca. Accessed May 14, 2012.

34. Woelkart K, Linde K, Bauer R. Echinacea for Preventing and Treating the Common Cold. Planta Med. 2008; 74(6):633-7.

35. Airborne. Product Information. Airborne, Inc. Minneapolis, MN. Available at: http://www.airbornehealth.com/ product-information. Accessed on July 2012.

36. Airborne Jr. Effervescent Health Formula Grape. Dietary Supplements Labels Database. United States National Library of Medicine. Available at: http:// dietarysupplements.nlm.nih.gov. Accessed July 2012.

37. Oduwole O, Meremikwu MM, Oyo-Ita A, et al. Honey for acute cough in children. Cochrane Database Syst Rev. 2012;3:CD007094.

38. Gwaltney JM Jr, Moskalski PB, Hendley JO. Hand-tohand transmission of rhinovirus colds. Ann Intern Med. 1978; 88:463-7.

39. Turner RB, Hendley JO. Virucidal hand treatments for prevention of rhinovirus infection. Antimicrob Agents Chemother. 2005; 56(5): 805-7.

40. Turner RB, Biedermann KA, Morgan JM, et al. Efficacy

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41.

42.

43.

44.

45.

46.

47.

48.

49.

July 2013

of Organic Acids in Hand Cleansers for Prevention of Rhinovirus Infections. Antimicrob Agents Chemother.

2004; 48: 2595-8.

Turner RB, Fuls JL, Rodgers ND. Effectiveness of hand sanitizers with and without organic acids for removal of rhinovirus from hands. Antimicrob Agents Chemother.

2012; 54(3): 1363-4.

Sullivan JE, Farrar HC. Clinical report – fever and antipyretic use in children. Pediatrics 2011; 127:580-587.

Berde CB, Sethna NF. Analgesics for the treatment of pain in children. NEJM 2002;(347) 14:1094-1103.

Smith SM, Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database of Systematic Reviews 2008; 1 :CD001831.

Motrin®. McNeil Consumer Healthcare Division. Available at: http://www.motrin.com. Accessed on July 2012.

Chang AB, Glomb WB. Guidelines for Evaluating Chronic Cough in Pediatrics: ACCP Evidence-Based Clinical Practice Guidelines. Chest 2006; 129: 260S283S. Chang AB, Landau LI, Van Asperen PP, et al. Cough in children: definitions and clinical evaluation. MJA 2006; 184: 398-403.

U.S. Food and Drug Administration. FDA Statement Following CHPA’s Announcement on Nonprescription Over-the-Counter Cough and Cold Medicines in Children. Available at: http://www.fda.gov/NewsEvents/ Newsroom/PressAnnouncements/2008/ ucm116964.htm. Accessed on: July 2012.

Diphenhydramine. Lexi-Drugs Online. Lexi-Comp

50.

51.

52.

53.

54.

55.

56.

57.

Online. Lexi-Comp, Inc. Hudson, OH. Available at: http://online.lexi.com/crlonline. Accessed July 2012.

Pseudoephedrine. Lexi-Drugs Online. Lexi-Comp Online. Lexi-Comp, Inc. Hudson, OH. Available at: http://online.lexi.com/crlonline. Accessed May 14, 2012.

Pseudoephedrine. Pediatric and Neonatal Lexi-Drugs Online. Lexi-Comp Online. Lexi-Comp, Inc. Hudson, OH. Available at: http://online.lexi.com/crlonline. Accessed May 14, 2012.

Dextromethorphan. Lexi-Drugs Online. Lexi-Comp Online. Lexi-Comp, Inc. Hudson, OH. Available at: http://online.lexi.com/crlonline. Accessed June 7, 2012.

Guaifenesin. Lexi-Drugs Online. Lexi-Comp Online.

Lexi-Comp, Inc. Hudson, OH. Available at: http:// online.lexi.com/crlonline. Accessed June 7, 2012.

Aspirin. Lexi-Drugs Online. Lexi-Comp Online. LexiComp, Inc. Hudson, OH. Available at: http:// online.lexi.com/crlonline. Accessed July 2012.

Acetaminophen. Lexi-Drugs Online. Lexi-Comp Online.

Lexi-Comp, Inc. Hudson, OH. Available at: http:// online.lexi.com/crlonline. Accessed July 2012.

Ibuprofen. Lexi-Drugs Online. Lexi-Comp Online. LexiComp, Inc. Hudson, OH. Available at: http:// online.lexi.com/crlonline. Accessed July 2012.

An Important FDA Reminder for Parents: Do Not Give Infants Cough and Cold Products Designed for Older Children. U.S. Food and Drug Administration. Accessed 17 October 2012. Available at: http:// www.fda.gov/Drugs/ResourcesForYou/ SpecialFeatures/ucm263948.htm.

July 2013 — Pediatric Over-the-Counter Medication Refresher for Pharmacists 1. Which non-pharmacologic treatment is NOT RECOMMENDED in a pediatric patient with a cough or cold?

A. Increasing fluid intake with water B. Receiving at least 10 hours of sleep C. Using a warm air humidifier D. Use of nasal bulb syringes in infants with congestion 2. NK is a 12-year-old boy who presents to clinic with a runny nose, cough and nasal congestion. NK states that he has felt “really bad all over” for the past 2 days and hasn’t been able to sleep well because he can’t breathe through his nose. He has not had a fever. NK is not taking any other medications, has NKDA and no significant PMH. Mom has not tried any form of therapy for his cold symptoms, but states she would like to get something to help him breathe at night so he can sleep. What would be the appropriate recommendation for NK?

A. Pseudoephedrine 30 mg q 4 to 6 hours; max 240 mg; appropriate counseling on all potential adverse effects B. Diphenhydramine 12.5 mg q 4 hours; max 75 mg/day; appropriate counseling on all potential adverse effects C. Phenylephrine 5 to 10 mg q 12 hours instead of pseudoephedrine; appropriate counseling on all potential adverse effects D. Nonpharmacologic therapy including a cold air humidifier, head elevation, and increased fluid intake 3. Which is NOT a challenge associated with over-thecounter medication use in children?

A. Administration by a single caregiver B. Inappropriate dosing C. Use of medications containing ≥2 active ingredients D. Use of an inappropriate measuring device

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July 2013

July 2013 CE—Pediatric OTC 4. A mom comes to your pharmacy with her 8 month old daughter, ML. She states ML has had a deep, nonproductive cough for the last 5 days which is very bothersome and is even preventing her from getting enough sleep at night. Mom thinks it may be from something she picked up from her new daycare, especially because she knows other kids have been sick recently. Mom wasn’t sure how she should treat the cough but states she was told to pick up some Children’s Tylenol Plus Cough and Sore Throat® (acetaminophen and dextromethorphan) by the mom of another kid. She has the product in her hand but wants to know what you would recommend for her daughter before she buys it. What would be your recommendation?

A. Nonpharmacologic therapy with increased fluid intake using Pedialyte ®, adequate sleep, and use of cold air humidifier B. Children’s Tylenol Plus Cough and Sore Throat® (acetaminophen 160 mg/5mL and dextromethorphan 5mg/mL); 5 mL q 4-6 h C. Children’s Delsym® (dextromethorphan 30mg/5mL); 0.2 mL q 6 to 8 hours D. Refer to physician

7. JS is a 7 year old little girl who is complaining of a headache, cough, and lots of “drainage in her throat.”

She says she has had the cough for about 24 hours without relief. JS confirms she does not have a history of allergies or sinus congestion. What is the best recommendation for JS with regard to an expectorant?

A. Acetaminophen 15mg/kg/dose every 4 to 6 hours as needed for cough B. Drinking 8 to 10 glasses of water throughout the day C. Guaifenesin 50mg every 4 hours D. Dextromethorphan 10mg every 8 hours 8. NM is a 5 month old WM who just received three immunizations. He is restless and will not stop crying.

His mother suspects NM is experiencing lingering pain at the injection site. What is the best analgesic for NM at this time?

A. Neonates do not experience pain. No treatment recommended.

B. Ibuprofen 10mg/kg/dose x 1 dose C. Acetaminophen 15mg/kg/dose x 1 dose D. Aspirin 10mg/kg/dose x 1 dose

9. MR is a 4 month old female brought to your community pharmacy by her mother. MR is febrile with a tem5. Which of the following statements is NOT true? perature of 101.2ºF. Her mother is very concerned and A. Green mucous typically indicates a bacterial infection, asks you for the “quickest thing” to bring her daughand most often requires physician referral ter’s fever down. What is your recommendation?

B. Avoiding exposure to persons with cold symptoms and A. MR should call her pediatrician or go to the emergency proper hand hygiene may help prevent the common room right away. cold B. Acetaminophen 30mg/kg as an initial loading dose, C. Nonpharmacologic therapy should always be considfollowed by 10mg/kg/dose every 4 to 6 hours thereafered as first line therapy in pediatric patients with mild ter until afebrile cough/cold symptoms C. Ibuprofen 10mg/kg/dose every 6 hours until afebrile D. Products including vitamin C or yogurt with active cul- D. No pharmacological therapy required. MR should be tures can reduce the severity and duration of the comtaken home and given an ice bath. mon cold in children 10. Which is a common factor that positively affects 6. What is the MOST appropriate treatment for cough pediatric medication adherence? in a 10 year old boy with a sore throat and persistent, A. A poorly tasting liquid formulation that does NOT inproductive cough? clude a sweetener or flavoring to mask the bitter taste A. Dextromethorphan 30mg every 4 hours as needed for B. A dosing schedule that requires administration every 6 cough hours B. Increased water intake and elevation of the head of C. A caregiver who doesn’t believe their child’s symptoms the bed or illness requires treatment C. Guaifenesin 400mg every 4 hours as needed for D. Open and clear communication between the provider cough and the caregiver D. Ibuprofen 10mg/kg/dose every 4 hours as needed for cough

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July 2013 CE—Pediatric OTC

July 2013

This activity is a FREE service to members of the Kentucky Pharmacists Association. The fee for non-members is $30. Mail completed forms to: KPERF, 1228 US 127 South, Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile.

Expiration Date: July 12, 2016 Successful Completion: Score of 80% will result in 1.5 contact hour or 0.15 CEU. Participants who score less than 80% will be notified and permitted one re-examination.

TECHNICIANS ANSWER SHEET. July 2013 — Pediatric Over-the-Counter Medication Refresher for Pharmacists Universal Activity # 0143-9999-13-007-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 2. A B C D

3. A B C D 4. A B C D

5. A B C D 6. A B C D

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

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

Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No I hereby certify that I completed this self-study program independently and without assistance from any other party.

Signature _________________________________________________ Date _________________________________

NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) PHARMACISTS ANSWER SHEET July 2013 — Pediatric Over-the-Counter Medication Refresher for Pharmacists Universal Activity # 0143-9999-13-007-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 2. A B C D

3. A B C D 4. A B C D

5. A B C D 6. A B C D

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

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

Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party.

Signature _________________________________________________ Date _________________________________

NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD)

The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy Education as a provider of continuing Pharmacy education.

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

THE KENTUCKY PHARMACIST

August 2013 CE â&#x20AC;&#x201D; COPD and CVD: Role of Beta-Blockers

July 2013

COPD and CVD: Exploring the Role of Beta-Blockers and COPD Treatments in Comorbid Disease By: Allison Meyer, PharmD and Debbie Minor, PharmD, The University of Mississippi Medical Center, Departments of Pharmacy and Medicine, Jackson, MS Reprinted with permission of the authors and the Mississippi Pharmacists Association where this article originally appeared. This activity may appear in other state pharmacy association journals. There are no financial relationships that could be perceived as real or apparent conflicts of interest.

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

Universal Activity # 0143-9999-13-008-H01-P&T 1.0 Contact Hour (0.1 CEUs) Goal: To review the role of beta-blocker (BB) therapy in the management of cardiovascular conditions and discuss the effects of these medications as well as treatments for chronic obstructive pulmonary disease (COPD) on associated morbidity and mortality.

Objectives: At the conclusion of this lesson, the reader should be able to: 1. Describe the role of BBs in the management of cardiovascular disease (CVD).

2. Discuss potential benefits as well as adverse effects associated with the use of BBs in patients with COPD. 3. Identify the association of inhaled COPD medication use and possible cardiovascular consequences. patients with COPD are highlighted in Table 1. The purpose of this review is to explore this role and discuss the effects COPD is a highly prevalent disease affecting approximately of these medications and COPD treatments on COPD and 15 million Americans.1 In 2007 it was the third leading cardiovascular morbidity and mortality. cause of death in the United States.2 Numerous observaBETA-BLOCKERS IN CARDIOVASCULAR DISEASE tional studies propose that patients with COPD are more likely to have coexisting cardiovascular conditions, includHeart Failure ing hypertension (HTN), heart failure (HF) and coronary artery disease (CAD), as well as diabetes and atherosclero- In several large clinical trials, metoprolol succinate, carvedilol and bisoprolol have demonstrated a reduction in morsis, compared to patients without this lung disease.3-8 A bidity and mortality in patients with systolic HF when added history of COPD also is associated with poor CVD outto baseline angiotensin converting enzyme inhibitor (ACEI) comes, including increased mortality and rehospitalization therapy.18-22 These agents decrease sympathetic nervous in HF and post-myocardial infarction (MI) patients, when compared to those without COPD.9-15 Whether these asso- system effects on the heart, resulting in improved left venciations are due to the disease process, smoking history or tricular (LV) ejection fraction and diastolic function, which are major determinants of the progressive clinical course of other factors is unclear.3,5-6 HF.23 Current guidelines recommend that the majority of BBs are indicated for many of the cardiovascular conditions patients with reduced LV systolic function be treated with that often accompany COPD, including HF, CAD, atrial fione of these BBs even in the presence of concomitant brillation (AF) and HTN. Screening and proper manageCOPD, diabetes or peripheral vascular disease.24-26 The ment of CVD is vital to improving patient outcomes. While presence of COPD is the most significant reason for paevidence suggests that BBs are generally well-tolerated in tients failing to receive adequate treatment.27 patients with COPD, many do not receive these lifesaving Coronary Artery Disease medications due to historical concerns for bronchocon16-17 striction and worsening lung function.

The role of BBs in BB therapy is considered standard of care post-MI.28-29 CVD management as well as recommendations for use in Most trials supporting this recommendation were published INTRODUCTION

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August 2013 CE â&#x20AC;&#x201D; COPD and CVD: Role of Beta-Blockers

July 2013

in the 1980s, sive agents, and Table 1: Recommendations for Use of BB in CVD and COPD prior to the roumetoprolol and Condition Effects of BB Recommendations in COPD* tine use of atenolol remain in Decrease sympathetic Use in patients with systolic HF ACEIs, thrombothe top 20 of the nervous system effects on as tolerated lytics and percu200 most commonHeart Failure heart taneous interly prescribed mediReduce morbidity and vention.30-31 cations.37 A metamortality in systolic HF More recent Reduce morbidity and Use in hemodynamically stable analysis of 13 trials studies have Coronary Artery mortality acutely post-MI patients post-MI, as tolerated comparing BBs to demonstrated a Disease Symptomatic relief of stable May use BB, CCB, or nitrates for other antihypertenpotential reducsives or placebo angina symptomatic angina Rate control May use BB, CCB, or digoxin tion in mortality, revealed a higher Atrial Fibrillation Maintain sinus rhythm reinfarction or risk of stroke and Potential increase in stroke, Use first-line agents (i.e. ventricular fibrilno difference in MI Hypertension no effect on MI risk diuretics, CCB, ACEI, ARB) lation post-MI in patients taking No longer first-line agent before BB with use of carBB.38 With the *Cardioselective preferred in all conditions vedilol or emergence of newmetoprolol sucer classes with cinate, though the primary endpoints were not significantly more favorable outcomes (i.e., diuretic, ACEI, angiotensin reduced by allocation to a BB.20,32 Similarly, in a recent ob- receptor blocker [ARB], CCB), these medications are no servational study, BB therapy did not reduce the primary longer generally promoted as first-line therapy for treatment cardiovascular endpoint in patients with a remote MI histo- of hypertension.39-40 The most prevalent cardiovascular ry, CAD without MI history or CAD risk factors only. 33 Based comorbidity in COPD is likely hypertension, which has imon previous affirmative evidence, a class I recommendation plications for COPD prognosis.27 remains for acute and long-term BB use in post-MI patients BETA-BLOCKERS IN CHRONIC OBSTRUCTIVE PULwith reduced LV function.28-29 In those with normal LV funcMONARY DISEASE tion, guidelines recommend using BBs for up to three years While no randomized controlled trials have been performed after a cardiac event (class IB).29 BBs also are first-line to definitively prove the benefits of BBs in patients with agents for symptomatic relief of stable angina, with an opCOPD, retrospective and observational data point to imtion of a calcium channel blocker (CCB) or long-acting ni34 proved survival and decreased hospitalizations with use of trate in those intolerant to BBs. Treatment with selective these medications.38,41-43 In observational analyses, cardiBBs is considered safe for patients with CAD and coexistoselective BBs appear to decrease mortality in COPD paing COPD.27 tients with CVD, including HTN, HF and atherosclerosis, as Atrial Fibrillation well as those undergoing coronary artery bypass graft surThe most frequent cardiac arrhythmia is AF. Beta-blockers gery.9,44-46 However, these patients, especially those with are useful for rate control in patients with AF and were severe COPD, are less likely to receive a BB or may be shown to be more effective than CCB, both as monothera- prescribed lower doses of BBs than those without py and in combination with digoxin.35-36 They are recomCOPD.9,12-15,17 mended as first-line initial therapy and may be used in comThe benefits from BB use in patients with COPD may be bination with a CCB and/or digoxin for patients with unconindependent of their value in CVD. Contrary to previous trolled heart rate and persistent AF.35 While BBs will not beliefs, the use of BBs does not appear to increase the rate convert a patient from AF to normal sinus rhythm, they can of COPD exacerbations.44-47 BBs may actually reduce the effectively maintain normal sinus rhythm. They also are incidence and severity of COPD exacerbations.47 Several effective in maintaining sinus rhythm in post-cardiac surobservational studies have demonstrated a mortality reducgery patients.35 Patients with COPD have an increased incition with BB use during COPD exacerbations.41-43 Additiondence of AF, and treatment can be challenging because of ally, patients with existing CVD and newly diagnosed the breathlessness and disability resulting from coexistence COPD have a higher mortality rate with BB discontinuaof these disease states.27 tion.43 Hypertension Most studies reviewing the use of BBs in COPD have been Historically, BBs have been widely used as antihypertenconducted in patients with HF using carvedilol or bisoprolol.

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August 2013 CE — COPD and CVD: Role of Beta-Blockers

July 2013

These medications, Table 2: Inhaled Beta-Agonists and Potential CVD Complications reported an inAcute Coronary creased risk of cardiparticularly carveTachycardia/Arrhythmias Heart Failure Syndromes dilol, may acutely ovascular mortality  Initial use  Chronic use may  May decrease forced with initial use of increase HF increase  Mild, transient expiratory volume IBAs.60 Initial use of hospitalizations and risk of ACS  Usually not clinically in one second IAC also was associmortality significant (FEV1) and cause ated with increased  No correlation to HF mild, transient mortality.60 Risk of development dyspnea and overall death and  May improve HF wheezing; howevcardiovascular exacerbations – relieve er, this typically events appears to be dyspnea does not result in lowest with the comDose-dependent, highest risk with excessive use of SABA the need for BB bination of longdiscontinuation or acting beta-agonists in a decrease in health-related quality of life.48-54 If respira- (LABA) and ICS.61-62 tory side effects occur, a trial of another BB is warranted. In Though tolerance usually develops, a common side effect a crossover study of patients with HF and COPD, switching of inhaled short-acting beta-agonists (SABA) is mild, dosefrom a cardioselective BB, i.e. bisoprolol or metoprolol, to dependent tachycardia.63 Arrhythmias, though rare, can carvedilol did not cause excess intolerance.55 occur with initial use of SABA and LABA,63-65 potentially The Global Initiative for Chronic Obstructive Lung Disease due to a decrease in serum potassium seen with these (GOLD) guidelines specifically address CVD management agents.66 Most of these reports do not reflect clinically sigin patients with COPD (Table 1). These guidelines recom- nificant arrhythmias, and the risk decreases over time.58,6366 mend that patients with HF, ischemic heart disease, AF Additionally, it has been proposed that impaired lung and HTN be treated as usual per respective guidelines as function is an independent predictor of arrhythmias.67 evidence does not suggest treating them differently.27 The There is a potential association between IBA use and HF use of BBs in patients with ischemic heart disease or HF, hospitalization and mortality, especially with chronic theraincluding those with severe COPD, is warranted as the py. This risk is highest in patients with excessive use of morbidity and mortality benefits outweigh the potential risk.

SABAs, i.e. > 3 canisters per month.66,68-70 There is no corThe GOLD guidelines also support the use of BBs in AF; relation, however, between IBA use and HF development.70 however, with the availability of other options, a trial of anConversely, these agents may improve HF exacerbations, other class of medication might be reasonable. Lastly, BBs potentially due to decreased cardiac workload resulting can be used in patients with HTN, as an adjunct to first-line from the decreased work of breathing.66 Some patients acagents. In all cases, the use of cardioselective BBs is rectually have hemodynamic improvement with acute use of ommended over other BBs.27 an IBA. Other potential benefits of these medications in HF patients include increased cardiac output, decreased peCOPD TREATMENTS AND CARDIOVASCULAR ripheral vascular resistance and improved pulmonary capilDISEASE lary wedge pressure.66 The most commonly prescribed medications for COPD include the inhaled beta-agonists (IBA), anticholinergics An increased risk of acute coronary syndrome (ACS) with (IAC) and corticosteroids (ICS). While these medications the use of IBAs also has been reported .71-72 Similar to the are generally well-tolerated, there is some concern for exrisk of arrhythmias and with HF, this effect appears to be acerbation of CVD, especially with the use of IBAs (Table dose-dependent, with the greatest risk in patients using > 6 2). Most supporting data for the risk of CVD stem from ob- canisters of a SABA per month.72 Many studies, however, servational studies in which cardiovascular morbidity and have found that IBA use does not worsen myocardial ischemortality are secondary outcomes. mia or increase the risk of ACS.66,73 In reference to CVD hospitalizations, several case-control studies have suggested a potential increase with use of ipratropium or IBA, while neither tiotropium nor ICS had an effect. Additionally, ipratropium may increase and ICS may decrease CV mortality. IBA use had no effect on mortality in these studies;56-59 however, a recent case-control study

While there may be an association between IBA use and cardiovascular events, most cases are mild and transient and are typically related to excessive use of these medications. Counseling patients on appropriate use of SABA and ensuring use of controller medications, as appropriate, is important for prevention of these negative cardiovascular 33

THE KENTUCKY PHARMACIST

August 2013 CE — COPD and CVD: Role of Beta-Blockers outcomes. Close follow-up is necessary, particularly with severe disease.

5.

The GOLD guidelines generally do not recommend altering COPD treatment strategies with coexisting HF, ischemic 6. heart disease, AF or HTN as there is no direct evidence that patients should be treated differently. 27 For patients with ischemic heart disease or AF, the guidelines state that it is reasonable to avoid high doses of IBAs. Appropriate 7. heart rate control may be difficult in patients with AF using high doses of IBAs. Patients with severe HF who are using IBAs should receive close monitoring by their healthcare providers due to the potential for an increased mortality and 8. hospitalization risk.27 CONCLUSION BBs have established morbidity and mortality benefits in many cardiovascular conditions that often coexist with COPD. Additional research is needed to further define the benefits and guide the treatment of patients with COPD and CVD, and many of these patients may not receive BB therapy due to concerns for bronchoconstriction. Evidence suggests, however, that these agents are typically welltolerated in COPD patients and may reduce CVD and COPD mortality as well as COPD exacerbations. Current guidelines for COPD are consistent with those for CVD management and support the role of BBs for treatment of particular cardiovascular conditions, with preference for the use of cardioselective agents. Additionally, proper education and appropriate use of COPD medications, particularly IBAs, will aid in the prevention of cardiovascular events.

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Pharmacists encounter these patients on a daily basis. We are in a unique position to influence patient care and decisions, particularly in the areas of medication use and selec14. tion. By understanding current issues related to therapy, we can effectively impact disease management and outcomes for many patients with COPD. REFERENCES

15.

1.

Centers for Disease Control and Prevention. Chronic obstructive pulmonary disease among adults—United States, 2011. 16.

MMWR. 2012;61(46):938-943.

2.

American Lung Association. Chronic obstructive pulmonary disease (COPD) fact sheet, February 2011. http:// www.lung.org/lung-disease/copd/resources/facts-figures/ COPD-Fact-Sheet.html. Accessed 6 May 2013.

3.

Mannino DM, Thorn D, Swensen A, Holguin F. Prevalence and outcomes of diabetes, hypertension and cardiovascular disease in COPD. Eur Respir J 2008;32:962-969.

Schnell K, Weiss CO, Lee T, et al. The prevalence of clinically-relevant comorbid conditions in patients with physiciandiagnosed COPD: a cross-sectional study using data from

4.

17.

18.

19.

34

July 2013

NHANES 1999-2008. BMC Pulm Med 2012;12:26-34.

Mapel DW, Hurley JS, Frost FJ, et al. Health care utilization in chronic obstructive pulmonary disease: A case-control study in a health maintenance organization. Arch Intern Med 2000;160:2653-2658.

Verduri A, Roca M, Bortolotti M, et al. COPD in the elderly is almost invariably associated with one or more chronic comorbidities [abstract]. Chest 2012;142 DOI:10.1378/chest 1388261.

Sin DD, Man P. Why are patients with chronic obstructive pulmonary disease at increased risk of cardiovascular diseases? The potential role of systemic inflammation in chronic obstructive pulmonary disease. Circulation 2003;107:15141519.

Barr RG, Ahmed FS, Carr JJ, et al. Subclinical atherosclerosis, airflow obstruction and emphysema: the MESA Lung Study. Eur Resp J 2012;39:846-854.

Mentz RJ, Schulte PJ, Fleg JL, et al. Clinical characteristics, response to exercise training, and outcomes in patients with heart failure and chronic obstructive pulmonary disease: findings from heart failure and a controlled trial investigating outcomes of exercise training (HF-ACTION). Am Heart J 2013;165:193-199.

Wakabayashi K, Gonzalez MA, Delhaya C, et al. Impact of chronic obstructive pulmonary disease on acute-phase outcome of myocardial infarction. Am J Cardiol 2010;106:305309.

Salisbury AC, Reid KJ, Spertus JA. Impact of chronic obstructive pulmonary disease on post-myocardial infarction outcomes. Am J Cardiol 2007;99:636-641.

Chen J, Radford MJ, Wang Y, et al. Effectiveness of betablocker therapy after acute myocardial infarction in elderly patients with chronic obstructive pulmonary disease or asthma. JACC 2001;37:1950-1956.

Stefan MS, Bannuru RR, Lessard D, et al. The impact of COPD on management and outcomes of patients hospitalized with acute myocardial infarction. Chest 2012;141:14411448.

Egred M, Shaw S, Mohammad B, et al. Under-use of betablockers in patients with ischaemic heart disease and concomitant chronic obstructive pulmonary disease. QJM 2005;98:493-497.

Gottlieb SS, McCarter RJ, Vogel RA. Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction. NEJM 1998;339:489-497.

Everely MJ, Heaton PC, Cluxton RJ. β-Blocker underuse in secondary prevention of myocardial infarction. Ann Pharmacother 2004;38(2):286-293.

Hawkins NM, Jhund PS, Simpson CR, et al. Primary care burden and treatment of patients with heart failure and chronic obstructive pulmonary disease in Scotland. Euro J Heart Fail 2010;12:17-24.

CIBIS-II investigators and committees. The cardiac insufficiency bisoprolol study II (CIBIS-II): a randomized trial. Lancet 1999;353:9-13.

MERIT-HF study group. Effect of metoprolol CR/XL in chronic heart failure: metoprolol CR/XL randomized intervention trial in congestive heart failure (MERIT-HF). Lancet

THE KENTUCKY PHARMACIST

August 2013 CE — COPD and CVD: Role of Beta-Blockers 1999:353:2001-2007.

20. The CAPRICORN Investigators. Effect of carvedilol on outcome after myocardial infarction in patients with leftventricular dysfunction: the CAPRICORN randomized trial.

Lancet 2001;357:1385-1390.

21. Carvedilol Prospective Randomized Cumulative (COPERNICUS) Study Group. Effects of initiating carvedilol in patients with severe chronic heart failure: results from the COPERNICUS Study. JAMA 2003;289:712-718.

22. Poole-Wilson PA, Swedberg K, Cleland JGF, et al. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol or Metoprolol European Trial (COMET): randomized controlled trial. Lancet 2003;362:7-13.

23. Eichhorn EJ, Bristow MR. Medical therapy can improve the biological properties of the chronically failing heart. A new era in the treatment of heart failure. Circulation 1996;94:2285 -2296.

24. McMurray JJV, Adamopoulos S, Anker SD, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Euro Heart J 2012;22:1787-1847.

25. Heart Failure Society of America: 2010 Comprehensive Heart Failure Practice Guidelines. Journal of Cardiac Failure 2010;16(6):e1-e194.

26. Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: J Am Coll Cardiol. 2009;53(15):e1-e90.

27. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2013.

Available at: http://www.goldcopd.org/uploads/users/files/ GOLD_Report_2013_Feb20.pdf.

28. Hamm CW, Bassand JP, Agewall S, et al. ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Euro Heart J 2011;32:2999-3054.

29. Smith SC, Benjamin EJ, Bonow RO, et al. AHA/ACCF Secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. JACC 2011;58:2433-2448.

30. Freemantle N, Cleland J, Young P, et al. β blockade after myocardial infarction: a systemic review and meta regression analysis. BMJ 1999;318:1730-1737.

31. de Peuter OR, Lussana F, Peters RJG, et al. A systemic review of selective and non-selective beta blockers for prevention of vascular events in patients with acute coronary syndrome or heart failure. Neth J Med 2009;67:284-294.

32. COMMIT collaborative group. Early intravenous then oral metoprolol in 45 852 patients with acute myocardial infarction: randomized placebo-controlled trial. Lancet 2005;366:1622-1632.

33. Bangalore S, Steg PG, Deedwania P, et al. β-blocker use and clinical outcomes in stable outpatients with and without coronary artery disease. JAMA 2012;308:1340-1349.

34. Fox K, Garcia MAA, Ardissino D, et al. Guidelines on the

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

35

July 2013

management of stable angina pectoris: executive summary.

Euro Heart J 2006;27:1341-1381.

Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation. JACC 2006;48:149-246.

Olshansky B, Rosenfeld LE, Warner AL, et al. The atrial fibrillation follow-up investigation of rhythm management (AFFIRM) study. JACC 2004;43:1201-1208.

Modern Medicine website. Top 200 generic drugs by total prescriptions. http://www.modernmedicine.com/ modernmedicine/data/articlestandard// drugtopics/252011/727243/article.pdf. Accessed November 21, 2012.

Lindholm LH, Carlberg B, Samuelsson O. Should β blockers remain as first choice in the treatment of primary hypertension? A meta-analysis. Lancet 2005;366:1545-1553.

NICE clinical guideline 127. Hypertension: Clinical management of primary hypertension in adults. http:// www.nice.org.uk/nicemedia/live/13561/56008/56008.pdf.

Accessed November 21, 2012.

Rosendorff C, Black HR, Cannon CP, et al. Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation 2007;115:2761-2788.

Stefan MS, Rothenberg MB, Priva A, et al. Association between beta-blocker therapy and outcomes in patients hospitalized with acute exacerbations of chronic obstructive lung disease with underlying ischemic heart disease, heart failure or hypertension. Thorax 2012;67:977-984.

Dransfield MT, Rowe SM, Johnson JE, et al. Use of βblockers and the risk of death hospitalized patients with acute exacerbations of COPD. Thorax 2008;63:301-305.

Rutten FH, Zuithoff PA, Hak E, et al. β-blockers may reduce mortality and risk of exacerbations in patients with chronic obstructive pulmonary disease. Arch Intern Med 2010;170:880-887.

Au DH, Bryson CL, Fan VS, et al. Beta-blockers as singleagent therapy for hypertension and the risk of mortality among patients with chronic obstructive pulmonary disease.

Am J Med 2004;117:925-931. van Gestel YRBM, Hoeks SE, Sin DD, et al. Impact of cardioselective β-blockers on mortality in patients with chronic obstructive pulmonary disease and atherosclerosis. Am J Resp Crit Care Med 2008;178:695-700.

Angeloni E, Melina G, Roscitano A, et al. β-blockers improve survival of patients with chronic obstructive pulmonary disease after coronary artery bypass grafting. Ann Thorac Surg 2013;95:525-31.

Farland MZ, Peters CJ, Williams JD, et al. Beta-blocker use and incidence of chronic obstructive pulmonary disease exacerbations. Ann Pharmacother 2013;47:651-656. Çamsari A, Arikan S, Avan C et al. Metoprolol, a β-1 selective blocker, can be used safely in coronary artery disease patients with chronic obstructive pulmonary disease. Heart Ves-

THE KENTUCKY PHARMACIST

August 2013 CE — COPD and CVD: Role of Beta-Blockers sels 2003;18:188-192.

49. van Gestel YRBM, Hoeks SE, Sin DD, et al. Beta-blockers and health-related quality of life in patients with peripheral arterial disease and COPD. International Journal of COPD 2009;4:177-183.

50. Lainscak M, Podbregar M, Kovacic D, et al. Differences between bisoprolol and carvedilol in patients with chronic heart failure and chronic obstructive lung pulmonary disease: a randomized controlled trial. Respiratory Medicine 2011;105 (S1):S44-S49.

51. Hawkins, NM, MacDonald MR, Petrie MC, et al. Bisoprolol in patients with heart failure and moderate to severe chronic obstructive pulmonary disease: a randomized controlled trial.

Euro J Heart Fail 2009;11:684-690.

52. Düngen HD, Apostolović S, Inkrot S, et al. Titration to target dose of bisoprolol vs. carvedilol in elderly patients with heart failure: the CIBIS-ELD trial. Euro J Heart Failure 2011;13:670 -680.

53. Salpeter SR, Ormiston TM, Salpeter EE. Cardioselective βblockers in patients with reactive airway disease: a metaanalysis. Ann Intern Med 2002;137:715-725.

54. Salpeter SR, Ormiston TM, Salpeter EE, et al. Cardioselective beta-blockers for chronic obstructive pulmonary disease: a meta-analysis. Respiratory Medicine 2003;97:1094-1101.

55. Jabbour A, Macdonald PS, Keogh AM, et al. Differences between beta-blockers in patients with chronic heart failure and chronic obstructive pulmonary disease: a randomized crossover trial. JACC 2010;55:1780-1787.

56. Lee TA, Pickard AS, Au DH, et al. Risk for death associated with medications for recently diagnosed chronic obstructive pulmonary disease. Ann Intern Med 2008;149:380-390.

57. Singh S, Loke YK, Furberg CD. Inhaled anticholinergics and risk of major adverse cardiovascular events in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. JAMA 2008;300:1439-1450.

58. Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest 2004;125:2309-2321.

59. Loke YK, Kwok CS, Singh S. Risk of myocardial infarction and cardiovascular death associated with inhaled corticosteroids in COPD. Eur Respir J 2010;35:1003-1021.

60. Gershon, A, Croxford R, Calzavara A, et al. Cardiovascular safety of inhaled long-acting bronchodilators in individuals with chronic obstructive pulmonary disease. JAMA Intern

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Med 2013;epub ahead of print.

61. Dong YH, Lin HH, Shau WY, et al. Comparative safety of inhaled medications in patients with chronic obstructive pulmonary disease: systematic review and mixed treatment comparison meta-analysis of randomized controlled trials.

Thorax 2013;68:48-56.

62. Calverley PMA, Anderson JA, Celli B, et al. Cardiovascular events in patients with COPD: TORCH Study results. Thorax 2010;65:719-725.

63. Sears MR. Adverse effects of β-agonists. J Allergy Clin Immunol 2002;110:S322-S328.

64. Wilchesky M, Ernest P, Brophy JM, et al. Bronchodilator use and the risk of arrhythmia in COPD: part 1: Saskatchewan cohort study. Chest 2012;142:298-304.

65. Wilchesky M, Ernest P, Brophy JM, et al. Bronchodilator use and the risk of arrhythmia in COPD: part 2: reassessment in the larger Quebec cohort. Chest 2012;142:305-311.

66. Maak CA, Tabas JA, McClintock DE. Should acute treatment with inhaled beta agonists be withheld from patients with dyspnea who may have heart failure? J Emerg Med 2011;40:135-145.

67. Buch P, Friberg J, Scharling H, et al. Reduced lung function and risk of atrial fibrillation in the Copenhagen city heart study. Eur Respir J 2002;21:1012-1016.

68. Mentz RJ, Fiuzat M, Kraft M, et al. Bronchodilators in heart failure patients with COPD: Is it time for a clinical trial? J Cardiac Fail 2012;18:413-422.

69. Au DH, Udris EM, Fan VS, et al. Risk of mortality and heart failure exacerbations associated with inhaled beta-adrenergic agonists among patients with known left ventricular systolic dysfunction. Chest 2003;123:1964-1969.

70. Au DH, Udris EM, Curtis JR, et al. Association between chronic heart failure and inhaled β-2-adrenoceptor agonists.

Am Heart J 2004;148:915-920.

71. Au DH, Lemaitre RN, Curtis JR, et al. The risk of myocardial infarction associated with inhaled β-adrenoceptor agonists.

Am J Resp Crit Care Med 2000;161:827-830.

72. Au DH, Curtis JR, Every NR, et al. Association between inhaled β-agonists and the risk of unstable angina and myocardial infarction. Chest 2002;121:846-851.

73. Suissa S, Assimes T, Ernst P. Inhaled short acting β agonist use in COPD and the risk of acute myocardial infarction.

Thorax 2003;58:43-46.

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August 2013 CE — COPD and CVD: Role of Beta-Blockers

July 2013

August 2013 — COPD and CVD: Exploring the Role of Beta-Blockers and COPD Treatments in Comorbid Disease 1. Patients with COPD are more likely to have: A. coronary artery disease B. hypertension C. heart failure D. diabetes E. All of the above

6. Studies of BB use in COPD patients with HF indicate that an initial increase in respiratory side effects may occur most often with which of the following medications?

A. Carvedilol B. Bisoprolol 7. Management of CVD with coexisting COPD, as discussed in the GOLD guidelines, should include: A. altering therapy with all cardiovascular conditions, including avoidance of BBs B. no differentiation between use of cardioselective and nonselective BBs C. use of cardioselective BBs in HF patients, including those with severe COPD

2. Which of the following statements is FALSE regarding beta-blocker use in heart failure?

A. BBs increase sympathetic nervous system effects on the heart.

B. Metoprolol succinate, carvedilol, and bisoprolol are recommended for use in systolic HF C. BBs reduce mortality and morbidity in systolic heart failure D. Cardioselective BBs are recommended by GOLD guidelines for use in HF with coexisting COPD

8. Changes in heart rhythms, including tachycardia and arrhythmias, with use of inhaled beta-agonists: A. are typically mild and transient B. can occur with initial use of both short- and long-acting beta-agonists C. may be due to a decrease in serum potassium seen with these agents D. All of the above

3. In patients with COPD and coexisting AF, BBs: A. are contraindicated B. decrease mortality and should be used in all patients C. can be used for rate control 4. According to the data presented, BBs may improve survival in COPD patients with all of the following coexisting disease states EXCEPT? A. Hypertension B. Heart Failure C. Atrial fibrillation D. Atherosclerosis

9. With regards to HF, use of inhaled beta-agonists: A. may improve HF exacerbations by decreasing cardiac workload from decreased work of breathing B. may result in development of HF C. in excessive amounts (i.e. > 3 canisters of SABA per month) may increase hospitalization and mortality D. Both a. and c E. Both b. and c

5. BBs may: A. reduce the incidence and severity of COPD exacerbations B. be inappropriately prescribed in lower doses in patients with CVD and coexisting COPD C. increase the rate of COPD exacerbations D. Both a. and b

10. In treatment recommendations for patients with COPD and CVD, the GOLD guidelines suggest the following EXCEPT: A. generally no alteration of COPD treatment strategies B. avoiding high doses of IBAs in patients with ischemic heart disease C. avoiding high doses of IBAs in patients with hypertension

Nominate your peers for a new feature in

The Kentucky Pharmacist We are looking for members to profile in coming editions of The Kentucky Pharmacist who are making the world a better place. Do you know someone who goes above and beyond the “above and beyond the call of duty”? Let us know!

Email Scott Sisco at ssisco@kphanet.org with a brief description of the story or to schedule a time to discuss.

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August 2013 CE — COPD and CVD: Role of Beta-Blockers

July 2013

This activity is a FREE service to members of the Kentucky Pharmacists Association. The fee for non-members is $30. Mail completed forms to: KPERF, 1228 US 127 South, Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile.

Expiration Date: July 16, 2016 Successful Completion: Score of 80% will result in 1.0 contact hour or 0.10 CEU. Participants who score less than 80% will be notified and permitted one re-examination.

TECHNICIANS ANSWER SHEET. August 2013 — COPD and CVD: Exploring the Role of Beta-Blockers and COPD Treatments in Comorbid Disease Universal Activity # 0143-9999-13-008-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D E 2. A B C D

3. A B C 4. A B C D

5. A B C D 6. A B

7. A B C 8. A B C D

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

Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No I hereby certify that I completed this self-study program independently and without assistance from any other party.

Signature _________________________________________________ Date _________________________________

NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) PHARMACISTS ANSWER SHEET August 2013 — COPD and CVD: Exploring the Role of Beta-Blockers and COPD Treatments in Comorbid Disease Universal Activity # 0143-9999-13-008-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D E 2. A B C D

3. A B C 4. A B C D

5. A B C D 6. A B

7. A B C 8. A B C D

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

Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party.

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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.

38

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THE KENTUCKY PHARMACIST

Senior Care Corner

July 2013

Senior Care Corner from the KPhA Academy of Consultant Pharmacists The Spring CE event took place on Saturday, April 20, 2013 at Sullivan University College of Pharmacy. We had an excellent program offering 4 hours of CEU. Presentations included Long-Term Care Pharmacy Legislation and Regulations in 2013 by Leah Tolliver, Medications as Risk Factors for Dementia and Delirium by Noll Campbell, Geriatric Pharmacotherapy Principles: Not so obvious elements leading to improved outcomes by Dee Antimisiaris, and Speaker Panel: The Affordable Care Act & Accountable Care Organizations: The changing face of pharmacy practice including BC Childress, Sean Jeffery, and Bonnie Lazor. The president of ASCP, Sean Jeffery, was in attendance to discuss national issues. Kim Croley represented KPhA and the Academy in a promotional booth. Other promotional booths included ASCP/KYASCP, SUCOP Drug Information Center, KY Pharmacy Museum, and KHELPS. The event was very successful. We are still waiting for the final financial information to see what our profit will be.

tions and put together a consensus statement. The primary topic of discussion was the proposed regulations changing and expanding the role of Automated Dispensing Machines in LTC facilities as well as some changes in the roles of the consultant pharmacist and pharmacist-in-charge that provide service to those LTC facilities. The lengthy discussion centered around the potential of ADM use in place of the current Emergency Box/First Dose Box that many pharmacy providers are utilizing in the facilities they serve. We plan to elect new officers, and we currently have Peggy Canler continuing as Academy Director of Government Affairs. Chris Miles has been nominated as Chair, Joey Mattingly as Vice Chair, Julie Owen as Academy Director of Organizational Affairs, and an opening for Academy Director of Public/Professional Affairs.

Respectfully,

The Academy met at the annual KPhA Annual Meeting at Elisha Bischoff, PharmD, BCPS the Louisville Downtown Marriott to discuss the LTC regula- Chair, KPhA Academy of Consultant Pharmacists

The Kentucky Renaissance Pharmacy Museum offers several ways way to show support of the Museum, our state's leading preservation organization for pharmacy.

While contributions of any size are greatly appreciated, the following levels of annual giving have been established for your consideration. Friend of the Museum $100  Proctor Society $250 Damien Society $500 Galen Society $1,000

Name______________________________________ Specify gift amount________________________ Address ____________________________________ City____________________Zip______________ Phone H____________________W________________ Email___________________________________ Employer name_____________________________________________________for possible matching gift.

Tributes in honor or memory of_____________________________________________________ Mail to: Kentucky Renaissance Pharmacy Museum, P.O.Box 910502, Lexington, KY 40591-0502 The Kentucky Renaissance Pharmacy Museum is a non-profit 501(c)(3) business entity and as such donations are tax deductible. A notice of your tax deductible contributions will be mailed to you annually.

Questions: Contact Lynn Harrelson @ 502-425-8642 or Lharrelsonky@aol.com

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KPhA New and Returning Members

July 2013

KPhA Welcomes New and Renewing Members May-June 2013 Cathy Adams Pineville, KY

Billy R Bowling Lexington, KY

Ben Doyle Nicholasville, KY

Kenneth Glass Midway, KY

John Adams Lebanon, KY

Dianna Bryant Hartford, KY

Debra Dunaway Henderson, KY

Thomas P Glover Providence, KY

Kasey Alford Smiths Grove, KY

Robert W Buckner Campbellsville, KY

James Dunaway Henderson, KY

Robert Goforth Somerset, KY

Sandra Foster Anderson Monticello, KY

William Bucy Bowling Green, KY

Anna Lee Dupont Louisville, KY

Wayne P Gravitt Wheelwright, KY

Michael Anneken Melbourne, KY

John Garland Byassee Clinton, KY

Margret Mae Easterling Jenkins, KY

Dwaine K Green The Villages, FL

Mark Antis South Portsmouth, KY

Margaret Christopher Winchester, KY

Michael Eastridge Lebanon, KY

Monte J Gross Stanton, KY

Karen M Arlinghaus Ft. Wright, KY

Kenneth Clayton Elkton, KY

David Edmundson Bowling Green, KY

Jennifer Grove Madison, IN

William M Ashby Cadiz, KY

Robert Clement Cadiz, KY

Harold Ellis Frankfort, KY

Donald Gubser Melvin, KY

Rosana W Aydt Villa Hills, KY

Arica C Collins Albany, KY

Kevin Emberton Edmonton, KY

David Guion Russellville, KY

Jason K Baker Louisville, KY

David E Collins Mayfield, KY

Chad Evans Maysville, KY

Larry Hadley Frankfort, KY

Jennifer Baker Louisville, KY

Teresa Collison Summersville, KY

Lorie Evans Quincy, KY

Catherine Hanna Lexington, KY

James D Ball Elizabethtown, KY

Paul M Cooper Morehead, KY

Jaime Janielle Fields Hindman, KY

Melodie Hawkins Mt Sterling, KY

Ellen Barger Mount Washington, KY

Kimberly Sasser Croley Corbin, KY

Justin M Fink Fort Wright, KY

Pamela Hays McKee, KY

Christopher Lee Barker Morehead, KY

Robert E Croley Corbin, KY

Jamie C Fletcher Hazard, KY

Gregory Hines Bowling Green, KY

Larry R Barnett South Williamson, KY

Robert E Cull Owenton, KY

Celeste C Flick Crestview Hills, KY

Tom Houchens London, KY

Barbara C Batsel Madisonville, KY

Jeffrey W Danhauer Owensboro, KY

Raymond Float Danville, KY

Morgan Howard Scottsville, KY

Margaret Beeler Lebanon Junction, KY

Steven Dawson McDowell, KY

Veronica Foster Munfordville, KY

Reymonda Howard London, KY

John K Beville Louisville, KY

Thomas Detraz Hopkinsville, KY

Cathy N Francisco Pikeville, KY

Robert Hughes Lexington, KY

Danny Biliter Richmond, KY

Dave Dickerson Morehead, KY

Sheila A Franklin Bimble, KY

Michael Ingram Cynthiana, KY

Joseph H Blandford Louisville, KY

Steve Doom Elizabethtown, KY

Lisa Freeman Paducah, KY

Kyla James Sellersburg, IN

Ralph E Bouvette Frankfort, KY

Barbara A Dorris Russellville, KY

Patricia Freeman Lexington, KY

Daniel Jones Paducah, KY

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THE KENTUCKY PHARMACIST

KPhA New and Returning Members

July 2013

Melinda Joyce Bowling Green, KY

Ross Melton Mount Sterling, KY

Ginger Scott Morgantown, WV

Charlsie Williams Paducah, KY

Kyle Katterjohn Paducah, KY

Kelly Mink Lancaster, KY

Jan Scott Earlington, KY

Cindi Williams Hazard, KY

Amber Kayse Morning View, KY

Bernardine Miracle Whitesburg, KY

William Sewell Utica, KY

James Wiseman Benton, KY

David Kelly Georgetown, KY

Jeffrey Moore Middlesboro, KY

Gina Sherrow Brodhead, KY

Reginald David Woolf South Fulton, TN

Ann Keown Scottsville, KY

Sonya Muncy Russell, KY

David Shipley Henderson, KY

Whitney Wright Dixon, KY

Brian Key Pineville, KY

Ann Murphy Princeton, KY

John Simkins Somerset, KY

Mary Ann Wyant Finchville, KY

Patricia Kinney Erlanger, KY

Frank Nicks Bowling Green, KY

Alan Simon Prospect, KY

Michael B Wyant Finchville, KY

Kristy Klebeck Maysville, KY

John F. Nie Independence, KY

Sarah Slabaugh Louisville, KY

Jeanne Zeis Covington, KY

Donald B Kupper Crestwood, KY

David O'Quinn West Liberty, KY

Lisa Smith Dry Ridge, KY

Mike Leake Danville, KY

Jamie Otte Florence, KY

James Stallard Neon, KY

Joe Lewis Hyden, KY

Eileen Palutis Richmond, KY

Nancy Stanton Holmes Mill, KY

Penny Liles Vanceburg, KY

Paul Patrick London, KY

Scott Stephens Cynthiana, KY

Michelle Lowe Paducah, KY

Kenneth Pearce Danville, KY

Dan Stevenson Portsmouth, OH

Aleshea Martin Louisville, KY

Risa Perry Almo, KY

Jacquelyn Strickland Hopkinsville, KY

Matt Martin Louisville, KY

Lavanya Wijeratne Peter Louisville, KY

David Bradley Stultz Flatwoods, KY

Tamara Maynard Prestonsburg, KY

Brookes Pickard Louisville, KY

Francis Britton Thompson London, KY

Velda Mcdaniel Georgetown, KY

Michael Pipkin Gilbertsville, KY

Gene Thompson Lexington, KY

John McFarland London, KY

Larry Powell Richmond, KY

Leah Tolliver Lexington, KY

Aaron Mcintosh Midway, KY

Elizabeth Prather Florence, KY

Earnest Watts Cornettsville, KY

Roy Mckendree Murray, KY

Marcella Robinson Paducah, KY

Lenville White Irvine, KY

Lynita Mcwaters Paducah, KY

Donald Ruwe Fort Thomas, KY

Thomas White Madisonville, KY

Mark Meador Scottsville, KY

Denise Schickling Villa Hills, KY

Rodney Whittington Princeton, KY

Beverly Meeks Paducah, KY

Lisa Schwartz Crestview Hills, KY

Gary Wientjes Morehead, KY

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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

KPhA Government Affairs/Pharmacy Health Screenings

July 2013

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) Credit Card (AMEX; Discover; MasterCard; VISA) Account #: ____________________________________________________ Expiration date: _______ CVV: ______________ Billing address (if different from above) ___________________________________________________________________________________

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

Pharmacy Health Screening Provide state of the art health screenings to help improve YOUR patientsâ&#x20AC;&#x2122; health and your bottom line.

Schedule a Health Screening Day at your pharmacy to offer YOUR patients a service to improve their health and potentially catch dangerous issues early!

The health screenings offer multiple advantages for your business including immediate profit from the screening process and the early recognition of diseases that are usually treated with medications as well as increase the health and longevity of your patients.

The process is a partnership between the Kentucky Pharmacists Association and Xcel Diagnostics and YOUR pharmacy to bring state of the art health screenings to your patients. The net profit is divided among the partners, including your pharmacy.

Call Xcel Diagnostics today to schedule your screening day.

(606) 218-5483 42

THE KENTUCKY PHARMACIST

Cardinal Health

July 2013

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THE KENTUCKY PHARMACIST

135th KPhA Annual Meeting

July 2013

Sponsors for the 135th KPhA Annual Meeting KPERF Golf Hole Sponsors

Annual Meeting Event Sponsors

AmerisourceBergen American Pharmacy Services Corp.

Booneville Discount Drug Capital Pharmacy and Medical Equipment Care More, Kimper & NOVA Pharmacies Congratulations Leon Claywell, Bowl of Hygeia Award Recipient Flexible Pharmacy Staffing George Hammons, Frankie Abner & Tom Houchens Medica Pharmacy and Wellness Center, Bardstown-Shepherdsville Pharmacists Mutual Companies Poole’s Pharmacy Care Republic Bank & Trust Rite Aid Rx Discount Pharmacy The Save-Rite Family of Pharmacies Tolliver Management Group Wayne’s Pharmacy

American Pharmacy Services Corporation Humana Jefferson County Academy of Pharmacists KY Governor’s Office of Health Information Exchange KPhA District 1 Kroger Corporation McWhorter College of Pharmacy at Samford University Medica Pharmacy and Wellness Center, Bardstown-Shepherdsville Northern Kentucky Pharmacists Association Rx Therapy Management Sullivan University College of Pharmacy University of Kentucky College of Pharmacy

Annual Meeting Supporter Rx Systems, Inc.

Sponsoring Pharmacy’s Future Student Pharmacist Support Cardinal Health Customers in Kentucky Matt Carrico Kim Croley Brian Fingerson Humana Grant County Drugs and Custom Compounding Centers, Dry Ridge, Williamstown, Crittenden Medica Pharmacy and Wellness Center, Bardstown-Shepherdsville

National Association of Chain Drug Stores Bob Oakley Duane Parsons Poole’s Pharmacy Care Donnie Riley Richard Slone Tolliver Management Group Wellcare of Kentucky Sam Willett Lewis Wilkerson 44

THE KENTUCKY PHARMACIST

135th KPhA Annual Meeting

July 2013

â&#x20AC;Ś and our 2013 Exhibitors AbbVie American Pharmacy Cooperative, Inc. AmerisourceBergen American Pharmacy Services Corp.

Astrazeneca Cardinal Health Dr. Comfort Eli Lilly & Co. EPIC Pharmacies HD Smith iMedicare Kentucky Cabinet for Health & Family Services Kentucky Renaissance Pharmacy Museum KHELPS KY Office of Health Information Exchange Lifetime Financial Growth Company McKesson Corporation

Merck Miami Luken Morris & Dickson Passport Health Plan Pharmacists Mutual Companies Pill Guard Medication Delivery Systems QS/1 Rite Aid RxMedic Samuels Products, Inc. ScriptPro Smith Drug Company SUCOP Student Organizations TEC Laboratories UK COP Experiential Ed/ CAPP UK Student Organizations UK Gerontology Walgreens Xcel Diagnostics

The outgoing members of the 2012-13 KPhA Board of Directors: outgoing President Kimberly Croley, Leah Tolliver, Jeff Mills, Lance Murphy, Chris Clifton, Outgoing Chair Lewis Wilkerson, Trish Freeman and Molly Trent.

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THE KENTUCKY PHARMACIST

2013-14 KPhA Board of Directors

July 2013

Welcome to the New Directors

Sullivan University College of Pharmacy Student Representative Heather Bryan is originally from Louisville, and now resides in Mt. Washington with her husband and three-year-old daughter.

She is a graduate of Murray State University with her Bachelors in Science and Nursing and is in her 2nd year at Sullivan. She loves being involved, staying busy, and being active.

Walgreens on Lime Kiln Lane in Louisville. He currently serves as chair of the Advisory Council to the Kentucky Board of Pharmacy. He has been married to his wife, Denise, for 19 years, and they have two wonderful children, Bayley Shea, 14 and Olivia Blaire, 11.

He was born and raised in Louisville, where he resides today.

Vice Speaker of the House of Delegates Ethan Klein was born and raised in Dallas, Texas, and earned his BS in chemistry from the University of Texas at Austin in 2004. In 2010, he graduated from the University of Charleston School of Pharmacy in Charleston, W.V. He then moved to Chicago to complete his PGY1 residency at the North Chicago Veterans Affairs. After completing the residency, he moved to Louisville, where he practices pharmacy in the community setting.

University of Kentucky College of Pharmacy Student Representative Brooke Herndon is a third-year student pharmacist at UK. She holds a B.S. in Chemistry with a minor in Biology from Bellarmine University. Brooke is a native of Louisville and currently lives in Lexington to attend school.

She serves as the President of the American Pharmacists Association â&#x20AC;&#x201C; Academy of Student Pharmacists and is an active member in Rho Chi, Phi Lambda Sigma and Lambda Kappa Sigma. When not studying or participating in extracurricular Director Chris Palutis is originally from the northeast activities, Brooke enjoys cheering on the CATS and attendPennsylvania area. He attended the Philadelphia College of ing sports games.

Pharmacy & Science and earned his Bachelor of Science Degree in Pharmacy in 1995. Chris has more than 17 years Director Chris Killmeier enjoys being a part of solutions for the profession of pharmacy. He has been a pharmacist of innovative pharmacy management experience, including for 22 years with Walgreens. Within Walgreens, he has positions in retail and long term care. He began his career held positions from staff pharmacist up to district pharmacy in the retail pharmacy sector, where he quickly rose supervisor and is currently pharmacy manager at through key areas of functional leadership responsibility

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THE KENTUCKY PHARMACIST

2013-14 KPhA Board of Directors

July 2013

of the KPhA Board of Directors including operations, technology, customer service, legal and regulatory compliance, clinical services and sales.

He was promoted and led pharmacy operations at national pharmacy chains CVS and Rite Aid, as well as the nation’s leading Long Term Care Pharmacy provider, Omnicare. He successfully leveraged his experience to maximize sales and profitability for these premiere organizations.

After a successful stint with Omnicare, Chris decided to venture out on his own. He and his wife, Consuelo (who is also a pharmacist), decided to return to Kentucky and open their own independent pharmacy in Lexington. The pharmacy (C&C Pharmacy) opened in February 2009 and has seen positive growth year after year. The pharmacy now employs 2 additional full-time pharmacists (in addition to Chris and Consuelo) as well as UK Interns and other pharmacy technicians.

of Pharmacy in May 1990.

He started his career as a Staff Pharmacist at Owensboro-Daviess County Hospital before becoming owner and pharmacist of Poole’s Pharmacy Care in Central City, Livermore and Owensboro in October 1990. Ron is a Community Based Faculty Member for the University of Kentucky College of Pharmacy, Ohio Northern University- Raabe College of Pharmacy, Samford College of Pharmacy and St. Louis College of Pharmacy.

Director Mary Thacker, is a 1993 graduate of UK College of Pharmacy. Having practiced community pharmacy for 17 years as both staff and pharmacy management, she chose to pursue a path in long-term care pharmacy and has thoroughly enjoyed the challenge the past two years. She lives in LouisChris and Consuelo reside in the Lexington area. ville with husband, Art, as well as kids Jack (12) and Audrey (9). She enjoys Past President Ron Poole was born in Covington, Ky., being a “soccer” mom, as well as a and raised in Williamstown, Ky. He married Lisa Wedding roadie for her son’s band, and assisin 1991 and they are the proud parents of Megan, Allie, tant coach to both kids’ Quick Recall Evan and Emma. teams. She loves music, gardening, He completed pre-pharmacy curriculum at Brescia Univer- cooking, reading, watching NFL, visiting the Caribbean sity in Owensboro and graduated with a Bachelor’s Deand spending time with her newly adopted 11-year-old gree in Pharmacy from the University of Kentucky College Dachshund.

2013-14 KPhA Executive Officers Chair — Kimberly Sasser Croley President — Duane Parsons President-Elect — Bob Oakley Secretary — Frankie Abner Treasurer — Glenn Stark

Directors Chris Clifton and Jeff Mills were reelected to the KPhA Board of Directors. Directors Trish Freeman and Chris Palutis were appointed to fill unexpired terms.

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THE KENTUCKY PHARMACIST

Pharmacy Law Brief

July 2013

Pharmacy Law Brief: Exclusion of Practitioners from Federally Funded Health Programs Author: Joseph L. Fink III, B.S.Pharm., J.D., Professor of Pharmacy Law and Policy and Kentucky Pharmacists Association Professor of Leadership, Department of Pharmacy Practice and Science, UK College of Pharmacy Question: I have read somewhere that the federal government has ratcheted up its level of activity with regard to excluding health professionals from health care programs that receive any federal funds, e.g., Medicare, Medicaid, TRICARE, programs for veterans, etc. What is that, are there implications for pharmacists and pharmacy and what can a practitioner who is “excluded” do to get reinstated?

Submit Questions: jfink@uky.edu check that the pharmacy’s computer system includes an edit for excluded prescribers at the point of dispensing.

Looking at an inpatient scenario, if a hospital employed an excluded pharmacist who dispensed medications to a Medicare beneficiary whose bill was covered under that program’s diagnosis-related group payment system, that bill would not be honored for payment. Moreover, that pharmacist would be open to penalties for violating his or her exclusion by causing a claim to be submitted for federal reimbursement during the period of exclusion.

Response: A number of federal statutes enacted over the years starting in 1977 have created a legal prohibition on payment by federal health care programs for items or services either furnished by an “excluded person” or at the request of such an individual, e.g., a prescription issued by Well, could an excluded pharmacist get around this by an excluded provider. This applies whether the federal promoving into an administrative or managerial role where, gram is funded wholly (think TRICARE) or in part (think say, no direct dispensing activities occur? The answer is Medicaid) with federal funds. no. Excluded individuals are prohibited from furnishing Program exclusion may be directed at any person who such services if payment comes from federal health care submits false or fraudulent claims for payment. Thus, this programs. Nor could that excluded pharmacist limit his or could include the owner of a pharmacy seeking reimburse- her activities to inputting billing information or reviewing ment or an employee pharmacist who initiated the claim. treatment plans. Those activities also would run afoul of the There also are potential civil monetary penalties that can exclusionary order. be directed at entities, e.g., pharmacies, that employ indiThis author has received inquiries from pharmacists who viduals who are currently subject to exclusion. It has been have been subject to exclusion orders asking several quesreported that as of April 2013, there were 51,000 individutions. First is “what can I permissibly do while excluded?” als and 3,000 business entities under exclusion.

The answer is, unfortunately, not much in pharmacy. One But the implications are even more expansive. No federal possibility might be a position with a poison control center health care program payment may be made for items or that receives no federal funds. The second question is services furnished on the prescription of an excluded prac- “What can I do to get out from under the five year exclusion titioner. So if a prescription were issued by an excluded order?” The answer to that, also unfortunately, is not much. prescriber a pharmacy could not be reimbursed for that by Passage of time is pretty much the only remedy with the a federal health program. hope that programmatic reinstatement to eligibility will follow.

Does that mean the pharmacist needs to verify that each and every prescriber from whom prescriptions are received How can it be determined whether a particular individual is are not under an exclusion order? Payment could certainly currently under an exclusion order? The website of the be denied in such situations. One way to avoid liability for HHS Office of the Inspector General presents this inforhonoring an order from an excluded prescriber is to double mation at http://oig.hhs.gov/exclusions.

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.

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Technician Review

July 2013

Technician Review From the KPhA Academy of Technicians In April 2013, the Kentucky Pharmacists Association Board of Directors voted in favor of the petition to found a new KPhA Academy for Pharmacy Technicians. The Academy’s approved mission statement is: To unite the pharmacy technicians throughout the Commonwealth to have one voice toward the advancement of our profession.



Don Carpenter — Chair



Patricia Robinson — Vice Chair



Christen Schenkenfelder — 1st Director



Heather Daniels — 2nd Director

 The founding 25 members have a wide footprint throughout the state of Kentucky.  The selected officers for 2013-2014 are as follows:

Kristina Blanton — 3rd Director Raychel Stevens — 4th Director

The Academy plans to continue recruiting additional technicians to become involved within our profession. Our objectives will be presented to the KPhA Board of Directors and the Board of Pharmacy Advisory Council.

We are excited about the changing environment in the pharmacy profession and look forward to being a part of that change. If you are a technician member of KPhA, you are eligible to be a member of the Pharmacy Technician Academy. There is no extra cost involved or responsibility. Our goal is for the role of the pharmacy technician to grow and evolve as a profession. We want to invite every technician to join the academy to have a voice in guiding our profession.

For more information on how to join the Pharmacy Technician Academy please email Don Carpenter at dacarpenter@st-claire.org.

Sincerely, Don Carpenter, BS, CPhT III 222 Medical Circle Drive Morehead, KY 40351 606-783-6741 dacarpenter@st-claire.org

Check out resources for Pharmacy Technicians at the KPhA Website: www.kphanet.org 49

THE KENTUCKY PHARMACIST

Pharmacy Policy Issues

July 2013

PHARMACY POLICY ISSUES: Overcoming Barriers to Implementing Pharmacogenetic Services in Community Pharmacy Author: Jonathan Hughes is a third professional year Pharm.D. student at the UK College of Pharmacy. Jonathan received his Bachelor of Science degree in Biology and Biochemistry at the University of Mississippi and is a native of Madison, Miss.

Issue: Implementing pharmacogenetic services into community pharmacy practice promises to bring community practice into the 21st century. However, many patients express fear that their insurance company or employer may use such information to discriminate against them. What can pharmacists seeking to implement pharmacogenetic services do to allay these fears?

Discussion: Of the several barriers existing to the implementation of pharmacogenetic services in community pharmacy, one of the most prominent—and, as I hope to show, most easily allayed—are fears regarding the use and privacy of genetic information. As has been discussed extensively in bioethical literature and such popular publications as The Immortal Life of Henrietta Lacks, genetic information is integral to who we are; indeed, it is our very blue print. In the past decade, the biomedical sciences have exploded in understanding how our genes affect our health, from the progression of disease to variations in drug efficacy and toxicity. However, patients often shrink away from even considering the potential benefit afforded by genetic testing because of fear that entities such as their employer or health insurance carrier may use such information to discriminate against them.

help them attain improved health outcomes without risk of losing insurance coverage or discrimination from employers will certainly encourage them to use pharmacogenetic services. Many community practitioners express concerns that their patients will not embrace such services if offered because of the fears posited above. Properly armed with knowledge about GINA, pharmacists can help diminish or remove this barrier between patients and improved health outcomes.

Many direct-to-consumer (DTC) genetic testing companies now exist and several are seeking partnership with community pharmacies. In this model (see Fig 1), the pharmacist would advertise the service and obtain buccal swabs from the patient to send to the DTC company for testing. The results of this test would then be sent back and incorporated into the patient’s health record to be consulted during In order to allay this fear and successfully incorporate phar- drug utilization review or medication therapy management. macogenetic services into their practice, pharmacists need To facilitate incorporation of this information, the partner to be familiar with and educate their patients regarding the DTC lab often provides software that will automatically detect gene-drug interactions when received.

Genetic Information Nondiscrimination Act (GINA) of 1 2008; While protected health information is always held === confidential under HIPAA, a patient’s health insurance Interested in finding out more about incorporating pharcompany may receive a patient’s genetic information incimacogenetic services into your practice? Join the dental to data exchanges as part of its regular course of CAPPNet listserv (http://pharmacy.mc.uky.edu/capp/ business. Title I of GINA specifically prohibits insurance cappnet.php) and stay tuned for CPE from UK College of companies from denying patients coverage2 or charging a Pharmacy on Implementing Pharmacogenetic Services in higher premium on the basis of a genetic test result.3 Title Community Pharmacy Practice!

II, on the other hand, focuses on employers, making it un1. Pub.L. 110-233, 122 Stat. 881 lawful for them to make decisions on hiring, promoting or in 2. 42 USC §300gg–53(a),(c) any way discriminating against an employee on the basis of a genetic test4 or to even attempt to acquire such genetic information5.

3. 42 USC §300gg–53(b)

Ensuring patients that their genetic information can only

5. 42 U.S.C. §2000f-1(b)

4. 42 U.S.C. §2000f-1(a)

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July 2013

Pharmacy Policy Issues Proposed Community Pharmacy Pharmacogenetic (PGx) Services Model PGx services advertised through in-store signage, patient leaflet inserts, or targeted recommendation

Patient inquires about new PGx services Consent

Collect buccal swab to obtain genetic sample Mail sample

Direct-to-Consumer (DTC) Genetic Testing Laboratory Partner

Patient Genetic Information Results returned to pharmacy R.Ph. performs DUR

Pharmacy electronic health record (EHR)

Comprehensive Medication Review (CMR) conducted as part of Medication Therapy

Patient presents with PGx interaction detected during computer-assisted DUR Interprofessional consultation and recommendation

R.Ph. Review and Assessment

Prescriber

R.Ph. counsels patient on conse-

Patient health outcomes are improved and patient-pharmacist relationship is strengthened

Figure 1. Proposed Pharmacogenetic Services Model in a Community Pharmacy.

Have an Idea?: This column is designed to address timely and practical issues of interest to pharmacists, pharmacy interns and pharmacy technicians with the goal being to encourage thought, reflection and exchange among practitioners. Suggestions regarding topics for consideration are welcome. Please send them to jfink@uky.edu.

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July 2013

Pharmacists Mutual

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APSC

July 2013

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THE KENTUCKY PHARMACIST

KPhA Board of Directors/Staff

July 2013

KPhA BOARD OF DIRECTORS

HOUSE OF DELEGATES

Kimberly Croley, Corbin kscroley@yahoo.com

Chair 606.304.1029

Cassandra Beyerle, Louisville cbeyerle01@gmail.com

Duane Parsons, Richmond dandlparsons@roadrunner.com

President 502.553.0312

Ethan Klein, Louisville kleinethan@gmail.com

Bob Oakley, Louisville Boakley@BHSI.com

President-Elect 502.897.8192

KPERF ADVISORY COUNCIL

Frankie Hammons Abner, Barbourville frankiehammons@gmail.com

Secretary 606.627.7575

Glenn Stark, Frankfort glennwstark@aol.com

Treasurer

Ann Amerson, Lexington amerson@insightbb.com

Ron Poole, Central City ron@poolespharmacycare.com

Past President

KPhA/KPERF HEADQUARTERS

Directors Heather Bryan, Mt. Washington Student Representative hcarby8529@my.sullivan.edu Matt Carrico, Louisville matt@boonevilledrugs.com

Vice Speaker of the House

Kim Croley, Corbin kscroley@yahoo.com

1228 US 127 South, Frankfort, KY 40601 502.227.2303 (Phone) 502.227.2258 (Fax) www.kphanet.org www.facebook.com/KyPharmAssoc www.twitter.com/KyPharmAssoc Robert McFalls, M.Div. Executive Director rmcfalls@kphanet.org

Chris Clifton, Erlanger chrisclifton@hotmail.com

Scott Sisco, MA Director of Communications & Continuing Education ssisco@kphanet.org

Trish Freeman, Lexington trish.freeman@uky.edu Brooke Herndon, Louisville brhe226@uky.edu

Speaker of the House

Student Representative

Chris Killmeir, Louisville cdkillmeier@hotmail.com Jeff Mills, Louisville* jeff.mills@nortonhealthcare.org Chris Palutis, Lexington chris@candcrx.com

Kelli Sheets Office Manager ksheets@kphanet.org Leah Tolliver, PharmD Director of Pharmacy Emergency Preparedness ltolliver@kphanet.org Nancy Baldwin Receptionist/Office Assistant nbaldwin@kphanet.org

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

KPhA sends email announcements weekly. If you arenâ&#x20AC;&#x2122;t receiving: eNews, Legislative Updates, Grassroots Alerts and other important announcements, send your email address to ssisco@kphanet.org to get on the list.

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50 Years Ago/Frequently Called and Contacted

July 2013

50 Years Ago at KPhA MEET THE BARBECUE CHAMPION A.E. Tucker, RPh, Bowling Green, who owns a drug store and is a State Representative, recently was featured in the Sunday Courier-Journal as a champion at cooking barbecue.

Here’s the story: Pharmacist’s Barbecue Could Win Votes Bowling Green residents who have sampled State Representative A.E. Tucker’s barbecue dishes would be inclined to vote overwhelmingly for his cooking.

The Democrat, who’s a pharmacist and owner of a drugstore, learned his barbecueing “20 years ago camping, while out hunting and fishing.”

He does some cooking indoors, but prefers outdoor barbecues for 12 to 20 guests.

For the past 10 years he has been using the same recipe for barbecue chicken. “I tried a number of others, but never found one I liked as well.”

- From The Kentucky Pharmacist, July 1963, Volume XXVI, Number 7.

Frequently Called and Contacted Kentucky Pharmacists Association 1228 US 127 South Frankfort, KY 40601 (502) 227-2303 www.kphanet.org Kentucky Board of Pharmacy State Office Building Annex, Ste. 300 125 Holmes Street Frankfort, KY 40601 (502) 564-7910 www.pharmacy.ky.gov Pharmacy Technician Certification Board 2215 Constitution Avenue Washington, DC 20037-2985 (800) 363-8012 www.ptcb.org

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

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

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

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

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

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July 2013

THE

Kentucky PHARMACIST 1228 US 127 South Frankfort, KY 40601

SAVE THE DATES KPhA Mid-Year Conference on Legislative Priorities November 2013 (Time and place TBD)

136th KPhA Annual Meeting and Convention June 5-8, 2014 Marriott Griffin Gate Resort and Spa Lexington, KY 56

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