The Kentucky Pharmacist Vol. 8 No. 5 by Kentucky Pharmacists Association

Y K C U T N E K E H T T S I C A M PHAR Vol. 8, No. 5 September 2013

f urs o o H 5 CE! E V I L

For mo re inform ation a nd to reg ister, g o to www. k Marriott Griffin Gate Resort, Lexington, KY November 15-16, 2013

phane t.org

Does your profile look like John Q. Pharmacist? Log in today at www.kphanet.org to update your information!

News & Information for Members of the Kentucky Pharmacists Association

Table of Contents

September 2013

Table of Contents Table of Contents— Oath— Mission Statement President’s Perspective Travels of Roamey, The KPhA Gnome KPhA Immunization Training 2013 KPhA Mid-Year Conference Message from Your Executive Director APSC 2013-14 KPhA Committees KPPAC Contribution Form Pharmacists Mutual/PTCB Bowl of Hygeia Sept. 2013 CE: Type 2 Diabetes Mellitus Sept. Pharmacist/Pharmacy Tech Quiz KPhA Emergency Preparedness Oct. 2013 CE: Migraine Headache

2 3 4 5 6 7 8 9 10 11 12 13 20 21 22

Oct. Pharmacist/Pharmacy Tech Quiz Kentucky Renaissance Pharmacy Museum KPhA New and Returning Members KPhA Government Affairs/Pharmacy Health Screenings Medicare Counseling HIPAA Privacy Changes APhA-ASP Summer Leadership Institute Cooper/Clayton Smoking Cessation Sessions Technician Review Pharmacy Law Brief Senior Care Corner Pharmacy Policy Issues Pharmacy Time Capsules Pharmacists Mutual Cardinal Health Generation Rx Award KPhA Board of Directors 50 Years Ago/Frequently Called and Contacted

30 31 32 34 35 36 37 38 39 40 41 42 43 44 45 46 47

Oath of a Pharmacist At this time, I vow to devote my professional life to the service of all humankind through the profession of pharmacy. I will consider the welfare of humanity and relief of human suffering my primary concerns. I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy outcomes for the patients I serve. I will keep abreast of developments and maintain professional competency in my profession of pharmacy. I will embrace and advocate change in the profession of pharmacy that improves patient care. I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public. The Kentucky Pharmacy Education and Research Foundation (KPERF), established in 1980 as a non-profit subsidiary corporation of the Kentucky Pharmacists Association (KPhA), fosters educational activities and research projects in the field of pharmacy including career counseling, student assistance, post-graduate education, continuing and professional development and public health education and assistance.

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

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.

THE KENTUCKY PHARMACIST

President’s Perspective

September 2013 that with professional experience. I believe our main strength aside from our technical knowledge is a deep passion and respect for our profession and our desire to provide quality care for our patients in whatever practice setting we serve.

PRESIDENT’S PERSPECTIVE

Pharmacy has always been a very dynamic profession. Changes come at a very rapid pace. We have to stay involved to affect these changes in a positive manner. One of the most important benefits KPhA provides for the profession is the alerts and information on bills that will impact everyday practice no matter the practice setting. None of us have the time to do this on an almost daily basis. KPhA provides that service. When there is a bill that we should either be against or support, KPhA provides a platform for all of us to voice comments and join grassroots efforts to affect the outcome of that bill. The lobbying done on our behalf is invaluable to each of us.

Duane W. Parsons KPhA President 2013-2014 The past couple of months as the president of your association have been, though hectic at times, quite a rewarding personal experience for me. Bob, Scott, and I, along with “Roamey,” have been able to visit with many of you in your workplaces. That alone is a great reward, but the excitement and passion for our profession exhibited by those we visited was just over the top. That was so encouraging, but then I thought, “I should expect that because for the most part we are visiting with pharmacists and associates that are involved in their profession and their associations. Why doesn’t that excitement and passion extend itself to all members of our profession?”

How to get others involved is often a difficult opportunity. We just need to keep encouraging others. Those who are involved usually have others that we look to for mentoring our professional involvement. That was probably not an easy task for our own mentors either, but they kept persevering. We can, too. We need to challenge each non KPhA member to join the organization and become involved now. They might not have time to serve on the Board of KPhA, but they might have time to serve on a committee or work group. The word that came to my mind was apathy. “Apathy” is deThey, too, can become mentors to other members of the profined as a lack of interest or emotion or just an indifference. fession. As we go about our daily routine, we need to keep We’ve all experienced this at points in our lives. I truly beon encouraging involvement to whatever level. Ask others if lieve we create our own career apathy by not being and staythe changes and challenges we face in our practices will afing involved in our own professional organizations and profect them. If the answer is “Yes”, remind them that they need fessional opportunities. When we relegate ourselves as pharto join the KPhA Team and support what’s going on in our macists to the humdrum of standing behind a counter—“lick, profession. Otherwise, we might not even be invited to comstick and pouring”—we create our own arenas for apathy. ment on issues of how we can better serve our patients. Those we have visited aren’t doing that. They are involved with their patients, their profession and the organizations that There is a definitive strength in numbers speaking with a loud voice. We need for that voice to become even louder. Our support them. legislators listen to those speaking in great volume. They The question becomes, “Why does an attitude of apathy hear concerns of those speaking that represent great numcreep in on some and not others?” For those of us who have- bers of their constituents. Let’s grow that number to such a n’t experienced apathy in our professional lives, the answer large volume that we can’t be ignored. We affect the daily is fairly simple. We stay involved. The challenge for us is to lives of the patients we serve in greatly positive ways. We make sure our colleagues don’t become a victim of apathy. need for our legislators to be fully aware of our impact. We need to challenge them to get and stay involved. We desire to be recognized with more opportunistic opportuNone of us have the time we need to do everything we want nities for collaborative care agreements. We desire to be recto do in our lives, but we always find time to do the important ognized with provider status within the healthcare system. To things. It might not mean that we devote lots of time to doing get there we must speak out even more. MEMBERSHIP everything, but we devote some time to things that matter. MATTERS!!! Our profession matters. I hope to visit many more of you in the coming months and When others have asked throughout my career what I do, I look forward to hearing your ideas and comments on how we always start with, “I am a pharmacist.” I can always follow can work together to advance this great profession. 3

THE KENTUCKY PHARMACIST

Roamey, the KPhA Membership Matters Gnome

September 2013

Follow Roamey on the KPhA Facebook Page, www.facebook.com/ KyPharmAssoc and on the KPhA Website (Roamey the KPhA Gnome link at the bottom of the home page). 4

THE KENTUCKY PHARMACIST

2013 KPhA Immunization Trainings

September 2013

2013 KPhA Immunization Training

During August, KPhA offered three Adult Immunization Training sessions around the Commonwealth. Special thanks to Cathy Hanna, Director of Research and Education with the American Pharmacy Services Cooperative, for traveling with us and providing excellent hands-on training!

Roamey traveled to all three trainings and had to have a picture with the trainees!

Barren River Lake State Resort Park

Natural Bridge State Resort Park

Kentucky Dam Village State Resort Park

THE KENTUCKY PHARMACIST

2013 KPhA Mid-Year Conference

September 2013

Marriott Griffin Gate Resort Lexington, KY November 15-16, 2013 $95 for Pharmacist Members $35 for Technician members $5 for Student Pharmacists

For the second straight year, YOUR KPhA will hold the Mid-Year Conference on Legislative Priorities. The schedule will include legislative presentations as well as continuing education on relevant topics like HIPAA changes implemented this fall, Hazardous Waste Disposal, Emergency Preparedness and Legislative Advocacy. We also will discuss the legislative priorities for the 2014 Kentucky Legislative Session. See you there!

Watch your eNews and the KPhA website for the latest information! Register now at www.kphanet.org! 6

THE KENTUCKY PHARMACIST

From Your Executive Director

September 2013

MESSAGE FROM YOUR

EXECUTIVE DIRECTOR Robert “Bob” McFalls Fall in Kentucky is a beautiful time. The leaves on many of our deciduous trees begin to change colors to vivid shades of red, orange and yellow along the miles and miles of backroads and, for us daily commuters, scenic interstates. Autumn is especially beautiful in the Great Smokey Mountains, and a drive to southeastern Kentucky is one of my favorite treks where the beauty reveals more of the Creator’s handiwork while benefitting from less mobile clog in other environs during this special time of year. President Parsons, Roamey the KPhA Membership Matters Gnome, Scott Sisco and I have been traveling many of these roadways since our Annual Meeting, meeting pharmacists and pharmacy technicians in your workplaces. We’ve enjoyed spending a few minutes discussing KPhA and the issues faced by all members of the pharmacy profession in Kentucky and look forward to more visits and working together to address the challenges and opportunities. If you have not already done so, be sure to check out Roamey’s travels on our Facebook page (www.facebook.com/ KyPharmAssoc) or on the KPhA Website (the link is at the bottom of our home page www.kphanet.org).

will include 10 hours per year so that technicians can get the 20 hours over two years they need to renew their certification. Technician members of KPhA are eligible to become members of the Academy at no additional cost (membership is $50 per year). For more information on the Academy and the FREE CE, see page 39 for a message from Academy Chair Don Carpenter. It’s also a good time to look forward to the final few months of the year and beyond. Last year, KPhA brought back the Mid-Year Conference with great reviews. We will continue to build on the success of that event with this year’s MidYear Conference on Legislative Priorities November 15-16 at the Marriott Griffin Gate Resort in Lexington. We’re planning continuing education programs on changes to HIPAA, Legislative Advocacy, Hazardous Material Disposal and Emergency Preparedness. We also will have legislative presentations to ramp up energy heading into the 2014 Kentucky Legislative Session. For the latest information on this event, be sure to check the KPhA Website (www.kphanet.org) and read your eNews. Stay connected to YOUR KPhA to receive the updates!

As the seasons begin to change and we bask in the beauty of Fall, it is a great time to reflect on the first half of 2013. KPhA has had a wonderful year, beginning with the success of passing Senate Bill 107 (with NO DISSENTING VOTES) which requires PBMs to disclose information to help you make better decisions for your business. We had a great Annual Meeting in Louisville with more than 250 pharmacists, pharmacy technicians and student pharmacists coming together to learn, laugh, network and establish Association policy.

Looking even further forward to a future season, I want to encourage you to mark your calendars for the 136th KPhA Annual Meeting and Convention June 5-8, 2014 at the Marriott Griffin Gate Resort in Lexington. This year marks the 100th anniversary of the first time KPhA held its annual meeting in Lexington. Special thanks to Gloria Doughty and the Kentucky Renaissance Museum for that historical factoid. Plan to be there and join in the celebration! It’s an exciting time in the pharmacy profession. Many changes are happening around all of us, and we want to do all we can to drive those changes together. YOUR KPhA is here to keep you informed and to advocate with YOU and on YOUR behalf. If you have questions, suggestions or just need an ear to bend for a few minutes, feel free to call on us, email me or drop in at the Association’s office in Frankfort. This is YOUR KPhA!

We also witnessed the creation of the new KPhA Academy of Pharmacy Technicians. This dedicated group is working on proposals to strengthen the profession and move the position of pharmacy technician from a job to a career. To help support this mission, members of the KPhA Academy will receive access to FREE online CE that is modeled after the Pharmacy Technician Certification Board’s exam. This

THE KENTUCKY PHARMACIST

APSC

September 2013

THE KENTUCKY PHARMACIST

2013-14 KPhA Committees

September 2013

2013-2014 KPhA Committees Executive Committee Kim Croley- Chair Frankie Abner Jeff Mills Bob Oakley Duane Parsons Glenn Stark Past Presidents Ron Poole - Chair Donnie Riley – Vice-Chair Johnny B. Anneken Joe Carr Jessika Chinn Leon Claywell George Hammons Melinda Joyce Dwaine Green Greg Naseman Anne Policastri Clay Rhodes Richard Slone Joel Thornbury Lewis Wilkerson Organizational Affairs Chris Clifton – Chair Lewis Wilkerson – Vice Chair Ralph Bouvette BC Childress Shane Fogle Matt Harman Brooke Herndon Casey Humes Joey Mattingly Pat Mattingly Judy Minogue Lance Murphy Duane Parsons Joel Thornbury Professional Affairs/ Public Affairs Cassy Beyerle – Chair

Anne Policastri – Vice-Chair Heather Bryan Justin Chafin Danielle Corbett Candace Robinson Cottle Allison Cubit Mark Edwards Cathy Hanna Jennifer M. Jaber Amy Larkin Jill Lee Jeff Mills Elizabeth Moore Meghann New Duane Parsons Misty Stutz Lisa Tang Molly Trent

Chris Killmeier John McFarland Anne Policastri Jill Rhodes Leah Tolliver Jonathan Van Lahr Kelly Whitaker

AD HOC COMMITTEES

Bob Oakley - Chair Ellen Barger Chad Corum Kim Croley Kyle Harris Alex Hughes Ashley Lanham Benjamin Mudd Duane Parsons Brent Simpkins Vance Smith Molly Trent

Ryan Hickson Duane Parsons Patricia Robinson Joel Thornbury Qurratulain Waheed Provider Status

New Practitioner Amanda Jett – Co-Chair Chad Corum – Co-Chair Alex Brewer Amanda Burton Khaai Le Meghann New Duane Parsons Megan Pendley Membership Engagement

Budget & Audit Glenn Starks – Chair Frankie Abner Kim Croley Trish Freeman Chris Killmeier Bob Oakley Duane Parsons Sam Willett

WORK GROUPS

Government Affairs

Emergency Preparedness

Richard Slone – Chair Ralph Bouvette Matthew Burke Peggy Canler Matt Carrico Leon Claywell Barry Eadens David Figg Larry Hadley Katie Herren Steve Hill Tom Houchens

Leah Caudill Len Gore Kyle Harris Duane Parsons Jacob Wishnia Health Information Technology Larry Blandford – Chair Barry Eadens Kyle Harris 9

Trish Freeman – Chair Nancy Barker Cassy Beyerle Ralph Bouvette Sarah Brouse Leon Claywell Holly Divine Barry Eadens Jan Gould Bill Grise Cathy Hanna Brooke Hudspeth Melinda Joyce Chris Killmeier Tracey Macaulay Bob McFalls Duane Parsons Bob Oakley Jill Rhodes Alyson Schwartz

For descriptions of the Committees and contact information for committee members, go to www.kphanet.org and click on About, Committees.

THE KENTUCKY PHARMACIST

KPPAC Contribution Form

September 2013

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

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

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

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

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

Anonymous Contributions: $50 per contributor, per election, maximum total of $1,000 per election.

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

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

THE KENTUCKY PHARMACIST

Pharmacists Mutual/PTCB

September 2013

Pharmacists Mutual Insurance offers Medicare Surety Bond In 2009 the Centers for Medicare and Medicaid Services (CMS) implemented Surety Bond Requirements for suppliers of Durable Medical Equipment, Prosthetics and Supplies (CMS-6006 -F). This ruling requires that each existing supplier must have a $50,000 surety bond to CMS.

To see if you qualify for a $250 Medicare Surety Bond, or would like information regarding our other products, please contact us:   

Pharmacists Mutual Insurance Company, through its subsidiary Pro Advantage Services, Inc. d/b/a Pharmacists Insurance Agency (in California), led the way to meet this requirement by negotiating  the price of the bond from $1,500 down to $250 for qualifying risks.

Call 800.247.5930 Extension 4260 E-mail medbond@phmic.com Contact a Pharmacists Mutual Field Representative or Sales Associate http:// www.phmic.com/phmc/services/ibs/Pages/ Home.aspx In Kentucky, contact Bruce Lafferre at 800.247.5930 ext. 7132 or 502.551.4815 or Tracy Curtis at 800.247.5930 ext. 7103 or 270.799.8756.

THE KENTUCKY PHARMACIST

Bowl of Hygeia

September 2013

Bowl of Hygeia Recipient Leon Claywell Gives Back to Community and Bowl of Hygeia Endowment Fund By Megan Roberson, Communications Manager for APhA Foundation Reprinted with permission of the APhA Foundation.

Leon Claywell, BSPharm, R.Ph., FACA, the 2013 Bowl of Hygeia Award recipient for Kentucky, has announced that he will match all contributions from Kentucky pharmacists to the Bowl of Hygeia endowment fund made after June 8, 2013. The owner of Medica Pharmacies in Bardstown and Shepherdsville, Claywell has a strong passion for community pharmacy and has dedicated his life to building a healthier community. As a community pharmacy owner, Claywell has devoted much of his time to community service. He is an active member of St. Joseph Parish in Bardstown, and for the past four years has provided medical supplies from his pharmacy to St. Joseph’s sister parish in Haiti. Claywell has also instituted a free vitamin program at the local elementary school and supported local youth sports teams by providing free first aid kits and offering use of his pharmacy parking lot for team fundraisers. Additionally, Claywell has provided countless health screenings for thousands of local patients as well as free and reduced flu vaccine clinics.

Claywell describes receiving the Bowl of Hygeia Award as “a plum after a long career in pharmacy.” He is humbled and truly honored to receive recognition for his service to the community. The inspiration for his generous offer to match all donations from Kentucky to the Bowl of Hygeia endowment fund stems from his love for pharmacy and community service.

Kentucky Contributors as of Aug. 26, 2013



Cassandra Beyerle



Cayce's Pharmacy, Inc.



Leon and Margaret Claywell



Brian Fingerson



George Hammons



Tom Houchens



Matthew and Aleshea Martin



Duane Parsons



Donald Riley



Patricia Thornbury



Simon Wolf

Claywell describes the $3,410 total contributions Bowl of Hygeia Award Help KPhA earn Leon’s Pledge! as the premier state Visit the Bowl of Hygeia page at pharmacy association www.aphafoundation.org award, and a means of to donate today! honoring community service and achievements of an individual pharmacist over time. He says he feels it is important that pharmacists understand that historically the Bowl has been financially supported by drug manufacturers. Personal sponsorship of the award has Claywell is passionate about promoting awareness of isbeen a challenge, but he believes the award should have a sues related to current and proposed rules and regulations permanent home and sponsor. “The APhA, NASPA and governing pharmacy. He advocates for community pharthe APhA Foundation are ideally situated to become that macy through his membership in professional pharmacy home,” says Claywell. “I think that individual pharmacists organizations, boards, and committees, including his serand pharmacist-supported organizations should consider vice as chairman of the Kentucky Pharmacists Political Adtaking on the responsibility of perpetuating the award for vocacy Council. He also frequently communicates with recognizing our deserving pharmacists of the future.” elected representatives at the local, state and federal levels about a variety of issues. Claywell is a powerful example of how pharmacists can When asked about his advice for young pharmacists, Claywell says they should look for opportunities to promote themselves and their pharmacy through service to the community. He encourages young pharmacists to become knowledgeable about each patient – his or her medical condition, as well as his or her personal and family situation. He feels it is important to understand patients’ needs in order to identify the appropriate course of action that will contribute to an improved quality of life.

make a significant impact on the lives and health of patients in their community. We applaud him for his careerlong service to the community and are grateful for his generous contribution to the Bowl of Hygeia. Through these gifts we are building the Bowl of Hygeia endowment so that pharmacists of his caliber can continue to be recognized for their service. To join Claywell in making a personal contribution to the Bowl of Hygeia endowment, visit the Bowl of Hygeia webpage at www.aphafoundation.org.

THE KENTUCKY PHARMACIST

Sept. 2013 CE-Type 2 Diabetes Mellitus

September 2013

Type 2 Diabetes Mellitus â&#x20AC;&#x201C; Management with a Patient-Centered Approach KPERF offers all By: Allison Meyer, PharmD, Auburn University Harrison School of Pharmacy Department of Pharmacy Practice, Mobile, AL; and Debbie Minor, PharmD, The University of Mississippi Medical Center Department of Medicine; Jackson, MS

CE articles to members online at www.kphanet.org

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. Universal Activity # 0143-9999-13-009-H01-P&T 1.5 Contact Hours (0.15 CEU) Goal To review guidelines for the management of type 2 diabetes mellitus and highlight recent updates that emphasize the need for a patient-centered approach. Objectives At the conclusion of this article, the reader should be able to: 1. 2. 3. 4.

Identify risk factors that influence the development of type 2 diabetes. Describe recommendations for the screening and diagnosis of type 2 diabetes mellitus. Review goals and considerations in the treatment of diabetes. Discuss the management of diabetes, highlighting the need for a patient-centered approach.

INTRODUCTION

DIAGNOSIS AND GOALS FOR TREATMENT

Diabetes mellitus is one of the most prevalent diseases and the seventh leading cause of death in the United States.1 This devastating disease affects more than 25 million Americans, approximately 8.3 percent of the population ages â&#x2030;Ľ 20 years old, and often leads to cardiovascular events as well as kidney failure, amputations and blindness. Approximately 90-95 percent of adults with diabetes have type 2 diabetes mellitus.1 Recent guidelines for management of this disease discuss a patient-centered and personalized approach to care. This review highlights components of the 2012 American Diabetes Association (ADA)/ European Association for the Study of Diabetes Position Statement for the Management of Diabetes and the ADA Standards of Medical Care in Diabetes.2,3

Unlike many other diseases, there is no distinction between the tests used for screening and diagnosis of diabetes mellitus. The diagnosis of diabetes can be made by A1c, fasting glucose, random glucose or a 2-hour plasma glucose after a 75 g glucose load (Table 2).2,4 Of these validated measures, A1c is a more stable and long-term measure of glucose and may be more convenient since fasting is not required.2 Though using A1c has advantages, it can be more costly than a fasting glucose and may vary based on race, age and other characteristics.2 Any of these tests should be repeated on a separate day if the first is elevated. If two different tests are performed, e.g., A1c and fasting glucose, the diabetes diagnosis is confirmed if both measures are above the threshold. If only one measure is increased, that specific test should be repeated and a diagnosis made if that result also is elevated.4

RISK FACTORS AND GUIDELINES FOR SCREENING Testing to identify asymptomatic individuals with type 2 diabetes mellitus is based on age and the presence of risk factors. The ADA recommends screening all people for diabetes starting at age 45 and as early as age 10 in individuals who are overweight (Body Mass Index [BMI] > 25 kg/ m2) and have risk factors (Table 1).2,4 Screening should be repeated every three years if a diagnosis of diabetes is not made. In patients who are at an increased risk of developing diabetes, screenings should be performed more frequently (Tables 1, 2).2

Ideally, fasting glucose levels should be between 70 and 130 mg/dL and post-prandial glucose levels less than 180 mg/dL for all patients with diabetes. The ADA recommends an A1c goal of < 7 percent for most patients, though a more or less stringent goal can be considered in selected patients. Targets for A1c should be individualized based on patient considerations (i.e., expected treatment efforts, potential risks, disease duration, life expectancy, important comorbidities, resources) and clinical judgment. The desires and values of the patient, along with consideration of 13

THE KENTUCKY PHARMACIST

Sept. 2013 CE-Type 2 Diabetes Mellitus Table 1: Risk Factors and Screening for Diabetes

September 2013 2,4

Screen people with no risk factors starting at age 45 years. With normal results, repeat screenings every 3 years. RISK FACTORS Physical inactivity Family history of diabetes (1st degree relative) Screen asymptomatic adults at any age with a BMI > 25 kg/m2 and one or more risk factors. With normal results, repeat screenings at 3-year intervals or more frequently if clinically warranted (e.g. pre-diabetes, risk status).

Ethnicity (e.g. African American, Latino, Native American, Asian American, Pacific Islander) Delivery of a baby > 9 lbs or diagnosis with gestational diabetes Blood pressure > 140/90 or taking antihypertensives HDL-cholesterol < 35 mg/dL and/or triglycerides > 250 mg/dL Polycystic ovary syndrome (PCOS) Pre-diabetes (see table 2) Cardiovascular disease Conditions with insulin resistance (e.g. severe obesity, acanthosis nigricans) Family history of diabetes (1st or 2nd degree relative)

Screen asymptomatic children starting at age 10 years or at onset of puberty if overweight plus 2 additional risk factors. Repeat screenings every 3 years.

potential benefits and risks, need to be applied with every treatment decision (Table 3). 2,6

Ethnicity (as above) Signs of insulin resistance (e.g. hypertension, dyslipidemia, PCOS, acanthosis nigricans) Maternal history of diabetes or gestational diabetes during childâ&#x20AC;&#x2122;s gestation

Table 2: Diagnosis of Pre-Diabetes and Diabetes2,4 Increased Risk for Diabetes (Pre-Diabetes) A1c 5.7-6.4 percent Impaired fasting glucose (100 -125 mg/dL) Impaired glucose tolerance (140 -199 mg/dL, 2 hours after 75 g glucose load)

overall populations and support a less stringent A1c goal for some paA1c > 6.5 percent 3 8-hour fasting plasma glucose tients. Though the risk of microvascular and > 126 mg/dL 2-hour plasma glucose > 200 macrovascular complicamg/dL (after 75 g glucose tions of diabetes are load) clearly related to glyceSymptoms and random mia, a patient-centered glucose > 200 mg/dL approach will more appropriately align the needs, preferences and tolerances of each patient.3 Diabetes Diagnosis

These recommendations for individualization of A1c and treatment goals are based on the results of studies suggesting that not all patients benefit from aggressive glucose management.2 The UKPDS study evaluated the effect of medications (metformin, insulin or sulfonylurea) vs. dietary restriction in newly diagnosed patients with diabetes on cardiovascular events and microvascular complications (vitreous hemorrhage, retinopathy, nephropathy). After a 10-year follow-up, patients receiving medications had a significant decrease in microvascular disease, myocardial infarctions and all-cause mortality. These findings support the recommendation for more aggressive glucose management in newly diagnosed patients, with the hope of preventing cardiovascular and microvascular complications.5 The ACCORD, ADVANCE and VADT trials evaluated patients with cardiovascular disease or risk factors and longstanding diabetes. These trials did not show a cardiovascular benefit with intensive glycemic control (A1c < 6 percent vs. A1c 7-8 percent) in the

ANTIHYPERGLYCEMIC THERAPY Lifestyle Over-nutrition and sedentary lifestyle are the major environmental factors that increase the risk of developing type 2 diabetes; hence, diet, exercise and education are a critical part of management and prevention. Progression to diabetes can be slowed or potentially prevented through therapeutic lifestyle changes (TLC) and possibly medications. 4 The Diabetes Prevention Program, a study of 3,234 prediabetic patients over 2.8 years, highlights the value of lifestyle behaviors in diabetes prevention. This study randomized patients to placebo or metformin 850 mg twice daily, both with standard lifestyle recommendations, or intensive

THE KENTUCKY PHARMACIST

Sept. 2013 CE-Type 2 Diabetes Mellitus Table 3: A1c Goals and Considerations A1c < 7 percent Consider A1c < 6.5 percent

Consider A1c < 8 percent

September 2013 difficult to know which treatment options are best for a patient. When choosing agents and treatment goals, a patientcentered approach should be utilized. Specific patient and medication characteristics should be considered, including the efficacy of the drug, potential for hypoglycemia, effect on weight, potential side effects, costs and preferences. For example, older patients with long-standing diabetes are at more risk for hypoglycemia, which can cause unsteadiness, falls and potentially fractures. They also are more likely to have comorbidities, such as renal disease, heart failure and osteoporosis, which can limit the use of certain medications or increase the risk of adverse effects. Because most patients with diabetes are overweight or obese, the effect of medications on weight is an important concern.3

2,3

Most patients Younger patients Recently diagnosed No frequent/severe hypoglycemia No significant cardiovascular disease Highly motivated Elderly patients Longstanding diabetes Frequent/severe hypoglycemia Significant cardiovascular disease or cardiovascular risk factors Extensive comorbidities Difficult-to-treat diabetes

Metformin, if not contraindicated, should be initiated in most patients unable to achieve their A1c goal with TLC. Based on an individual patientâ&#x20AC;&#x2122;s needs or preferences or if metformin cannot be used, a sulfonylurea, thiazolidinedione (TZD), lifestyle modifications alone. Patients randomized to intendipeptidyl peptidase 4 DPP-4 inhibitor (DPP-4I), glucagonsive lifestyle changes underwent an individualized 16like peptide-1 (GLP-1) agonist or insulin may be a reasonacourse curriculum with a focus on healthy eating habits (low ble option as first, second or third line therapy. In general, if -fat, low-calorie diet) and moderate exercise (150 minutes glucose targets are not achieved after 3 months of therapy per week) to achieve a 7 percent weight loss from baseline. with TLC and metformin or baseline A1c is high (> 9 perThe incidence of new-onset diabetes was lowest in the incent), combination therapy with one or two additional agents tensive lifestyle group and highest with placebo, with signifi- from the above classes is recommended (Table 4). Other cant differences between all three groups. Based on these agents or classes (e.g. meglitinides, alpha-glucosidase inresults, 6.9 patients would need to undergo intensive lifehibitors, bile acid sequestrants, amylin mimetics, dopaminestyle modifications and 13.9 would need to take metformin 2 agonists) also may be appropriate for selected patients.3 to prevent one case of diabetes in three years.6 Weight loss Metformin, sulfonylureas, TZDs and GLP-1 agonists reduce and exercise also improve coincident cardiovascular risk A1c by 1-1.5 percent, whereas the other non-insulin agents factors and other consequences of obesity.3,7 lower A1c by only 0.5-1%. For this reason, patients with an All newly diagnosed patients and those at risk for developA1c > 9 percent at diagnosis can reasonably be started on a ing diabetes should be counseled on necessary TLC.2,3 two-drug regimen and potentially insulin. Initiating insulin Suggestions for dietary interventions, physical activity and should be highly considered in patients with severely unconweight reduction should be personalized with considerations trolled diabetes with catabolism, either at the time of diagnofor the individualâ&#x20AC;&#x2122;s preferences and culture. Ideally, TLC sis or later in treatment. Those with fasting glucose levels > consists of moderate exercise for at least 150 minutes per 250 md/dL, consistent random glucoses > 300 mg/dL, ketoweek and a healthy diet to include increased fiber and nuria, an A1c > 10 percent or symptomatic diabetes, should whole grains and decreased saturated fat, carbohydrates receive insulin to rapidly lower glucose levels. Eventually and calories. A modest weight reduction of 5 to 10 percent many patients require insulin therapy, including basal and can improve glycemic control and other cardiovascular risk shorter-acting.2,3,7 factors. Patients that are highly motivated and have an A1c Metformin near target (<7.5 percent) can be given a 3 to 6 month trial Metformin, a biguanide, is first line therapy for most patients of TLC before pharmacotherapy. For those with a higher with type 2 diabetes.2,3,7 This medication works primarily by A1c, successful TLC can allow for modification or possible discontinuation of pharmacotherapy. TLC requires periodic lowering fasting glucose and decreasing hepatic glucose assessment and counseling should be an integrated part of production. The most common side effects of metformin are gastrointestinal upset and diarrhea. These side effects can maintenance treatment. 3 be minimized by taking the medication with food, starting Pharmacotherapy with 500 mg daily and slowly titrating to 1000 mg twice daily With the frequent emergence of new medications, it can be as tolerated. Metformin is contraindicated in patients at risk 15

THE KENTUCKY PHARMACIST

Sept. 2013 CE-Type 2 Diabetes Mellitus Table 4: Treatment of Diabetes

September 2013

2,3

Therapeutic Lifestyle Changes for All Patients Initial Drug Therapy Two-Drug Regimen Three-Drug Regimen

Complex Insulin Regimen

Metformin ADD Sulfonylurea ADD TZD or DPP-4I or GLP-1 agonist or Insulin

ADD TZD ADD Sulfonylurea or DPP-4I or GLP-1 agonist or Insulin

ADD DPP-4I ADD Sulfonylurea or TZD or Insulin

ADD GLP-1 Agonist ADD Sulfonylurea or TZD or Insulin

ADD Insulin ADD TZD or DPP-4I or GLP-1 agonist

Multiple daily doses of insulin

activation of the nuclear transcription factor PPAR-Îł.7 These agents do not generally cause hypoglycemia and may be more effective in overweight individuals; however, they are associated with weight gain. Because TZDs commonly cause edema, they are contraindicated in NYHA Class III/IV heart failure. TZDs also have been linked to bone fractures.7 In 2010, the FDA restricted access to rosiglitazone due to increased risk of myocardial infarction and other cardiovascular disease events.8 Use currently is limited to patients already controlled on this medication or who cannot be controlled on other anti-diabetic agents. Practitioners and special mail-order pharmacies wanting to provide rosiglitazone must be enrolled in the AvandiaRosiglitazone Medicines Access Program.8 Because of these restrictions, pioglitazone is more widely used.2,3 This agent may decrease triglyceride and increase HDLcholesterol levels, the typical pattern of dyslipidemia in patients with diabetes. A recent study with pioglitazone Sulfonylureas showed a potential risk of bladder cancer, though this mediSulfonylureas are the oldest marketed class of oral diabetes cation is not renally cleared and requires no dosage reducmedications.2,3 The most commonly used medications in tion in kidney disease. Pioglitazone has a modest cardiothis class are the 2nd generation agents: glimepiride, glipiz- vascular benefit when added to standard diabetes regimens ide and glyburide. Sulfonylureas stimulate insulin release in patients with macrovascular disease.2,3 from pancreatic beta cells and reduce hepatic glucose outIncretin System: DPP-4Is and GLP-1 Agonists put.3,7 The glucose-lowering effects are rapid in comparison to some other classes and are near fully realized at halfThe oral DPP-4Is (alogliptin, linagliptin, saxagliptin, maximal doses; higher doses should generally be avoided. sitagliptin) and injectable GLP-1 agonists (exenatide, liragBecause insulin release is independent of glucose intake, lutide) work through the incretin system. These medications the potential for prolonged hypoglycemia is high, particular- either mimic the actions of the physiologic hormone GLP-1 ly in the elderly. Glyburide is associated with a substantially or prevent the degradation of GLP-1 and glucosegreater risk of hypoglycemia compared with other 2 nd gendependent insulinotropic peptide (GIP) by DPP-4. These eration sulfonylureas and thus is non-preferred. An average incretin hormones are secreted in the small intestine in a weight gain of approximately 2 kg is common with therapy. 7 glucose-dependent manner. Ingestion of food triggers GLPSulfonylureas reduced myocardial infarction and microvas- 1 release which then lowers glucose levels by stimulating cular disease compared to dietary management in the 10insulin and inhibiting glucagon secretion. GLP-1 agonists year follow-up of the UKPDS study.6 The low cost of suland DPP-4Is primarily decrease post prandial glucose; fonylureas is attractive for many patients. however, they also lower fasting plasma glucose. 2,3,7 The GLP-1 agonists also slow gastric emptying and decrease Thiazolidinediones appetite, offering an attractive option for many obese paPioglitazone and rosiglitazone increase insulin sensitivity by tients as they modestly decrease weight. The DPP-4Is are of lactic acidosis (e.g., advanced renal insufficiency, alcoholism) and prescribing guidelines warn against use in patients with a serum creatinine > 1.5 mg/dL in males or > 1.4 mg/dL in females. Recent studies and clinical experience suggest, however, that metformin is safe unless the estimated glomerular filtration rate falls below 30 mL/minute. The major non-glycemic effect of metformin is either weight stability or modest weight loss. This provides an additional benefit for obese patients, though it also is effective in leaner patients. This medication does not cause hypoglycemia and is inexpensive, making it a well-tolerated and convenient first line agent for most patients.2,3,7 In the 10-year follow-up of the UKPDS study, metformin reduced cardiovascular events and mortality compared to dietary management. Patients receiving metformin as initial therapy had fewer cardiovascular events than patients receiving a sulfonylurea or insulin.6

THE KENTUCKY PHARMACIST

July 2013 CE—Pediatric OTC

September 2013

weight neutral. Neither of these incretin-based classes cause hypoglycemia. The most common side effects of GLP-1 agonists are nausea and vomiting, particularly early in therapy. DPP-4Is are generally well tolerated, though reports of urticarial and angioedema have occurred. Pancreatitis has questionably been associated with both classes. In animals, GLP-1 agonists have been linked to thyroid tumors. DPP-4Is and GLP-1 agonists are not recommended for combination as they target the same pathway. GLP1 agonists and DPP-4 antagonists may also decrease cardiovascular risk factors, but long-term benefits have not been studied.2,3,7 Insulin Diabetes progression causes dysfunction and loss of pancreatic beta-cells.2,3 When the pancreas can no longer produce and secrete enough insulin to maintain normal glucose levels, patients require exogenous insulin.2,3 Basal insulin, either intermediate-acting (NPH) or longacting (glargine and detemir), is initiated prior to meal time insulin in most patients.2,3 The long-acting insulins are typically dosed once daily and may be associated with less nocturnal hypoglycemia. NPH usually is dosed twice daily and is generally a less expensive option than the longacting insulins.2,3 Initially, patients should be started on basal insulin at approximately 0.1-0.2 units/kg/day.2,3,7 Many patients can be educated to self-titrate, with small dose increases (e.g., 1-2 units) once or twice a week until fasting glucose targets are achieved.3 Allowing self-titration engages the patient as an active member of the care team and is more convenient, though the practitioner should maintain frequent contact. Patients unable to maintain goal glucose levels with a noninsulin regimen along with basal insulin should receive prandial insulin.2,3 Rapid insulin – lispro, aspart and glulisine – has a quick onset of action and is dosed just prior to meals. The onset of action of regular insulin is about 30 minutes, which may be an inconvenience. These shorteracting insulin regimens should be titrated and individualized based on a patient’s typical diet, changes in carbohydrate intake and exercise to achieve goal glucose levels.2,3 One approach involves adding insulin to one meal at a time, starting with the meal with the highest carbohydrate intake. This highly individualized approach takes into account the patient’s diet and typical post-prandial glucose measurements. A second approach involves using a fixed combination of intermediate-acting insulin with a prandial insulin administered twice daily with breakfast and dinner. This approach is less flexible compared to the insulin dose of the components; however, it may be convenient and ac17

ceptable for patients with regular eating habits and a need for a more simplistic regimen.3,7 For most patients, metformin should be continued once insulin is initiated as it increases insulin sensitivity. Insulin secretagogues (e.g., sulfonylureas, meglitinides), however, do not provide additional benefit and increase the risk of hypoglycemia. These agents may be continued if the patient is only receiving basal insulin, but should be discontinued once prandial insulin is initiated. All insulin regimens have been associated with weight gain. TZDs in combination with insulin also may cause excessive edema and weight gain. Insulin clearance may be slower in renal disease; caution should be used when titrating. In patients with advanced liver disease, insulin is the preferred agent. Recent data suggests that GLP-1 agonists with insulin may be beneficial in some patients.3 Meglitinides, Alpha-Glucosidase Inhibitors, SodiumGlucose Co-Transporter 2 Inhibitor, Bile Acid Sequestrants, Amylin Mimetics, Dopamine-2 Agonists The following medications and classes are used less commonly because of either limited efficacy, a high propensity for adverse effects or higher costs. However, for selected patients, they each may offer an acceptable option based on individual preference or need. The meglitinides, nateglinide and repaglinide, stimulate insulin secretion, similar to the sulfonylureas.2,3,7 These medications, however, have a much shorter half-life and must be dosed with each meal, which may affect compliance. Side effects are similar to the sulfonylureas, though they may cause less hypoglycemia.2,3,7 Acarbose and miglitol are alpha-glucosidase inhibitors that slow carbohydrate absorption in the gut, decreasing postprandial glucose.2,3,7 They require dosing with each meal, and because of their site of action, they frequently cause gastrointestinal symptoms, such as flatulence.2,3,7 Canagliflozin, the newest medication for diabetes, is a sodium-glucose co-transporter 2 (SGLT2) inhibitor that lowers the renal threshold for glucose and increases urinary glucose excretion. This medication specifically reduces reabsorption of glucose filtered through the renal tubules and lowers A1c approximately 1 percent. It has been studied as both mono- and combination therapy. Increased urination, myocotic infections and urinary tract infections were observed in clinical trials.9 The overall role of canagliflozin in diabetes management is yet to be determined. Colesevelam is a bile acid sequestrant more commonly used in hyperlipidemia to decrease LDL cholesterol.2,3,7 The mechanism of action in diabetes is poorly understood.

THE KENTUCKY PHARMACIST

Sept. 2013 CE-Type 2 Diabetes Mellitus

September 2013

Colesevelam may increase triglyceride levels and may cause constipation. There is a potential for drug interactions by binding to other medications.2,3,7

as a team can effectively impact disease management and outcomes for many patients with diabetes.

REFERENCES Pramlintide works through the incretin system and activates 1. Centers for Disease Control and Prevention. National amylin receptors. It is administered subcutaneously and diabetes fact sheet: national estimates and general has effects similar to the GLP-1 agonists. Use is limited information on diabetes and prediabetes in the United because of modest efficacy, side effects and frequent dosStates, 2011. Atlanta, GA: U.S. Department of Health ing schedule. It is typically reserved for patients treated with and Human Services, Centers for Disease Control and intensive insulin therapy.3,7 Prevention, 2011. The dopamine-2 agonist bromocriptine modulates hypotha2. American Diabetes Association. Standards of Medical lamic regulation of metabolism and increases insulin sensiCare in Diabetes – 2013. Diabetes Care 2013;36:S11tivity. Though it does not cause hypoglycemia, use is limS66. ited by the high cost and dopaminergic-type adverse effects.3 3. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of Hyperglycemia in Type 2 Diabetes: A PatientCONCLUSION Centered Approach. Diabetes Care 2012;35:1364-79. Diabetes is a disease that is associated with numerous complications, increased medical costs and increased mor- 4. Inzucchi SE. Diagnosis of Diabetes. NEJM 2012;367:542-50. bidity and mortality. The risk factors for this disease are epidemic in our population. Methods for diagnosis have 5. Holman RR, Paul SK, Bethel MA, et al. 10-year followevolved over the years with A1c as the most recent addiup of intensive glucose control in type 2 diabetes. N tion. Based on recent research and findings, the goals of Engl J Med 2008;359:1577–1589. therapy and recommendations for the management of indi6. Diabetes Prevention Program Research Group. Reducvidual patients have been refined. With the many options tion in the incidence of type 2 diabetes with lifestyle available for treatment, the choice to use specific agents in intervention or metformin. NEJM 2002;346:393-403. type 2 diabetes mellitus should be patient-centered, focusing on both patient and disease factors. Communication 7. Nathan DM, Buse JB, Davidson MB, et al. Medical and engaging the patient in medication selection will help management of hyperglycemia in type 2 diabetes: a ensure compliance, avoidance of adverse effects and apconsensus algorithm for the initiation and adjustment of propriate disease management. Motivating patients to adtherapy: a consensus statement of the American Diadress necessary TLC remains a critical part of managebetes Association and the European Association for the ment. Ultimately, it is the patient who decides how well his/ Study of Diabetes. Diabetes Care. 2009;32:193-203. her diabetes will be managed. Using a patient-centered approach encourages attention to the variable and progres- 8. FDA Drug Safety Communication: Updated Risk Evaluation and Mitigation Strategy (REMS) to Restrict Acsive nature of type 2 diabetes and is crucial for improving cess to Rosiglitazone-containing Medicines including outcomes. Avandia, Avandamet, and Avandaryl. FDA Website: Pharmacists and pharmacy technicians encounter patients http://www.fda.gov/Drugs/DrugSafety/ucm255005.htm. with diabetes on a daily basis. We are in a unique position 9. INVOKANA™(canagliflozin) product labeling. 2013 to influence patient care and decisions, particularly in the Janssen Pharmaceuticals, Inc. Titusville, NJ. areas of medication use and selection and lifestyle behaviors. By understanding current issues related to therapy, we

Marriott Griffin Gate Resort



$95 for Pharmacist Members

Lexington, KY



$35 for Technician members

November 15-16, 2013



$5 for Student Pharmacists

THE KENTUCKY PHARMACIST

September 2013

Sept. 2013 CE-Type 2 Diabetes Mellitus

September 2013 — Type 2 Diabetes Mellitus – Management with a Patient-Centered Approach 1. All people should be screened for diabetes beginning at age: A. 10 years. B. 45 years. C. 60 years.

7. What initial treatment would be reasonable for Patient A? (Assume no co-morbidities and normal renal function) A. TLC B. TLC and metformin C. TLC and pramlintide D. Either A. or B.

2. Which of the following would not warrant a diabetes screening prior to age 45? A. Family history of diabetes B. African American ethnicity C. LDL-cholesterol > 160 mg/dL D. Polycystic ovarian syndrome

8. Sulfonyureas are associated with all of the following EXCEPT: A. hypoglycemia. B. glucose-dependent insulin secretion. C. weight gain. D. rapid glucose lowering.

3. Based on results of the Diabetes Prevention Program, the most effective way to prevent progression of prediabetes to diabetes is: A. metformin. B. intensive lifestyle modification. C. insulin. D. glipizide.

9. Weight gain is associated with all of the following classes of medications EXCEPT: A. sulfonylureas. B. insulin. C. GLP-1 agonists. D. TZDs.

4. For most patients with diabetes, an A1c goal of < 6.5 percent is acceptable. A. True B. False

10. For most patients, insulin is most appropriately initiated as: A. basal insulin once or twice daily. B. prandial insulin with each meal. C. prandial plus basal insulin twice daily.

5. An 80 year old woman has had diabetes for 15 years. She has osteoporosis and frequently becomes hypoglycemic. What is the most appropriate A1c goal for her? A. < 7 percent B. < 10 percent C. < 6.5 percent D. < 8 percent

11. Colsevelam and bromocriptine are less frequently used in diabetes because of: A. cost. B. side effects. C. less relative efficacy. D. one or all of the above.

6. Patient A has an A1c of 6.8 percent and fasting glucose of 135 mg/dL. Does this patient have diabetes? A. Yes B. No

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.

THE KENTUCKY PHARMACIST

Sept. 2013 CE-Type 2 Diabetes Mellitus

September 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: September 10, 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. September 2013 — Type 2 Diabetes Mellitus – Management with a Patient-Centered Approach Universal Activity # 0143-9999-13-009-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C 2. A B C D

3. A B C D 4. A B

5. A B C D 6. A B

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

9. A B C D 10. A B C

11. 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 September 2013 — Type 2 Diabetes Mellitus – Management with a Patient-Centered Approach Universal Activity # 0143-9999-13-009-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C 2. A B C D

3. A B C D 4. A B

5. A B C D 6. A B

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

9. A B C D 10. A B C

11. 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.

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

THE KENTUCKY PHARMACIST

KPhA Pharmacy Emergency Preparedness

September 2013

September is Emergency Preparedness Month 

KPhA, in conjunction with the Kentucky Renaissance  Pharmacy Museum, is planning an Open House to celebrate Pharmacists Month in October at KPhA Headquarters in Frankfort. We plan to have the Mobile Pharmacy set up for demonstrations to the public and se lected exhibits from the museum. Watch eNews for more information.

As KPhA leaders travel around the state to pharmacies, we are promoting the emergency preparedness program. When KPhA visits your pharmacy, be sure to ask about how you can help in the event of a disaster! If you are interested in hosting an Emergency Preparedness CE program in your area, please contact Leah Tolliver at 502-227-2303 or ltolliver@kphanet.org.

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

October is American and Kentucky Pharmacists Month! Share your pictures of celebrations on our Facebook Page: facebook.com/KyPharmAssoc 21

THE KENTUCKY PHARMACIST

Oct. 2013 CE â&#x20AC;&#x201D; Migraine Headache

September 2013

Migraine Headache: Updated Recommendations for Preventive Therapy By: Emily White, PharmD, Kris Harrell, PharmD, and Deborah Minor, PharmD, University of Mississippi Medical Center, Departments of Pharmacy, Pharmacy Practice and Medicine 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. Universal Activity # 0143-9999-13-010-H01-P&T 2.0 Contact Hours (0.2 CEUs)

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

Goal: To discuss migraine headaches and recent guideline updates for evidence-based preventive treatment. Objectives: At the conclusion of this lesson, the reader should be able to: 1. Review the pathophysiology and clinical presentation of migraine 2. Discuss indications for and considerations in selection of preventive migraine therapy 3. Describe preventive therapy recommendations based on evidence provided in recent guideline updates INTRODUCTION Headache is one of the most common complaints encountered by healthcare practitioners and among the top three reasons given by adults for visiting United States emergency departments. Migraine headache, one of the most common primary headache disorders, affects approximately 6 percent of men and 18 percent of women and occurs during the most productive years of life (18 to 59 years of age).1,2 The pain and other associated symptoms of migraine can not only diminish the quality of life for those with the headache, but also have a great impact on family members and employers. Despite the high prevalence of migraine headaches, studies indicate that most headache sufferers do not seek appropriate medical care. Patients with migraines are underdiagnosed and undertreated.1,2 In 2004, it was found that only one-half of patients with evident symptoms of migraine had been formally diagnosed by a physician.2 Appropriate care with an individualized approach to treatment can result in a reduction in attack frequency and severity, thus minimizing headache-related disability and emotional distress and improving the patientâ&#x20AC;&#x2122;s quality of life.1,2 Treatment strategies for migraine must address both immediate and long-term goals. Acute migraine therapies should provide consistent, rapid relief and enable the patient to resume normal activities at home, school or work. Recurrence of symptoms and treatment-related adverse effects should be minimal. When migraine attacks occur frequently or symptomatic therapies are ineffective, preventive therapy should be considered.2 In April 2012, new recommendations for the treatment of episodic migraine prevention in adults were released from the collaborative efforts of the

American Academy of Neurology (AAN) and the American Headache Society (AHS).3,4 These guidelines build upon the previous standards and review contemporary evidence supporting the use of pharmacologic, nonsteroidal antiinflammatory drug (NSAID) and complementary therapies for migraine prevention.3,4 The goal of this review is to discuss the general pathophysiology and clinical presentation of migraine headaches and describe options for preventive therapy, in reference to the recently published guidelines for preventive treatment. PATHOPHYSIOLOGY OF MIGRAINE Migraine headaches are defined as episodic, neurovascular events involving severe, pulsating head pain often accompanied by a wide variety of secondary symptoms. Theories of the etiology and pathophysiology of migraine have evolved over the past decade, but remain less than completely understood.2,5 Migraines appear to result from complex central nervous system (CNS) dysfunctions in the trigeminovascular system.6 Cerebral vascular tone and nociception are altered and the associated pain and symptoms are a combination of altered perceptions resulting from neural suppression and activation of subcortical structures and trigeminal systems. Neuronal and broad sensory processing are thought to be regulated at least in part by serotonergic neurons in the brainstem. Genetic factors appear to influence CNS sensitivity to migraine-specific triggers or environmental factors and the susceptibility to attack occurrence and frequency.2,7 CLINICAL PRESENTATION OF MIGRAINE The clinical presentation of the migraine attack can typically be divided into several phases (Table 1).2,8 Migraine headaches, with or without aura, typically begin with a gradual

THE KENTUCKY PHARMACIST

Oct. 2013 CE — Migraine Headache

September 2013

Table 1: Clinical Presentation of Migraine Headache General Common, recurrent, severe primary headache disorder that interferes with normal functioning. Two major subtypes - migraine without aura and migraine with aura. A thorough headache history should include age at onset, attack frequency and timing, duration of attacks, precipitating or aggravating factors, ameliorating factors, description of neurologic symptoms, characteristics of the headache pain (quality, intensity, location and radiation) and associated signs and symptoms. Signs and Symptoms Characterized by recurring episodes of throbbing pain, that last from 4 to 72 hours when untreated. Signs include a stable pattern, absence of daily headache, positive family history for migraine, normal neurologic examination, presence of triggers, menstrual association, long-standing history, improvement with sleep and subacute evolution. Premonitory Symptoms Occur in the hours or days before headache onset. Include neurologic (e.g., allodynia, phonophobia, photophobia, hyperosmia, difficulty concentrating), psychological (e.g., anxiety, depression, euphoria, irritability, drowsiness, fatigue, hyperactivity, restlessness), autonomic (e.g., polyuria, diarrhea, constipation) and constitutional symptoms (e.g., anorexia, food cravings, stiff neck, excessive yawning, extreme thirst). Aura A complex of positive and negative focal neurologic symptoms that precede or accompany an attack. Aura is most often visual, frequently affecting half the visual field. Sensory and motor symptoms (e.g., paresthesias or numbness of arms/ face, dysphasia or aphasia, weakness, hemiparesis) also may occur. Symptoms typically evolve over 5 to 20 minutes and last < 60 minutes, with headache usually occurring within 60 minutes of the end of the aura. Headache Pain is usually gradual in onset, peaking in intensity over minutes to hours and often severe. Headache is typically unilateral, in the frontotemporal region, but can occur anywhere or become generalized during the attack. Gastrointestinal symptoms almost invariably accompany the headache (e.g., nausea, vomiting, diarrhea, cramping). Other systemic symptoms (e.g., facial/scalp/periorbital edema, nasal stuffiness) and sensory hyperacuity (e.g., photophobia, phonophobia, osmophobia) also are common. Pain is usually aggravated by physical activity. Not all symptoms are present at every attack. Resolution As the headache pain wanes, various symptoms and mood changes are experienced. Symptoms range from tiredness, irritability, malaise, impaired concentration and scalp tenderness to feeling unusually refreshed or euphoric. onset of pain, most often unilaterally, near the frontal or temporal regions of the brain. The pain can become more generalized as the headache progresses. “Premonitory symptoms” are experienced by 20 percent to 60 percent of migraineurs and can occur in the hours or days before the onset of headache. These symptoms can vary widely among migraineurs but usually are consistent within an individual. The terms “prodrome” and “warning symptoms” should be avoided as these are often used mistakenly to include aura. Approximately one-third of migraine patients do experience auras, a multifaceted combination of focal neurological symptoms that occur just before or occasionally during a migraine attack.2,7,8 Migraines frequently occur in early mornings, but can happen at any time of day. Secondary symptoms including sensory, cognitive and especially gastrointestinal-related can accompany the headache and further impair daily activities. Even after the headache pain dissipates, psychological or neurological symptoms may persist for hours.2,8 CONSIDERATIONS FOR PREVENTIVE TREATMENT Approximately 25 percent of patients who suffer from severe migraines experience four or more attacks over a

Table 2: Goals of Therapy in Long-Term Migraine Treatment  Reduce migraine frequency, severity and disability  Reduce reliance on poorly tolerated, ineffective or unwanted acute pharmacotherapies  Improve quality of life  Prevent headache  Avoid escalation of headache medication use  Educate and enable patients to manage their disease  Reduce headache-related distress and psychological symptoms month.5 Frequent use of acute treatments is less than optimal management and can exacerbate headaches, leading to the development of medication-overuse or rebound headaches. To prevent medication-overuse headaches from occurring, it is recommended that acute treatments be limited and prophylactic therapy be considered.2 Unfortunately, it is estimated that only 3 to 13 percent of the 38 percent of patients who qualify for migraine preventive therapy actually receive it.1 Preventive therapy should be considered in the setting of

THE KENTUCKY PHARMACIST

Oct. 2013 CE — Migraine Headache

September 2013

Table 3: Preventive Migraine Therapies Drug β-Adrenergic antagonists AtenololB A

Metoprolol

NadololB Propranolol

TimololA

Initial Dose

Usual Range

Comments

50 mg/day

50–200 mg/day

100 mg/day in divided doses

100-200 mg/day in divided doses

40-80 mg/day

80–240 mg/day

40 mg/day in divided doses

40–160 mg/day in divided doses

20 mg/day in divided doses

20–60 mg/day in divided doses

10 mg at bedtime

20–50 mg at bedtime

37.5 mg/day

75-150 mg/day

Available as extended release; increase dose after 1 week

25 mg/day

50-200 mg/day in divided doses

As effective as amitriptyline, propranolol or valproate; increase by 25 mg/week Monitor levels if compliance is an issue

Dose short-acting 4 times a day and long-acting 2 times a day; available as extended release Dose short-acting 2-3 times a day and long-acting 1-2 times a day; available as extended release

Antidepressants AmitriptylineB Venlafaxine

Antiepileptics TopiramateA

Valproic acid/ divalproex sodiumA

250-500 mg/day in divided doses, or daily for extended release Nonsteroidal anti-inflammatory drugs IbuprofenB KetoprofenB Naproxen sodiumB

500–1,500 mg/day in divided doses, or daily for extended release

400-1,200 mg/day in divided doses 150 mg/day in divided doses 550-1,100 mg/day in divided doses

Use intermittently, such as for menstrual migraine prevention; daily or prolonged use may lead to medication-overuse headache and is limited by potential toxicity

2.5 mg/day or 5 mg/day in divided doses 2 mg/day in divided doses

Taken in the perimenstrual period to prevent menstrual migraine.

Triptans FrovatriptanA NaratriptanB ZomitriptanB

5-7.5 mg/day in divided doses

recurring migraines that produce significant disability; frequent attacks requiring symptomatic medication more than twice per week; symptomatic therapies that are ineffective, intolerable or contraindicated; if migraines are more severe and/or have a risk of neurological damage; or, if patients prefer this approach. Preventive therapy also may be administered preemptively or intermittently when headaches recur in a predictable pattern (e.g., exercise-induced migraine or menstrual migraine). The goals of therapy for long-term migraine treatment are identified in Table 2.2,5,9-11

The preventive management of migraine should begin with the identification and avoidance of factors that consistently provoke migraine attacks in susceptible individuals. Patients should be encouraged to keep a headache diary to document the frequency, severity and duration of attacks as well as responses to medications and potential trigger factors. Patients also can benefit from adherence to a general wellness program that includes regular sleep, exercise and eating habits, avoidance of headache triggers, smoking cessation and limited caffeine intake.2,5,10,11

THE KENTUCKY PHARMACIST

Oct. 2013 CE â&#x20AC;&#x201D; Migraine Headache

September 2013

Table 3 Continued Miscellaneous HistamineB

1-10 ng 2 times/week

Magesium gluconateB

400 mg/day

MIG-99B (feverfew)

10-100 mg/day in divided doses

PetasitesA

100-150 mg/day in divided doses

800 mg/day in divided doses

150 mg/day in divided doses

RiboflavinB

400 mg/day in divided 400 mg/day in divided doses doses A Level A - established efficacy; should be used (> 2 Class I studies) B Level B - probably effective (1 Class I or 2 Class II studies)

May cause transient itching and burning at injection site May be more helpful in migraine with aura and menstrual migraine Withdrawal may be associated with increased headaches Use only commercial preparations, plant is carcinogenic Benefit only after 3 months

Preventive migraine therapies are usually administered on a daily basis with the goal of reducing the frequency, severity and duration of attacks and improving responsiveness to symptomatic therapies.3,5 The lowest effective dose should be used for initiation and then gradually titrated upward until a therapeutic effect is achieved or side effects become intolerable. Drug doses for migraine prophylaxis are often lower than those necessary for other indications.5,9

factors.3,4

The selection of an agent for migraine prophylaxis should be based on patient response, tolerability, convenience of the drug formulation and coexisting conditions.3,11 The recent guideline updates provide recommendations as to the level of efficacy for particular agents, though there is insufficient evidence as to how to choose one therapy over another. Those with the highest level of efficacy should be used for treatment, with consideration of individual patient

Beta blockers have a long history of established use and evidence for migraine prevention. Metoprolol, propranolol and timolol have the strongest evidence of efficacy (Level A), reducing the frequency of attacks by 50 percent in greater than 50 percent of patients. Atenolol and nadolol are classified as probably effective (Level B), while nebivolol and pindolol are possibly effective.3 The mechanism for migraine prevention with beta blockers is not fully under-

RECOMMENDATIONS FOR PREVENTIVE TREATMENT To develop the recent guidelines, the AAN and AHS reviewed and evaluated studies of preventive migraine therapies. To be included in the analysis, trials had to be randomized, controlled studies with masked outcome assessments of safety and efficacy (considered class I or II studies).3,4 Results of the included studies were then categorized into levels based upon the proven efficacy of each Though some reduction in attack frequency may be evitherapy. Agents were considered effective if they reduced dent after the first month, 2 to 3 months is usually necesmigraine frequency, the number of migraine days or the sary to achieve an observable clinical benefit. An adequate severity of migraine attacks. Therapies with definitive evitherapeutic trial (usually 6 months) should be given to dence of treatment efficacy were assigned a Level A recjudge maximal efficacy. Patients should be counseled and ommendation and Level B where evidence indicated probmonitored closely for therapeutic response, adverse reac- able effectiveness.3,4 Therapies recognized with Level A tions, abortive therapy needs and management compliand B recommendations, along with dosages and general ance.3,5,9 Overuse of acute headache medications can in- medication comments, are summarized in Table 3.2-4 Furterfere with the effects of preventive treatment.11 Prophyther information regarding the specific details from their lactic treatment should usually be continued for at least 6 evaluation can be found within the published updates and to 12 months after the frequency and severity of headat the website, www.neurology.org.3,4 aches have diminished. Gradual dosage reduction or disOf note, though other agents have established or probable continuation of therapy may be reasonable after a proefficacy, only propranolol, timolol, divalproex sodium and longed headache-free interval. Many patients with mitopiramate are currently approved by the Food and Drug graines experience less severe and fewer attacks over a Administration for migraine prophylaxis.2 lengthy period following discontinuation of prophylactic medications or taper to a lower dose.3,5 Beta Adrenergic Antagonists

THE KENTUCKY PHARMACIST

Oct. 2013 CE â&#x20AC;&#x201D; Migraine Headache stood. They appear to raise the migraine threshold by affecting adrenergic or serotonergic neurotransmission in specific CNS pathways.2 Agents possessing intrinsic sympathomimetic activity are typically not effective for migraine prevention.5 Beta blockers are generally well tolerated. Side effects can include drowsiness, fatigue, sleep disturbances, memory disturbances, depression, impotence, bradycardia, hypotension and weight gain. These medications should generally be prescribed with caution in patients with preexisting asthma, peripheral vascular disease, cardiac conduction disturbances, bradycardia, depression and hypotension. Although not used first line to treat hypertension, beta blockers may be useful along with other therapies in migraine patients with hypertension or angina.2,3,5 Antidepressants Various classes of antidepressants have been used for migraine prevention, with beneficial effects that are independent of their antidepressant activity.2,5 The anti-migraine properties of antidepressants may be related to downregulation of central 5-HT2 receptors, increased levels of synaptic norepinephrine and enhanced endogenous opioid receptor activity. The only antidepressants with probable effectiveness for migraine prevention (Level B) are the tricyclic antidepressant (TCA) amitriptyline and serotoninnorepinephrine reuptake inhibitor (SNRI) venlafaxine. The use of other antidepressants is based primarily on clinical and anecdotal experience. No selective serotonin reuptake inhibitors, including fluoxetine, have demonstrated effectiveness as prophylactic therapy.3

September 2013 migraine prevention, including increased inhibition facilitated by Îł-aminobutyric acid (GABA), modulation of the reduction of excitatory neurotransmitter glutamate and hindering sodium and calcium ion channel activity. This class is particularly useful in migraineurs with comorbid seizure, bipolar illness or anxiety disorders.2,3 Common early side effects with valproic acid/divalproex sodium are nausea and vomiting. These are typically selflimiting and less frequently to occur with gradual titration. Other side effects include alopecia, tremor, asthenia, somnolence and weight gain. The risk of hepatotoxicity appears to be low in patients with no underlying metabolic or neurologic disorder; however, liver function tests should be obtained at baseline and with dosage adjustments or symptoms. Valproates are contraindicated in pregnant women and patients with a history of chronic liver disease or pancreatitis.2,3 Topiramate should be initiated at a low dose and slowly titrated upward to minimize adverse effects. Approximately 50 percent of patients treated to target doses are responders with a 50 percent or greater reduction in mean headache frequency. Benefits can be observed within as early as two weeks of beginning therapy, with significant reductions in migraine frequency within the first month. Paresthesia, fatigue, anorexia, diarrhea, weight loss, memory/ language problems, taste perversion and nausea are adverse events associated with treatment. Weight loss occurs in 9 to 12 percent of patients and is a unique adverse effect, as weight gain is a common reason for discontinuation of other preventive medications. Topiramate should be used with caution or avoided in patients with a history of cognitive impairment or kidney stones.2,3,5 As more evidence is available, there may be a role for other antiepileptics in migraine prevention. Carbamazepine is possibly effective, and a recent study evaluated gabapentin, though data are insufficient to determine efficacy. Lamotrigine is classified as possibly or probably ineffective according to the guidelines.3

Anticholinergic properties limit the use of TCAs in patients with benign prostatic hypertrophy or glaucoma. Orthostatic hypotension and cardiac toxicity also can occur. Sedation, increased appetite and weight gain are more common side effects with TCAs. The most common side effects reported with venlafaxine are drowsiness, nausea and vomiting. 2,3 Concomitant therapy of SNRIs and triptans can potentially cause serotonin syndrome. Although it appears that the likelihood of CNS adverse events is extremely low, regulaNonsteroidal Anti-inflammatory Drugs tory agencies caution against concurrent administration. Regular or daily use of NSAIDs for the treatment of miThe potential risk of these combinations should be carefully graine attacks or other headaches may be associated with considered and discussed with each patient.2 the development of medication overuse headache. However, intermittent use of NSAIDs to prevent headaches that Antiepileptics Antiepileptic medications are increasingly popular and have recur in a predictable pattern, such as menstrual migraine, emerged as important therapeutic options for migraine pre- can be a reasonable option.4 Administration of NSAIDs in vention. Topiramate is the most extensively studied medithe perimenstrual period can be beneficial in women with cation for migraine prevention to date. Per the guidelines, true menstrual migraine. NSAIDs should be initiated 1 to 2 topiramate and valproic acid/divalproex sodium have estab- days prior to the expected onset of headache and continlished efficacy and Level A recommendations for use. Anued during the period of vulnerability.2 Agents that have tiepileptic drugs have multiple proposed mechanisms in demonstrated probable effectiveness (Level B) include ibu26

THE KENTUCKY PHARMACIST

Oct. 2013 CE — Migraine Headache

September 2013

profen, ketoprofen and naproxen sodium. NSAIDs inhibit prostaglandin synthesis and appear to prevent neurogenically mediated inflammation in the trigeminovascular system. Potential gastrointestinal and renal toxicity limit the prolonged use of these agents, and NSAIDs should be avoided or used cautiously in patients with previous ulcer disease, renal disease or hypersensitivity to aspirin.2 Serotonin Receptor Agonists Three of the available serotonin receptor agonists (triptans) have been shown to have some efficacy for short-term prevention of menstrually associated migraine.3 Frovatriptan, the triptan with the longest half-life, has the most conclusive evidence (Level A). Naratriptan and zolmitriptan are probably effective and should be considered (Level B). Triptans work through vasoconstriction of intracranial arteries, inhibition of vasoactive peptide release and inhibition of neural transmission.2 Adverse effects to the triptans are common but usually mild to moderate in nature and of short duration. These include paresthesias, fatigue, dizziness, flushing, warm sensations and somnolence.2,3 “Triptan sensations,” including tightness, pressure, heaviness or pain in the chest, neck or throat also are reported by up to 25 percent of patients. The mechanism of these symptoms is unknown, but a cardiac source of pain seems unlikely in most patients.12 The triptans are contraindicated in patients with a history of ischemic heart disease (e.g., angina pectoris, Prinzmetal’s angina or previous myocardial infarction), uncontrolled hypertension and cerebrovascular disease. For migraine prevention, the triptan is usually started 1 or 2 days before the expected onset of headache and continued during the time of vulnerability.2,3 A separate indication for pure menstrual migraine currently is being deliberated by regulatory authorities. Complementary Treatments Various complementary therapies have been used and studied for the prevention of migraine. Butterbur, or petasites, is the only herbal treatment with established efficacy (Level A) and appears to act on calcium channels, preventing peptide-leukotriene formation. Riboflavin, or vitamin B2, has been found to have probable effectiveness (Level B) and appears to work centrally, increasing energy efficiency. It is well tolerated by most patients; however, the benefits of therapy became significant only after 3 months. Various formulations of magnesium have been studied for migraine prevention with mixed results, though overall probable effectiveness (Level B). CNS levels of magnesium are known to be significantly low during migraine attacks and supplementation is thought to decrease neuronal excitability. Magnesium may be particularly useful in patients experiencing migraines accompanied by auras or those associated with menstruation. MIG-99, the relatively stable extract

of feverfew, is the most studied herbal preparation for migraine prevention. Feverfew, also Level B, may work by inhibiting the release of serotonin as well as prostaglandin synthetase, thereby reducing inflammation.2,4,5 Subcutaneous histamine has been compared to traditional therapies (i.e., sodium valproate, topiramate) with favorable results in improving headache frequency, duration and intensity, indicating probable effectiveness (Level B).4 Possibly Effective and Other Agents The guidelines review various other agents that have been used for migraine prevention. Based on limited evidence, some of these are considered possibly effective and may be considered for migraine prevention. Others, such as verapamil, have been widely used but have conflicting or inadequate evidence to support or refute their use.3 The angiotensin-converting enzyme inhibitor lisinopril and the angiotensin II receptor blocker candesartan provided effective migraine prevention in recent studies and are considered possibly effective.3 Selection of one of these agents could be useful in patients with hypertension, diabetes mellitus, renal disease or those needing secondary stroke prevention; however, they should be used cautiously in those with hypotension.3 Based on other studies, telmisartan is probably ineffective.2,3 Clonidine and guanfacine have demonstrated possible efficacy, though use is limited by common side effects (e.g., depression, drowsiness).3 Coenzyme Q10 was well tolerated and effective for migraine prevention in a small, controlled study.4,5 In one study, cyproheptadine (4 mg/day) was as effective as propranolol (80 mg/day) in reducing migraine frequency, duration and severity, while the combination was more effective in reducing the frequency of attacks.3,4 The calcium channel blockers have been widely used for preventive treatment, though evidence supporting their use is inadequate or conflicting. Extensive clinical experience with verapamil suggests a possible role in migraine prevention and choosing this medication may be valuable in patients with hypertension. Side effects of verapamil can include constipation, hypotension, bradycardia, atrioventricular block and exacerbation of congestive heart failure. 2,3,5 CONCLUSION Many migraineurs receive inadequate care and experience substantial levels of pain and disability. Improvements in migraine diagnosis and treatment can improve the quality of life for these patients and those around them. Recent guideline updates for preventive therapy identify agents with established and probable efficacy. These recommendations should be considered when selecting an agent and medications with the highest level of efficacy should be

THE KENTUCKY PHARMACIST

September 2013

Oct. 2013 CE — Migraine Headache

used. There is insufficient evidence as to how to choose of the American Academy of Neurology and the Amerione therapy over another. Selection of an agent should be can Headache Society. Neurology 2012;78:1346-1353. based on individual patient response, tolerability, conven5. Bigal ME, Lipton RB. The preventative treatment of ience of dosing, coexisting conditions and preference. Pamigraine. Neurologist 2006;12(4):204-213. tient counseling and careful monitoring are essential in initiating the most appropriate pharmacotherapy, documenting 6. Goadsby PJ. Pathophysiology of migraine. Neurol Clin. therapeutic successes and failures, identifying medication 2009;27(2):335-360. contraindications and preventing or minimizing adverse 7. Cutrer FM, Bajwa ZH, Sabahat A. Pathophysiology, events. clinical manifestations, and diagnosis of migraine in References adults. UpToDate 2012;12:1-23. 1. Lipton RB, Bigal ME, Diamond M, et al. The American Migraine Prevalence and Prevention Advisory Group. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 2007;68:343-349.

8. Headache Classification Committee of the International Headache Society. The international classification of headache disorders, 2nd ed. Cephalalgia 2004;24 (Suppl 1):1–151.

2. Minor DS. Headache Disorders. In: DiPiro JT, Talbert 9. Silberstein SD, Dodick D, Freitag F, et al. PharmacoRL, Yee GC, et al., eds. Pharmacotherapy: A Pathological approaches to managing migraine and associatphysiologic Approach, 8th ed. New York City: McGrawed comorbidities – clinical considerations for monotherHill;April 2011, 1061-1075. apy versus polytherapy. Headache 2007;47:585-599. 3. Silberstein SD, Holland S, Freitag F, et al. Evidencebased guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012;78:1337-1345. 4. Holland S, Silberstein SD, Freitag F, et al. Evidencedbased guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee

10. Bajwa ZH, Sabahat A. Preventive treatment of migraine in adults. UpToDate 2012;14:1-13. www.uptodate.com. 11. Buse DC, Rupnow FT, Lipton RB. Assessing and managing all aspects of migraine: migraine attacks, migraine-related functional impairment, common comorbidites, and quality of life. Mayo Clin Proc 2009;84 (5):422-435. 12. Loder E. Triptan therapy in migraine. N Engl J Med 2010;363:63-70.

KPhA MEMBERSHIP BENEFIT Discounts on Safety Supply Kits YOUR KPhA negotiated a discount with SafetyNET for disaster survival kits. These kits are stored in backpacks and have supplies to last a three days in case of a disaster. Go to www.kphanet.org and click on Membership—Benefits for more information and to find out how to order your kit.

THE KENTUCKY PHARMACIST

Oct. 2013 CE — Migraine Headache

September 2013

October 2013 — Migraine Headache: Updated Recommendations for Preventive Therapy 1. Migraine headaches affect approximately what percent of women? A. 5 percent B. 10 percent C. 18 percent D. 25 percent 2. Migraines appear to result from CNS neurovascular dysfunctions in which system? A. trigeminovascular B. neurofundibular C. nigrostriatal D. vagosomatic 3. Auras are experienced by approximately what percent of patients with migraine headache? A. 10 percent B. 25 percent C. 33 percent D. 50 percent 4. Each of the following is a reason to start prophylactic migraine therapy EXCEPT: A. attacks are infrequent and controlled with acute therapy. B. the patient prefers that approach. C. migraines cause significant impairment. D. acute therapies are contraindicated. 5. Patients should take preventive therapies: A. only when not taking acute therapies. B. only if they experience aura associated with headaches. C. usually daily regardless of migraine occurrence.

6. Based on the updated guidelines, all of the following beta blockers are recommended for migraine prevention EXCEPT: A. Atenolol. B. Metoprolol. C. Propranolol. D. Acebutolol. 7. Based on the updated guidelines, which of the following antidepressants is recommended for migraine prevention? A. bupropion B. fluoxetine C. sertraline D. venlafaxine 8. Based on the updated guidelines, which of the following antiepileptic drugs should NOT be used for migraine prevention? A. divalproex sodium B. lamotrigine C. topiramate D. valproic acid 9. Of the triptans, _________ has the most evidence of efficacy for menstrually associated migraine. A. frovatriptan B. naratriptan C. sumatriptan D. zolmitriptan 10. Among complementary therapies, ________ has demonstrated the most effectiveness in preventing migraines. A. niacin B. petasites C. St John’s Wort D. thiamine

KPhA MEMBERSHIP BENEFIT As a KPhA member, you are eligible for a discount on Lexicomp online or mobile app. Lexicomp online is $547 for one user, and as an optional add-on, you may purchase Lexi Mobile for $143 one user. To get the discounted price or if you have questions about the LexiComp products, contact Amy Norkus 317-735-5361, Amy.norkus@wolterskluwer.com. 29

THE KENTUCKY PHARMACIST

Oct. 2013 CE — Migraine Headache

September 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: September 13, 2016 Successful Completion: Score of 80% will result in 2.0 contact hour or 0.2 CEU. Participants who score less than 80% will be notified and permitted one re-examination. TECHNICIANS ANSWER SHEET. October 2013 — Migraine Headache: Updated Recommendations for Preventive Therapy Universal Activity # 0143-9999-13-010-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 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

NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) PHARMACISTS ANSWER SHEET October 2013 — Migraine Headache: Updated Recommendations for Preventive Therapy Universal Activity # 0143-9999-13-010-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 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

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

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

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

THE KENTUCKY PHARMACIST

Kentucky Renaissance Pharmacy Museum

September 2013

Kentucky Renaissance Pharmacy Museum moves to KPhA with help from students Due to a significant amount of lead-based paint, the historic Fayette County Courthouse was closed earlier this year and therefor, forced Kentucky’s only pharmacy museum to relocate. Many volunteers were needed to make this move possible, which entailed packing up many unique and priceless pieces from various collections donated from across the state. The founder, Ms. Gloria Doughty, is responsible for not only the existence of this museum but also for its accomplishment of being nationally recognized. She has worked diligently to provide a place where Kentucky’s pharmacy heritage could be shared with the public and “contribute to the understanding, development and history of Pharmacy in Kentucky.”

love, devotion and excitement for each piece that makes up the museum was very evident, and we felt lucky to be able to share in its final moments in Lexington.

As fourth year pharmacy students, with no prior knowledge of this museum’s existence, we were astounded at the number of collections it held, as well as the uniqueness of the pieces. Even more astonishing was that Ms. Gloria could tell you the history behind each and every piece; her

Megan and Kristina are currently on APPE rotation at Laurel Heights with Tom Houchens, RPh. and Kim Croley, PharmD, RPh. who were delighted to be able to loan them to Ms. Gloria Doughty, RPh. to assist with this massive undertaking!

On August 14, the collections were moved to the KPhA building in Frankfort, where some of the collection will be on display. All other items are currently in storage until a new location is found. We were grateful for the opportunity to learn more about Kentucky’s pharmacy history and only hope that we will get to see it restored in a new location someday soon! - Megan Martin and Kristina Huey 4th year UKCOP students

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 31

THE KENTUCKY PHARMACIST

KPhA New and Returning Members

September 2013

KPhA Welcomes New and Renewing Members July-August 2013 Jennifer Anderson Morehead, KY

Terri L Chism Brandenburg, KY

Timothy L Ford Campbellsville, KY

H. Harper Housman Paducah, KY

Samuel T Armes Crossville, TN

Lisa Clontz Prospect, KY

Sherri Forrest Brentwood, TN

Bryan Howze St. Augustine, FL

John E Ausenbaugh Dawson Springs, KY

Aimee Cloud Louisville, KY

Julian Simms Frank Paris, KY

James Howze St. Augustine, FL

Deronda Kay Back Jackson, KY

Kimberly Lynn Corley Owensboro, KY

Donald T Fritts Morganfield, KY

Jacob Hutti Louisville, KY

Richard B Bergman Sarasota, FL

Allison R Cubit Lexington, KY

Judy Gallagher Madisonville, KY

Constance H. Jones Russell Springs, KY

Elisha Bischoff Louisville, KY

Casey B Culyer Erlanger, KY

Timothy L Gallagher Madisonville, KY

Helen Jones Columbia, KY

Jacqueline E Blair Mason, OH

Marcelle R Curtis Shelbyville, KY

Joyce M Gardner Hodgenville, KY

William Keck Corbin, KY

Larry Blandford Goshen, KY

Michael F Daniels Taylor Mill, KY

Gale M Garner Paducah, KY

Jerry Knifley Columbia, KY

Charles Boggs Dandridge, TN

Kimberly Daugherty Louisville, KY

Daniel K Gray London, KY

Robert Knott Paducah, KY

Charlotte Lanae Bowling London, KY

Patrick Deluca Lexington, KY

Charles J Gross Hazard, KY

Amy Tackett Larkin Lexington, KY

Terry Box Cynthiana, KY

James Denton Georgetown, KY

Erik Grove Madison, IN

Judith Lawson Monticello, KY

Lanny G Branstetter Horse Cave, KY

Marie Denton Georgetown, KY

Philip S Hamilton Ludlow, KY

Ken Lewis Louisville, KY

Phillip Brewer London, KY

David Dubrock Arlington, KY

Kyle Harris London, KY

Leslie Little Berea, KY

Mark A Britt Louisville, KY

Everett Dunaway Jackson, KY

Jeffrey Harrison Tompkinsville, KY

Pamela Luebbe-Haeberlin Louisville, KY

Brenda C Brown Scottsville, KY

Portia Dunaway Jackson, KY

Phillip Layne Hatcher Pikeville, KY

John Lutz Louisville, KY

Wendell Doug Butler Burkesville, KY

Michael Durbin McKee, KY

Shirley Henson Smithland, KY

Laura Maples Villa Hills, KY

Kenneth D Calvert Glasgow, KY

Mary Enzweiler Covington, KY

Kevin Higgins Benton, KY

Nicholas Maroudas Williamson, WV

Mary Campbell Shepherdsville, KY

Peggy A Fishburn Scottsville, KY

Julie Hinkel Ft. Thomas, KY

John Marshall Henderson, KY

Peggy Canler Louisville, KY

Jennifer L Fitch Lexington, KY

Carolynn Horn Philpot, KY

Catherine Mcclish Louisville, KY

Michelle Casto-Litton Zionsville, IN

Lindsey K Flanders Bowling Green, KY

Jerry J Horwitz Cincinnati, OH

Jennifer Mccreary Louisa, KY

Vickie Chaudry Corbin, KY

Matthew Flanders Bowling Green, KY

Jan Houchens London, KY

Sheldon Mccreary Louisa, KY

THE KENTUCKY PHARMACIST

KPhA New and Returning Members

September 2013

Leeann Mcdonald Dunnville, KY

Levi Rice Beaver Dam, KY

Larry Spears Crittenden, KY

Kim Wheately Bardstown, KY

Laurie Meeks Lexington, KY

James Robinette London, KY

William Spoo Louisville, KY

Angela G Whetstone Tiline, KY

Jesica Mills Louisville, KY

Richard L Roeding Lakeside Park, KY

Glenn Stark Frankfort, KY

Kelly Lynn Whitaker Hickory, KY

Boyd Minnich Mount Sterling, KY

Denise Rueff Louisville, KY

Sandra Staton Albany, KY

David Whitley Russellville, KY

Laura Murphy Somerset, KY

Bonnie Russell Elizabethtown, KY

Cheryl Steiner Hopkinsville, KY

Kimberly Wilkerson Frankfort, KY

Daniel Nall Louisville, KY

Larry Russell Elizabethtown, KY

Martha Stepp Harlan, KY

Lewis Wilkerson Frankfort, KY

David Nation Owensboro, KY

Thomas Rust Cold Spring, KY

Doris Stone Kevil, KY

James Wilson Paducah, KY

James Rodney Neat Louisville, KY

Angela Sandlin Louisville, KY

David Riley Stultz Greenup, KY

Franklin Wishnia Louisville, KY

William Nebel Kuttawa, KY

Phillip Sandlin Louisville, KY

Patrick Sumner Louisville, KY

Simon Wolf Louisville, KY

Johnny Nixon Tompkinsville, KY

Stanley Scates Lexington, KY

Richard Sutton Paducah, KY

William D Wooden Leitchfield, KY

Jamie Norman Russellville, KY

Aron Schwartz Louisville, KY

Anthony Tagavi Louisville, KY

David E Wren Louisville, KY

Elizabeth Pablo Clarkson, KY

Benjamin Scott Lexington, KY

Mary L. Thacker Louisville, KY

Sue E Wynn Whitley City, KY

Dennis Parker Glasgow, KY

George Shackleford Corbin, KY

Joel Thornbury Pikeville, KY

Barbara Sue Yates Horse Cave, KY

Myron M Pass Louisville, KY

Charles Shannon Louisville, KY

Patricia Thornbury Lexington, KY

Charles Peal Lexington, KY

Edwin Shelton Owensboro, KY

Sandra Thornbury Dorton, KY

Andrea Pearson Bowling Green, KY

Nancy K Shepherd Paducah, KY

Timothy Tracy Lexington, KY

Charles C Pearson Bowling Green, KY

Frances Sherrill Paducah, KY

Charles Turk Williamson, WV

Michael Perdue Catlettsburg, KY

Thomas Shively Owensboro, KY

John Vaal Edgewood, KY

Bernard Poe Owenton, KY

Sherri Short Richmond, KY

Kelly Walker Philpot, KY

Shirley Price Owensboro, KY

Angela Slaughter Covington, KY

Robert Wallace Dry Ridge, KY

John Russell Prine Bowling Green, KY

John Sorrell Cynthiana, KY

Norman Walton Bardstown, KY

Thomas Ranz Louisville, KY

Francis Southall Lebanon, KY

Jeffrey Warner Jamestown, KY

Wendy Renfrow Barlow, KY

Stephanie Southern Paducah, KY

L Dwayne Watson Paducah, KY

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

September 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 34

THE KENTUCKY PHARMACIST

Medicare Counseling

September 2013

Why pharmacists are better than insurance brokers for Medicare Counseling seniors on which Medicare plan is right for them If you’re a pharmacist with Medicare patients, you’re probably used to fielding their questions about which Part D plan they should choose for an upcoming enrollment opportunity. If so, you know that it can be a time-consuming process. And while you love serving your patients, when it comes to comparing Medicare plans, you’re often just too busy. But helping seniors through the Medicare enrollment process has mutual benefits for both the customer and the pharmacy. Seniors come to you with these questions because pharmacists are in the best position to help. Unlike insurance brokers, the pharmacist already has access to the list of medications a patient is taking, which is crucial knowledge when choosing a Medicare plan.

Quantity Limits, Step Therapy and Prior Auths, they can even suggest substituting therapeutically equivalent drugs that can lower a patient’s prescriptions costs. So what’s in it for the pharmacist to help seniors choose a Medicare plan? Pharmacists already know the value of seniors’ loyalty to their drugstore. Pharmacies using iMedicare have already seen big benefits from offering the service: Seniors flock to those pharmacies, seeking professional expertise in picking a Medicare plan. With the average Medicare patient on six drugs, each new customer can be worth at least $900 in additional profit for the pharmacy. So with one extra Medicare patient a year, iMedicare pays for itself.

In addition to providing that valuable service, you also can We’ve seen time and time again that our pharmacy cusinform seniors of the Part D plans that allow them to contintomers who provide the most services—including medicaue coming to your pharmacy for all of their needs. tion therapy management and Medicare plan consultaDepending on which Part D plan a senior selects, they tions—see the greatest increases in customers, revenues could end up enrolled in a plan that doesn’t fully pay for and profits. If you’re a pharmacy, start helping more patheir necessary drugs—or even prevents them from using tients with Medicare and grow your business! the beloved pharmacy that has served them for years, forcFlaviu Simihaian, CEO ing them instead to another pharmacy miles away because Phone: (704) 769-0540 it’s the plan’s “preferred pharmacy.” Besides all the inconhttp://iMedicare.com venience, choosing the wrong Part D plan also can cost seniors thousands of dollars extra per year. So where does the pharmacist come in? There are resources to help seniors through this process. The government’s website, Medicare.gov, is difficult to navigate so that seniors with several prescriptions may find its plan comparison process harder than doing their taxes. The Medicare plan literature seniors receive in the mail is may be biased towards whichever insurance company sent it. Hence, seniors often ask for help from family or an insurance broker, who too often lack an understanding of all the options available, or plan requirements like Quantity Limits, Step Therapy or Prior Authorization. Failing to account for those technical factors can have huge impacts on the cost and hassle seniors will face when filling prescriptions. Pharmacists, on the other hand, combine the best of both worlds. You are one of the most trusted healthcare providers, studies have shown, and independent pharmacies provide a more thorough level of pharmaceutical care by scheduling time to conduct MTM, screen for interactions and answer questions. Because pharmacists have a wealth of medication knowledge and experience dealing with

YOUR KPhA has partnered with iMedicare as an endorsed vendor to provide KPhA Members with a discount on iMedicare Products. For more information, contact iMedicare and request YOUR KPhA Membership Discount! THE KENTUCKY PHARMACIST

HIPAA Privacy Changes

September 2013

HIPAA Privacy Changes September 23rd Is Here; Are You Prepared? In January, the Department of Health and Human Services published a Final Rule containing numerous changes to the HIPAA Privacy, Security, Breach Notification and Enforcement Rules. The Rule took effect on March 26, 2013, but pharmacy covered entities (and their business associates) have until Sept. 23, 2013, to include the new requirements in business associate agreements effective after Jan. 25, 2013.

a security breach, including the information required under the new Breach Reporting Rule. 4) The business associate must enter into a business associate agreement with any subcontractor to which the business associate discloses PHI.

5) If the agreement delegates any of the covered entity’s HIPAA compliance obligations to the business associate, the business associate must fulfill those obligations to the For “BA agreements” or “BAAs” which were in effect prior to same extent as the covered entity. Jan. 25, 2013, the new requirements do not have to be included until the earlier of when the agreement is renewed Covered entities should act swiftly to incorporate the new requirements into their business associate agreements, or modified, or by Sept. 22, 2014. and existing business associates must begin to evaluate Two of the changes that pharmacies need to be aware of which of their subcontractors handles PHI and to negotiate under the revised rules are: (i) changes to business associa business associate agreement appropriate for the arate agreements; and (ii) changes to Notices of Privacy rangement to ensure that the subcontractors will appropriPractices. These changes do not affect the fundamental ately safeguard PHI. nature of HIPAA compliance, but they do introduce a speChanges to Notices of Privacy Practices cific “to do” list for pharmacies. The Final Rule requires important additions to a pharmacy’s Notice of Privacy Practices to be provided to pharmacy Under the Final Rule, business associates now will be dipatients effective Sept. 23, 2013. rectly obligated to comply with the HIPAA Privacy and Security Rules. Further, a subcontractor of a business associ- The Final Rule requires pharmacy Notice of Privacy Pracate that handles PHI on behalf of the business associate tices to explain that patient authorization is required before now also is considered a business associate. Thus, a busi- PHI may be used for marketing or fundraising purposes, ness associate agreement will now be required for entities with limited exceptions. Another significant change for the that receive PHI from the covered entity pharmacy and for Notice is to inform patients that they will receive a breach that entity’s downstream contractors who handle the PHI. notification in the event their PHI is compromised as providThis change is so significant that it is difficult to overstate its ed in the Breach Notification Rule. Business Associate Agreements

importance. For example, beginning on Sept. 23, 2013, a The Final Rule ushers in extensive changes to the HIPAA data storage vendor of a business associate also will be landscape. Pharmacies should work swiftly to implement considered, separately, a business associate. these changes in order to ensure compliance by the deadSpecifically, in addition to existing obligations required by line. The risk of ignoring HIPAA responsibilities is dangerthe Privacy Rule, the Final Rule requires that business as- ous and costly. sociate agreements include the following provisions:

Clay B. Wortham is an attorney with McBrayer, McGinnis, 1) The business associate must limit its uses and disclo- Leslie & Kirkland, PLLC. Clay is a member of the firm’s sures of PHI to meet the covered entity’s minimum neces- health law department in the Lexington office. He can be sary policies and procedures (and business associates’ will reached at 859.231.8780 or cwortham@mmlk.com. want to ensure that the covered entity is required to make For more on HIPAA Changes, register for those policies available to the business associate). 2) The business associate must implement safeguards for electronic PHI in accordance with the HIPAA Security Rule. 3) The business associate must notify the covered entity of 36

the KPhA Mid-Year Conference Nov. 15-16, 2013 www.kphanet.org

THE KENTUCKY PHARMACIST

APhA-ASP Summer Leadership Institute

September 2013

A Weekend of Leadership Training and Advocating for Pharmacy From this training workshop, I learned that you have to modify Serving as the Chapter President of the American Pharmayour leadership skills to match the cists Association – Academy of Student Pharmacists styles of different teams you are (APhA-ASP) at the University of Kentucky College of Pharworking with throughout diverse macy provides vast opportunities for learning experiences situations. It is important to be flexioutside the classroom. The APhA-ASP Summer Leaderble in your leadership approach so ship Institute (SLI) in Washington, D.C. is a three-day event you can work with fellow leaders to which brings student pharmacists together from across the accomplish mutual goals. nation for networking and unique learning opportunities. Each year the college sends a leader within APhA-ASP to The rest of the weekend was spent involve her in the legislative process and learn skills on networking with fellow student how to become a more effective leader. This year I was pharmacists from across the naBrooke Herndon privileged to have the opportunity to attend SLI and engage tion. I was provided the opportunity in meaningful networking with fellow student pharmacists to visit APhA Headquarters on the and have dialogue with legislators regarding issues pertiNational Mall in Washington, D.C., and receive a tour of nent to pharmacists. local historical sites on Friday evening. Throughout the By: Brooke Herndon, PharmD Candidate 2015

The weekend started with visits to Capitol Hill, where I had meetings with staff members from Senator Mitch McConnell’s and Representative John Yarmuth’s offices to discuss the importance of provider status for pharmacists. Each meeting lasted between 15-20 minutes and allowed constituents of the legislators to provide information for the groundwork of moving towards provider status for pharmacists. This provided a unique opportunity to become involved in the legislative process and begin advocating for the profession.

weekend, student pharmacists from across the nation were able to exchange ideas regarding chapter goals and achievements, fundraising ideas and unique membership opportunities. Being afforded the time to spend with student pharmacists from across the nation was invaluable and served to increase knowledge regarding APhA and make contacts with national leaders to help throughout my year as Chapter President.

I will continue to use the skills I learned at SLI throughout my term as Chapter President and hopefully motivate othThe following day was devoted to leadership development ers to become involved with national organizations. It also training. This workshop provided information on how to as- is important as a leader to train your upcoming officers to sess your leadership ability and helped to identify areas of continue the achievements of previous years. Thank you to weakness in leadership skills. After helping to identify areas the Kentucky Pharmacists Association for providing me the ability to learn so much about leadership and begin advoof weakness, the speaker provided information on how to maximize these skills to make you the best leader possible. cating for my profession.

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

Would you rather receive the journal electronically? Email ssisco@kphanet.org to be placed on the Green list for electronic delivery. Once the journal is published, you will receive an email with a link to the online version. 37

THE KENTUCKY PHARMACIST

Cooper/Clayton Smoking Cessation

September 2013

Cooper/Clayton Smoking Cessation Method and the Impact of Free Nicotine Replacement and Pharmacist-Led Sessions on Smoking Cessation By: Tracy McWhirter, PharmD, MBA and Julie Burris, PharmD Smoking is the leading cause of preventable death with approximately 450,000 deaths per year. There also have been a few studies that have demonstrated that greater utilization of pharmacists in cessation efforts could have a significant impact on smoking rates, as well as the prevention of tobacco-related diseases and overall improvement in public health across the U.S.1 The InterNational Center for Advanced Pharmacy Services (INCAPS) at the Sullivan University College of Pharmacy has implemented a successful smoking cessation program following the Cooper/ Clayton Method.

place in early 2013 with 13 of 23 (57 percent) participants completing that program. The 2013 spring program had 14 of 26 (54 percent) participants scheduled to complete the program.

INCAPS has partnered with the Louisville Metro Department of Health and Wellness to procure free nicotine replacement products for Cooper/Clayton class participants and has worked with the Kentucky Cancer Program (KCP) on training new facilitators. On May 24, 2013, Sullivan University College of Pharmacy hosted a facilitator training session for second-year student pharmacists, along with The Cooper/Clayton Smoking Cessation Method is a highly about 30 outside community members. Through the efforts successful program started in 1985 by Dr. Thomas Cooper, of KCP and the Kentucky Department for Public Health, DDS, a heavy smoker for 36 years, and Dr. Richard Claylocal health departments and numerous community partton, a sociologist and internationally recognized expert on ners have ongoing classes and training as well conducted addictions. This 12-week program incorporates education, throughout the state. skills training and social support, along with the use of nicoPotential participants can be directed to the Louisville Metro tine replacement products including patches, gum and lozDepartment of Health and Wellness website or by phone at enges. Patients continue to smoke the first week, keeping a (502) 574-STOP (7867). Those interested in learning more diary of cigarette use to assess the patient’s level of addicabout being a facilitator may visit the KCP website at: tion, which helps make them aware of situations that may http://www.kcp.uky.edu/CC-facilitator training.html. INCAPS trigger increased smoking habits. The weekly hour-long at Sullivan University College of Pharmacy began its fourth support sessions include videos encouraging patients to session on Aug. 13, 2013. stay on track and discuss possible hurdles in the smoking cessation process such as depression, anxiety, overeating References: and cravings. The duration for nicotine replacement prod1. Dent LA, Harris KJ, Noonan CW, et. al. Randomized ucts is approximately 10 weeks and includes titration trial assessing the effectiveness of a pharmacistthroughout the course with the goal of ending the program delivered program for smoking cessation. Ann Pharnicotine free.2 macother 2009; 43:194-201. The InterNational Center for Advanced Pharmacy Services 2. The Cooper/Clayton Method to Stop Smoking: A (INCAPS) held its first Cooper/Clayton Smoking Cessation Twelve Week Comprehensive Program. The Institute Method course in the fall of 2012. The United States Defor Comprehensive Behavioral Smoking Cessation. partment of Health reports the average smoking cessation http://www.stopsmoking4ever.org/. Accessed June 20, rate for a given smoking cessation method of at least eight 2013. weeks’ duration is approximately 25 percent.3 INCAPS’ first class enrolled 18 participants of which 11 finished the pro- 3. U.S. Department of Health and Human Services. Clinical Practice Guideline: Treating tobacco use and degram smoke free, correlating to a 61 percent success rate pendence: May 2008 update. after the 12-week program. An additional session took

Update your profile today at www.kphanet.org 38

THE KENTUCKY PHARMACIST

Technician Review

September 2013

Technician Review From the KPhA Academy of Technicians The KPhA Pharmacy Technician Academy is working for you. The Academyâ&#x20AC;&#x2122;s proposals have been submitted to the KPhA Board, the KSHP Board and the Advisory Council to the Board of Pharmacy. The Advisory Council was the first group to meet and discuss the proposals. After some open dialogue the Council decided that the proposals will be reviewed by the KPhA and KSHP boards so they could be prepared to discuss all of the proposals. Our proposals are intended to keep the pharmacy profession advancing. In our continually evolving profession, the goal is to enhance the patientâ&#x20AC;&#x2122;s pharmaceutical care in all settings.

We continue to recruit new members to the Pharmacy Technician Academy in order to increase our voice. If you are a KPhA Pharmacy Technician member, you can be an academy member with no extra cost. The KPhA Board approved our recommendation to contract with CEI, an online CE provider. The KPhA Pharmacy Technician Academy members will have access to free CE online that is designed around the Pharmacy Technician Certification Board exam. For more information please contact Don Carpenter at dacarpenter@st-claire.org.

KPhA Member Pharmacy Technicians

FREE CE KPhA Technician members are eligible for Free CE modeled on PTCB standards by becoming a member of the KPhA Pharmacy Technician Academy. The mission of the KPhA Academy of Pharmacy Technicians is: To unite the pharmacy technicians throughout the Commonwealth to have one voice toward the advancement of our profession. To follow what is currently happening with your profession please read our newsletter articles and become involved.

For more information contact Don Carpenter via email at dacarpenter@st-claire.org 39

THE KENTUCKY PHARMACIST

Pharmacy Law Brief

September 2013

Pharmacy Law Brief: National Practitioner Data Bank – What Is It? 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: A physician colleague who has applied for privileges at a new hospital made a comment about his apSubmit Questions: jfink@uky.edu plication being run through the “National Practitioner Data Bank.” What is that? Does that have any connection to that federal regulations govern disclosure of the facts. So who National Provider Identifier number I got several years ago? may access the entries there? There is a long list of entities with such authority and commonly encountered examples Response: The National Practitioner Data Bank would be hospital credentialing offices, peer review groups, (NPDB) was established through legislation enacted by state licensure boards and Medicaid Fraud Control Units. Congress having the multiple goals of protecting the public, And yes, an individual practitioner may enter the system to improving the quality of health care services and combating view his or her own profile. fraud and abuse in the health care arena. It serves as a national repository for data on a wide variety of transgresTurning to the final question, the National Provider Identifier sions by health professionals and businesses in the broad (NPI) number is totally unrelated. The 1996 statute known health care industry, with the most common, and perhaps as HIPAA mandated creation of this system and NPI’s were most important, being damage awards in malpractice lawfirst issued by CMS during 2006. The goal was to facilitate suits, actions by state licensing board that result in loss of electronic transactions by easing identification of the proprofessional licensure and actions by state or federal aufessional or business entity providing goods or services. thorities that exclude the professional or a business from Finally, as a gratuitous addition, one other number looming participating in Medicare or Medicaid. Other entries may large in the lives of pharmacists should be mentioned. The come from negative findings or actions by peer review orNational Association of Boards of Pharmacy has created a ganizations or private accreditation organizations plus cerdatabase to record and track a pharmacist’s participation in tain final adverse actions taken by state law enforcement continuing pharmacy education. Designated as “CPE Moniagencies or Medicaid Fraud Control Units. tor” by NABP, this activity requires that the pharmacist have The government’s website for the program describes it as a an “NABP e-Profile ID”, a six digit number associated with “confidential information clearinghouse.” It goes on to proyour continuing education records. That number looming in vide this more detailed description – it is “primarily an alert the professional lives of pharmacists does not connect to or flagging system intended to facilitate a comprehensive what is discussed above. review of the professional credentials of health care practitioners, health care entities, providers and suppliers.” Thus, it is designed to collect in one place data from a variety of Disclaimer: The information in this column is intended for sources about adverse decisions or actions regarding coveducational use and to stimulate professional discussion among ered individuals or firms. Nonetheless, the government colleagues. It should not be construed as legal advice. There is website cautions that “the information from the Data bank no way such a brief discussion of an issue or topic for educational or discussion purposes can adequately and fully address the should be used in conjunction with, not in replacement of, multifaceted and often complex issues that arise in the course of information from other sources.” 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.

Information in the database is not available to the public like, say, opinion ratings on Angie’s List™. The Data Bank treats as confidential the information reported to it. Detailed

Are you connected to KPhA? Join us online!

@KyPharmAssoc @KPhAGrassroots

KPhA Company Page

Facebook.com/KyPharmAssoc

THE KENTUCKY PHARMACIST

Senior Care Corner

September 2013

Senior Care Corner from the KPhA Academy of Consultant Pharmacists

The KPhA Academy of Consultant Pharmacists recently elected new officers. Congratulations to the new leaders of this important section of KPhA Members!  Chair - Chris Mills  Vice Chair - Joey Mattingly  Director of Organizational Affairs - Julie Owen  Director of Public/Professional Affairs - Darren Parks Peggy Canler will continue as Director of Government Affairs

Fink Elected to Medical School Accreditation Organization Joseph L. Fink III, Professor of Pharmacy Law and Policy as well as the Kentucky Pharmacists Association Professor of Leadership in the UK College of Pharmacy, has been elected to serve a three-year term as a Public Member of the Liaison Committee on Medical Education, the agency that accredits M.D. degree programs in the U.S. and Canada. His term began July 1, 2013. The purpose of LCME accreditation is to protect the public by advancing the quality of medical care provided to patients and, thereby, reducing morbidity and mortality. The Liaison Committee on Medical Education (LCME) was founded in 1942 to unify the separate accreditation activities of the Association of American Medical Colleges (AAMC) and the Council on Medical Education and Hospitals of the American Medical Association (AMA). Since the advent of the Higher Education Act adopted by the United States government in 1965, the LCME has been recognized by the U.S. Department of Education as the reliable authority for the accreditation of programs of allopathic medical education leading to the M.D. degree. The LCME has 19 members including medical educators and administrators, practicing physicians, two medical students and two public members. A faculty member at UK since 1981, Dr. Fink also is a Professor in the College of Public Health, Professor in the Martin School of Public Policy and Administration and Professor of Clinical Leadership and Management in the UK College of Health Sciences. He received his professional education in pharmacy at the Philadelphia College of Pharmacy and Science and then completed his legal education at Georgetown University Law Center. KPhA congratulates Dr. Fink on his election to this leadership opportunity.

THE KENTUCKY PHARMACIST

Pharmacy Policy Issues

September 2013

PHARMACY POLICY ISSUES: Pediatric Oncology Medication Shortages: A Hindrance to Successful Treatment? Author: Danielle E. Corbett is a second professional year pharmacy student at the University of Kentucky College of Pharmacy. She was born and raised in Lexington, Ky., and completed her pre-pharmacy coursework at the University of Kentucky. Issue: There has been quite a bit in the media recently about medication shortages. What is behind this development and what is being done about it? I understand injectables and especially oncology medications may be in short supply. Discussion: Drug shortages are defined as “a situation in which the total supply of all clinically interchangeable versions of a FDArelated drug is inadequate to meet the current or projected demand at the user level.”1 In 2011, drug shortages affected 251 medically necessary drugs with 73 percent of these including sterile-injectable products such as chemotherapy agents.2 The problems emerging from these drug shortages for pediatric oncology patients are accumulating, and in the past few years there has been an increasing number of relapse patients. A study at the University of Utah Drug Information Service showed that the amount of drug shortages of oncology medications has almost doubled in the past six years. These studies further demonstrate that patients who received alternative drug therapies due to chemotherapy drug shortages are relapsing and, as a result, requiring more aggressive measures such as stem cell treatments. The majority of drug shortages are believed to be due to the lack of quality in drugs being manufactured leading to numerous recalls. Current manufacturers are facing a major dilemma of being in a “bad market equilibrium” due to lack of rewarding high quality drug manufacturing. 3 Therefore, companies are making budget cuts and the first thing appearing to be eliminated from the list are quality invest-

ments such as equipment maintenance. An additional setback is that drug companies do not have the desire to compound these pediatric chemotherapy agents due to the decreased opportunities for profit in manufacturing them. Of the approximately 1.7 million new cases of cancer diagnosed each year, only 12,000 to 15,000 of them involve children under 15 years of age.4 Fortunately, the FDA has taken steps to mitigate the consequences of the numerous drug shortages occurring. In 2011, they were able to prevent up to 195 drug shortages and although this amount decreased to 100 in 2012, this is a tremendous improvement. The FDA’s success in preventing these shortages is simply due to the fact that manufacturers are notifying the FDA of their potential drug shortage more promptly. Additionally, President Obama placed Executive Order No. 13588 which encourages manufacturers to quickly notify the FDA of all potential drug shortages.5 Congress was quick to follow up this order and passed the Food and Drug Administration Safety and Innovation Act in July 2012, which encourages pediatric drug development. FDA Commissioner Margaret D. Hamburg stated that, “Support for FDA user fees is a testament to the important role FDA plays in America’s healthcare continuum. FDA’s medical product decisions sit at the intersection of public health, innovation and com-

Have an Idea?: This column is designed to address timely and practical issues of interest to pharmacists, pharmacy interns and pharmacy technicians with the goal being to encourage thought, reflection and exchange among practitioners. Suggestions regarding topics for consideration are welcome. Please send them to jfink@uky.edu. 42

THE KENTUCKY PHARMACIST

September 2013

Pharmacy Policy Issues merce and touch the lives of nearly every American every day."

AboutFDA/CentersOffices/CDER/ ManualofPoliciesProcedures/ucm079936.pdf. Accessed on March 15, 2013.

In conclusion, the only way that healthcare professionals can delay this unprecedented amount of shortages is to 2. Economic and Technological Drivers of Generic Sterile promote the importance of action by manufacturers. The Injectable Drug Shortages J Woodcock and M WosinFDA has been working diligently to prevent these shortagska es but communication between manufacturers and the FDA is key. With this communication, the FDA can work 3. http://www.bostonglobe.com/lifestyle/healthwellness/2012/12/27/drug-shortage-linked-increasedwith other companies to help avert the shortage issues and chance-relapse-childhoodincrease production of oncology medications. With that in cancer/9eoABZJMtCqK0BBaR3YEpI/story.html. mind, health professionals can work as a team to not only prevent the future risk of shortages but also reduce the 4. http://www.dukechronicle.com/articles/2012/02/27/ impact on thousands of pediatric oncology patients. cancer-drug-shortage-threatens-patients. References: 5. http://www.whitehouse.gov/the-press1. Center for Drug Evaluation and Research (CDER) at office/2011/10/31/executive-order-reducingFood and Drug Administration (FDA): Drug Shortage prescription-drug-shortages. Management. http://www.fda.gov/downloads/

Pharmacy Time Capsules 2013 Third Quarter 1988—Twenty-five years ago: American College of Physicians called for enhanced education in rational therapeutics including “increased communication with pharmacists, as health care professionals with particular knowledge in this area.” RU-486 (mifepristone) first marketed in France as a safe and effective method of early abortion.

1963—Fifty Years Ago: Oncovin (vincristine), an alkaloid derived from rosy periwinkle, was used as a folk medicine for diabetes. Eli Lilly & Co discovered it to be an effective treatment for several forms of leukemia.

1938—Seventy-five Years Ago: APhA undertook a national campaign to work with dental associations and dentists to increase appropriate prescribing.

1913—One hundred Years Ago:

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

University of Puerto Rico formed.

THE KENTUCKY PHARMACIST

September 2013

Pharmacists Mutual

THE KENTUCKY PHARMACIST

Cardinal Health Generation Rx Award

September 2013

THE KENTUCKY PHARMACIST

KPhA Board of Directors/Staff

September 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 Sullivan University hcarby8529@my.sullivan.edu Student Representative Matt Carrico, Louisville matt@boonevilledrugs.com Chris Clifton, Erlanger chrisclifton@hotmail.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 www.twitter.com/KPhAGrassroots www.youtube.com/KyPharmAssoc Robert McFalls, M.Div. Executive Director rmcfalls@kphanet.org

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

Speaker of the House

University of Kentucky Student Representative

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

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

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. 46

THE KENTUCKY PHARMACIST

50 Years Ago/Frequently Called and Contacted

September 2013

50 Years Ago at KPhA CONVENTION RESOLUTIONS Be it Resolved that the Kentucky Pharmaceutical Association condemns the commercial promotion of prescription legend drugs to the public, by any manner, including advertising which is likely to induce, directly or indirectly, the procurement of such drugs. Adopted *** Be It Resolved that the Kentucky Pharmaceutical Association introduces at the 1964 session of the State Legislature an act insuring the complete control of pharmacies by pharmacists. Not Adopted - A selection of the resolutions presented at the 86th Annual Convention of the Kentucky Pharmaceutical Association printed in The Kentucky Pharmacist, September 1963, Volume XXVI, Number 9.

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 Classifieds

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.

Clean Room Class 10,000 (ISO 7) USP 797 for sterile compounding. Laminar flow hood, antechamber and clean room. Aluminum and glass walls. Sink+plumbing, inspection box, HEPA filtration. Buyer transports. $15,000. novapharmacy@gmail.com or Call Joel at 606-432-2274.

THE KENTUCKY PHARMACIST

September 2013

THE

Kentucky PHARMACIST 1228 US 127 South Frankfort, KY 40601

SAVE THE DATES

October 2013 Share YOUR photos at facebook.com/KyPharmAssoc

136th KPhA Annual Meeting and Convention

November 15-16, 2013 Marriott Griffin Gate Resort and Spa Lexington, KY

June 5-8, 2014 Marriott Griffin Gate Resort and Spa Lexington, KY 48

THE KENTUCKY PHARMACIST