The Kentucky Pharmacist Vol. 9, No. 5 by Kentucky Pharmacists Association

Y K C U T N E K THE T S I C A M R A PH Vol. 9, No. 5 September 2014

Get Involved - Stay Involved Membership Matters in YOUR KPhA

News & Information for Members of the Kentucky Pharmacists Association

Table of Contents

September 2014 Sept. 2014 CE — CPE Monitor Sept. Pharmacist/Pharmacy Tech Quiz Oct. 2014 CE — Evaluation of the Respiratory and Cardiovascular Systems Oct. Pharmacist/Pharmacy Tech Quiz Kentucky Renaissance Pharmacy Museum KPhA New and Returning Members Pharmacy Law Brief Pharmacy Policy Issues Pharmacists Mutual Cardinal Health KPhA Board of Directors 50 Years Ago/Frequently Called and Contacted

Table of Contents Table of Contents— Oath— Mission Statement 2 President’s Perspective 3 KPhA Mid-Year Conference on Legislative Priorities 4 KPhA Open House 5 From your Executive Director 6 APSC 8 2014-15 KPhA Committees 9 Technician Review 10 Aug. 2014 CE — Evaluation of Eyes, Ears, Nose, Mouth &Throat 11 July Pharmacist/Pharmacy Tech Quiz 18 KPhA Emergency Preparedness 19

20 24 25 32 33 34 36 38 40 41 42 43

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

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

Editorial Office: © Copyright 2014 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 Pharmacy Education and Research Foundation (KPERF), established in 1980 as a non-profit subsidiary corporation of the Kentucky Pharmacists Association (KPhA), fosters educational activities and research projects in the field of pharmacy including career counseling, student assistance, post-graduate education, continuing and professional development and public health education and assistance. It is the goal of KPERF to ensure that pharmacy in Kentucky and throughout the nation may sustain the continuing need for sufficient and adequately trained pharmacists. KPERF will provide a minimum of 15 continuing pharmacy education hours. In addition, KPERF will provide at least three educational interventions through other mediums — such as webinars — to continuously improve healthcare for all. Programming will be determined by assessing the gaps between actual practice and ideal practice, with activities designed to narrow those gaps using interaction, learning assessment, and evaluation. Additionally, feedback from learners will be used to improve the overall programming designed by KPERF. 2

THE KENTUCKY PHARMACIST

President’s Perspective

September 2014 Budget and Audit Committee – The committee is chaired by the Treasurer, Glenn Stark. The other members of the committee include the officers of the Association and one or more at-large member(s) of the Board. The Committee shall provide guidance to the Board by assuring the adoption of an annual operating budget, assure that an annual audit of finances is performed, reviews and reports on finances quarterly and performs other duties as necessary to oversee the financial health and viability of the Association.

PRESIDENT’S PERSPECTIVE Robert Oakley KPhA President 2014-2015

Government Affairs (GA) Committee – Many thanks to Past President Richard Slone, who has agreed to serve again as chair. The GA Committee assists the Association with the development and maintenance of a grassroots program to support the Association’s legislative and regulatory initiatives that affect the practice of pharmacy. The committee also helps to raise awareness of and contributions to the Government Affairs fund which assists in our lobbying efforts in Frankfort.

One of the first responsibilities as the President of YOUR KPhA is to get the leadership team assembled for the coming year. The team is more than just the elected officers and directors of the Association. The leaders of KPhA also include all of the volunteers who have agreed to serve as the chair or a member of one of the many KPhA Committees and Workgroups.

Membership Engagement Committee – This committee is chaired by the President-Elect of the Association, Chris Clifton. I view this to be one of the most vital committees to the Association. Without members, we do not exist. My goal for this committee is to continue to identify strategies that will engage and thereby grow membership by helping to identify, communicate and demonstrate the value of KPhA to new and existing members. The committee will promote the core message that MEMBERSHIP MATTERS in YOUR KPhA.

Why is this so important? It is important because it is the committees of KPhA that give input and guidance to the Executive Director, President and Board of Directors for KPhA. Most committees are open to all pharmacists, pharmacy technicians and pharmacy students who are members of KPhA. I want to thank all of the members who have volunteered to serve on these committees for the coming year. The roles and responsibilities of the Committees are outlined in the bylaws of the Association. Here is a list of the committees and the key roles that they play for KPhA:

New Practitioner Committee – This committee will be cochaired this year by Chris Harlow and Briana Kocher. This committee represents and provides service to new pharmacists with the goal of increasing the visibility of KPhA and to help the next generation of pharmacists get involved and stay involved in KPhA following graduation from pharmacy school.

Organizational Affairs (OA) – This committee will be cochaired by Judy Minogue and Lewis Wilkerson. The OA committee reviews and considers matters related to (but not limited to) the internal affairs of the Association. These matters also include soliciting and vetting nominations for Officers, Board of Directors and all awards of the Association except for the Meritorious Service Award.

There are also several work groups that are formed by the Association to help provide additional guidance to the leadership of KPhA. These are formed on an ad hoc basis. There are currently three workgroups. They are:

Past Presidents Advisory Committee – Past President Ray Bishop has volunteered his services as chairman of this Committee of distinguished past leaders of the Association. Emergency Preparedness Workgroup – John Evans has agreed to step up to the plate to chair this workgroup. This This committee serves in an advisory capacity to me as committee will work with Leah Tolliver from KPhA staff in President. Ray also will be a voting member of the Board. developing and working with the Kentucky Department for Professional Affairs/ Public Affairs Committee – Cassy Public Health (KDPH) and in other related emergency preBeyerle has agreed to serve again as chair this year. The paredness activities for the Association. primary areas of responsibility for this committee are policies that relate to the practice of pharmacy and relationships to the general public. The committee also vets applications for the Board of Pharmacy nominations.

Continued on Page 7

THE KENTUCKY PHARMACIST

2014 Mid-Year Conference on Legislative Priorities

September 2014 Register today: www.kphanet.org Pharmacists: $95 Technicians: $35 Students: FREE or $5 for lunch

Friday, November 14, 2014 KPhA Student Legislative Day in partnership with Sullivan University College of Pharmacy and University of Kentucky College of Pharmacy 8:30 a.m.

Registration Opens

**9-10 a.m.

Federal and State Regulatory issues in the pipeline — Board of Pharmacy Executive Director Mike Burleson & BOP President Cathy Hanna

**10:15-11:15 a.m.

Substance Abuse in Kentucky: The Impact of House Bill 1 — Maryellen B. Mynear, Inspector General, Kentucky Cabinet for Health and Family Services

11:30a.m.

Lunch

**12:30-2 p.m.

Pharmacy and the Pursuit of Provider Status — Stacie Maass, APhA Senior VP, Pharmacy Practice and Government Affairs

**2:15-3:15 p.m.

Effective Legislative Involvement — Trish Freeman, Director of the Center for the Advancement of Pharmacy Practice & Jan Gould, Senior Vice President - Government Affairs, Kentucky Retail Federation

3:15-5 p.m.

Legislative Presentations - How the Legislature Works — Sen. Julie Denton - Legislative issues briefing — Government Affairs Committee Chair Richard Slone - House of Delegates Meeting - Kentucky PBM Transparency Act Update

Saturday, November 15, 2014 7:30 a.m.

Registration Opens/Continental Breakfast

**8:15-9:15 a.m.

Ebola Crisis – Doug Thoroughman, PhD, MSCAPT, US Public Health Service, CDC Career Epidemiology Field Officer, Kentucky Department for Public Health

**9:30-10:30 a.m.

Protecting Your Pharmacy: Financial/Patient Data and Store Security and Liability — Bruce Lafferre, CLU, ChFC, LTCP, MSFS, MSM, RHU, REBC, Pharmacists Mutual

**10:45-11:45 a.m.

An Introduction to Poison Control in the 21st Century — Ashley Webb, MSc, PharmD, DABAT, Director, Kentucky Regional Poison Control Center

**Continuing education credit 4.5 Contact Hours Available Friday 3 Contact Hours Available Saturday

Additional Certification Programs **9 a.m. – 5 p.m. MTM Certification Program **Noon – 6 p.m. Adult Immunization Training Additional Registration Required. Lunch will be provided.

THE KENTUCKY PHARMACIST

Kentucky & American Pharmacists Month

September 2014

Open House 2014 YOUR KPhA opened it’s office to members and dignitaries Oct. 2 to kick off Pharmacists Month. Check out KPhA’s Youtube for videos of the program. Also, visit the KPhA Website to read the Proclamation from Gov. Steve Beshear and for a toolkit on how you can develop your own promotion!

THE KENTUCKY PHARMACIST

From Your Executive Director

September 2014

MESSAGE FROM YOUR

EXECUTIVE DIRECTOR Robert “Bob” McFalls I am pleased to report that Stacie Maass, Senior Vice President for Pharmacy Practice and Government Affairs with APhA, will be in attendance to provide us with the latest news from the federal level on our pursuit of provider status for pharmacists. Senator Julie Denton is scheduled to talk about the legislative process, and Jan Gould will help us understand how to make it all happen in terms of our grassroots advocacy. Worried about the Ebola Crisis? Attend and hear the latest from Dr. Doug Thoroughman, representing CDC and the Kentucky Department for Public Health, who recently returned from West Africa. Concerned about how you would continue your business operations after a disaster? Hear from Bruce Lafferre on ways to manage risk and protect your pharmacy. We’ll also learn about how we plan to advance our Collaborative Care Agreement authority in the 2015 legislative session from Dr. Trish Freeman along with a report from Government Affairs Chairman Richard Slone on other parts of our legislative agenda. And we will be spending time together on the MAC Transparency bill passed in 2013 — we will be reviewing the legislation that passed, discussing what it was intended to do and addressing what is needed to ensure compliance by the pharmacy benefit managers. To round out our educational time together, we will learn about how we can improve poison control efforts and learn how Kentucky is addressing substance abuse issues with our new Inspector General Maryellen Mynear. Other plans are in the work— suffice it so say that YOU do not want to miss the 2015 Mid -Year Conference. See you there!

There are more ways to celebrate American and Kentucky Pharmacists Month than there are days in the year. To assist you in your endeavors, KPhA has developed a toolkit as a resource. Some of the tips are in boxes on this page and the next. For more content, visit the KPhA website under Resources. We look forward to hearing from you on how you are promoting the profession and connecting with your peers, patients and community about YOUR special month. And, don’t forget to email information, clips and event photos to Scott at ssisco@kphanet.org. 2014 KPhA Mid-Year Conference In 2012, YOUR KPhA resurrected its “Winter Workshop” in a revised Mid-Year Conference on Legislative Priorities format. Mark your calendar and plan to participate with more than 200 student pharmacists from SUCOP, UKCOP and UCCOP. We have an exciting couple of days planned.

Ideas for Getting out into the Community for Pharmacists Month Senior Citizen Centers are always looking for new, exciting educational events. Set up a brown bag medication review event at a local Senior Citizen Center. Hold a healthcare event in your community or get involved in your local health fair. Present information on pharmacy to people in the community. Promote the event in advance and invite the public. Speak with the local school nurse on educating high school teachers about pharmacy. Ask the guidance counselor if you can set up a presentation on careers in pharmacy for career day. Contact the media in your area, write a news release and talk with the media about Kentucky & American Pharmacists Month. Use social media! 6

THE KENTUCKY PHARMACIST

From Your Executive Director

September 2014

Ideas for the Community Pharmacy!

Ideas for Health Systems and LTC Facilities!

Record a special answering message promoting Kentucky & American Pharmacists Month when you answer your phone, “Thank you for calling. We are celebrating Kentucky & American Pharmacists Month. Pharmacists are your medication experts! How can I help you?”

Place information in your facility’s newsletter about Kentucky & American Pharmacists Month. Decorate the hospital or institution lobby with posters or displays. Create a lunch tray tent card explaining the goals of the pharmacy and services you offer.

Conduct an Immunization Day/Week— hold a flu clinic, blood pressure clinic or osteoporosis screening.

Hold an “open house” for all employees to visit the pharmacy.

Decorate your pharmacy for the month of October with banners and posters highlighting Kentucky & American Pharmacists Month.

Host a visit for your senator or representative and provide him/her with a view of the role of the pharmacist.

Hold a medication educational session with snacks at a convenient time, and invite the public.

Ideas for Students/Colleges of Pharmacy!

Hold an “open house” at your pharmacy and hand out goody bags with an informational brochure inside.

Create a YouTube video promoting pharmacists!

Give an OTC “tour” to your patients on how to select the best OTC products for their individual condition.

Spread the word on social media! Create a banner and ask your school to display the banner to promote Kentucky & American Pharmacists Month.

Invite local students to visit your pharmacy for a class trip and give them a tour of the pharmacy.

Work with pharmacies in your area to hold wellness events!

tice in Kentucky. The profession was close to seeing this happen in the legislature this year, but it did not. This group Health Information Technology (HIT) Workgroup – This will redouble its efforts in this area for the next legislative group will be led by Jennifer Barker. The HIT workgroup session. I also have asked this group to take on the addiassists KPhA in its mission to advance the profession of tional challenge of improving the transitions of care bepharmacy by monitoring the development of HIE via a for- tween the institutional and community pharmacy practice mal committee interface with the state. They also help build for the benefit of our patients. awareness of and educate pharmacists about HIE and educate other provider networks what pharmacists are capa- I look forward to working with the Committees and Workgroups this year. I am excited about the opportunities ble of doing. KPhA is fortunate that the past chair, Larry before us as a profession. Please look at the KPhA website Blandford, has been appointed to the KHIE Coordinating to learn more about the Committees and their members. Council. Even if you are not a member of one of the Committees or Provider Status/Collaborative Care Workgroup – The chair Workgroups, I know they would like to hear from you. of this group is once again Trish Freeman. The primary role Please do not hesitate to forward your ideas or suggestions of this group will be to advise KPhA in the Association’s for KPhA to me or one of the Committee chairs. After all, efforts to expand the definition of collaborative care pracTHIS IS YOUR KPhA.

Continued from Page 3

THE KENTUCKY PHARMACIST

2014 KPERF Golf Scramble

September 2014

THE KENTUCKY PHARMACIST

2014-15 KPhA Committees

September 2014

2014-15 KPhA Committees Membership Engagement

Duane Parsons - Chair Bob Oakley - President Chris Clifton Glenn Stark Brooke Hudspeth Matt Carrico

Elizabeth Moore Misty Stutz Lisa Tang Sonia Erfani Michael Tucker Megan Reynolds Christopher Sissle

Past Presidents

Ad Hoc Committees

Ray Bishop – Chair Ron Poole – Vice Chair Donnie Riley Johnny B. Anneken Joe Carr Jessika Chinn Leon Claywell Kim Croley Dwaine Green George Hammons Melinda Joyce Clay Rhodes Richard Slone Joel Thornbury Lewis Wilkerson

Budget & Audit

Executive Committee

Organizational Affairs Judy Minogue – Co-Chair Lewis Wilkerson – Co-Chair Ralph Bouvette BC Childress David Collins Shane Fogle Matt Harman Ryan Hatfield Brooke Herndon Pat Mattingly Lance Murphy Joel Thornbury Bradley Browning

Professional Affairs/ Public Affairs Cassy Beyerle – Chair Anne Policastri – Vice-Chair Heather Bryan Justin Chafin Danielle Corbett Candace Robinson Cottle Allison Cubit Cathy Hanna Jennifer M. Jaber Amy Larkin Jill Lee Jeff Mills

Glenn Stark – Chair/Treasurer Chris Clifton Brooke Hudspeth Chris Killmeier Bob Oakley Duane Parsons Sam Willett

Government Affairs Richard Slone – Chair Ralph Bouvette Matthew Burke Peggy Canler Matt Carrico Leon Claywell Barry Eadens David Figg Larry Hadley Ryan Hatfield Katie Herren Steve Hill Chris Killmeier Ethan Klein Christian Polen Anne Policastri Jill Rhodes Leah Tolliver Jonathan Van Lahr Kelly Whitaker Michelle DeLuca Fraley Hanna Burgin

New Practitioner Briana J Kocher – Co-Chair Chris Harlow – Co-Chair Amanda Jett Alex Brewer Amanda Burton Khaai Lee Megan Pendley Molly Trent Stacie Silvers Mark Huffmyer Kelli Carpenter 9

Chris Clifton – Chair Kim Croley Kyle Harris Kevin Lamping Benjamin Mudd Duane Parsons Brent Simpkins Mallory Megee

Work Groups Emergency Preparedness John Evans – Chair Donna Johnson Andrea Kirchner Joanne Taheri Jonathan Hughes Brian Ferguson Len Gore Jacob Wishnia Susan L. Victor

Health Information Technology Jennifer Barker – Chair Barry Eadens Kyle Harris Ryan Hickson Patricia Robinson Joel Thornbury Leon Claywell

CCA/Provider Status 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 Chris Killmeier Katie Lentz Duane Parsons Bob Oakley Jill Rhodes Alyson Schwartz Carolynn Horn Joan Haltom

THE KENTUCKY PHARMACIST

Technician Review

September 2014

Technician Review From the KPhA Academy of Technicians The Academy welcomes Megan Reynolds as the newest Academy delegate. Megan is the Assistant Director of the Pharmacy Technician program at Sullivan University and has several years of experience as a technician. She will make a great delegate for the Academy with her experience and dedication to the advancement of pharmacy technicians.

anyone taking the certification test. The exact starting date has not been released yet. All continuing education must be technician specific for 2015. It is not required that all CE be ACPE, but it will have to be technician specific. The amount of in-service hours will drop to five hours and by 2018 it will be zero. There is a lot of movement for advancing technicians coming from the national scene and we are hopeful that Kentucky will become a leader for change in The KPhA Pharmacy Technician Academy continues to work toward the advancement of the pharmacy technician the Pharmacy Technician profession. We will keep you inprofession. We are involved in discussions with the Adviso- formed on the changes coming from PTCB and within Kenry Council to the Board of Pharmacy promoting change for tucky. pharmacy technicians. Our goals are to improve patient The Academy also is seeking new members. We continusafety and play an important role in the evolving pharmacy ously strive to increase our strength of numbers. The more profession. technicians represented in the Academy the stronger our The Pharmacy Technician Certification Board (PTCB) has announced some new initiatives and we want to make sure the KPhA technicians are well informed. As many of you know, starting in 2014 if you had to re-certify, 1 hour of patient safety continuing education along with the 1 hour of law is required. PTCB plans to start a background check on

message will be. By joining the KPhA Pharmacy Technician Academy you are eligible to join the Collaborative Education Institute (CEI) which provides up to 10 hours of technician specific CE every year. If you are interested in finding out more about the Academy 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. All KPhA Technician Members are eligible for Academy Membership at no additional cost. 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 10

THE KENTUCKY PHARMACIST

Aug. 2014 CE â&#x20AC;&#x201D; Eyes, Ears, Nose, Mouth and Throat

September 2014

Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 2 of 4: Evaluation of Eyes, Ears, Nose, Mouth and Throat By: Kimberly A. Messerschmidt, PharmD; Professor of Pharmacy Practice, SDSU College of Pharmacy. Clinical Pharmacist, Sanford USD Medical Center and Kelley J. Oehlke, PharmD; Residency Program Director, Clinical Pharmacy Specialist, Ambulatory Care, Sioux Falls VA Health Care System Reprinted with permission of the authors and the South Dakota 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 # 0143-9999-14-008-H04-P&T 2.0 Contact Hours (0.2 CEU) Goal: To enhance pharmacistsâ&#x20AC;&#x2122; knowledge regarding patient assessment. Objectives

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

At the conclusion of this article, the reader should be able to: 1. 2. 3. 4. 5.

Assess the eyes, ears, nose, mouth and throat to identify common self-treatable medical conditions. Recognize common ocular complaints and know which symptoms require physician referral. Differentiate between symptoms associated with a common cold, influenza and allergic rhinitis. Recognize symptoms that indicate a potential sinus infection. Identify symptoms that may be useful in differentiating between viral and streptococcal pharyngitis. Introduction

In the first installment of this series we introduced the QuEST process, which is a tool designed to help pharmacists elicit the information needed to provide appropriate recommendations regarding self-care1. In this next section, we continue to explore opportunities for utilizing basic patient assessment skills in the ambulatory care setting, with a focus on assessment of the eyes, ears, nose, mouth and throat. EYES

In addition to local conditions, sometimes systemic disease can alter the appearance of the external eye. For example, renal impairment can cause excessive fluid retention resulting in periorbital edema, and hyperthyroidism can cause an abnormal protrusion of the eyeball known as exophthalmos. The unintentional loss of the lateral portion of the eyebrows may indicate untreated hypothyroidism, and slowly growing light-yellow plaques on the inner eyelids called xanthelasmas are frequently associated with dyslipidemia. One of the more common ocular problems a pharmacist encounters is redness of the eye. Although most cases are relatively benign, some require immediate medical attention. Conjunctivitis, an inflammation or infection of the clear mucous membrane lining the eye, can be the result of infectious or noninfectious etiologies.

The eyes can be affected by a number of medical conditions, some of which are amenable to self-treatment while others may require immediate medical attention. The potential risk to vision from ophthalmic problems requires the pharmacist to accurately distinguish between the two sceNoninfectious causes most commonly stem from seasonal narios. or perennial allergies. Hallmark symptoms include bilateral When examining the eyelids and surrounding areas, note redness, a profuse watery discharge, puffiness and itching. the quantity, distribution and texture of the eyebrows; also In more severe cases, a mucoid discharge may be noted. check the eyelids for masses, drooping, redness and swell- To help identify allergies as the cause of the symptoms, ing. A chronic inflammatory condition of the eyelid margins ask the patient about the presence of any non-ocular sympis called blepharitis. Inflammation and infection of a gland toms of allergic rhinitis such as rhinorrhea (runny nose), in the eyelid or the follicle of an eyelash may result in a sneezing, nasal congestion, post-nasal drip, itching of the hordeolum (sty). ears, nose, throat, or palate and systemic symptoms such

THE KENTUCKY PHARMACIST

Aug. 2014 CE — Eyes, Ears, Nose, Mouth and Throat

September 2014

QuEST Process1 

Quickly and accurately assess the patient (e.g., symptoms, current medications and medical conditions, allergies)

  

Establish that the patient is an appropriate candidate for self-care Suggest appropriate strategies for self-care Talk with the patient about: √ The medication’s actions, proper administration, and potential adverse effects √ What to expect from treatment √ Appropriate follow-up usually accompanied by tearing and ocular irritation. Within one to two days a purulent, yellow-green discharge may be noted, often resulting in crusting and matting of the eyelids that develops overnight. Patients should be referred to a physician for antibiotic drops whenever a bacterial infection is suspected.

Table 1. Patient counseling tips to prevent the spread of pink eye Thoroughly wash hands on a regular basis. Avoid touching eyes with hands. Avoid close contact with other individuals.

Another common ocular complaint is dry eye; this condition is especially problematic in the elderly population. Patients with dry eyes typically complain of general ocular discomfort, itching, burning or stinging, redness and a foreign body sensation3. Medications that can exacerbate dryness include diuretics and those drugs with anticholinergic side effects such as antihistamines, tricyclic antidepressants and phenothiazines.

Use a clean towel and washcloth daily. Change pillowcases frequently. Avoid sharing objects that may be contaminated (e.g., towels, washcloths, eye cosmetics). Throw away eye cosmetics and disposable contact lenses (and lens supplies) that may be contaminated.

Self-treatment with artificial tears and/or ocular emollients (during the night) can be recommended for up to three days. Likewise, the use of ocular vasoconstrictors should Conjunctivitis secondary to viral infection is the most combe limited to three days in order to prevent rebound conmon infectious cause of a red eye. This condition usually junctivitis; these products should also be avoided in paoccurs during, or shortly after an upper respiratory tract tients with narrow-angle glaucoma. infection and is characterized by a “pink eye”, swollen eyelids and a profuse watery discharge. Patients also may Patients should not self-treat most ophthalmic conditions complain of light sensitivity, itching and/or a mild foreign- for longer than 72 hours without consulting a physician. body sensation or scratchiness. Symptoms associated with Other indications for physician referral include symptoms of viral conjunctivitis are usually self-limiting and tend to re- ocular pain, blurred vision that does not clear with blinking, solve over a period of one to three weeks. photophobia, or any history of trauma, or chemical or thermal exposure. A patient complaining of a unilateral red eye The symptoms typically start out in one eye, but commonly that is accompanied by severe ocular pain, visual defects spread to the other eye within a day or two. Cold comor nausea and/or vomiting should be referred to a physician presses and lubricating eye drops may help control mild for immediate evaluation to rule out acute angle-closure symptoms. Since pink eye is highly contagious, patients glaucoma. should be counseled regarding good hygiene practices to minimize the spread of infection2 (Table 1). EARS as malaise and fatigue.

If the patient is experiencing severe eye pain it may indicate corneal trauma, in which case the patient should be referred to their physician in order to rule out a corneal abrasion. Bacterial conjunctivitis also presents with a red eye and is

Examination of the ears begins with the inspection of the outer ear and surrounding skin, looking for any redness, swelling or lesions. Special attention should be given to non-healing skin lesions, which may indicate a squamous cell carcinoma. This condition occurs most frequently in fair

THE KENTUCKY PHARMACIST

Aug. 2014 CE — Eyes, Ears, Nose, Mouth and Throat

September 2014

Table 2. Otic symptoms and conditions requiring physician referral

the ear’s natural defenses and allows inflammation and infection to take place.

Signs or symptoms of potential infection (i.e., ear pain, drainage, or fever) Tinnitus Dizziness Perforation of the ear drum (including tympanostomy tubes, recent ear surgery or trauma)

If the patient complains of pain or itching in the ear canal, or if any discharge or inflammation is noted, perform the “tug test”. To do this, gently tug on the ear to move it up and down, and press on the tragus (the piece of cartilage that protects the opening of the ear canal). Movement of the external ear is painful in acute otitis externa, and these patients, as well as any other patient with a suspected ear infection (otitis media), should be referred to his/her physician.

Loss of hearing Lightheadedness, loss of balance, vertigo, nausea or vomiting Foreign objects in the ear canal

Problems with ear wax are another common otic complaint, especially in patients over the age of 65. If excessive or impacted wax causes bothersome symptoms, such as a -skinned individuals who have had frequent sun exposure. feeling of pressure, fullness or itching, or if it interferes with The lesion is usually located on the upper rim of the ear hearing or causes trapping of moisture, it should be reand results in a raised, crusted lesion with a central ulcera- moved. Options for removal include over the counter ear wax softeners, or manual removal by a physician. tion. The entrance to the ear canal also should be examined for drainage, excessive earwax (cerumen) and redness or swelling. Some patients have a tendency to accumulate and retain excessive moisture in the ear canal, especially after bathing, swimming, sweating or just being exposed to a humid environment. This may result in a condition called water-clogged ears. The patient may complain of a feeling of wetness or fullness, which can be accompanied by gradual hearing impairment. Ear drops containing isopropyl alcohol in anhydrous glycerin can be used to dry out the ears after each exposure to water, but these products should be avoided in children less than 12 years of age, and in those with other exclusions for self-treatment (Table 2).

The use of cotton-tipped swabs, or other foreign objects such as bobby-pins, should be avoided due to the potential for pushing the hardened wax further into the ear canal or causing trauma. A summary of the symptoms of the most common otic disorders is provided in Table 3.

Pharmacists also should be aware of the potential effect of medication use on the ear and its functions. Drug-induced ototoxicity can present itself in a number of ways, and it very commonly goes unrecognized. Medications may impair the auditory function of the ear (hearing) by affecting the eighth cranial nerve, and as a result, patients may notice a muffling of sounds, or they may complain of fullness in the ears or hearing loss. Tinnitus frequently precedes or coincides with hearing loss and may be described as a If left untreated, water-clogged ears may develop into acute ringing, buzzing, ticking or roaring sound. otitis externa, or “swimmer’s ear”, which is an inflammation or infection of the outer ear canal. This occurs when contin- Medications also may result in vestibular toxicity. Since the ued water exposure, along with the patient’s attempts to vestibular system influences balance and equilibrium, vesremove the excess moisture, results in the breakdown of tibular toxicity can result in symptoms of lightheadedness,

Table 3. Selected symptoms of common otic disorders Water-clogged ears

Otitis externa

Otitis media

Impacted cerumen

Pain

Often

Usually

Rarely

Hearing difficulty

Possible

Usually

Often

Purulent discharge

Common

If perforation

Bilateral symptoms

Possible

Fairly common

Appropriateness of self-treatment

Yes

In selected cases#

Never

In selected cases*

# Only if individual has a history of swimmer’s ear and can reliably recognize recurrences *For adults only, self-treatment for up to four days is appropriate. 13

THE KENTUCKY PHARMACIST

Aug. 2014 CE — Eyes, Ears, Nose, Mouth and Throat

September 2014

Table 4. Differentiating between a cold and influenza fatigue also may be present. Towards the end of a cold, the Symptom

Common Cold

Influenza

Fever

Rare

Headache

Mild or absent

Sudden onset, often > 102o F (38.9°C) Prominent

Myalgias/ arthralgias Fatigue, weakness

Mild or absent

Prominent

Mild or absent

Runny nose, sneezing

Common

Extreme, up to 2 weeks Less common

Nasal congestion

Common

Less common

Sore throat

Common

Cough (usually non-productive)

Less common

Common, persistent

Usually mild, hacking

Ocular

Watery eyes

Duration

7 days

Complications

Sinus congestion, earache

Can be severe Pain, burning, photophobia 7 days Bronchitis, pneumonia

runny nose typically turns into a stuffy nose, and up to 20 percent of patients develop a nonproductive cough. Over the counter cold products containing antihistamines and decongestants can help ameliorate symptoms, but do not “cure” or shorten the duration of the cold. With influenza, the symptoms are generally more severe and often are accompanied by a high fever and muscle aches (Table 4).

Allergic rhinitis also may be difficult to distinguish from a common cold, but in general, patients suffering from allergies are more likely to complain of itching of the eyes, ears, nose and palate, and the duration of symptoms usually exceeds one week. Make sure to specifically ask patients about the recent use of topical nasal decongestants, since the use of these drugs for more than three to five days, or at doses which are higher than recommended, can cause rebound nasal congestion. Allergy patients should be referred to their physician for suspected complications (e.g., ear, sinus or pulmonary infection) or co-morbidities (e.g., asthma, obstructive sleep apnea) that need medical evaluation, or if they are not responding adequately to nonprescription treatment. If nasal drainage is present, note the color and consistency of the discharge. Clear, watery drainage is often associated with allergic rhinitis or the first stage of a common cold. Yellow, green or blood streaked discharge indicates a possible sinus infection. To assess for sinus problems, ask the patient about any symptoms of nasal congestion, facial pain, pressure or tenderness, and about any recent upper respiratory tract infections. To detect tenderness, use your thumbs to press upward under the eyebrows and under both cheekbones. Excessive discomfort or pain suggests sinusitis.

loss of balance, vertigo, nausea and vomiting. Most often these effects are reversible upon discontinuation of the offending drug. Medications associated with potential ototoxicity include antibiotics (e.g., erythromycin, aminoglycosides, vancomycin), loop diuretics, quinine, cisplatin, salicylates and NSAIDs. Any patient with symptoms suggestive of drug-induced ototoxicity should be referred to a physiWith sinus congestion, the patient’s speech will have a nacian for further assessment. sal quality. A patient is more likely to have a sinus infection (rather than just a cold) if symptoms have not improved NOSE AND SINUSES after about 10 days, or if symptoms worsen (rather than When inspecting the nose, start by examining the external improve) after five to seven days. surface for skin lesions, erythema or drainage. Check the patency of the nasal passages by occluding one nostril at a Other symptoms indicating a potential sinus infection intime and asking the patient to inhale through the other nos- clude, but are not limited to, the following: a low-grade fetril. Air passage should be noiseless and unobstructed. If ver, cough, malaise, nasal congestion that is unresponsive significant congestion is noted, question the patient about a to nasal decongestants, a preceding upper respiratory inrecent upper respiratory tract infection such as a common fection, toothache, headache or facial pain (especially upon cold, or any allergic symptoms like itching, puffy or watery awakening or bending over) and purulent nasal drainage. eyes, or a watery nasal discharge. Symptoms of a common Individually, each of these signs or symptoms has poor cold can vary slightly depending on which one of over 200 prognostic value, but when seen in combination they can viruses is causing the cold, but most commonly it starts be highly predictive of a sinus infection. When a sinus inwith a scratchy, sore throat, followed by a runny nose, fection is suspected, the patient should be referred to a sneezing and watery eyes. A mild headache, malaise and physician for further evaluation and treatment. 14

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Aug. 2014 CE — Eyes, Ears, Nose, Mouth and Throat MOUTH AND THROAT Mouth When inspecting the mouth, use a tongue blade and penlight to examine the lips, gums, cheeks, tongue, teeth and palate. Have the patient remove any lipstick or dentures in order to facilitate your examination. Also note any unusual odor to the patient’s breath. A sweet odor, similar to ripened bananas, may indicate diabetic ketoacidosis, while a foul or putrid odor may be a sign of a dental or pulmonary infection. Observe the lips for color, moisture, swelling, asymmetry or presence of lesions. Common findings include herpes simplex lesions (cold sores or fever blisters) which are recurring lesions that are usually located on the border of the lip. These painful lesions usually start as a small cluster of vesicles that rupture and form a yellowish-brown crust. Healing generally occurs over a period of 10 to 14 days. Any non-healing lesion should be examined by a physician to rule out carcinoma. Dry, cracked or inflamed lips can be a sign of sun or wind exposure, dehydration or poorly fitting dentures. An asymmetrical drooping of one side of the mouth may be the result of Bell’s Palsy (inflammation or dysfunction of the facial nerve) or a cerebrovascular accident and should be promptly referred to a physician to determine the cause.

September 2014

creamy-white, curd-like patches. The area under the patches is often reddened and sore. These lesions may be found on the cheeks, tongue, throat, hard and soft palate and gums. Patients more susceptible to oral thrush are those on certain medications such as inhaled or systemic steroids, antibiotics or other immunosuppresants, as well as those who smoke, are diabetic or have an immunosuppressive disorder. Patients with suspected thrush should be referred to a physician for further evaluation and treatment. Throat To inspect the throat, use a tongue blade and penlight to visualize the posterior portion of the oral cavity and the tonsils. Insert the tongue blade posteriorly, no further than the uvula to avoid provoking the gag reflex. Moistening the tongue blade with warm water may help avoid triggering this reflex. While pressing gently downward on the tongue, ask the patient to say “aaah”. This raises the soft palate and allows for better visualization of the oropharynx and tonsillar area. Observe the surrounding region for inflammation, erythema, exudate or lesions. Small, irregular spots of pink or red lymphatic tissue and small blood vessels are commonly present.

The color of the tonsils usually blends in with the pink color of the pharynx and they normally should not project beyond the limits of the tonsillar pillars. If the tonsils are redNext, ask the patient to open her mouth. Note the state of dened, swollen or covered with whitish spots, or exudate, dental hygiene and observe for any signs of inflammation an infection may be present. A yellowish, mucoid drainage of the gums (gingivitis) or easy bleeding, both of which may in the pharynx is typical of postnasal drip. be an early symptom of periodontal disease. Gingival hyperplasia (enlargement of the gums) may be associated A sore throat, or pharyngitis, is one of the most common with pregnancy, leukemia or exposure to certain drugs reasons a patient seeks medical attention. This condition is (e.g., calcium channel blockers, phenytoin, cyclosporine). usually caused by the invasion of the pharyngeal tissue by A yellowish to brown discoloration of the teeth from tobac- a pathogen, although non-infectious etiologies (e.g. gasco, coffee, tea or prior tetracycline use is a fairly common troesophageal reflux disease, post-nasal drainage) also but benign finding. are possible. Both bacterial and viral organisms can produce a sore throat. Inspect the gums, cheeks and palate for erythema, lesions or swelling. The normal oral mucosa should be pink and Approximately 50 to 80 percent of pharyngitis is due to viral moist. A lack of saliva under the tongue may be an indica- pathogens, while Group A streptococcus is by far the most tion of dehydration. Aphthous ulcers (canker sores) are common bacterial pathogen. Since untreated streptococcal small, painful pale yellow to white spots or ulcerations that pharyngitis (strep throat) may lead to complications such are often surrounded by a reddened halo. They are a fairly as rheumatic fever, one of the most important tasks in evalbenign finding and usually heal within seven to 10 days uating a patient with a sore throat is to decide whether or without treatment. Leukoplakia presents as a thickened not they may have strep throat. and painless white patch and may occur anywhere on the Table 5 lists common findings associated with both streptooral mucosa. This finding is usually the result of chronic coccal and viral pharyngitis. Although individual signs and irritation such as from chewing tobacco and is considered a symptoms are not accurate enough to make a clear diagpre-malignant condition that should be further evaluated. nosis, patients with one or fewer of the cardinal findings Oral thrush is a yeast infection of the mouth that results in (i.e., tonsillar exudate, swollen tender anterior cervical

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Aug. 2014 CE — Eyes, Ears, Nose, Mouth and Throat

September 2014

Table 5. Characteristic findings associated with pharyngitis Signs and symptoms suggestive of streptococcal pharyngitis

Signs and symptoms suggestive of viral pharyngitis

Sudden onset of severe throat pain

Cough

Pain on swallowing

Temp ≤101° F (38.3°C)

Fever > 101° F (38.3°C)*

Runny nose

Headache and malaise

Hoarseness

Abdominal pain (especially in children)

Conjunctivitis

Nausea and vomiting

Pharyngeal vesicles and/or ulcers

Rash

Malaise

Enlarged or tender cervical lymph nodes* Pharyngeal erythema, exudate Tonsillar erythema, enlargement, exudates* Bad breath Lack of cough* * cardinal symptoms of strep throat

nodes, absence of cough, history of fever) have a relatively low risk of strep throat.

REFERENCES

CONCLUSION

SUGGESTED READINGS

1. Leibowitz K, Ginsburg D. Counseling self-treating paIt is important to refer any patient with suspected strep tients quickly and effectively. Proceedings of the APhA throat to his/her physician for further assessment, diagnoInaugural Self-Care Institute; May 17-19, 2002. sis and care. A low grade fever and malaise often accom2. Pink eye (conjunctivitis). Available from URL: http:// pany the viral sore throat. Although distressing to the pawww.mayoclinic.com/health/pink-eye/DS00258. Updattient, this condition is usually benign and self-limited. Dured May 22, 2010. ing the acute phase of pharyngitis, most patients will benefit from rest, adequate fluid intake, antipyretic/analgesic 3. Pray, SW. Minor eye problems in the elderly. US Pharm 2009;34(6):12-17. therapy and warm salt water gargles.

Patients commonly present to their community pharmacy  seeking a recommendation for the treatment of symptoms involving the eyes, ears and upper respiratory tract. While many of these conditions can be self-treated, some require physician referral, and it is imperative for the pharmacist to be able to distinguish between the two.  By utilizing basic patient assessment skills, the pharmacist is able to guide the patient regarding the most appropriate  treatment to pursue, whether it be self-treatment or further evaluation by a physician. Using these skills, along with effective communication techniques, allows the pharmacist to build long-term, trusting relationships that optimizes pa-  tient care.

Berardi RR, Ferreri SP, Hume AL, Kroon LA, Newton GD, Popovich NG et al, editors. Handbook of Nonprescription Drugs: An Interactive Approach to Self-care. 16th ed. Washington DC: The American Pharmaceutical Association; 2009. Dipiro JT, et al (eds): Pharmacotherapy: A Pathophysiologic Approach. 7th ed. McGraw Hill; 2008. Jones RM and Rospond RM. Patient Assessment in Pharmacy Practice. 2nd ed. Baltimore (MD): Lippincott Williams & Wilkins; 2006. Longe RL and Calvert JC. Physical Assessment: A Guide for Evaluating Drug Therapy.1st ed. Vancouver: Applied Therapeutics, Inc; 1994.

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Aug. 2014 CE — Eyes, Ears, Nose, Mouth and Throat

September 2014

August 2014 — Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 2 of 4: Evaluation of the Eyes, Ears, Nose, Mouth and Throat 1. Which of the following statements best describes symptoms typically associated with allergic conjunctivitis? A. Unilateral redness, irritation and purulent discharge B. Bilateral redness, watery discharge and ocular itching C. Severe ocular pain and redness D. Crusting and matting of the eyelids, particularly upon awakening

7. Symptoms that suggest a patient has influenza rather than a common cold include: A. Nasal congestion. B. Myalgias and arthralgias. C. Runny nose and sneezing. D. Sore throat.

2. A patient presenting with a unilateral red eye and severe ocular pain should be: A. Instructed to self-treat with acetaminophen for up to five days. B. Referred to a physician if the symptoms do not improve on their own within 72 hours. C. Referred to a physician for immediate evaluation. D. Told to practice thorough hand washing and to avoid sharing contaminated objects with others. 3. Which of the following statements regarding the selftreatment of common ocular problems is FALSE? A. Patients should not self-treat most ophthalmic conditions for longer than 72 hours without consulting a physician. B. The use of ocular vasoconstrictors should be limited to three days in order to prevent rebound conjunctivitis. C. Patients experiencing severe eye pain should be referred to their physician as it may be a sign of a corneal abrasion. D. Patients who have experienced a chemical exposure to the eye should be instructed to flush well with water and call their physician if the pain and/or vision problems do not resolve within 72 hours. 4. Which of the following otic conditions is potentially appropriate for self-treatment? A. Symptoms of ear pain, fever and drainage B. Suspected drug-induced ototoxicity C. A repeat case of swimmer’s ear D. Impacted cerumen in a patient with dizziness and tinnitus 5. Pain associated with the “tug test” is most suggestive of: A. Otitis externa (swimmer’s ear). B. Ear wax impaction. C. Ototoxicity. D. Otitis media.

8. Symptoms of purulent nasal discharge, cough, nasal congestion, facial pain or tenderness, and a headache are most consistent with: A. Influenza. B. Strep throat. C. A sinus infection. D. Seasonal allergies. 9. Leukoplakia is a pre-malignant condition found on the: A. Oral mucosa. B. Nose. C. Scalp. D. Eyelids. 10. Painful, creamy-white, curd-like patches in the oral cavity are due to: A. Chronic irritation. B. A viral infection. C. A bacterial infection. D. Yeast. 11. Which of the following symptoms are more likely to be suggestive of viral pharyngitis rather than streptococcal pharyngitis? A. Enlarged cervical lymph nodes and a high fever B. Tonsillar exudate C. Sudden onset of severe throat pain D. Low grade fever, runny nose and a cough 12. Which of the following are signs and symptoms of streptococcal pharyngitis that should alert you to recommend a prompt referral to a physician? A. Pain on swallowing, temperature < 101° F (38.3°C) B. Runny nose and cough C. Temperature >101° F (38.3°C) with tonsillar exudate D. Low grade fever, runny nose and a cough

6. Clear, watery nasal discharge accompanied by an itchy nose and eyes is most consistent with : A. A bacterial sinus infection. B. A common cold. C. Influenza. D. Allergic rhinitis.

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Aug. 2014 CE — Eyes, Ears, Nose, Mouth and Throat

September 2014

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 27, 2017 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. August 2014 — Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 2 of 4: Evaluation of the Eyes, Ears, Nose, Mouth and Throat (2.0 contact hours) Universal Activity # 0143-9999-14-008-H04-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D

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

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

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

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

Personal NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) PHARMACISTS ANSWER SHEET August 2014 — Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 2 of 4: Evaluation of the Eyes, Ears, Nose, Mouth and Throat (2.0 contact hours) Universal Activity # 0143-9999-14-008-H04-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D

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

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

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

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

Personal NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy Education as a provider of continuing Pharmacy education.

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

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September 2014

KPhA Pharmacy Emergency Preparedness

Make a plan and practice Disasters and other emergencies occur with very little warning, so make sure that you and your family have a plan in place to handle several types of emergencies. For more information on developing emergency plans, visit http:// www.ready.gov/make-a-plan. Once you have your plan, be sure to practice it until all members of your family are comfortable with the plan!

Drop, Cover and Hold On With a major fault line near the western end of Kentucky, a major earthquake is possible. For more information on earthquake drills, visit http://quake.ualr.edu/schools/guide/section6d.htm.

Pharmacy Personnel Training Program KPhA Director of Pharmacy Emergency Preparedness Leah Tolliver, PharmD, is developing a training program for Pharmacy Personnel on preparing for a disaster, both in the pharmacy and at home. Watch the KPhA eNews and the calendar on www.kphanet.org for dates and more information.

KPhA Pharmacy Emergency Preparedness Initiative Interest Form Name: ______________________

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) 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.

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

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Sept. 2014 CE — CPE Monitor

September 2014

CPE Monitor – A New Continuing Education Tracking System for Pharmacy By: Bernie Hendricks, RPh, Continuing Education Coordinator, South Dakota State University College of Pharmacy Reprinted with permission of the authors and the South Dakota Pharmacists Association where this article originally appeared. This activity may appear in other state pharmacy association journals. There are no financial relationships that could be perceived as real or apparent conflicts of interest.

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

Universal Activity # 0143-9999-14-009-H04-P&T 1.0 Contact Hours (0.1 CEU) Pharmacist Objectives At the conclusion of this article, the reader should be able to: 1. 2. 3. 4.

Describe the CPE Monitor mechanism for tracking / verifying continuing education credits. Name two primary benefits of the new CPE Monitor program. Describe the process for pharmacists to obtain an e-Profile ID. Identify the two key pieces of information that a pharmacist must submit to be properly credited for successful completion of continuing education programs. 5. Describe the process of a pharmacist reviewing / verifying information on earned continuing education credits. Pharmacy Technician Objectives 1. 2. 3. 4.

Describe the CPE Monitor mechanism for tracking / verifying continuing education credits. Name two primary benefits of the new CPE Monitor program. Describe the process for pharmacy technicians to obtain an e-Profile ID . Identify the two key pieces of information that a pharmacy technician must submit to be properly credited for successful completion of continuing education programs. 5. Describe the process of a pharmacy technician reviewing / verifying information on earned continuing education credits. Background – Continuing Pharmacy Education (CPE)

“live” (didactic) CPE.

Continuing pharmacy education is required for re-licensure in all 50 states, along with the District of Columbia, Guam, and Puerto Rico.

Some states allow a “carry-over” of hours, where extra hours of CPE earned in a given year are allowed to be carried over into the next reporting period.

CPE requirements vary from state to state regarding the number of contact hours required (annually or biennially), the composition of the CPE and the format (live or home study).

Kentucky law requires pharmacists to earn 15 hours of CPE each year. Extra hours do not carry over to the next year, and one hour of HIV/AIDS CPE is required every 10 years. Newly licensed pharmacists do not have to complete CPE hours the year they graduate, but must complete the standard 15 hours the next year.

The number of CPE “contact hours” required for relicensure ranges from 10 – 20 per year, depending on the state or territory. The most common requirements are “15 hours per year,” or “30 hours biennially,” or “12 hours per year.” Some states express their requirements in terms of continuing education units (CEUs), in which 1 CEU is equivalent to 10 “contact hours.”

CPE credit – tracking and verification

The CPE Monitor program is a new tracking service for continuing pharmacy education which is a “national collaborative effort between the National Association of Boards of Certain states require a set number of CPE hours in speci- Pharmacy® (NABP®) and the Accreditation Council for fied topic areas such as pharmacy law, or AIDS/HIV, safety Pharmacy Education (ACPE).” or pain management. And numerous states require that a This program will electronically “store and authenticate data specified number of hours must be completed as for completed CPE units,” for pharmacists and pharmacy 20

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Sept. 2014 CE — CPE Monitor

September 2014

technicians. To accomplish this, ACPE-accredited providers of continuing pharmacy education programs will upload verification to a participant’s e-Profile account, following successful completion of a given continuing education program.

e-Profile Account

Data will be stored in a central repository managed by NABP. Individual pharmacists and pharmacy technicians will be able to access the information in their own accounts, and Boards of Pharmacy will be able to verify CPE information of those seeking re-licensure. This electronic storage and authentication process should efficiently streamline subsequent tracking and verification of continuing pharmacy education credit. Paper copies of ACPE Statements of Credit for continuing pharmacy education units (CPE units) earned by pharmacists and pharmacy technicians have been eliminated in this new, stream-lined process. Testing – implementation By April of 2012 an NABP-ACPE pilot program had been completed, and nearly 50 ACPE-accredited providers had “transitioned their systems to transmit data” to the CPE Monitor database. These 50 providers were the first to require participants to provide “e-Profile ID number” and birthdate in “MM/DD” format in order to earn CPE credit. The balance of ACPE-accredited providers transitioned their systems during 2012, with full transition of all providers required by Dec. 31, 2012. KPERF transitioned as of September 2012.

In step two, pharmacists and pharmacy technicians also will create individual e-Profile accounts in order to track their CPEs completed. e-Profile accounts can be created by going to www.NABP.net, then “CPE Monitor,” and then clicking on “create an e-Profile.” Electronic tracking Following the successful completion of a given continuing education program, the ACPE-accredited provider of that program will transmit verification by uploading the appropriate credit award to the national database maintained jointly by ACPE and NABP, where it will be posted to the participant’s e-Profile account. Case example 1: A pharmacist goes to an ACPE approved live program and earns credit for 3 separate CE sessions (1.5 hours, 2 hours, 1 hour). The ACPE-accredited provider, utilizing the participant’s e-Profile ID and MMDD, will upload verification of that credit to the participant’s e-Profile account citing the amount of credit, the Universal Program Identification number for each session completed, and relevant date(s). The participant will then be able to log in to his/her account with the “username” and “password” established during the initial set-up to confirm the credit awards and comprehensive listings of past CPE units successfully completed and credited.

Note: If a participant logs in to his/her e-Profile account and notices that he/she has not been properly credited in the account, then the participant will need to contact the ACPE noted that by April 2012 “more than 142,000 pharmacists and 62,000 pharmacy technicians” had set up their provider of that program to reconcile that credit issue. NABP e-Profiles for electronic transmission and tracking of Case example 2: A pharmacy technician submits two sepatheir CPE units earned. rate home study courses on pharmacy law (2 hours, 2 hours) to an ACPE-accredited provider. The provider then corrects NABP has affirmed, “All information is maintained in a the two post-tests submitted, and verifies completeness of highly secure environment.” And, “CPE Monitor will not additional requirements (evaluation, needs survey). Once track CPE from non-ACPE-accredited providers. Until this feature is provided in Phase 2, non-ACPE-accredited CPE successful completion of requirements has been determined, the provider of the two CPE programs will need the particiwill need to be submitted directly to the Board of Pharmapant’s e-Profile ID number and MMDD to properly upload the cy.” This includes CPE earned that is accredited by the appropriate credit, the Universal Program Identification NumKentucky Board of Pharmacy. ber, and the date(s) for the courses. Registration / e-Profile ID Note: If the participant has not obtained an e-Profile ID For step one, pharmacists and pharmacy technicians are (ePID) in advance, then the provider will be required to put required to register with CPE Monitor on the NABP website the credit verification ‘on hold,’ until the participant obtains (www.MyCPEmonitor.net ) to obtain their NABP e-Profile ID the e-Profile ID and provides that and the MMDD (month/ (ePID). This unique ID number, along with a participant’s day of date of birth). MMDD (month/day of date of birth) will be needed for the Records participant’s e-Profile account to be properly credited for earned CPE units.

Using their “username” and ‘password,” pharmacists and 21

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Sept. 2014 CE — CPE Monitor

September 2014

pharmacy technicians will be able to login to their eProfile accounts anytime to verify or confirm the number of CPE units (CE credits) that have been earned in a given period of time. They also will be able to print hard-copy records if they wish. Any discrepancies will need to be reconciled with the provider of a given program.

Reminders Pharmacists and pharmacy technicians will need to keep a good record of their e-Profile “Username” and “Password,” in order to confirm that they have been properly credited for CE.

Following each live program event or home study course Boards of Pharmacy also will be able to access licensee submitted, participants should verify on their individual eaccounts to insure that CE requirements have been met for Profile accounts that they have received the correct numre-licensure each year. ber of CPE units (credits) for that event or course. ParticiNote: A given Board of Pharmacy may independently veri- pants should also periodically verify that they are on track fy information in e-profile accounts of those seeking refor accumulating the proper number of credits for relicensure. Or a Board may require a pharmacist or pharma- licensure as those dates approach. cy technician to print a hard copy report from their e-Profile Pharmacy students: If a pharmacy student would happen account and submit with re-licensure application. to establish an e-Profile account prior to becoming licensed as a pharmacist, that student would later need to go back Benefits into his/her e-Profile to update that account with the pharHard copy Statements of Credit will eventually be eliminatmacist license number and state. ed – thus avoiding the issue of lost copies and the subsequent tracking down of various providers for “replacement Pharmacists and pharmacy technicians who develop any copies.” problems setting up or accessing their accounts, printing statements or verifying accumulated credit, are urged to Boards of Pharmacy will be able to view e-Profile account contact NABP’s Customer Service at 847-391-4406 or verification of CPE units earned for re-licensure applicaemail them at custserv@nabp.net (or rcowan@nabp.net). tions. Additional information on CPE Monitor may be obtained by Licensees also will be able to print a hard-copy statement visiting www.MyCPEmonitor.net . from their NABP e-Profile which verifies the accumulated CPE units earned for a given time period. And certain References: Boards of Pharmacy (or other “licensing jurisdictions”) may 1. NABP “Survey of Pharmacy Law 2012” require their pharmacists and pharmacy technicians to sub2. ACPE “Electronic Mailbag,” April 12, 2012 mit such a “hard copy” statement for re-licensure.

KPhA Government Affairs Contribution Name: _______________________________Pharmacy: _____________________________

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

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

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Sept. 2014 CE — CPE Monitor

September 2014

September 2014 — CPE Monitor – A New Continuing Education Tracking System for Pharmacy 1. Pharmacists and pharmacy technicians may obtain their new e-Profile ID number by: A. Contacting their Board of Pharmacy. B. Logging in to the ACPE website. C. Logging in to the NABP website, www.MyCPEmonitor.net. D. Automatically receiving it when they license. 2. In order for a pharmacist or pharmacy technician to access their existing “NABP e-Profile” account, they will need to log in with their: A. Username and Password. B. e-Profile ID Number and MMDD. C. Username, password, and e-Profile ID number. D. MM/DD and SSN.

6. Boards of Pharmacy or other “licensing jurisdictions” for pharmacist and pharmacy technician re-licensure applications: A. May access individual e-Profile accounts to confirm that CE requirements have been met for a given time period. B. May require pharmacists and pharmacy technicians to submit a paper statement from their e-Profile accounts for CE verification. C. Either a or b. D. Neither a nor b.

7. Boards of Pharmacy may continue to accept continuing education credits for re-licensure from non-ACPE accredited providers following the full implementation of CPE Monitor. 3. At the time when all ACPE-accredited providers are re- A. True quired to have fully transitioned to the CPE Monitor system, B. False all pharmacists and pharmacy technicians will be required to obtain and submit their “e-Profile ID” number (ePID) and 8. “Live” CPE and “home study CPE” credit earned by “MMDD” in order to insure the proper electronic transmispharmacists and pharmacy technicians will both be treated sion of CPE unit (CE credit) to their accounts. the same by ACPE accredited Providers following full imA. True plementation of CPE Monitor – with all credit uploaded to B. False the CPE Monitor database A. True 4. All ACPE-accredited providers will be required to fully B. False transition to the CPE Monitor electronic tracking system by: A. April 2012. 9. If a pharmacist or pharmacy technician checks their eB. July1, 2012. Profile account and notices that he/she has not been C. December 31, 2012. properly credited for a CE program successfully completed, D. December 1, 2013. that person should contact: A. The Board of Pharmacy. 5. Continuing education credit earned that is not ACPE B. Customer Service at NABP. approved will automatically be included and properly credit- C. Their local internet service provider (ISP). ed into the CPE Monitor system, beginning December 31, D. The ACPE accredited provider of that program who 2012. would have been tasked with uploading the credit inforA. True mation. B. False 10. If a person needs to submit an e-Profile ID (ePID) for a given CE program and has misplaced or cannot remember the number, then he/she should: A. Log in to their e-Profile account to access the ePID. B. Call their state Board of Pharmacy. C. Call their state Pharmacists Association. D. All of the above.

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

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September 2014

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: October 22, 2017 Successful Completion: Score of 80% will result in 1.0 contact hour or 0.1 CEU. Participants who score less than 80% will be notified and permitted one re-examination. TECHNICIANS ANSWER SHEET. September 2014 — CPE Monitor – A New Continuing Education Tracking System for Pharmacy (1.0 contact hours) Universal Activity # 0143-9999-14-009-H04-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B 5. A B 2. A B C D 4. A B C D 6. A B C D

7. A B 8. A B

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

Personal NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) PHARMACISTS ANSWER SHEET September 2014 — CPE Monitor – A New Continuing Education Tracking System for Pharmacy (1.0 contact hours) Universal Activity # 0143-9999-14-009-H04-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B 5. A B 2. A B C D 4. A B C D 6. A B C D

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Oct. 2014 CE — Respiratory & Cardiovascular Systems

September 2014

Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 3 of 4: Evaluation of the Respiratory and Cardiovascular Systems By: Kimberly A. Messerschmidt, PharmD; Professor of Pharmacy Practice, SDSU College of Pharmacy. Clinical Pharmacist, Sanford USD Medical Center and Kelley J. Oehlke, PharmD; Residency Program Director, Clinical Pharmacy Specialist, Ambulatory Care, Sioux Falls VA Health Care System Reprinted with permission of the authors and the South Dakota 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 # 0143-9999-14-010-H04-P&T 2.0 Contact Hours (0.2 CEU) Goal: To enhance pharmacists’ knowledge and skills regarding patient assessment. Learning Objectives

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

At the conclusion of this article, the reader should be able to: 1. 2. 3. 4. 5. 6.

Perform a basic assessment of the respiratory system. Evaluate a patient for signs and symptoms of respiratory distress. Identify symptoms associated with a cough that indicate the need for physician referral. Perform a basic assessment of the cardiovascular system including pulse, respiratory rate and blood pressure. Describe the proper technique for blood pressure measurement. Identify the characteristics of the most common causes of chest pain.

non-pulmonary conditions (e.g., heart failure, gastroesophageal reflux). The initial assessment should start with evalSL is a 54-year-old male who approaches the pharmacy uating the patient for any obvious signs of respiratory discounter with an over the counter (OTC) cough and cold tress that indicate a need for physician referral (Table 1). product. The patient explains that he has been taking this Observe the patient’s pattern and ease of breathing. It multi-symptom cold formula for the past two days, but when should be smooth and even, and appear effortless, with a he actually read the product directions, he saw a warning rate of 12 to 20 breaths per minute. Note the depth of the which recommended that patients with heart disease or respirations and whether the patient is using accessory high blood pressure should consult a physician before usmuscles (i.e., neck, abdominal, or intercostal muscles). ing the product. He asks for your advice regarding an alterThese muscles are used to augment breathing when the native treatment as his blood pressure has been elevated. diaphragm cannot move sufficient air. Recalling the QuEST/Scholar process (page 12)1 which was introduced in the first installment of this series, you Next, listen to the patient’s breath sounds for any abnorbegin your consultation by assessing the patient. malities. Wheezing is a high pitched, continuous, squeaky sound that can sometimes be heard without the aid of a In this section, we will continue to explore opportunities for stethoscope. It is caused by air flowing through narrowed utilizing basic patient assessment skills in the ambulatory or partially obstructed airways. This narrowing may be due care setting, with a focus on assessment of the respiratory to excessive secretions, inflammation or bronchospasm, and cardiovascular systems. and it is commonly seen in lung diseases such as asthma or chronic obstructive pulmonary disease (COPD), or in As you read this module, think about the case above and how you would apply the QuEST process in order to formu- acute bronchitis. Wheezing also may be induced by exposure to certain medications (e.g., aspirin, NSAIDs, betalate the best plan for this patient’s care. blockers) in susceptible individuals. Stridor is a serious, RESPIRATORY SYSTEM high-pitched, wheezing type of sound that occurs when Typical respiratory symptoms such as shortness of breath there is a significant partial obstruction of the upper airway, or cough may arise from a variety of pulmonary, as well as such as when a foreign object like food, or swelling due to Introduction

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Oct. 2014 CE — Respiratory & Cardiovascular Systems Table 1. Signs and symptoms of respiratory distress

September 2014

Increased respiratory rate

Table 2. Symptoms associated with a cough that indicate a need for physician referral

Use of accessory muscles

Fever

Retractions of the intercostal spaces

Night sweats

Wheezing or stridor

Hemoptysis

Dyspnea

Unintended weight loss

Pursed lip breathing

Productive cough with purulent sputum (e.g., thick, colored)

Cyanosis of the skin or lips Changes in mental status (e.g., confusion, somnolence, restlessness or anxiety)

Increasing symptoms in a patient with underlying pulmonary disease Poor response to self-treatment

Nasal flaring, especially in newborns an infection threatens to occlude the airway.

and debris from the respiratory tract; therefore, it can be counterproductive to suppress.

Next, evaluate the patient’s ease of breathing. A patient with dyspnea may say they are short of breath, winded or breathless. To help determine the severity of their symptoms, note whether they can speak in complete sentences without being forced to stop for a breath. Also, ask how their breathing is affecting their daily life. Can they carry groceries into the house? Do they have any problems dressing or bathing themselves? If the patient has dyspnea that has not been formally evaluated, or if they have any other signs or symptoms of respiratory distress, they should immediately be referred to their physician.

The most common etiologies of a cough are postnasal drip due to allergies or upper respiratory tract infection, cigarette smoking, poorly controlled or undiagnosed asthma and gastroesophageal reflux3. Other less common causes include heart failure, malignancy, other pulmonary diseases and drugs such as angiotensin converting enzyme (ACE) inhibitors.

If the dyspneic patient has a previous diagnosis of obstructive lung disease and is using an inhaler, the pharmacist should always assess medication adherence; this includes having the patient demonstrate their inhaler technique. Studies have shown that a large percentage of patients do not use their inhalers correctly. Providing oral or written instruction on administration technique is not good enough, as this approach results in only about one-half of patients being able to use their inhaler correctly2. An actual demonstration of appropriate technique by the pharmacist, while the patient observes and then repeats the demonstration, is the most effective method of teaching this somewhat complicated task. This approach results in 75 percent of patients using acceptable technique. Since the efficacy of an inhaled medication is highly dependent upon proper administration, it is well worth the extra time it takes to teach the correct administration method to make sure the patient is getting the most benefit. Another common respiratory complaint is cough. This symptom can be classified in a number of ways: acute (less than three week duration) or chronic, and productive (associated with the expectoration of secretions from the lower respiratory tract) or nonproductive (dry, hacking). It is important to remember that the cough reflex is a vital respiratory defense mechanism designed to expel secretions

A typical ACE inhibitor induced cough can begin anytime from hours to months after initiation of the offending drug. It usually starts out as a tickling sensation in the back of the throat, and the resulting cough is generally described as being non-productive and poorly responsive to antitussives. The typical ACE inhibitor induced cough generally resolves within one to four weeks after drug discontinuation3. A cough associated with a common cold is usually caused by post-nasal drainage and may respond to the use of a decongestant/antihistamine combination. Any cough that lasts for more than one week, or is accompanied by symptoms suggestive of an underlying infection or more serious condition should always be evaluated by a physician (Table 2). VITAL SIGNS and CARDIOVASCULAR SYSTEM The vital signs (pulse, respiration, blood pressure and temperature) are considered to be the baseline indicators of a patient’s health status. Pain assessment is often times considered the fifth vital sign. Evaluation of the vital signs may be incorporated into any practice setting, measured together or separately and obtained in a brief period of time. Pulse A person’s pulse represents the number of cardiac cycles per minute. Because it is easily accessible, the radial pulse (wrist) is most commonly taken. When determining the radial pulse, the pharmacist should:

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Oct. 2014 CE — Respiratory & Cardiovascular Systems

September 2014

Table 3. Guidelines for proper blood pressure measurement5 

Ask the patient if he or she has smoked or ingested caffeine within the previous 30 minutes. If the patient answers “yes”, record the information and recognize that it may impact the blood pressure.



The patient should be seated in a chair with his back supported, feet flat on the floor and bare arm supported at heart level.



Make sure the patient has been allowed to rest for at least five minutes before measuring her blood pressure.



Determine the appropriate cuff size.



Palpate the brachial artery along the inner arm near the crease of the elbow.



Center the bladder of the cuff over the brachial artery and wrap the cuff snuggly around the arm, placing the lower edge of the cuff approximately one inch above the antecubital space (fold of the arm).



Position the manometer dial so it can be easily read.



Instruct the patient not to talk during the measurement.



Determine the maximum inflation level (how much to inflate the cuff). While palpating the radial pulse, inflate the cuff to the point at which the radial pulse can no longer be felt, then add 30 mmHg to this reading.



Rapidly deflate the cuff and wait 30 seconds before reinflating.



Insert the stethoscope earpieces, making sure they point forward when in place.



Place the bell of the stethoscope lightly, but with an airtight seal, over the palpable brachial artery. Note that the diaphragm of the stethoscope also may be used; however, the bell is designed to detect low-pitched sounds and should be used if possible.



Rapidly inflate the cuff to the maximum inflation level.



Slowly release the air, allowing the pressure to fall steadily at 2 to 3 mmHg/second.



Note the pressure at the first appearance of repetitive sounds and record this as the systolic pressure.



Continue listening, noting the pressure at which the last sound is heard. This is the diastolic pressure.



Continue listening until 20 mmHg below the diastolic pressure, then rapidly and completely deflate the cuff.



Record the patient’s blood pressure in even numbers, along with the patient’s position (i.e., sitting, standing, lying), cuff size (if a non-standard size is used) and the arm (right or left) used for measurement.



Wait 1 to 2 minutes before repeating the pressure measurement in the same arm.



Place the pads of the index and middle fingers on the  palmar surface of the wrist near the base of the thumb.



Press down until pulsation is felt, being careful not to occlude the artery.



If the rhythm is regular, count the number of beats in 30 seconds and multiply the number by two. If the rhythm is irregular, count the number of beats in one minute.

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Oct. 2014 CE — Respiratory & Cardiovascular Systems

September 2014

Table 4. Medications that have the potential to increase blood pressure 4 Adrenal steroids (prednisone, fludrocortisone, triamcinolone) Amphetamines/anorexiants (phendimetrazine, phentermine, sibutramine) Antivascular endothelin growth factor agents (bevacizumab, sorafenib, sunitinib) Calcineurin inhibitors (cyclosporin and tacrolimus) Decongestants Erythropoiesis stimulating agents (erythropoietin and darbepoietin) Estrogens (usually oral contraceptives) Nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors Others: venlafaxine, bromocriptine, bupropion, buspirone, carbamazepine, clozapine, desulfrane, ketamine, metoclopramide 

Record the finding as beats per minute (bpm).

The normal resting adult pulse should be between 60 and 100 bpm. In an adult, a heart rate less than 60 bpm is called bradycardia, and a heart rate greater than 100 bpm is called tachycardia. However, a well-conditioned athlete or patient on medications that may slow the heart rate (e.g., beta-blockers) may have a normal, resting heart rate of less than 60 bpm. Respiratory Rate Respirations are often counted and evaluated without the patient’s knowledge because sudden awareness of this measurement may alter the patient’s normal respiratory rate and pattern. The pharmacist should observe the rise and fall of the patient’s chest, and the ease with which breathing is accomplished. For a normal adult, the rate is expected to be 12 to 20 respiratory cycles per minute. Count the number of respiratory cycles (i.e., inspiration and expiration) that occur in 30 seconds and multiply by two. Record the value as respirations per minute (rpm). For adults, a respiratory rate of less than 12 rpm is called bradypnea, and a respiratory rate of greater than 20 rpm is called tachypnea. Also observe the regularity and rhythm of the breathing pattern.

accurate measurement is essential. Indirect measures of blood pressure are made with a stethoscope and a sphygmomanometer. Each sphygmomanometer is composed of a cuff with an inflatable bladder, a pressure manometer and a rubber hand bulb with a pressure control valve to inflate and deflate the bladder. Cuffs are available in a number of sizes to accommodate the wide range of arm circumferences. To determine the appropriate cuff size, compare the length of the bladder with the circumference of the patient’s upper arm. For the most accurate measurement, the bladder length should be at least 80 percent of the arm circumference. Electronic sphygmomanometers, which do not require the use of a stethoscope, also are available. The electronic sphygmomanometer senses vibrations and converts them into electrical impulses. The impulses are transmitted to a device that translates them into a digital readout. The instrument is relatively sensitive and also is capable of simultaneously measuring the pulse rate. It does not, however, indicate the quality, rhythm and other characteristics of a pulse and should not be used in place of your touch in assessing the pulse.

Identifying, treating and monitoring a patient’s blood pressure are extremely important steps in reducing the risk of Blood Pressure cardiovascular disease, as 72 million Americans have high 4 Blood pressure is a peripheral measurement of cardiovas- blood pressure . In addition, blood pressure is an estabcular function. It is the pressure placed on arterial walls by lished parameter for initiating and adjusting medication the blood, and it is controlled by heartbeat force, blood vol- therapy. Guidelines for performing blood pressure measume and vessel tone. Blood pressure has two components. urement are summarized in Table 3. Systolic blood pressure represents the maximum pressure Measurement Errors that is felt on the arteries during left ventricular contraction. Diastolic blood pressure is the resting pressure that the Many factors can affect a blood pressure reading including blood exerts between each ventricular contraction. age, race, time of day, weight, emotions and medications. Table 4 contains a list of medications that have the potenBP Measurement tial to increase blood pressure. Patient position is another Because signs and symptoms of hypertension are comimportant factor to consider to ensure accuracy. For exammonly absent or ambiguous (e.g., headache, dizziness), ple, if the patient has her legs crossed during measure28

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Oct. 2014 CE — Respiratory & Cardiovascular Systems

September 2014

Table 5. Classification of blood pressure for adults ages 18 and older (JNC VII) Blood Pressure Classification

Systolic Blood Pressure (mmHg)*

NORMAL

120-139

Stage 1

140-159

HYPERTENSION Stage 2

Pharmacists who participate in blood pressure screenings <80 should be aware 80-89 that hypertension is 90-99 diagnosed by a physician only after a ≥100 patient has had elevated readings on two separate occasions. Additionally, pharmacists should be familiar with the national guidelines that delineate individual blood pressure goals and preferred pharmacological treatment based upon each patient’s concurrent disease states6,7. Irregular blood pressure measurements (high or low), in which the patient is experiencing symptoms, should be referred for medical attention. Both hypertensive urgencies (with no signs of organ impairment) and emergencies (with evidence of target organ dysfunction) are characterized by the presence of a very elevated blood pressure (i.e., greater than 180/120 mm Hg) and should be referred.

Diastolic Blood Pressure (mmHg)*

<120

PREHYPERTENSION

>160

HYPERTENSION

*Treatment determined by highest BP category Table 6: Characteristics of common causes of chest pain Cardiac Gastrointestinal Musculoskeletal Patient history

Cardiac risk factors

Gastritis or indigestion

Trauma

Type of pain

Heavy pressure, crushing, squeezing across anterior chest; often radiating to arms, neck, jaw, shoulder, back

Substernal burning; may radiate to the back; may be squeezing; may be hard to distinguish from cardiac pain

Sore, dull achy feeling or sharp, knifelike pain

Associated symptoms

Sometimes dyspnea, nausea, vomiting, sweating; dizziness, lightheadedness or fainting

Regurgitation, dysphagia, nausea

May have local tenderness

Aggravating factors

Physical exertion, stress, cold

Large or fatty meals, bending over, lying down

Physical movement, coughing, breathing

Relieving factors

Rest, nitroglycerin

Antacids

Rest, heat, pain medications

Cardiovascular System

ment, the result may be falsely elevated. Using a cuff that is too small also may produce falsely elevated readings. Conversely, a cuff that is too large can produce a falsely low reading.

Although few pharmacists routinely perform a complete cardiovascular assessment, a basic understanding of how to evaluate common cardiac symptoms will help the pharmacist determine the most appropriate course of action, including referral to a physician.

Chest pain is probably one of the more worrisome symptoms a pharmacist can encounter. Chest pain occurring secondary to myocardial ischemia is termed angina pectoris, but it also is important to remember that similar pain may result from gastrointestinal, pulmonary, abdominal or musculoskeletal disorders. Although each may possess subtle differences in symptomatology (Table 6), it can still be quite difficult to determine the cause. Therefore, most cases of new onset chest pain should be referred to a physician for further evaluation, especially in patients with underlying risk factors for cardiovascular disease (CVD).

For the most accurate blood pressure assessment, two or more readings, each separated by two minutes, should be averaged. If the first two readings differ by more than 5 mmHg, additional readings should be obtained and averaged. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VII)* provides guidelines for the Palpitations are an uncomfortable awareness of the heartclassification of blood pressure readings which are summa- beat that may be an indicator of a relatively benign or serirized in Table 5. ous underlying condition. Patients may describe them as a 29

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Oct. 2014 CE — Respiratory & Cardiovascular Systems fluttering or pounding sensation in their chest. They may say their heart is racing, skipping beats or having extra beats. Patients with palpitations should have a complete medication history taken, with special attention given to the use of sympathomimetics, vasodilators, anticholinergics and the withdrawal of beta-blockers. Non-prescription drug usage, including caffeine and illicit drugs (e.g., cocaine, amphetamines) also should be evaluated when appropriate. These patients should be referred to a physician if palpitations are persistent, or are accompanied by shortness of breath, lightheadedness, dizziness or fainting, or if there is a history of coronary heart disease (CHD). Patients with known cardiovascular disease should always consult their physician or pharmacist before initiating a new OTC medication or dietary supplement since many of these products can cause cardiovascular side effects or interact with their prescription medications8. CONCLUSION Patients commonly present to their community pharmacy seeking advice regarding the treatment of their respiratory and cardiovascular conditions. In the introductory case, SL is concerned about the impact of his multi-symptom cough and cold product on his underlying hypertension. A thorough patient assessment would reveal that his only symptom is a dry cough, and changing his multi-symptom cold medication to a single ingredient cough suppressant would eliminate any unnecessary medications, such as decongestants, that may adversely affect his health. Additionally, by measuring his current blood pressure, the pharmacist would be able to reassure the patient and determine whether or not any intervention was necessary.

tients quickly and effectively. Proceedings of the APhA Inaugural Self-Care Institute; May 17-19, 2002. 2. Kuehn BM. Education key to treating airway disease. JAMA 2007;298(22):2601-7. 3. Irwin RS, Baumann MH, Boulet LP, et at. Diagnosis and management of cough: Executive Summary. Chest 2006; 129:1S-23S. 4. Dipiro JT, et al (eds): Pharmacotherapy: A Pathophysiologic Approach. 7th ed. McGraw Hill;2008. 5. William JS, Brown SM, Conlin PR. Blood-pressure measurement. N Engl J Med 2009;360(5):e6. 6. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension 2003;42(6):1206-52. 7. Rosendorff C, Black JR, Cannon CP, et al. Treatment of hypertension in the prevention and management of ischemic heart disease: A scientific statement from the American Heart Association Council for high blood pressure research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation 2007;115(21):2761-2788. 8. Tachjian A, Maria V, Jahangir A. Use of herbal products and potential interactions in patients with cardiovascular diseases. J Am Coll Cardiol 2010;55:515–25. SUGGESTED READINGS 

Berardi RR, Ferreri SP, Hume AL, Kroon LA, Newton GD, Popovich NG et al, editors. Handbook of Nonprescription drugs: An Interactive Approach to Self-Care. 16th ed. Washington DC: The American Pharmaceutical Association; 2009.



Dipiro JT, et al (eds): Pharmacotherapy: A Pathophysiologic Approach. 7th ed. McGraw Hill; 2008.



Jones RM and Rospond RM. Patient Assessment in Pharmacy Practice. 2nd ed. Baltimore (MD): Lippincott Williams & Wilkins; 2006.



Longe RL and Calvert JC. Physical Assessment: A Guide for Evaluating Drug Therapy.1st ed. Vancouver: Applied Therapeutics, Inc; 1994.

By utilizing these basic patient assessment skills, the pharmacist is able to recommend appropriate self-care treatment and build a trusting relationship in the process. *Editor’s Note: At the time of original publishing, JNC VII guidelines were in use and now the more liberal JNC VIII guidelines are available. Practitioners may be choosing to follow the updated JNC VIII guidelines outlined in the table in the July 2014 issue of The Kentucky Pharmacist, page 19. REFERENCES

September 2014

1. Leibowitz K, Ginsburg D. Counseling self-treating pa-

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Oct. 2014 CE — Respiratory & Cardiovascular Systems

September 2014

October 2014 — Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 3 of 4: Evaluation of Respiratory and Cardiovascular Systems 1. The most effective method of assuring that a patient is using her inhaler correctly is to: A. Answer any questions they ask about their inhaler. B. Provide them with verbal instructions, then ask if they have any questions. C. Provide them with written instructions and tell them to call if they have any questions. D. Demonstrated the appropriate technique, then have the patient show you how they are going to use their inhaler; supplement with written instructions.

7. The normal resting adult pulse should be between ____ and ____ beats per minute. A. 12 and 20 B. 40 and 90 C. 60 and 100 D. 90 and 120

8. For a normal adult, the respiratory rate is between ____and ____ respiratory cycles per minute. A. 12-20 B. 16-20 2. Wheezing is caused by air movement through narrowed C. 40-90 airways. This narrowing can occur from: D. 60-100 A. Inflammation and/or infection. B. Excessive secretions. 9. For adults, a respiratory rate of less than 12 rpm is C. An adverse drug reaction. called D. All of the above. A. Bradycardia. B. Bradypnea. 3. Which of the following descriptions indicate the need for C. Tachycardia. immediate physician referral? D. Tachypnea. A. A respiratory rate of 18 breaths per minute in a 60 year -old patient 10. Chest pain associated with a musculoskeletal origin is B. An asthma patient who is not wheezing, but looks most typically described as a: “blue” around his lips A. Heavy pressure radiating to the neck or jaw. C. A COPD patient who complains of chronic shortness of B. Burning sensation that is worse when lying down. breath when he climbs the stairs C. Sharp, knifelike pain that is exacerbated by physical D. None of the above movement. D. A crushing pain associated with nausea and sweating. 4. Which of the following scenarios describes a patient who would be an appropriate candidate for self-treatment 11. Palpitations: of his cough? A. Are always indicative of a serious underlying cardiac A. A 63 year-old COPD patient with a productive cough condition. and a new complaint of coughing up green sputum B. May be felt as a fluttering or pounding sensation in the B. A 25 year-old with a cold, and a cough that kept him chest. from sleeping well last night C. Are usually benign and only need to be evaluated by a C. An otherwise healthy 30 year-old who complains of a physician if the patient experiences fainting. cough associated night sweats fever, and unintended D. Are always considered a medical emergency. weight loss D. An 18 year-old with a three week history of poor re12. Heavy pressure, crushing and squeezing across the sponse to OTC cough suppressants anterior chest, often radiating to the arms, neck, jaw, shoulder and back, may be indicative of which of the following? 5. Age, race, time of day, weight, emotions, patient position A. Cardiac chest pain and medications may affect which of the following? B. Musculoskeletal chest pain A. Proper beta-blocker dosing C. Gastrointestinal chest pain B. Blood pressure measurement D. GERD chest pain C. Nasal congestion D. Treatment of cough 6. Proper blood pressure monitoring should include which of the following? A. Patient resting for at least 30 minutes B. Large cuff size C. Feet placed flat on the floor D. Slow inflation of the cuff

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Oct. 2014 CE — Respiratory & Cardiovascular Systems

September 2014

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: October 22, 2017 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 2014 — Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 3 of 4: Evaluation of Respiratory and Cardiovascular Systems (2.0 contact hours) Universal Activity # 0143-9999-14-010-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D

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

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

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

Personal NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) PHARMACISTS ANSWER SHEET October 2014 — Pharmacist Patient Assessment Skills for Optimizing Self-Care, Part 3 of 4: Evaluation of Respiratory and Cardiovascular Systems (2.0 contact hours) Universal Activity # 0143-9999-14-010-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D

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

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

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

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Kentucky Renaissance Pharmacy Museum

September 2014

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

For more information on the museum, see www.pharmacymuseumky.org or contact Gloria Doughty at g.doughty@twc.com or Lynn Harrelson at lharrelsonky@aol.com.

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. 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.

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

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.

2014 Mid-Year Conference on Legislative Priorities Nov. 14-15, 2014 Griffin Gate Marriott Resort, Lexington, KY 33

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KPhA New and Returning Members

September 2014

KPhA Welcomes New and Renewing Members July-August 2014 Brittany Anderson Bulan

Veronica Foster Munfordville

Amy Larkin Lexington

Charles Pearson Bowling Green

Samuel Armes Crossville

William Fugate Louisville

Nick Ledgerwood Lexington

Angela Pence Campton

Elisha Bischoff Louisville

Patricia Gooch Pikeville

Kelsey Lee Owensboro

David Potts Louisville

Michael Blacketer Louisville

Wayne Gravitt Wheelwright

Joe Lewis Hyden

Thomas Ranz Louisville

Jacqueline Blair Mason, Ohio

Jennifer Grove Madison, Ind.

Pamela Luebbe-Haeberlin Louisville

Judith Rech Mount Sterling

Larry Blandford Goshen

William Hall Whitesburg

Catherine Mcclish Louisville

James Rickett Williamsburg

Terry Box Cynthiana

Lisa Hart Frankfort

Velda McDaniel Georgetown

Brandy Robertson Barlow

Stephen Britt Louisville

Steve Hart Frankfort

Kristi McGregor Louisville

Denise Robison Louisville

Robert Buckner Campbellsville

Shirley Henson Smithland

Aaron Mcintosh Midway

Bonnie Russell Elizabethtown

Mary Campbell Shepherdsville

Kevin Higgins Benton

William Merrick Louisville

Larry Russell Elizabethtown

Peggy Canler Bowling Green

Ashley Hubbard Manchester

David Morgan Manchester

Tamara Schlensker Louisville

William Chauvin Elizabethtown

Mark Huffmyer Lexington

Ann Murphy Princeton

Tara Schutte Louisville

Lisa Clontz Prospect

Robert Hughes Lexington

Owen Neff Centerville, Ohio

Jan Scott Earlington

Lysette Daniels Smiths Grove

Audrey Hurley Louisville

Meghann New Lexington

Janelle Seitz Mount Vernon

Michael Daniels Taylor Mill

Bill Hurley Simpsonville

Frank Nicks Bowling Green

William Sewell Utica

Debra Dunaway Henderson

Jacob Hutti Louisville

Ronald Nix Louisville

Edwin Shelton Owensboro

James Dunaway Henderson

Donna Johnson Louisville

Christopher Noetzel Flemingsburg

Sherri Short Richmond

Harold Ellis Frankfort

Kim Jones Williamsburg

Myron Pass Louisville

Joe Silvers Monticello

Mary Enzweiler Covington

Briana Kocher Lexington

Kenneth Pearce Danville

Patricia Slone Hindman

Scott Ferguson Lexington

Andrea Kramer Covington

Andrea Pearson Bowling Green

Jamie Stake Greenup

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KPhA New and Returning Members Geneva Staten Louisville

Stuart Waldman Louisville

Drane Stephens Eminence

Norman Walton Bardstown

David Stultz Greenup

Lewis Wilkerson Frankfort

Terry Sutton Henderson

Kimberly Wilkerson Frankfort

Audra Swearingen Louisville

Franklin Wishnia Louisville

Joanne Taheri Louisville

David Wren Louisville

Timothy Tracy Lexington

Andrey Yazykov Lexington

September 2014 MEMBERSHIP MATTERS: To YOU, To YOUR Patients To YOUR Profession! KPhA Honorary Life Members Ralph Bouvette Leon Claywell Gloria Doughty Ann Amerson Stewart

Jonathan Van Lahr Webster

Know someone who should be on this list? Ask them to join YOU in supporting YOUR KPhA!

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Pharmacy Law Brief

September 2014

Pharmacy Law Brief:

New Data Breach Laws in Kentucky Author: Peter P. Cohron, B.S.Pharm., J.D., Practicing pharmacist and attorney, Henderson, Ky. Question: I understand that Kentucky has two new data breach laws that went into effect in July 2014. I understand that health care providers under the HIPAA rules are exempt. Do these new laws have any effect on pharmacy? Response: Kentucky enacted two new data breach notification laws — HB 232 and HB 5 — in 2014. These define the type of breach, the information that should have been protected and notice requirements so that affected individuals will be informed in a timely manner.

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

The practice of pharmacy is exempted as it is subject to HIPAA. However, there are several aspects of business that occur in many pharmacies, community and institutional, that are not covered by HIPAA. Thus, these business activities, including but not limited to sales and purchase notice is required to every Kentucky resident where his or contracts, sales transactions, provision of services, etc., fall her unencrypted data has been accessed by an unauthorunder these new laws. ized entity. A reasonable belief is far less than a 100 percent assurance but if a reasonable person with the same The purpose and intent of the bills is to protect Personally information would reach the same level of suspicion of a Identifiable Information, or PII (differentiated from the inforbreach, acting on that belief cannot result in liability. Submation gathered in pharmacies for the proper preparing and ject only to the needs of law enforcement (the police may dispensing of prescriptions known as Protected Health Inask for a delay if they are investigating and notice may aid formation or PHI). PII includes a person’s name used in the unauthorized party to escape), notice must be made in combination with any one or more of the following: Social an expedient manner and without undue delay. Security Number, driver’s license number, credit or debit card numbers and any other personal information obtained HB 232 lays out in detail the notification methods, and I refer the reader to those. In essence, for less than 1,000 in the normal course of business. affected persons, the notification must be done individually In order to meet the requirements of the bills, a business though informing the media is permitted. For more than must establish security policies and procedures, including 1,000 persons, all consumer reporting agencies and credit breach investigation policies and procedures. If the busi- bureaus that maintain nationwide files also must be notified. ness, as most pharmacies do, conducts business with any However, if existing business policies and procedures are governmental agency, these policies and procedures must consistent with the timing requirements of HB 5, they may be in place by Jan. 1, 2015. Second, though not yet a re- be substituted and will be considered to be in compliance quirement, encryption of data is strongly suggested. Data with the law. This is important for multistate businesses mapping, or knowing where the data is kept, is needed and such as pharmacy chains that must meet the requirements limiting access to the computers holding the data is again of data breach notification laws of several states. strongly advised. Finally, the laws call for affected entities In order to minimize the damage and costs aligned with a to review business insurance policies for adequate cyberbreach, these bills suggest assembling all employees who insurance coverage, with emphasis on apportionment of oversee and have access to PII and run drills to practice costs when a breach occurs between the business and a and prepare for data breaches. The entities also should nonaffiliated third party. have a breach investigation team named and prepared to If and when a breach occurs or the business is informed step in upon notification of a breach. The group’s job will be that there is a reasonable belief that such has happened, to seek the source of the breach in a timely manner, as well 36

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Roamey visits University of Cincinnati COP

September 2014

as having the responsibility to, if necessary, notify the police and work with them. Most Kentucky pharmacies do not limit their business with the public to prescriptions and health services. â&#x20AC;&#x153;Out frontâ&#x20AC;? buying and sales are a significant part of the business, and these transactions are not covered by the auspices of HIPAA. Thus, certain business conducted in a pharmacy will fall under these new laws. Pharmacists should make themselves aware of the need to protect PII and the steps to take in the event of a breach. While the criteria for handling a PHI breach under HIPAA and a PII breach under these new Kentucky laws are not largely exclusive of each other, pharmacists should not rely on one to cover the other.

Roamey (and KPhA ED Robert McFalls and Director of Communications and CE Scott Sisco) visited University of Cincinnati College of Pharmacy APhA-ASP chapter in September. Thanks for the invitation, and YOUR KPhA looks forward to strengthening this relationship!

Are you connected to YOUR KPhA? Join us online!

Facebook.com/KyPharmAssoc

@KyPharmAssoc @KPhAGrassroots

KPhA Company Page

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Pharmacy Policy Issues

September 2014

PHARMACY POLICY ISSUES: Freedom of Speech and Off-Label Promotion of Pharmaceuticals Author: Devin Pence is a third professional year Pharm.D. student at the University of Kentucky College of Pharmacy and also is pursuing a Master of Business Administration degree at the Gatton College of Business and Economics. A native of Leitchfield, Ky., he completed his pre-pharmacy coursework at the University of Louisville. Issue: A federal Court of Appeals ruled in the case of United States v. Caronia that a pharmaceutical sales representative engages in Constitutionally-protected free speech when discussing off-label use of a medication. This court decision drastically changes governmental regulation of pharmaceutical promotional activities. What are the implications of this for the future of drug promotion and education by pharmaceutical industry representatives? Discussion: In December of 2012, the Second Circuit ly 20 pecent of all prescriptions are intended for an off-label Court of Appeals in Manhattan ruled in favor of Caronia in use, proving the potential magnitude of this increased acthe United States v. Caronia case. The judges ruled that cess to information.2 Drug companies could provide preprosecuting Alfred Caronia, a pharmaceutical sales repre- scribers with helpful data that they’ve gathered on the safesentative, for promoting the legitimate, off-label use of ty and efficacy of these therapies, leading to better care for Xyrem®, a drug used to treat narcolepsy, for treatment of millions of patients. insomnia was a violation of free speech.1 Pharmaceutical While the Caronia court ruling has potential for great imcompanies and their representatives have long been propact on the pharmaceutical industry, it is still unclear what hibited from discussing and promoting drug indications unthe magnitude of this impact will be. Since the Caronia rulapproved by the FDA and therefore not in the labeling to ing, there have been at least two court cases involving potential clients and prescribers, and have had to pay millarge drug companies, Amgen and Par, which have been lions of dollars in settlesettled with both firms ments to the U.S. govpaying large penalties to ernment for doing so. the government. These However, the court’s decases don’t offer much This column is designed to address timely and practical cision in the Caronia evidence on the Caronia issues of interest to pharmacists, pharmacy interns and case could be a step in a case’s potential impact pharmacy technicians with the goal being to encourage more lenient direction for because both lawsuits thought, reflection and exchange among practitioners. drug marketing and edualready were well underSuggestions regarding topics for consideration are welcation by drug compaway before the ruling of come. Please send them to jfink@uky.edu. nies. Using this ruling as the case was delivered.3 a foundation for their proOnly time will tell if phartection, pharmaceutical maceutical companies will manufacturers soon may be able to promote their drugs for begin utilizing the Caronia case ruling as a defense, and if safe and effective off-label uses, as well as provide prejudges will see that defense as being sufficient to acquit scribers with useful information that could improve use of them. medications for off-label indications. With this newly acquired defense, pharmaceutical compaSome challengers to the ruling argue that permitting these nies and their representatives may find themselves headcompanies to promote unlabeled uses would be danger- ing toward a more open and profitable future, one where ous, stating that the firms would be free to make any claims they may be free to discuss and promote off-label drug usthey wanted about their medications. This argument fails to es and be free from the fear of lawsuits or FDA administraacknowledge that drug companies still would be required to tive challenges, assuming what is said is truthful and safe. make truthful claims that were not intended to deceive the If this were the case, patients also could benefit from inprescriber or render the medication misbranded. On the creased prescriber access to data on off-label medication contrary, the ruling could have significant benefits for pa- usage that would result in safer and more effective theratient outcomes if pharmaceutical companies were now able pies. The Caronia case has far-reaching potential and it will to provide prescribers with the most detailed and up to date be interesting to see what effects it will have on pharmainformation available on off-label drug usage. Approximate- ceutical industry in the coming years.

Have an Idea?:

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September 2014

Consultant Pharmacists Dinner CE Event

JAMA Internal Medicine 166.9 (2006): 1021-026. JAMA Network. JAMA Internal Medicine, 8 May 2006. Web. 13 Jan. 2014.

References:

1. Fauber J. "Court: Off-Label Drug Marketing Is 'Free Speech'." Medpagetoday.com. N.p., 4 Dec. 2012. Web. 13 Jan. 2014. 3. Radick R. "Caronia and the First Amendment Defense To Off-Label Marketing: A Six Month Re-Assessment." 2. Radley DC, Finkelstein SN, Stafford RS. "Off-label Forbes. 29 May 2013. Web. 13 Jan. 2014. Prescribing Among Office-Based Physicians FREE."

KPhA Academy of Consultant Pharmacists Invite you to a Dinner CE Event! Napa River Grill 1211 Herr Lane Louisville KY Monday October 27th at 6pm TWO HOURS OF LIVE CE “Bugs and Drugs” by Dr. Kim Croley, CGP, FASCP, FAPhA Clinical Pharmacist UAN 0143-0000-14-044-L01-P Learning Objectives – At the completion of this program, the participant will be able to: 1) Compare and contrast the antimicrobial drug classes. 2) Understand the types of antimicrobial drug resistance that can occur. 3) Create treatment plans for which antimicrobial therapy can be managed successfully. 4) Relate prudent use of antimicrobial therapy to quality metrics. Free for KPhA Academy of Consultant Pharmacists and/or ASCP (Kentucky Chapter) members, $5 for non-members Also presenting: “Namenda XR (memantine HCl) and the treatment of moderate to severe dementia of the Alzheimer’s type” Dr. Amita Patel, MD, Geriatric Psychiatrist RSVP to Julie Owen at Julie.O@me.com by Oct 22th

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September 2014

Pharmacists Mutual

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Cardinal Health

September 2014

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KPhA Board of Directors/Staff

September 2014

KPhA BOARD OF DIRECTORS

HOUSE OF DELEGATES

Duane Parsons, Richmond dandlparsons@roadrunner.com

Chair 502.553.0312

Ethan Klein, Louisville kleinethan@gmail.com

Speaker of the House

Bob Oakley, Louisville Boakley@BHSI.com

President

Chris Harlow, Louisville cpharlow@gmail.com

Vice Speaker of the House

Chris Clifton, Villa Hills chrisclifton@hotmail.com

President-Elect

KPERF ADVISORY COUNCIL

Brooke Hudspeth, Lexington brooke.hudspeth@kroger.com

Secretary

Kim Croley, Corbin kscroley@yahoo.com

Glenn Stark, Frankfort glennwstark@aol.com

Treasurer

KPhA/KPERF HEADQUARTERS

Raymond J. Bishop raybishop13@gmail.com

Past President Representative

Directors Matt Carrico, Louisville* matt@boonevilledrugs.com Tony Esterly, Louisville tonye50@hotmail.com

Robert McFalls, M.Div. Executive Director rmcfalls@kphanet.org

Matt Foltz, Villa Hills mfoltz@gomedcare.com

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

Chris Killmeier, Louisville cdkillmeier@hotmail.com Mallory Megee, Nicholasville mallory.megee@uky.edu

University of Kentucky Student Representative

Jeff Mills, Louisville jeff.mills@nortonhealthcare.org

Angela Gibson Director of Membership & Administrative Services agibson@kphanet.org Leah Tolliver, PharmD Director of Pharmacy Emergency Preparedness ltolliver@kphanet.org

Chris Palutis, Lexington chris@candcrx.com Christian Polen cpolen7392@my.sullivan.edu

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

Sullivan University Student Representative

Elizabeth Ramey Receptionist/Office Assistant eramey@kphanet.org

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

KPhA sends email announcements weekly. If you arenâ&#x20AC;&#x2122;t receiving: eNews, Legislative Updates, Grassroots Alerts and other important announcements, send your email address to ssisco@kphanet.org to get on the list. 42

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50 Years Ago/Frequently Called and Contacted

September 2014

50 Years Ago at KPhA RELIEF WORK L.R. Hugg, R.Ph., a graduate of the University of Kentucky College of Pharmacy, Class of 1933, is interested in vacation and emergency relief work in any section of Kentucky. For several years Hugg owned and operated his own store in Paducah, selling the store in March, 1964. He has had experience in retail pharmacy, hospital pharmacy and an apothecary shop. For a reference you can contact Kolb Brothers Drug Company, Paducah, or L.S. DuBois Son & Company, Paducah. - From The Kentucky Pharmacist, October 1964, Volume XXVII, Number 10.

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

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

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

KPhA Remembers KPhA desires to honor members who are no longer with us. Please keep KPhA informed by sending this information to eramey@kphanet.org. Deceased members for each year will be honored permanently at the KPhA office. 43

THE KENTUCKY PHARMACIST

September 2014

THE

Kentucky PHARMACIST 1228 US 127 South Frankfort, KY 40601

Mark your Calendar Or weâ&#x20AC;&#x2122;ll send Duane and Kim after you! 2014 Mid-Year Conference on Legislative Priorities November 14-15, 2014 Griffin Gate Marriott Resort Lexington, KY

Save the Date 137th KPhA Annual Meeting & Convention June 25-28, 2015 Holiday Inn University Plaza and Sloan Convention Center Bowling Green, KY

For more upcoming events, visit www.kphanet.org. 44

THE KENTUCKY PHARMACIST