The Kentucky Pharmacist July/August 2018

Vol. 13 No. 4 July/August 2018

THE KENTUCKY

PHARMACIST Official Journal of the Kentucky Pharmacists Association

INSIDE: Welcome to President Chris Palutis 2018 Annual Meeting & Convention Wrap Up

TABLE OF CONTENTS FEATURES Professional Awards |4 & 5| Annual Meeting & Convention Sponsors | 8 | Annual Meeting & Convention Highlights |14, 15, 20, 38, 41, 48, 49 |

Mission Statement: The mission of KPhA is to advocate for and advance the profession through an engaged membership.

Editorial Office: ©Copyright 2018 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.

Publisher: Mark Glasper

House of Delegates Summary | 16 & 17 | Annual Meeting & Convention Exhibitors | 41 | Hepatitis A Information |45|

On the Cover Pictured left to right: KPhA member Consuelo Palutis and KPhA President Chris Palutis

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IN EVERY ISSUE President’s Perspective |3| My KPhA Rx |9| Advocacy Matters |21| Continuing Pharmacy Education |23| Campus Corner |37 | New KPhA Members | 39 | Pharmacy Law Brief | 44 | Pharmacy Policy Issues | 46|

Managing Editor: Sarah Franklin Editorial, advertising and executive offices at 96 C Michael Davenport Blvd., Frankfort, KY 40601.

Phone: 502.227.2303 Fax: 502.227.2258.

Email: info@kphanet.org.

Website: www.kphanet.org.

ADVERTISERS APSC|11| EPIC |10 & 39 | PTCB |29| Pharmacists Mutual |42| Cardinal |43|

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PRESIDENT’S PERSPECTIVE Adapted from the President’s address delivered at the Ray Wirth Awards Banquet during the 140th KPhA Annual Meeting and Convention.

Let me start by expressing my gratitude to our outgoing chairwoman, Dr. Trish Freeman, our outgoing president, Dr. Chris Harlow, the full BOD, our Executive Director Mark Glasper, and the KPhA staff (Angela, Sarah, and Jody). I would also like to thank everyone here tonight as you all play pivotal roles for this great association. And, I would be remiss not to thank all of our sponsors as well. Please know your support of KPhA is appreciated and never taken for granted.

“I feel the obligation to set an agenda and put things in motion to ensure we are a force from this moment going forward.”

I want you all to know I take this responsibility bestowed upon me with gratitude, and an enormous amount of enthusiasm. For those that know me well, I am sure my decision to run for the presidency was surprising. To be honest, you were correct; it even caught me off-guard. But I can honestly say, as of right now, it was one of the best decisions I have made in my professional career.

ly said “I am a pharmacist”. I have been asked why I answer that way instead of giving specifics. My explanation is simple; it is because that is what Chris Palutis I am most proud of. Knowing this about me, will make President, KPhA part of what I plan to focus on as your President for our KPhA more understandable.

Well, as my 2-year appointed term was coming to a close, I was undecided about running for re-election. To be honest, I wasn’t sure I brought enough to the group.

But then on a sunny day in Frankfort, I was stopped on the sidewalk of our old building by a man we all know and love, Rick Slone. I could go into specifics, but to make a long story short, Rick had said some very impactful words. It inspired me enough that at that very moment, I agreed to not only run to be on the board, but I decided to run for Treasurer. Thanks Rick, I appreciate you.

Over my 2-year term as Treasurer, I became more entrenched into the association and as the months went by, Let me take you back to the beginning. It all started 5 I felt I was making a difference. I really enjoyed being years ago when I was appointed to the board by Duane part of KPhA and looked forward to every visit to the Parsons. My first year on the board was a learning expe- office to review the financials, sign checks and discuss rience and it was clear KPhA played a much bigger role any open business items. And as much as I enjoyed that, than I had expected in how the landscape of our profes- I enjoyed the board meetings even more. In fact, after sion was developing. It became obvious there were a lot the meetings, I would recap the day with my wife with of very intelligent people who dedicated their time, exenergy you cannot fake. As the end of my 2-year term as pertise and unwavering support. It was truly an inspiring Treasurer approached, I was confident I had made a experience. I quickly realized I was no longer able to positive impact and I felt the need to continue being part simply sit back and complain. It was my time to join the of the solution and decided to throw my hat into the ring fight. I have accomplished many things throughout my for president. Which brings us to tonight. career from Executive Management positions with CVS, While everyone on the board, or our members for that Rite Aid and Omnicare to currently owning 2 independmatter, don’t always agree on issues set in front of us to ent pharmacies. But, what has always been my most debate, I believe it is important to have open and honest prized accomplishment is the ability for me to be a phardialogue. We have all earned the right to have our voicmacist. Whenever asked what I do for a living, regardes heard and to defend our positions. If we not only less of what my current position was at the time, I simpContinued on page 6 |3| www.KPHANET.org

Annual Meeting & Convention Professional Awards

Bowl of Hygeia

KPhA Pharmacist of the Year

William “Pat” Mattingly, Lebanon Pictured with 2017 – 18 KPhA President Chris Harlow and 2017 – 18 Chair Trish Freeman

Richard Slone, Hazard Pictured with 2017-–18 KPhA President Chris Harlow, 2017-–18 Chair Trish Freeman and 2018 -–19 KPhA President Chris Palutis

Cardinal Health Generation Rx Suzanne Francis, Florence Pictured with 2017 – 18 KPhA President Chris Harlow and 2017 – 18 Chair Trish Freeman

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Pharmacists Mutual Distinguished Young Pharmacist of the Year Jesica Mills Pictured with 2017 – 18 KPhA President Chris Harlow and 2017 – 18 Chair Trish Freeman

KPhA Distinguished Service Award

KPhA Professional Promotion Award

Emily Blaiklock, Atlanta Pictured with 2017-–18 KPhA President Chris Harlow, 2017-–18 Chair Trish Freeman

Dean Cindy Stowe, Louisville Pictured with 2017-–18 KPhA President Chris Harlow, 2017-–18 Chair Trish Freeman

KPhA Technician of the Year Award Sarah Lisenby, Crestwood Pictured with 2017-–18 KPhA President Chris Harlow, 2017-–18 Chair Trish Freeman

Jan Gould KPhA Meritorious Service Award Rep. Danny Bentley, Russell Pictured with 2017-–18 KPhA President Chris Harlow, 2017-–18 Chair Trish Freeman

KPhA Excellence in Innovation Award Not Pictured J Leon Claywell, Bardstown

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PRESIDENT’S PERSPECTIVE CONT. voice our opinion and defend our positions, but also LISTEN with open minds and hearts, there is no doubt we will come to a consensus. And we will end up with a path forward better than any of us would have come up with if making the decision in our own silo. After all, it is not about who wins, or who loses a vote on a particular topic. It is about the solutions ultimately decided on that is best for KPhA and our members. In the end, when we can have our individual opinions heard respectfully, everyone wins. It is with this open exchange of ideas that I plan to lead our KPhA. I want to let all of you know what I plan to focus on during my presidency. But first, I couldn’t be more thankful for the work that has been done by my predecessors over the years. Aside from the legislative wins they have spearheaded, they had to ward off other bills that would have negatively affected our profession. This goes without saying, but I will continue to advocate for our profession and help drive our legislative agenda.

KPhA Chair Chris Harlow presents KPhA President Chris Palutis with the Presidential Journal at the Ray Wirth Awards Banquet.

networking opportunities for our current members. But I would also like to attract new members of all age groups with an emphasis on new pharmacists. I believe we need to continue to build membership that creates a pipeline of talented colleagues that will step up and choose to help guide our great association. I recently attended the With that being said, I feel the obligation to set an agen- National Alliance of State Pharmacy Associations, and I da and put things in motion to ensure we are a force promise you, all state pharmacy associations across the from this moment going forward. During my year as country are struggling with attracting new pharmacists. I president, my focus will be multifaceted. It will include, have already started discussions with some new pharmabut not be limited to; Membership Engagement, Clinical cists to find out what would attract them to our KPhA. I Services and I also plan to advocate for our relevancy. won’t go through the entire list, but I would like for us to Let’s start with, Membership Engagement: Our KPhA offer networking opportunities that will include short topics of interest such as how to best deal with student loan debt, other financial planning activities as well as purely social and networking meet-and-greet type of events. I believe these types of events will attract new members as well as provide more benefits to our existing membership base. I believe we are in a time, with new pharmacists that have a different mindset. So, we need to continue the great services we are used to providing, but we also need to adapt and offer additional programs folks are indicating they are looking for in our KPhA.

KPhA President Chris Palutis addresses the attendees at the Ray Wirth Awards Banquet.

would not exist if not for our members. While membership has been, is currently and will remain strong, there is always room for improvement. I believe KPhA needs to provide valuable services such as Advocacy, CE and |6| Kentucky Pharmacists Association | July/August 2018

Next, Clinical Services: I want KPhA to take the lead statewide, and hopefully set the bar for other state orgs by providing the training necessary for all pharmacists and pharmacies to take full advantage of the board approved protocols. Not only will we be recognized as an innovative force, but we will create a model to ensure proper compensation for our services. And at the same time, bring an additional revenue stream to our KPhA. These first two priorities will enable our KPhA to be-

come even more involved in the legislative process and hopefully move us toward a more level playing field with the lobbyists that simply have input based on dollars spent. We may never be able to match the dollars, but when you add together our value-added services, with our collective determination to advocate for our profession, I believe we can rival any lobbying group gutsy enough to challenge our resolve.

our patients has become taken for granted. Please know that I am not searching for us to have extra special adoration, glory, or to be placed upon a pedestal. But what I plan to fight for is the relevancy for services we already render. As your president, I plan on bringing this message to every group I have the opportunity to address.

Lastly, advocating for our relevancy: So, let me explain what I mean by saying “advocating for our relevancy”.

As we all know, the trend right now is that pharmacists need to become more outcomes based to remain valuable in the healthcare system. That, in order for us to exist in the future, we must change the way we practice. In short, many folks are implying that what we do on a daily basis now will become obsolete and therefore render our profession irrelevant. Please know that I am all for advancing our profession. And as your President, I agree we need to evolve our clinical services to meet the current healthcare demands of 2018 and beyond.

But also know, it will be hell or high water before I allow anybody to convince me or this association that what we do today as pharmacists is becoming irrelevant or obsolete. In fact, as we advance our profession and expand our reach in the healthcare arena while we continue to do what we do now, there will actually be a need for more pharmacists, not less. I will fight to keep our roots firmly planted in our profession. We’ve literally been doing this since 2600 BC. And I’m not talking about counting by fives!

KPhA President Chris Palutis addresses the attendees at the Ray Wirth Awards Banquet.

Again, I agree that our profession should always be forward thinking. Such as offering immunizations, opioid dependence solutions, anti-psychotic injections, MTM, and the like, which we already do today.

While these items will be of major focus, please know that I am open to any suggestion any member of this great association wants to discuss.

However, we will ALWAYS need pharmacists to be involved in evaluating medication therapies and I will not allow other groups to convince people or our legislators that what we do today will ever be obsolete.

For the student pharmacists in the room. I thank you for your participation here tonight and throughout this entire weekend. Please continue to stay involved, our profession depends on it.

I believe something has been overlooked. We let others make us believe that what we do every day as retail, hospital, compounding, home health care, nuclear, etc., is not enough. I for one think that is nonsense. We are tasked with a responsibility many other professions cannot possibly fathom. What we have to realize is that our knowledge, combined with our unwavering empathy for

And finally, I want to close by applauding all of you and am honored to be part of this great profession.

And I vow, as your president, to make our voice heard.

We deserve it. Thank you again for allowing me to be President of our KPhA.

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Thank You to Our 2018 Annual Meeting & Convention Sponsors Annual Sponsors

Annual Silver Sponsor

Event Sponsors

Friday Luncheon

Saturday Breakfast Sponsor

Opening Reception Sponsor

President’s Reception Cincinnati & Louisville Divisions Ray Wirth Awards Banquet Sponsor Tote Bags Sponsor

Preceptor Luncheon Sponsor

Preceptor Luncheon Sponsor

Jefferson County Academy of Pharmacists (JCAP) & Northern Kentucky Pharmacy Association Break Sponsor

Pharmacy Future Sponsors Trish R. Freeman Duane Parsons Richard Slone

Friend of the Profession Sponsors

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MY KPhA Rx Annual Meeting Offers Something for Everyone

By Mark Glasper KPhA Executive Director/CEO KPhA just finished its 140th Annual Meeting & Convention at the Marriott RiverCenter in Covington, KY and I know that not everyone can attend the event. Sometimes, even those who do attend cannot always be present for every function. It’s my pleasure now to give you a little overview of what you may have missed and a behind-the-scenes look at how the event gets done.

Plan Your Work; Work Your Plan While the Annual Meeting & Convention kicked off Thursday with the Kentucky Pharmacy Research and Education Foundation (KPERF) golf scramble, many months and even years of planning went into preparing for the four-day event. Hotel site visits were made more than two years in advance of the meeting with a final contract signed in April 2016. Meeting facilities tend to get booked two-five years in advance, so we always need to be looking down the road for the venues we want at

the prices that work for our members.

It’s not just the meeting rooms we look at either.

There’s the number of sleeping rooms/nights we expect, food and beverage, audio-visual needs, and additional space for related events (exhibitions, receptions, etc.). We also need to be sure there’s plenty of affordable parking as well as area amenities such as restaurants, attractions and golf courses.

Future pharmacists enjoy seeing eye to eye with sharks at the Newport Aquarium.

Pre-conference Events Entertain

Hitting the green at the KPERF golf scramble.

Devou Park Golf Course played host to the KPERF golf scramble which is held annually just before the meeting begins. Beautiful rolling terrain and city vistas of Cincinnati combined to challenge the seven groups of golfers who supported this year’s event with proceeds going to KPERF’s educational pursuits. Golfers teed off in a shotgun start and battled Continued on page 12 |9| www.KPHANET.org

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for first-place bragging rights as well as for longestdrive and closest-to-the pin skill contests. A big thank you goes out to the sponsors of the golf scramble where every hole was spoken for and prizes provided.

tions took on an educational tone with presentations by AstraZeneca at the Friday luncheon and CoverMyMeds at the Saturday breakfast. We thank these companies for important sponsorship support.

No sooner were the golfers finished with sharing stories at the 19th hole (clubhouse) when everyone had to get ready for the Opening Reception that evening at the Newport Aquarium. The family friendly event included dinner and allowed attendees to wander through the facility at their own pace because the entire venue was reserved for KPhA guests. Docents added interesting trivia about the marine life while attendees were able to get up close and personal by petting some of the friendly species. A walk on netting over the huge shark tank was a highlight to the evening. Thank you WellCare for sponsoring this aquatic adventure!

Attendees had the opportunity to participate in the business of KPhA at the opening and closing House of Delegates meetings on Friday and Saturday.

Speaker of the House of Delegates Amanda Jett presided over the many presentations from KPhA committees, KPERF and the Kentucky Pharmacists Political Advocacy Council (KPPAC) and others.

2017-2018 KPhA President Chris Harlow gave his report highlighting the progress of the KPhA Strategic Plan. Finally, HOD attendees voted on the new Vice Speaker of the House with Ben Mudd winning the election. New KPhA Officers and Board of Directors were sworn into office as well.

Attendees visit with exhibitors at the bustling exhibit hall.

Kate Probst presents at the KPhA Annual Meeting & Convention.

Exhibition Overflows with Interest More than 40 exhibitors packed the atrium space CEs Inform; HOD Conducts Business with an overflow room being needed when exhibiConference registration proceeded smoothly with tor support swelled beyond expectations – a good the help of many UKCOP and SUCOP students problem to have! I did my very best to visit with and 2017– 2018 KPhA Chair Trish Freeman who each exhibitor and to thank them for their support. pitched in to greet attendees. Continuing education We’re so appreciative of all of our exhibitor and programming featured new Board Authorized Pro- sponsorship friends who made the exhibition such a tocols as well as concurrent sessions to maximize success. the number of topics presented. Even meal funcAttendees were able to move freely among the ex|12| Kentucky Pharmacists Association | July/August 2018

hibitor tables while they sought out the latest products and services for pharmacists and their patients.

Two exhibition sessions were held Friday evening and Saturday morning to allow attendees ample time to meet exhibitors without the worry of missing CE opportunities.

Kim Croley passes the gavel to Bob Oakley during the annual “passing of the gavel” ceremony.

Ray Wirth Awards Banquet Shines The stars shone brightly at the Ray Wirth Awards Banquet Saturday night as KPhA moved its awards ceremony from the closing HOD meeting to the anAttendees applaud while the legislators address the KPPAC recepnual banquet. I had the honor of serving as the emtion. cee for the evening as well as the distinct pleasure of KPPAC Reception Attracts Legislators introducing the award honorees. I also was moved The KPPAC Reception Friday night not only atby the many, fine acceptance speeches that reflected tracted a large audience of attendees, but it also served as a huge drawing card for Kentucky legisla- the heart and soul of those receiving the awards. tors who wanted to voice their support for pharma- KPhA is truly thankful for the continued support of cists. Among those in attendance were Senate Ma- Kroger (Cincinnati and Louisville Divisions) as our jority Floor Leader Senator Damon Thayer, Sena- sponsor of the banquet. Transaction Data Systems tor Ralph Alvarado, M.D., Representative Danny also sponsored the President’s Reception immediBentley, Representative Robert Goforth, Repreately before the banquet and we thank them for sentative Kimberly Moser, Representative Addia their support.

Wuchner and candidate Derek Lewis.

New KPhA President Chris Palutis concluded the Outgoing KPPAC Chair Matt Carrico addressed the audience and spoke of the importance of supporting KPPAC while eloquently thanking the legislators in attendance. Then, one by one, the legislators all voiced their appreciation for the support they’ve received from pharmacists and the need to keep the profession strong. Thanks doesn’t begin to cover the gratitude we feel for the legislators who came out on a Friday evening to demonstrate their support of pharmacy in Kentucky.

banquet by setting the tone for his year in office with his President’s acceptance speech. He indicated his focus will be on membership engagement, clinical services and advocating for pharmacy’s relevance – all worthy endeavors. His complete address can be found in his first President’s Perspective beginning on p. 3. I look forward to working this year with Chris and the entire KPhA Board of Directors on behalf of our valued members throughout the Commonwealth of Kentucky.

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2018 KPERF Golf Scramble

Almost made it in at Devou Park Golf Course.

Bob Oakley putts on the green.

Joe Carr, Sam Willett, Don Kupper, Duane Parsons and Clark Kebodeaux take in the sights at Hole 5.

Angela Brunemann, Brook Ross and Marilin Castle celebrate.

SUCCOP and UKCOP were represented on the course.

Winners Circle First Place: Don Kupper, Duane Parsons, Sam Willett, Clark Kebodeaux and Joe Carr Second Place (tie): Ron Nieporte, Tim Kroger, Charles Clifton and Pat Mattingly/Amanda McCoy, Andrea Jackson, Scott Simon and Dave Roth Last Place: Angela Brunemann, Brook Ross, Marilin Castle and Eric Nordman Longest Drive: Chris Palutis (men’s); Amanda McCoy (women’s) Closest to the Pin: Chip Diehl

Special Thanks to KPERF’s Golf Scramble Hole Sponsors Bingham Greenebaum Doll LLP | C&C | Flexible Pharmacy Services | Government Affairs | Harrod & Associates | Lanham & Company | Medica Pharmacy & Wellness Center | Pharmacists Mutual | Political Advisory Council (KPPAC) | Republic Bank & Trust | Rx Discount Pharmacy | St. Matthews Community Pharmacy | Sullivan University College of Pharmacy | The Clifton Family | UK College of Pharmacy Class of 1974 | Walgreens |14| Kentucky Pharmacists Association | July/August 2018

Welcome Reception KPhA hosted a welcome reception which was sponsored by WellCare on Thursday, June 14 at the Newport Aquarium in conjunction with the KPhA Annual Meeting & Convention.

Ideas for a family-friendly reception location in Lexington for 2019?

Let us know by emailing us at info@kphanet.org.

|15| www.KPHANET.org

House of Delegates Report House of Delegates Summary Amanda Jett—2018 Speaker Tyler Stevens—2018 Vice Speaker and Chair of the Reference Committee Joe Fink—Opening Parliamentarian Joe Carr—Closing Parliamentarian

Secretary Brooke Hudspeth chaired the credentialing process. She reported that 29 were needed for a Simple Majority and 39 were needed for a 2/3 Majority vote.

The following reports were presented and/or filed to the At the 2018 KPhA House of Delegates members from House of Delegates: throughout the Commonwealth gathered to discuss, debate and make recommendations to not only shape OUR  Report of the 2017-18 President Chris Harlow—moving to tomorrow’s closing ceremonies as Chris unable to be here KPhA, but also to push forward OUR beloved profes Report of the 2017-18 Treasurer Duane Parsons sion. 

Report of the Executive Director Mark Glasper

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KPPAC Report—Matt Carrico

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KPERF—Bob Oakely

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RxTM—Cathy Hanna

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Organizational Affairs—Joel Thornbury & Sam Willett

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Government Affairs—Richard Slone

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Membership Engagement—Chris Palutis

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New Practitioner—Martika Martin

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Student Engagement—Jaclyn Ochsner and Nathan Hughes

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Professional Affairs—Misty Stutz

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Educational Programming—Tyler Stevens

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Emergency Preparedness Work Group—Joanne Taheri

Speaker Amanda Jett addresses the House of Delegates.

House of Delegates Opening Session Speaker Amanda Jett convened the Opening Session of the KPhA House of Delegates on Friday, June 15, 2018 at 8:00 AM. Delegates were slated in accordance with the updated KPhA Bylaws, and annual reports of the association were presented.

The Invocation was presented by Jessika Chilton Chinn.

Duane Parsons led everyone in the Pledge of Allegiance.

Amanda Jett led the Oath of a Pharmacist.

The minutes from the previous House of Delegates meet- KPhA members complete the credentialing process. ing were presented. A motion was moved to approve the minutes and seconded. Motion carried.

Delegates present: 58 |16| Kentucky Pharmacists Association | July/August 2018

Reference Committee Speaker Jett appointed the Reference Committee as follows: Kim Croley, Joe Carr, Sam Willett, Ben Mudd, Judy Minogue, students Steven Drog and Dharti Patel, and Vice Speaker Tyler Stevens serving as chair. Speaker Jett announced that the committee would meet Saturday morning and the meeting would be open to all interested KPhA members. The committee’s charge was to discuss the resolutions from the House of Delegates and to provide feedback to the House in accordance with the Rules and Procedures.

A motion was presented and carried to accept The Policy and Procedural manual as presented by The Reference Committee.

Installation of the 2018-19 Incoming KPhA Board of Directors 

Jessika Chilton-Chinn, Director

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Chad Corum, Director

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Dharti Patel , UK College of Pharmacy Student Representative

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Stephen Drog, Sullivan College of Pharmacy Student Representative

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Tyler Stevens, Speaker of the House of Delegates

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Ben Mudd, Vice Speaker of the House of Delegates

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Don Kupper, President-Elect.

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Chris Harlow, Chair

Brooke Hudspeth, Secretary, and Matt Carrico, Director will be installed at the July 26, 2018 Board of Directors meeting.

The 2018 House of Delegates, once again, was a time for discussion and debate. This is when we decide the next steps for OUR KPhA and look forward to more involvement and discussion in the House as we advance OUR profession. Speak up to become involved, serve on a committee, become a delegate in the House and voice OUR stance. KPhA is YOU!

KPERF Chair Bob Oakley recites the Oath of a Pharmacist.

Closing Session The Closing Session convened on Saturday, June 16, 2018. During this session, recommendations of the Reference Committee were discussed and the vote for ViceSpeaker commenced.

The report of the Credentialing Committee was presented by Tyler Stevens.

The election was conducted for Vice Speaker with Brian Garcia and Ben Mudd receiving nominations. A vote via paper ballot was held. Ben Mudd was elected as the Vice Speaker of the House of Delegates.

Speaker Jett called on Vice Speaker Tyler Stevens, Chair of the Reference Committee, for its recommendations.

Action taken by the House is also listed below. 

New KPhA Board of Directors are installed during the Closing Session of the House of Delegates.

The Organizational Affairs Committee provided an updated “KPhA Policy and Procedural Policy Manual.” The Reference Committee recommended to accept the changes as presented by the committee.

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Become a KPhA Ambassador Today!

Do you have a passion for building and growing relationships?

Do you possess a knowledge of KPhA and an appreciation for the Pharmacy profession?

Are you well connected in your region?

If so, then the KPhA Ambassador Program is for you.

Visit www.kphanet.org/ambassador-program to learn more!

Volunteer Today Pharmacist, pharmacy technician and student pharmacist recruitment is still underway for the Kentucky Pharmacists Association emergency preparedness program! Pharmacy professionals play a critical part in responding to emergency events such as a natural disaster or infectious disease outbreak.

For more information on how you can be involved in the KPhA Pharmacy Emergency Preparedness Initiative, contact KPhA 502-227-2303 or by email at jjaggers@kphanet.org.

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6. See It All KPhA is the only statewide pharmacy organization that represents all pharmacists in all practice settings—you can learn about all the opportunities available within pharmacy and gain insights from pharmacists representing a variety of practice settings.

7. Develop Your Leadership Skills Participate as an active leader in a variety of committees and volunteer leadership positions that will develop your skills as you give back to your profession.

1. Strengthen Your Career KPhA members enjoy educational opportunities designed to increase knowledge and keep up with the latest information.

2. Advance Patient Care

8. Make a Positive Impact By joining KPhA, you are taking a step to ensure the future of the profession in Kentucky. We can’t do this important work without YOU.

The more you learn about drug and treatment updates through our publication, The Kentucky Pharmacist, as well as through attending OUR KPhA meetings, the better equipped you are to help your patients.

9. Make the Connection

3. Network with Others in Your Field

KPhA partners with many industry partners that offer discounts or important expertise that can positively impact your pharmacy.

KPhA members are invited to join their colleagues at the KPhA Annual Meeting & Convention and the Legislative Conference.

4. Advocate for Your Profession By joining KPhA, you are supporting the only organization representing the unified voice of all pharmacists.

During the past year, KPhA’s work on health care legislation and regulation increased policy makers’ awareness of the pharmacist’s role in health care. KPhA continues to

5. Proclaim Your Professionalism Adding your name to the ranks of your colleagues who are members declares your pride in the profession. Support KPhA’s advocacy efforts as we work with policy makers to implement health care reform legislation and as we continue to advocate for regulations that positively impact the profession.

10. Gain the Competitive Edge KPhA gives you exclusive access to unique experiences, career information, and resources designed to meet your needs and provide support as you advance in your career.

JOIN TODAY WWW.KPHANET.ORG

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KPPAC Reception

Attendees listen to legislators address the KPPAC reception on Friday, June 15.

Rep. Danny Bentley and Rep. Addia Wuchner connect with students during the KPPAC reception.

KPPAC chair Matt Carrico mingles with members and the many legislators who addressed the attendees.

Sam Willett, Chris Harlow, Chris Clifton, Trish Freeman, Richard Slone, Chris Killmeier, Chris Palutis and Matt Carrico enjoy the skyline at the reception.

KPhA Executive Director Mark Glasper discusses Annual Meeting events with KPhA President Chris Palutis and his wife and fellow pharmacist member Consuelo Palutis.

Ralph Bouvette and Trish Freeman connect with Rep. Robert Goforth during the reception.

Donate online to the Kentucky Pharmacists Political Advocacy Council Go to www.kphanet.org and click on the Advocacy tab for more information about KPPAC and the donation form. |20| Kentucky Pharmacists Association | July/August 2018

Advocacy Matters Ways you can support KPhA’s Advocacy efforts today! 

Participate in grassroots advocacy efforts

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Get to know your legislators—they should know your name

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Donate to the Political Advocacy Council and the Government Affairs Fund

Photo by: Matt Turner

Donate online to the KPhA Government Affairs Fund Funds contributed to KPhA Government Affairs are applied directly to our lobbying efforts in terms of staffing and contracted lobbying services. Company donations are acceptable for Government Affairs contributions, unlike contributions to Political Advocacy Funds, like KPPAC. Go to www.kphanet.org form. |21| www.KPHANET.org

Sam Willett, RPh, Capital Campaign Donor

“

KPhA has always been devoted to its mission of advocating for and advancing the profession of pharmacy, a profession that has been very rewarding to me personally and financially. Donating to the capital campaign is just a small token of appreciation to the professional organization that supports all pharmacists.�

Leave a legacy by making a tax-deductible donation online at www.kypharmacyfuture.net |22| Kentucky Pharmacists Association | July/August 2018

July CPE Article Patient-Specific Considerations and Clinical Pearls: Applying the 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults By: Justin McCann, PharmD*, Elisabeth Sulaica, PharmD**, Stacy A. Taylor, PharmD, MHA, BCPS* *University of Kentucky College of Pharmacy **UK HealthCare The authors declare that there are no financial relationships that could be perceived as real or apparent conflicts of interest.

Universal Activity # 0143-0000-18-011-H01-P & T 1.0 Contact Hours (0.10 CEU) Expires 07/25/21

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

Goal: The purpose of this review is to increase understanding of the recommendations for the treatment and management of hypertension through application of patient-specific cases.

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

Describe approaches for treatment of hypertension in different patient populations

2.

Compare and contrast indications, contraindications, and side effects for first-line antihypertensive agents

3.

Develop patient care plans for hypertension treatment based on varying patient characteristics

As detailed in the companion hypertension update continuing education document published in the previous edition of The Kentucky Pharmacist, the American Heart Association and American College of Cardiology task force published updated Blood Pressure Guidelines in 2017.1 The updated guidelines continue to recommend the same four primary antihypertensive classes as first-line agents: thiazide diuretics, angiotensinconverting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), and calcium channel blockers (CCB). These antihypertensive classes are recommended based on data from large clinical trials demonstrating not only a decrease in blood pressure but also a reduction of the risk of clinical events such as myocardial infarction, stroke, and cardiovascular death.2,3 All are efficacious in lowering blood pressure and preventing cardiovascular clinical events in patients without compelling indications. However, the order of utilization of these classes may differ across specific patient populations.1 The current document will first discuss considerations that lead to the preferential recommendation of one or more antihypertensive classes for primary prevention in specific patient populations. Second, this document will provide clinical pearls for the four primary antihypertensive classes, including clinically significant side effects. Finally, the document will provide patient case scenarios for practice and application.

emphasis on patients being instructed to monitor their blood pressure at home between clinic visits. Once the diagnosis of hypertension is established, all patients with an indication for antihypertensives should be evaluated to determine the most appropriate therapy for their blood pressure control. Proper assessment should include a thorough medical history including race, cardiovascular history, chronic kidney disease history, and a physical assessment. Baseline laboratory assessment should be completed prior to initiation of antihypertensive therapy to screen for diabetes, hyperlipidemia or secondary causes of hypertension such as hyperthyroidism. Recommended lab testing includes a complete blood count, lipid profile, thyroid-stimulating hormone, serum creatinine, sodium, potassium, glucose, calcium, and a urinalysis. After the diagnosis has been established and screening tests have been completed, an appropriate antihypertensive agent can be initiated.1

Treatment Recommendations for Specific Patient Populations Nonblack

According to the guidelines, any of the four first-line agents can be considered for initial antihypertensive treatment in the 1 The approach to blood pressure treatment should be patient- general nonblack population. The guideline update does not specific. The guideline update stresses the importance of tak- recommend any one of these agents over another in the abing multiple blood pressure readings to establish the diagnosis sence of compelling indications. of hypertension.1 Due to patient stress and other variables, blood pressure is often higher in the ambulatory clinic setting than at home. Therefore, the guideline update places a greater |23| www.KPHANET.org

history of smoking, blacks, and age ≥65 years. The angiotensin converting enzyme is responsible for the metabolism of Several trials have specifically analyzed cardiovascular outbradykinin. The proposed mechanism of action of angioedecomes based on race, noting a disparity in blood pressure low- ma is an increase in bradykinin presence. Prevention of bradyering effects and cardiovascular outcomes for some drugs in kinin breakdown is also the cause of another common side black patients. The ALLHAT trial found a 51% higher rate of effect of ACE inhibitors – the dry cough. Additional ACE stroke in black patients taking an ACE inhibitor when cominhibitor side effects include an increase in serum creatinine pared to a CCB.4 Subsequently, a subgroup analysis from the (SCr), a marker of kidney function. With initiation of an ACE ALLHAT trial found that a thiazide diuretic was shown to be inhibitor it can be anticipated to have up to a 30% increase in more effective in improving cerebrovascular and cardiovascu- SCr which will likely improve within the first 2 months. ACE lar outcomes, as well as heart failure outcomes in black painhibitor discontinuation should be considered if SCr increastients when compared to ACE inhibitor use.4 Based on imes >30% above the patient’s baseline creatinine.11 Finally, proved outcomes, thiazide diuretics or calcium channel block- ACE inhibitors can cause hyperkalemia or an elevation in ers are recommended preferentially in black patients.1 Addiserum potassium. Depending on the severity of hyperkalemia, tionally, the guidelines recognize that black patients are more the ACE inhibitor may require dose reduction or discontinualikely to require two or more antihypertensive medications to tion based on the provider’s clinical evaluation.10 achieve blood a pressure goal of less than 130/80 mmHg. 1 Appropriate monitoring and patient counseling are key to enChronic Kidney Disease suring safe and effective ACE inhibitor use. The SCr and potassium should be monitored 1-2 weeks after ACE inhibitor For patients with chronic kidney disease (CKD) stage 3 initiation or dose titration. Side effects should be clearly ex(creatinine clearance < 60 mL/min) or worse, the guideline plained and include monitoring for dizziness, orthostasis, dry recommends initial hypertension treatment with an ACE incough, and signs and symptoms of angioedema. When coun1 hibitor or an ARB if an ACE inhibitor is not tolerated. The seling about angioedema, it is important for the patient to unrecommendation of an ACE inhibitor or ARB as first-line derstand it can occur at any time whether it is soon after ACE therapy also extends to patients of any creatinine clearance inhibitor initiation or years later.10 value in the presence of proteinuria (urine albumin ≥ 300 mg per day or an albumin-to-creatinine ratio ≥ 300 mg/g ) as Angiotensin Receptor Blockers studies have demonstrated that an ACE inhibitor or ARB showed evidence of improved kidney outcomes in this patient Similar to ACE inhibitors, ARBs also block the effects of angiotensin II through a different mechanism. The ARB class sepopulation. When considering first-line therapy selection in black patients with CKD, evidence supports initiating an ACE lectively inhibits the angiotensin II receptor in order to block inhibitor or ARB over other agents. The renal protective bene- the effects of angiotensin II which include vasoconstriction fits of ACE inhibitors in black patients were demonstrated in and aldosterone secretion. The net clinical effects are similar the AASK study,5 making an ACE inhibitor or ARB the first- to those attained by ACE inhibitors in regard to blood pressure lowering, alterations in kidney function, and vascular and line recommendation for all patients with CKD regardless of cardiac remodeling.6 Additionally, ARBs have also previously race. demonstrated both blood pressure lowering effects and deClinical Pearls for First-Line Antihypertensive Classes creased cardiovascular outcomes including cardiovascular death.12,13 Transient elevations in SCr and risk of hyperkalemia Angiotensin-Converting Enzyme (ACE) inhibitors are also similar to ACE inhibitors. The one common side efACE inhibitors are a class of medications that inhibit the angi- fect that differs between ACE inhibitors and ARBs is that ARB use is not associated with the development of a dry otensin-converting enzyme to ultimately prevent the convercough. Since the ARB class does not inhibit the angiotensin sion of angiotensin I to angiotensin II. Angiotensin II has a converting enzyme, it does not have an effect on bradykinin variety of effects that include increased vasoconstriction, aldosterone release resulting in increased sodium reabsorption, metabolism. Therefore, with ARB therapy bradykinin is meand alterations in renal function secondary to direct renal vas- tabolized normally and does not build up causing the bradykinin-associated dry cough.6 oconstriction. These effects can cause an increase in blood pressure, alterations in kidney function, and both vascular and Given the proposed bradykinin-related mechanism of ACE cardiac remodeling. Inhibiting the production of angiotensin inhibitor-induced angioedema one would predict that angiII decreases the undesirable effects and lowers blood presoedema should also not be a concern with ARB use. Unfortu6 sure. nately, this has not been the case in clinical practice. Angioedema has been reported in approximately 0.1% of patients ACE inhibitors have previously been shown to both lower taking ARBs compared to 0.3% of patients taking ACE inhibiblood pressure and decrease the incidence of cardiovascular outcomes including cardiovascular death, nonfatal stroke, and tors. The mechanism of ARB-associated angioedema is not recurrent non-fatal myocardial infarction (MI).7-9 While ACE fully understood but it is hypothesized that some patients may inhibitors have been found to reduce cardiovascular events in have low plasma concentrations of a different enzyme 14 patients with hypertension, there are important side effects to (aminopeptidase P) that also helps breaks down bradykinin. remember. The most severe side effect is angioedema found to The 2017 Guideline states that an ARB may be instituted in patients with ACE inhibitor-associated angioedema, but recoccur at an incidence of 0.1-0.7%.10 ACE inhibitor-induced angioedema has been associated with risk factors including a Black

|24| Kentucky Pharmacists Association | July/August 2018

ommends a 6-week waiting period between cessation of the ACE inhibitor and initiation of the ARB.1 Thiazide Diuretics A 2014 meta-analysis through the Cochrane Library outlined concerns associated with the use of thiazide diuretics which included electrolyte abnormalities.15 Thiazide diuretics inhibit sodium reabsorption by blocking the sodium-chloride cotransporter in the distal convoluted tubule of the kidney, facilitating the excretion of sodium and water. Due to this mechanism, a major side effect of diuretic use is the increased risk of electrolyte abnormalities. Along with sodium other electrolytes, such as potassium and magnesium, are excreted more readily.6 It is important that patient labs are monitored closely when initiating these agents to prevent the depletion of electrolytes and possible adverse drug events including arrhythmias. This depletion can be countered by the addition of an agent that increases potassium levels such as the aforementioned ACE inhibitors or ARBs or a potassium-sparing diuretic such as triamterene.15 The use of thiazides can also increase serum concentration of glucose, uric acid, and creatinine.6 The proposed mechanism of thiazide-induced hyperglycemia is a result of potassium depletion, subsequently reducing insulin secretion and peripheral sensitivity to insulin. However, studies have not found a correlation between serum potassium and insulin levels in patients on thiazides. In a 2016 review, it was found that thiazide diuretics increased fasting plasma glucose almost 5 mg/dL when compared to other agents and placebos.16 In regard to uric acid elevations, caution is recommended when considering thiazides in patients with gout due to their propensity to increase serum uric acid.1 This elevation occurs due to uric acid competing with thiazides for organic acid transporters in the proximal tubule.6 In the 2014 Cochrane Review, within the 13 trials that reported serum uric acid levels, there was an average increase of 13 Âľmol/L in patients on thiazides.15 Thiazides also have the potential to increase Scr, therefore it is recommended that clinicians assess renal function upon initiation and periodically follow-up while on thiazides.6 Calcium Channel Blockers When considering the CCBs, there are two subclasses into which agents can be classified: dihydropyridines (DHP) which include agents such as amlodipine, felodipine, nisoldipine, and nifedipine and non-dihydropyridines (nonDHP) which include verapamil and diltiazem. The DHP CCBs are the subclass of CCBs most commonly used to treat hypertension. The DHPs have a greater effect on peripheral vasodilation than the non-DHPs, thus providing rationale for their effectiveness in blood pressure control.6 Peripheral edema is one of the most common adverse effects with CCBs. The mechanism of edema with CCBs is proposed to arise from preferential arteriolar dilatation, thus increasing the pressure gradient between the arteriolar and venous capillaries, leading to extravasation of intravascular fluid.6 In a 2011 meta-analysis evaluating almost 100,000 patients taking CCBs, the incidence of peripheral edema was 12.3% with DHPs, 3.1% with non-DHPs, and 3.2% with placebo.17 The

incidence of edema and withdrawal rates continued to increase throughout the duration of therapy with CCBs. Studies have shown a reduced incidence of edema with the addition of an ACE inhibitor or ARB. Diuretics have not proven to be beneficial in reducing DHP-associated edema since mechanistically the edema is not due to fluid retention.17 Another identified adverse effect of CCB therapy is gastroesophageal reflux secondary to relaxation of the esophageal sphincter. A 2007 retrospective observational study identified trends surrounding CCBs and gastroesophageal reflux.18 Reflux was more commonly observed with verapamil and the DHP CCBs (specifically amlodipine) and least commonly observed with diltiazem. Of 241 patients reporting no history of reflux prior to taking CCBs, 85 (35.3%) patients developed reflux-related symptoms after beginning CCBs. In 130 patients that reported pre-existing reflux symptoms, almost half (45.4%) reported worsening of reflux symptoms upon commencing CCBs. These effects were more prevalent overall among patients taking DHPs than those taking non-DHPs.29 For patients who report worsening or new-onset reflux, clinicians may consider histamine-2 receptor antagonists or proton pump inhibitors for symptom relief or alternative antihypertensive therapy.

Conclusion The updated 2017 Blood Pressure Guideline continues to recommend thiazide diuretics, ACE inhibitors, ARBs, and CCBs as first-line antihypertensive agents. All four classes are included as first-line recommendations due to clinical trial results demonstrating positive effects on blood pressure and reduction in myocardial infarction, stroke, and cardiovascular death. In patients without compelling indications, any of the four classes may be selected as first-line therapy. In select populations some classes are recommended over others. In black patients first-line therapy should include either a thiazide diuretic or a calcium channel blocker due to improved clinical outcomes with these two classes. In patients with CKD, ACE inhibitors should preferentially serve as the agent of first choice due to the renal protection afforded by these agents. In CKD patients who are intolerant to ACE inhibitors, ARB agents are recommended. However, the order of utilization of these classes may differ across specific patient populations.

All four classes of agents are associated with different side effect profiles which may make specific agents more or less desirable or lead to additional monitoring based on patientspecific characteristics. As medication experts, pharmacists can play a unique role in providing medication information, recommendations, and advice regarding the side effect profiles and patient-specific considerations that may need to be taken into account to achieve optimal patient outcomes. Patient case scenarios are provided as the assessment for this educational activity to provide an opportunity for practice and application.

References: 1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/ PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017;1-193.

|25| www.KPHANET.org

2. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;265:3255-3264.

16. Zhang, X., & Zhao, Q. Association of Thiazide-Type Diuretics With Glycemic Changes in Hypertensive Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials. J Clin Hypertens. 2016;18(4):342-351.

3. Kostis JB, Cabrera J, Cheng JQ, et al. Association between chlorthalidone treatment of systolic hypertension and long-term survival.

JAMA. 2011;306:2588-2593.

17. Makani H, Bangalore S, Romero J, et al. Peripheral edema associated with calcium channel blockers: Incidence and withdrawal rate-a meta-analysis of randomized trials. J Hypertens.

2011;29(7):1270-1280.

4. Leenen FH, Nwachuku CE, Black HR, et al. Antihypertensive and lipid-lowering treatment to prevent heart attack trial collabora18. Hughes J, Lockhart J, Joyce A. Do calcium antagonists contribtive research group. Clinical events in high-risk hypertensive patients ute to gastro-oesophageal reflux disease and concomitant noncardiac randomly assigned to calcium channel blocker versus angiotensinchest pain? Br J Clin Pharmacol. 2007;64(1):83-89. converting enzyme inhibitor in the Antihypertensive and LipidJuly 2018 — Patient-Specific Considerations and Clinical Lowering Treatment to Prevent Heart Attack Trial. Hypertension.

2006;48(3):374-384.

Pearls: Applying the 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pres5. Wright JT Jr, Bakris G, Greene T, et al; African American Study sure in Adults of Kidney Disease and Hypertension Study Group. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. AB is a 53 year-old black female who presents to your primary pre2002;288(19):2421-2431. vention clinic after being referred by her primary care physician. Past medical history is significant for chronic obstructive pulmonary dis6. Hillal-Dandan R. “Renin and Angiotensin.” Goodman & Gilease (COPD), osteoporosis, CKD (CrCl 50 mL/min). man’s. 13 ed. Brunton LL. New York City, NY: McGraw-Hill Education, 2018. AccessMedicine.

Medications: Fluticasone/salmeterol 250/50 inh BID; ibandronate http://accessmedicine.mhmedical.com.ezproxy.uky.edu/book.aspx? 150 mg PO once monthly bookid=2189. [Accessed 2018 Mar 25].

Baseline BP: 147/89, 144/88, 148/94 mmHg taken at three separate 7. Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind clinic visits comparison of placebo and active treatment for older patients with Wt: 110 kg Ht: 65 inches isolated systolic hypertension: the Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet. 1997;350:757-764.

Allergies: NKDA 8. Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin1. When considering which antihypertensive agent to initiate, converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients: the Heart Outcomes Prevention Evaluation Study what would you consider?

Investigators. New Engl J Med. 2000;342:145-153. a. Age (53) and gender (female) 9. PROGRESS Collaborative Group. Randomised trial of a perinb. Age (53) and disease state (CKD) dopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet. c. Race (black) and gender (female) 2001;358:1033-1041. d. Race (black) and disease state (CKD) 10. Brown T, Gonzalez J, Monteleone C. Angiotensin-converting 2. What would be the most appropriate antihypertensive regimen enzyme inhibitor-induced angioedema: A review of the literature. J to initiate for AB? Clin Hypertens. 2017;19:1377-1382.

11. Bakris GL and Weir MR. Angiotensin-Convertin Enzyme Inhibi- a. tor-Associated Elevations in Serum Creatinine. Arch Intern Med. b.

2000;160:685-693.

12. Dahlof B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359(9311):995-1003.

13. Julius S, Kjeldsen SE, Weber M, et al. Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE randomised trial. Lancet.

2004;363(9426):2022-31.

14. Cohen DL, Townsend RR. Can an angiotensin receptor blocker be used in a patient in whom angioedema developed with an angiotensin-converting enzyme inhibitor? J Clin Hypertens.

2008;10(12):949-950.

Hydrochlorothiazide 25 mg PO daily

c.

Lisinopril 10 mg PO daily

d.

Metoprolol Succinate 50 mg PO daily

AB returns to your primary prevention clinic 1 month after beginning lisinopril 10 mg PO daily for newly-diagnosed HTN. Patient denies dizziness or lightheadedness, but does complain of a productive cough, runny nose, and sneezing.

Today’s BP: 138/84 mmHg 3. Which of the following is NOT likely to be an adverse effect for AB based on her regimen? a.

15. Musini VM, Nazer, M, Bassett K, et al. Thiazide diuretics for the b. treatment of high blood pressure. Cochrane Database of Systematic c.

Reviews 2014, Issue 5. Art. No.: CD003824. DOI: 10.1002/14651858.CD003824.pub2. d.

|26| Kentucky Pharmacists Association | July/August 2018

Amlodipine 5mg PO daily

Peripheral edema Hyperkalemia Dry cough Angioedema

Pertinent Labs:

1 Month Ago

Today

Normal Range

Glucose

121 H

143 H

(80-99) mg/dL

BUN

25 H

33 H

(7-20) mg/dL

Creatinine

2.1 H

2.8 H

(0.6-1.0) mg/dL

Un/Cr Ratio

11

13

(8-20) *

Sodium

139

137

(136-144) mmol/L

Potassium

3.8

4.8

(3.6-4.9) mmol/L

Chloride

103

104

(102-109) mmol/L

CO2

22

25

(22-31) mmol/L

Calcium, Total

9.0

9.1

(8.8-10.0) mg/dL

4. What would be your assessment and plan regarding AB’s tolera- d. Atrial Fibrillation tion of her regimen?

8. CD requests to begin a CCB because his friend had taken one for years with great results. You would like to select an agent from a. Acute kidney injury; hold lisinopril until Scr recovers a CCB subclass shown to have better efficacy in lowering blood b. Cough; discontinue lisinopril and change to ARB pressure but would also like to avoid the agent shown most likely to aggravate GERD. Which would be the most ideal CCB to initic.

Hyperkalemia; decrease dose of lisinopril ate? d.

Hyperglycemia; discontinue lisinopril and change to alternate agent

5. AB returns to your clinic 3 months after you change her blood pressure regimen to amlodipine 10 mg daily and hydrochlorothiazide 25 mg daily. She is noted to have the following side effects, likely secondary to hydrochlorothiazide: a.

Hyperkalemia and hyperglycemia

b.

Hypokalemia and hypoglycemia

c.

Hyperkalemia and hypoglycemia

d.

Hypokalemia and hyperglycemia

Case 2 CD is a 45 year-old black male who is referred to your primary prevention clinic for initiation of pharmacotherapy for hypertension.

Past medical history is significant for gastroesophageal reflux disease (GERD), atrial fibrillation, osteoarthritis, and hyperlipidemia.

a.

Verapamil

b.

Amlodipine

c.

Diltiazem

d.

Felodipine

CD returns to your primary prevention clinic 3 months after starting felodipine 5 mg daily and chlorthalidone 12.5 mg daily. Patient reports great adherence to medications but does complain of swelling in his lower extremities, particularly around his ankles.

Today’s BP: 132/82 mmHg 9. What antihypertensive therapy adjustment may potentially relieve his “swelling”? a. Increase felodipine to 10 mg daily b. Increase felodipine to 10 mg daily and chlorthalidone to 25 mg daily

Medications: Pantoprazole 40 mg PO daily, warfarin 5 mg PO daily, c. Discontinue felodipine and increase chlorthalidone to 25 mg daily acetaminophen 500 mg PO twice daily, and atorvastatin 40 mg PO d. Discontinue chlorthalidone and initiate lisinopril 5 mg daily daily Baseline BP: 142/98, 143/91, 144/90 mmHg taken at three separate Case 3 clinic visits; HR 69 bpm 6. What would be the most appropriate antihypertensive regimen to initiate for CD? a.

Lisinopril 10 mg PO daily

b.

Chlorthalidone 12.5 mg PO daily

c.

Lisinopril/hydrochlorothiazide 10/12.5 PO daily

d.

Valsartan 80 mg daily

7. If you were to initiate a DHP CCB for CD, which condition listed on his PMH would be of most concern? a.

Osteoarthritis

b.

Hyperlipidemia

c.

Gastroesophageal reflux disease

10. JL is a 55 yo white male who has been taking HCTZ 25 mg for the past three months and lisinopril 10 mg for about three weeks.

He denies swelling of the lips/tongue or any subjective adverse symptoms. As you are evaluating his labs, what side effects could CD possibly experience from his hydrochlorothiazide? a.

Hyperglycemia

b.

Electrolyte disturbances

c.

Increased uric acid

d.

All of the above

CPE Quiz Online www.surveymonkey.com/r/CEQuizJuly18 |27| www.KPHANET.org

This activity is a FREE service to members of the Kentucky Pharmacists Association.

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Expiration Date: 07/25/2021 Successful Completion: Score of 80% will result in 1.0 contact hour or .10 CEUs. TECHNICIANS ANSWER SHEET July 2018 â&#x20AC;&#x201D; Patient-Specific Considerations and Clinical Pearls: Applying the 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (1.0 contact hour) Universal Activity # 0143-0000-18-011-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D E 3. A B C D E 5. A B C D E 7. A B C D E 9. A B C D E 2. A B C D E 4. A B C D E 6. A B C D E 8. A B C D E 10. A B C D E Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieved the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet.

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PHARMACISTS ANSWER SHEET July 2018 â&#x20AC;&#x201D; Patient-Specific Considerations and Clinical Pearls: Applying the 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (1.0 contact hour) Universal Activity # 0143-0000-18-011-H01-P Name _______________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D E 3. A B C D E 5. A B C D E 7. A B C D E 2. A B C D E 4. A B C D E 6. A B C D E 8. A B C D E

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

Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieved the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet.

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Signature ____________________________________________Completion Date___________________________ Personal NABP eProfile ID #_____________________________ Birthdate _______ (MM)_______(DD)

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

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

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August CPE Article Insulin and Beyond: A Review of Diabetes Injectables By: Claire Stall, PharmD; Elizabeth Elliott, PharmD; and Monica Roberts, PharmD (PGY-1 CommunityBased Pharmacy Residents, University of Kentucky College of Pharmacy) The author declares there are no financial relationships that could be perceived as real or apparent conflicts of interest. He does report that he chaired the group that created the latest version of the APhA Code of Ethics for Pharmacists.

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Learning Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: 1. Identify brand and generic names of antidiabetic injectable medications along with their mechanisms of action, typical dosing, and storage requirements.

2. Apply clinical pearls related to injectable antidiabetic medications to ensure appropriate product dispensing and provide high -quality patient counseling.

3. Recognize the concentration of various injectable products and determine appropriate dosing and days’ supply. ing errors. Concentration is also a key element to calculating the days’ supply of an insulin product (see figure 1).

Concentration is typically expressed in units/mL but is often With more than 30 million diabetes patients in the United States, drug manufacturers have focused significant effort on abbreviated using the “U-” designation. The most common concentration of insulin is 100 units/mL or U-100. Other developing new therapies and expanding therapy options to .1 treat this complicated, chronic disease state In addition to a concentrations of insulin include 200, 300, and 500 units/ flood of new oral antidiabetic medications, many new injecta- mL. Patients with higher insulin requirements may benefit from using a more concentrated insulin. Reducing injection ble antidiabetic drugs have come to market, with more than 20 insulin, non-insulin, and combination injectable products volume with a concentrated product can provide more predictable absorption and reduce pain, discomfort, and leaknow available. These injectables are typically expensive, reage.2 In addition, concentrated insulin formulations have quire patient education for proper administration, and have duration specific storage requirements to ensure stability and potency. shown a more stable pharmacokinetic profile, longer 2 of action, and decreased risk of hypoglycemia.

Patients who The variety of brand names and similarities in packaging, currently require twice-daily injections of long-acting U-100 function, and naming can cause confusion among both patients and pharmacy staff. Given the high-risk nature of insu- insulin may benefit from the more reliable 24-hour duration of a single dose of a concentrated basal insulin.2 Since tradilin-containing products, it is crucial that pharmacists and technicians be familiar with all injectable antidiabetic medica- tional insulin syringes are measured in units based on U-100 insulin, most new concentrated insulin products are manufactions. This article reviews diabetes injectables with a special tured as prefilled pens that display units to reduce errors. The focus on the newest products available in the class. patient simply dials the dose in units, and the correct volume is administered.

Insulin

Introduction

Insulin therapy is the backbone of many diabetes drug therapy regimens. The four types of insulin currently available are classified based on their onset and duration of action: rapidacting, short-acting, intermediate-acting, and long-acting.

Combination insulin-only products are also available in a fixed ratio of intermediate- and rapid-acting insulin (see table 1 on next page).

The rapid-acting insulin Humalog® (lispro) is available in both U-100 and U-200 formulations. The U-200 insulin is an advantage for patients who need a higher dose of mealtime insulin (>20 units/day).3 Long-acting Toujeo® (glargine) is only available as a U-300 concentration. Long-acting Tresiba® (degludec) is available in both U-100 and U-200 products. Both Toujeo® (glargine) and Tresiba® (degludec) come only as prefilled pens to avoid the need for patients to convert from units to mL.

Several new insulin products have been approved in recent years. In addition to new formulations that affect onset and duration of action, a variety of insulin concentrations have been approved. Pharmacists and technicians should stay alert to the concentration of each insulin product to avoid dispens- Humulin® R (regular) is available as U-100 and U-500 con|30| Kentucky Pharmacists Association | July/August 2018

Table 1. Insulin products4 Class

Brand

Generic

Duration

Typical Dosing

Rapid

Fiasp®

aspart

3–4 hours

Before a meal

Notes

Novolog®

Short

Apidra®

glulisine

Humalog®

lispro

Humulin® R

regular

5–7 hours

30 minutes before a meal

Can be mixed with intermediate insulin

NPH

12–18 hours

Once or twice a day

Appearance is cloudy

glargine

Up to 24+ hours

Once a day as basal insulin

Once or twice a day before a meal

Novolin® R Intermediate

Humulin® N Novolin® N

Long

Lantus® Basaglar® Toujeo®

Combinations

Levemir®

detemir

Tresiba®

degludec

Novolog® Mix 70/30

aspart protamine / aspart lispro protamine/ lispro

14–24 hours

lispro protamine/ lispro regular/NPH

14-24 hours

Humalog® Mix 75/25 Humalog® Mix 50/50 Novolin® Mix 70/30

centrations. Humulin® R (regular) U-500 is used for patients who are obese and need a higher amount of insulin for tighter glucose results.3 While the onset of Humulin® R (regular) U500 is similar to short-acting insulin, the duration of action can extend up to 24 hours.3 The risk of an overdose is significant if U-500 insulin is incorrectly dispensed or dosed. Steps have been taken by the manufacturer to change the labeling of this insulin to alert the pharmacist that U-500 insulin is being dispensed.3 Humulin® R (regular) U-500 vials should always be dispensed with U-500 syringes, which were introduced in 2016.4 The specialized syringes are marked in units to ensure that the patient is able to properly measure the dose without the need for conversion to milliliters.4 New insulin formulations have also been approved in recent years, offering providers additional opportunities to tailor insulin therapy to specific patient needs. Following is a brief overview of these new products.

Fiasp® (aspart): This ultra-rapid-acting insulin was approved by the FDA in September 2017. Fiasp® (aspart) is manufactured as a 100 unit/mL vial or prefilled pen. It is a meal-time insulin that can be administered right before a meal or up to 20 minutes after the meal is complete. The active molecule of Fiasp® (aspart) is identical to Novolog® (aspart).5 However, Fiasp® (aspart) also contains niacinamide (vitamin B3) and the amino acid L-Arginine to speed up absorption and stabilize the product.5 The manufacturer reports that these changes

14–24 hours

Up to 24 hours

30-45 minutes before a meal

reduce the onset of Fiasp® (aspart) to 2.5 minutes.5 This new insulin is intended for patients whose blood sugar fluctuates rapidly when a meal is started or who do not want to wait 15 minutes for the onset of a short-acting insulin before starting a meal. Fiasp® (aspart) has been shown to more closely mimic the body’s endogenous insulin response, improving post-meal glucose control.5 As with all insulin therapies, the most common adverse reaction with Fiasp® (aspart) is hypoglycemia.5 Tresiba® (degludec): Tresiba® (degludec) is a long-acting insulin that was approved by the FDA in September 2015. An advantage of Tresiba® (degludec) is that it can be injected at any time of day as long as doses are at least 8 hours apart. For example, if a patient injects Tresiba® (degludec) in the morning one day and forgets to inject the dose in the morning of the next day, the patient can inject the dose in the evening and still maintain blood glucose control.3 Tresiba® (degludec) is stable at room temperature for 56 days after opening and therefore does not typically require refrigeration by the patient.3 New glargine varieties: Basaglar® (glargine) is a long-acting insulin that has the exact same amino acid make-up as Lantus® (glargine). Basaglar® (glargine) has shown similar efficacy and safety as Lantus, but it is not a generic to Lantus® (glargine).3 Rather, insulin products are considered biologics by the FDA, and Basaglar® (glargine) was approved as a |31| www.KPHANET.org

Figure 1. Calculating days’ supply for insulin

Calculating days’ supply on insulin requires knowing the product, its concentration and packaging, and the patient’s specific dose. Follow the two examples below to practice calculating days’ supply.

Rx:

Lantus Solostar 1 box 32 units SQ daily

Rx: Concentration = 100 units/ml Dose = 32 units/day

Lantus vial 1 vial 32 units SQ daily

Box of pens = 5 pens with 3 mL each = 15 mL

Vial = 10 mL

1. Determine units per package:

1. Determine units per package:

2. Determine how many days box will last:

2. Determine how many days vial will last:

“follow-on” biologic to Lantus® (glargine). When converting from Lantus® (glargine) to Basaglar® (glargine), the dose should remain the same.3 Toujeo® (glargine) is a long-acting insulin that is more concentrated than Lantus® (glargine) or Basaglar® (glargine). Toujeo® (glargine) is formulated in a 300 units/mL pen that contains 1.5 mL of insulin whereas Lantus® (glargine) and Basaglar® (glargine) are formulated in 100 units/mL pens that contain 3 mL. When converting from Lantus® (glargine), start Toujeo® (glargine) at the same dose.3 However, Toujeo® (glargine) has been shown to have a smaller glucose-lowering effect, so a higher daily dose of Toujeo® (glargine) may ultimately be needed to maintain control.3

scheduled to be discontinued and removed from the market

by July 2018.9 Details of the GLP-1 products and Symlin® (pramlintide) are listed in table 2. The “Glycemic Control Algorithm,” published by the American Association of Clinical Endocrinologists and American College of Endocrinologists, is a useful tool to determine the role in therapy for antidiabetic agents.10 The 2017 algorithm does not include the use of Symlin® (pramlintide).10 The algorithm indicates GLP1 agonists for use as monotherapy, in dual therapy with metformin, or in triple therapy.10

In addition to improving glucose control, there is a potential for cardiovascular benefits from GLP-1 agonists. In the LEADER trial, published in 2016, Victoza® (liraglutide) reduced the risk of myocardial infarction, stroke, or cardiovasNon-Insulin Injectables There are two types of non-insulin injectable therapies for the cular death in patients with type II diabetes and high risk for treatment of diabetes: amylin analogs and glucagon-like pep- or established atherosclerotic cardiovascular disease 11 tide 1 (GLP-1) agonists. Symlin® (pramlintide), the only am- (ASCVD). The American Diabetes Association Standards of Medical Care in Diabetes — 2018 recommends adding Victoylin analog agent on the market, works synergistically with insulin to decrease post-prandial blood glucose levels by three za® (liraglutide) or SGLT-2 inhibitor Jardiance® main mechanisms: slowed gastric emptying, decreased post- (empagliflozin) after lifestyle management and metformin in prandial glucagon secretion, and centrally-mediated appetite the treatment of patients with type II diabetes and established 11 suppression, which decreases food consumption.6 GLP-1 ago- ASCVD. However, these standards note that studies of GLP -1 agonists other than Victoza® (liraglutide) have not shown nists also exert their effects by slowing gastric emptying and conclusive evidence of cardiovascular benefit and that a class preventing glucagon secretion, but they also increase insulin secretion.7 A major difference in the mechanisms of Symlin® effect of GLP-1 agonists on ASCVD is still under investiga11 (pramlintide) and the GLP-1 agonists is that GLP-1s work in tion. a glucose-dependent manner, thus lowering the likelihood of The decision to use GLP-1 agonists should be patient-specific hypoglycemia. Symlin® (pramlintide) carries a black-box warning regarding the increased risk of severe hypoglycemia based on route of administration, risks and contraindications, and adverse reactions. GLP-1s would not be the best choice when used with insulin.6 for patients with an aversion to needles. The use of GLP-1 There are currently six GLP-1 products on the market. A new agonists is contraindicated in patients with familial or personal history of medullary thyroid carcinoma and in patients GLP-1 agonist, Ozempic® (semaglutide) was approved in with multiple endocrine neoplasia syndrome type 2.6 There is December 2017 and is expected to be available in early 2018.6,8 Another GLP-1 product, Tanzeum® (albiglutide), is an associated risk of the development of thyroid C-cell tu|32| Kentucky Pharmacists Association | July/August 2018

mors with GLP-1 agonists, and most of the products carry a black-box warning related to such tumors.6 GLP-1 agonists are not recommended therapy for patients who are pregnant.

It is important to note that all of the studies comparing GLP1s were non-inferiority, rather than superiority, studies. The 2008 DURATION-1 study compared the safety and efficacy of Byetta® (exenatide IR) dosed twice daily and Bydureon® (exenatide ER) dosed once weekly and found that, at 30 weeks, patients who received Bydureon® (exenatide ER) had greater reductions in A1C and were more likely to achieve A1C goals than those who were receiving Byetta® (exenatide IR).12 The following year, the LEAD-6 trial compared the safety and efficacy of Victoza® (liraglutide) daily and Byetta® (exenatide IR) twice daily and found that patients taking Victoza® (liraglutide) had greater improvements in A1C than those taking Byetta® (exenatide IR).13 Victoza® (liraglutide) was also better tolerated, had a lower risk of hypoglycemia, and had the potential for weight loss.13 The DURATION-6 trial, published in 2013, compared the safety and efficacy of once-weekly Bydureon® (exenatide ER) and daily Victoza® (liraglutide) and found that both therapies led to reduction in A1C, with greater reductions in patients using Victoza® (liraglutide).14 The most common adverse effects were nausea, vomiting, and diarrhea, all of which were more frequent in patients taking Victoza® (liraglutide) and decreased with time in both groups of patients.14 In 2014, the AWARD-1 trial compared the safety and efficacy of Trulicity® (dulaglutide) with placebo and Byetta® (exenatide IR) in patients with type 2 diabetes and found that both Trulicity® (dulaglutide) and Byetta® (exenatide IR) were more effective than placebo at lowering A1C.15 Patients who received Trulicity® (dulaglutide) were more likely than those receiving Byetta® (exenatide IR) and placebo to achieve their A1C goal, and patients who received Trulicity® (dulaglutide) were less likely to experience hypoglycemia than those who received Byetta® (exenatide IR).15 The GetGoal-X trail, published in 2013, compared the safety and efficacy of daily Adlyxin® (lixisenatide) and twice daily Byetta® (exenatide IR).16 Adlyxin® (lixisenatide) was non-inferior to Byetta® (exenatide IR) in reduction of A1C and had fewer incidents of hypoglycemia and nausea.16 Elements beyond efficacy also affect the selection of GLP-1 products. Bydureon® (exenatide ER), Byetta® (exenatide IR), Victoza® (liraglutide), and Adlyxin® (lixisenatide) should be used cautiously in renal dysfunction and should not be used with severe renal impairment or end stage renal disease.6 None of the available GLP-1 products require hepatic dosage adjustments. Since GLP-1 agonists are associated with slowed gastric emptying, they should not be used in patients with severe GI disease or gastroparesis.6 Additionally, most of these agents are associated with an increased risk for gallbladder disease and pancreatitis, and Victoza® (liraglutide) has a risk for suicidal behavior.6 Insulin and GLP-1 Combinations While insulin therapy is most effective for lowering A1C, it also leads to hypoglycemic adverse reactions and weight gain.

The combination of insulin with a GLP-1 agonist supports

less hypoglycemia and better weight control.3 As the use of dual therapy increases, combination products have come to market to reduce patients’ need for multiple injections. The following two combination products are now available.

Soliqua® 100/33 (glargine and lixisenatide): Soliqua® (glargine and lixisenatide) is approved by the FDA for patients who are currently on Adlyxin® (lixisenatide) alone or receiving less than 60 units/day of a glargine product. Compared to glargine alone, Soliqua® (glargine and lixisenatide) showed a greater reduction in A1C.17 Soliqua® (glargine and lixisenatide) is dosed on the insulin component. Patients who are not controlled on less than 30 units of basal insulin or on Adlyxin® (lisixenatide) should initiate Soliqua® (glargine and lixisenatide) at 15 units daily, which delivers 15 units of glargine and 5 mcg of lixisenatide.17 Patients who are not controlled on 30 to 60 units of basal insulin should initiate Soliqua® (glargine and lixisenatide) at 30 units daily.17 Soliqua® (glargine and lixisenatide) is given 1 hour prior to the first meal of the day. The most common adverse effects of Soliqua® (glargine and lixisenatide) are hypoglycemia, nausea, and headache. Soliqua® (glargine and lixisenatide) should be refrigerated before opening and can be stored at room temperature for 14 days after opening.17 Xultophy® 100/3.6 (degludec and liraglutide): Xultophy® (degludec and liraglutide) was approved by the FDA for patients who are currently inadequately controlled on less than less than 50 units/day of basal insulin. Xultophy® (degludec and liraglutide) has been shown to improve a patient’s glycemic profile as well as improve A1C.18 This medication is administered at the same time each day without regard to food.

Xultophy® (degludec and liraglutide) is dosed on the degludec component. The starting dose for Xultophy® (degludec and liraglutide) is recommended at 16 units, which delivers 16 units of degludec and 0.58 mg of liraglutide.18 The maximum daily dose is degludec 50 units/liraglutide 1.8 mg.

The liraglutide component may increase the risk of thyroid tumors and cancer.18 If a patient presents with a lump in the neck, swelling of the neck, or trouble swallowing, refer him to a healthcare provider immediately. Do not recommend Xultophy® (degludec and liraglutide) to patients who have a personal or familial history of medullary thyroid carcinoma.

Xultophy® (degludec and liraglutide) prefilled pens should be refrigerated before opening and can be stored either at room temperature or refrigerated for up to 21 days after opening.18 Conclusion The variety of diabetes injectable products available provides greater flexibility for more patient-centered therapeutic options. With the recent increase in injectable medications available for diabetes management, specific characteristics, such as formulation, concentration, and onset and duration of action, can be difficult for pharmacists and technicians to distinguish. This brief review of the newest injectable medications intends to guide pharmacy staff as they dispense and counsel patients regarding these products to improve outcomes and reduce medication errors.

|33| www.KPHANET.org

Table 2. Non-insulin injectable products4 Brand (Generic) Symlin® (pramlintide ) Byetta® (exenatide, IR)

Dosing 15–120 mcg

Frequency With each meal

5–10 mcg

Twice daily 60 min before meals Daily

Storage After Opening1 Room temp

Shelf-Life After Opening 30 days

Missed Dose Directions Resume with next regular meal

£ 77°F

30 days

Omit missed dose and resume normal schedule

Nausea, diarrhea, headache, URI, antibody formation

Refrigerator or room temp

30 days

Resume with next scheduled dose. If more than 3 days pass, reinitiate at 0.6 mg/day to avoid GI upset

GI symptoms, which usually ease in the first 3 weeks, antibody formation Nausea, vomiting, diarrhea, constipation, abdominal pain, flatulence, GERD, elevated amylase and lipase

Room temp

14 days

Administer within one hour of the next meal

Room temp

56 days

Administer ASAP within 5 days. If more than 5 days pass, omit dose and resume on next scheduled day

Common Side Effects Nausea, vomiting, anorexia, hypoglycemia, headache Nausea, vomiting, diarrhea, headache, hypoglycemia

Victoza® (liraglutide)

0.6, 1.2, 1.8 mg

Adlyxin® (lixisenatide)

10–20 mcg

Daily within 1 hr of first meal

Ozempic (semaglutide )

0.5–1 mg

Weekly

Trulicity® (dulaglutide)

0.75–1.5 mg

Weekly

Nausea, vomiting, diarrhea, abdominal pain

Room temp

14 days

Bydureon® (exenatide, ER)

2 mg

Weekly

Nausea, vomiting, diarrhea, headache, hypoglycemia

£ 77°F

4 weeks prior to mixing; inject immediately after mixing

Tanzeum® (albiglutide)

30–50 mcg

Weekly

Hypoglycemia, nausea, diarrhea, injection site reaction, URI

Room temp

4 weeks prior to mixing; 8 hours after mixing

Discontinued in July 2017

Notes2

Solution should be clear and colorless Prime pen before using

Needle comes attached to device Administer ASAP within 3 days. If more than 3 days pass, omit dose and resume on next scheduled day

After mixing, solution will be white/off -white and cloudy Needles provided Reconstitution may be difficult for patients with dexterity issues Needles provided

1

Store all products in refrigerator before opening All pen products require pen needles unless noted here URI = Upper respiratory tract infection GERD = Gastroesophageal reflux disease

CPE Quiz Online

2

www.surveymonkey.com/r/CEQuizAug18

August 2018 — Insulin and Beyond: A Review of Diabetes Injectables 1.What is the days’ supply of the following prescription?

Rx:

Toujeo 1 box (3 pens) 63 units SQ daily A. 23 days B. 21 days C. 30 days D. 35 days

B. Take half the normal dose immediately and resume the normal schedule on Sunday C. Take the full dose immediately and switch her dosing day to Tuesdays D. Take the full dose immediately and resume the normal schedule on Sunday 3. Which of the following brands contain insulin glargine? i. Levemir® ii. Soliqua® iii. Basaglar® iv. Trulicity®

A. B. C. 2. Patient SF usually takes her weekly dose of Trulicity® (dulaglutide) on Sunday because it is the only day her daughter can D. help her. SF and her daughter come to your pharmacy on Tuesday evening in a panic because they just realized they forgot her last dose. What do you tell SF? A. Skip the dose entirely and resume the normal schedule on Sunday

|34| Kentucky Pharmacists Association | July/August 2018

all of the above i, ii, and iii ii and iii iii only

4. Which of the following GLP-1 agonists is dosed once daily?

A. Trulicity® (dulaglutide) B. Victoza® (liraglutide) C. Byetta® (exenatide IR) D. Ozempic® (semaglutide) 5. What is the benefit of Tresiba® versus other long-acting insulin formulations?

A. Extended duration of action allows flexibility in the timing of daily doses B. Inclusion of a GLP-1 agonist with the insulin supports better weight control C. Faster onset allows more flexibility with timing of mealtime doses D. U-300 concentration allows for lower injection volumes 6. Which of the following brands is made in a U-200 formulation?

A. Novolin® N B. Novolog® C. Humulin® R D. Humalog® 7. Fiasp® has the same active ingredient as ___________. The onset of action of Fiasp® is ______.

A. Lantus® (glargine), 30 minutes B. Lantus® (glargine), 2.5 minutes C. Novolog® (aspart), 2.5 minutes D. Novolog® (aspart), 30 minutes 8.Which of the following patients should not be started on Bydureon® (exenatide ER)?

A. A patient who was unable to tolerate Victoza® (liraglutide) side effects B. A patient with known hepatic dysfunction C. A patient with a family history of medullary thyroid carcinoma D. A patient who has never used Byetta® (exenatide IR) 9. A patient taking the maximum dose of Xultophy® would receive: A. 50 units of insulin degludec and 1.8 mg of liraglutide B. 100 units of insulin glargine and 33 mcg of lixisenatide C. 50 units of insulin glargine and 16 mcg of lixisenatide D. 100 units of insulin degludec and 1.8 mg of liraglutide 10. Which of the following is not part of the mechanism of GLP-1 agonists?

A. Slowed gastric emptying B. Decreased post-prandial glucagon secretion C. Increased insulin secretion D. Increased glucose uptake by skeletal muscle

Safe Disposal of Controlled Substances in Effect on July 14, 2018 SB 6 which requires the pharmacy to inform patients about safe disposal of controlled substances, will take effect on July 14, 2018. The pharmacy can inform patients by posting a sign or by written or verbal communication. KPhA is selling signage (13" x 25") for $10.60 (members) and $15.90 (non-members) with shipping/taxes included.

Purchase from KPhA online: www.kphanet.org/store |35| www.KPHANET.org

This activity is a FREE service to members of the Kentucky Pharmacists Association.

The fee for non-members is $30. Mail completed forms to: KPERF, 96 C Michael Davenport Blvd., Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile.

Expiration Date: 7/25/21 Successful Completion: Score of 80% will result in 1.5 contact hours or .15 CEUs. TECHNICIANS ANSWER SHEET. August 2018 — Insulin and Beyond: A Review of Diabetes Injectables (1.5 contact hours) Universal Activity # 0143-0000-18-012-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 2. A B C D 4. A B C D

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

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

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

Information presented in the activity:

Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieved the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet.

Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party.

Signature ____________________________________________Completion Date___________________________ Personal NABP eProfile ID #_____________________________ Birthdate _______ (MM)_______(DD)

PHARMACISTS ANSWER SHEET August 2018 — Insulin and Beyond: A Review of Diabetes Injectables (1.5 contact hours) Universal Activity # 0143-0000-18-012-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________

PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D

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

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

Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieved the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet.

Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party.

Signature ____________________________________________Completion Date___________________________

Personal NABP eProfile ID #_____________________________ Birthdate _______ (MM)_______(DD)

The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation |36| Kentucky Pharmacists Association | July/August 2018

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

Campus Corner Preceptor Highlight: Kimberly Flynn Kimberly Flynn, PharmD, BCPS is a Clinical Pharmacy Specialist at St. Joseph East in Lexington, Kentucky. This summer, we caught up with Dr. Flynn to ask her about her experience as a pharmacist and preceptor.

where we practice. We just have to get the systems in place to make those responsibilities a part of the norm. I believe our roll currently is to be active, not only legislatively, but maybe even more so at our work places to make sure we continue to push for expanded clinical responsibilities and payment for those activities.

How long have you been a preceptor?

It’s often said that if we can fix the problems in Kentucky, then we can fix them nationally. What role do I’ve been practicing for nine years, and a you see pharmacists playing in addressing some of Kentucky’s public health challenges? primary preceptor for University of Kentucky (UK) students for six years.

Pharmacists can play an invaluable role in providing care to patients in hospitals and ambulatory settings. I really think the What types of rotations/courses do you precept for? key is going to be expanding our ability to prescribe for comAmbulatory Oncology at St. Joseph East mon uncomplicated ailments and work collaboratively with physicians in areas such as tobacco cessation, vaccine indicaWhat do you like most about precepting? tion and administration, chemotherapy and medication eduI learn just as much from students as they do from me! cation, etc. Taking care of these areas really frees up the phyWhat inspired you to pick your specific area of patient sicians to take care of complex health concerns such as cancer and its treatment. I’m excited about the things I’m seeing care? happen across our state and the U.S. as far as collaborative My very last rotation in residency was in an outpatient oncol- practice agreements. ogy clinic. I thought I didn’t like oncology during pharmacy Why did you choose to partner with the University of school, but this rotation changed my mind. It is such a Kentucky College of Pharmacy? unique niche for a pharmacist in that your skills really feel valuable. After my residency at Norton Healthcare, I picked Every student I have had has been very well-prepared with an up extra hours in the oncology clinic and found that I didn’t excellent foundation knowledge to start rotations. Most are really “feel” like I was working. The nurses, physicians, and very self-motivated and are a joy to teach. patients all had a great respect for “their” pharmacist. That’s when I realized that I wanted to be someone’s oncology pharmacist, too!

Unpacking the Alphabet Soup of Precepting

What would you tell someone who is thinking about doing a rotation at your location? What should they expect?

Don’t forget to register for the annual UK & Sullivan Preceptor Workshop on Saturday, August 25, 2018. This year’s workshop will take place the UK College of Pharmacy in Lexington, KY from 9:15am - 3:15pm.

I think this rotation gives students an excellent chance to explore several aspects of pharmacy that they may not get else- Selected talks include, What’s the Hyper with IPE? Nuts & where, including IV training, hazardous drug compounding, Bolts for Preceptors, Board-Authorized Protocols, and more. interaction with patients, as well as one-on-one time with speYou may register for this free event online: http://bit.ly/ cialty skilled physicians, nurses and nurse practitioners. preceptorworkshop.

How would you would explain the role of the pharmaIf you have additional questions, please contact Autumn cist in improving patient care?

Rice: autumn.rice@uky.edu.

Pharmacists are well educated and well prepared to take on additional responsibilities for our patients, physicians, and |37| www.KPHANET.org

Thank You for Your Service Please join us in thanking our Board of Director members who completed their terms for their service to KPhA and its members. We recognize you for your individual contributions to the success of KPhA. Not Pictured: Nathan Hughes, Sullivan College of Pharmacy Representative

Jaclyn Ochner, UK College of Pharmacy Representative with President Chris Palutis.

2018-2019 KPhA Chair Chris Harlow presents 2017-2018 KPhA Chair Trish Freeman with a recognition award.

Sam Willett, Matt Carrico, Chad Corum, Jesika Chilton-Chinn are presentedwith recognition awards from 2017â&#x20AC;&#x201D;2018 KPhA Chair Trish Freeman for their service to the KPhA Board of Directors.

Speaker of the House Amanda Jett receives a recognition award from 2018-2019 Chair Chris Harlow.

KPhA Secretary Brooke Hudspeth receives a recognition award from 2017-2018 KPhA Chair Trish Freeman.

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 info@kphanet.org to get on the list. |38| Kentucky Pharmacists Association | July/August 2018

Welcome to KPhA! We’re so happy to have you!

The list reflects new memberships received from May1, 2018— June 30, 2018 Jerry Barnette Jr.

Jesica Mills

Justin Sandlin

Jared Cole

Gale North

Charles Shackelford TC Trial

Jonathan Harmon

Viodalia Osman

Lindsay Villalbos

Alex Klingenbeck

Daniel Randloph

Leonard Westbay Alyssa Young

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

If you see one of these new members, please welcome them to the KPhA family!

|39| www.KPHANET.org

Campus Corner Sullivan University College of Pharmacy & Health Sciences â&#x20AC;&#x201C; Doctor of Pharmacy Class of 2021 As we concluded congratulations for our Class of 2018 Doctor of Pharmacy graduates, we immediately launched into the final preparations for our incoming P1 student pharmacists. Sullivan Universityâ&#x20AC;&#x2122;s Doctor of Pharmacy Class of 2021 began their journey to graduation with their new student orientation the last days of June. The summer quarter officially started on July 2, 2018 with 66 students in the P1 class.

The first week of class for the P1 student pharmacists was highlighted by their White Coat Ceremony on Friday, July 6, 2018 with their family and friends in attendance to share in this monumental occasion.

The P1 student pharmacists were officially welcomed into the profession of pharmacy with the reciting of the Pledge of Professionalism.

Sullivan University College of Pharmacy Class of 2018 Doctor of Pharmacy graduates.

|40| Kentucky Pharmacists Association | July/August 2018

Annual Meeting & Convention

Thank you to our Annual Meeting & Convention Exhibitors Abbvie Adapt Pharma Aetna Alkermes Amerisource Bergen Ameritas Amplicare Ananda Professional Animal Med Express APCI APSC Arbor Pharmaceutical LLC AstraZeneca BestRx Cardinal CBD Hemp Oil Compliant Pharmacy Alliance Cooperative Cover My Meds Eli Lilly & Co EPIC GM Hemp Co. GeriMed HD Smith Ideal Protein of America Integrative Therapeutics KOWA Pharmaceuticals of America KY Health Information Exchange (KHIE) McKesson Novartis Pharmacists Mutual Insurance Companies Pfizer QS/1 Samuels Products, Inc. Smith Drug Company University of Cincinnati University of Kentucky, CAPP WellCare |41| www.KPHANET.org

|42| Kentucky Pharmacists Association | July/August 2018

|43| www.KPHANET.org

Pharmacy Law Brief Legal Aspects of Clinical Practice Guidelines or Algorithms Author: Joseph L. Fink III, BSPharm, JD, DSc (Hon), FAPhA, Professor of Pharmacy Law and Policy and Kentucky Pharmacists Association Professor of Leadership, Department of Pharmacy Practice and Science, UK College of Pharmacy Question: During my time in the profession there seems to have been a major shift in the reliance of physicians and other prescribers on clinical practice guidelines or algorithms to guide or at least inform their prescribing decisions. Is my interpretation correct? Has there been some legal consideration driving this shift?

Response: For many years individual physicians and organized medicine resisted development of clinical practice guidelines or algorithms to guide patient care decision-making. With the advent of managed care this resistance was overcome, and now such schema have been developed and promoted by a wide variety of entities, including voluntary health agencies and organizations of professionals focused on a particular field or specialty.

The National Heart, Lung and Blood Institute, a subdivision of the National Institutes of Health, has defined the pronouncements this way: "Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances" [1]. They define the role of specific diagnostic and treatment modalities in the diagnosis and management of patients. The statements contain recommendations that are based on evidence from a rigorous systematic review and synthesis of the published medical literature.” [2] Insurers and managed care organizations were in the forefront of developing these statements because having them in place facilitated their use for coverage or payment decisions. Their existence also supported underwriters’ denial of coverage for experimental or investigational therapies.

There are a number of legal issues associated with development or adoption of clinical practice guidelines.

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.

Those include: (1) potential liability exposure of those who participate in developing such guidelines; (2) implications for potential liability exposure when following such recommendations; (3) implications of deviating from such guidelines on one’s potential liability exposure; and (4) responsibility for critically evaluating competing guidelines on the same topic. The role of such statements in professional liability lawsuits is potential extensive, being available for use by either the plaintiff or the defendant depending on the facts of the case. While the guidelines cannot in and of themselves establish the standard of “due care” for purposes of a professional liability claim, they can buttress or support the testimony of professional peers. In this regard the role of guidelines is somewhat parallel to regulations adopted by government agencies; they cannot be the sole basis for establishing a legal duty but they can play an important supportive role.

Clinical practice guidelines can be viewed as a readily available source of evidence-based thinking to guide clinical practice. They cannot replace the judgment of a seasoned professional but can be a valuable adjunct.

Perhaps their role could be viewed as parallel to that of a medication’s package insert when introduced at trial.

Just as the insert does not limit the prescriber’s decision about use of the pharmaceutical a clinical practice guideline also should not. Continued on pg. 47...

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Pharmacy Policy Issues Pharmacy Policy Issues: Gabapentin Schedule Change Impacts Pharmacy Practice Author: Dharti N. Patel is a third professional year PharmD student at the UK College of Pharmacy as well as a student in the MBA degree program at the UK Gatton College of Business and Economics. A native of Louisville, she completed her pre-professional education at the University of Louisville. sented by patients from other states, they must be consistent with Kentucky specific law. Many of the surrounding states like Indiana, Ohio, and Tennessee do not consider gabapentin a controlled substance. While these states are moving forward in reporting gabapentin Discussion: Effective July 1st, 2017, gabapentin was re- dispensing to their state PDMP programs, it is not officially a controlled substance and therefore the prescripclassified from a non-scheduled drug to a Schedule V tions presented by providers in these states might not drug in Kentucky through the approval of 902 KAR comply with Kentucky’s new law.6 These prescriptions 55:035.1 This is due to the medication’s potential for abuse and dependence when taken with other pharma- must considered as invalid by KY pharmacies. ceuticals.2 This new regulation has impacted communi- With a Schedule V drug, inventory and recordkeeping ty pharmacy practice in a variety of ways from accept- is also regulated differently. Gabapentin must now be ing prescriptions, handling inventory, recordkeeping, included in the controlled substance inventory that ocand ordering. curs bi-annually. Pharmacies must also store records of Issue: Kentucky has recently enacted a law changing the drug gabapentin from a non-scheduled drug to a Schedule V drug. What implications does this have pharmacy, and how does it change practices?

When accepting prescriptions in the pharmacy, either through telephone, fax, or written, gabapentin now has additional requirements in order to consider the prescription valid. Prescriptions must now have a valid prescriber issuing the prescription, one with a valid DEA registration number. In the state of Kentucky this will require nurse practitioners seeking to prescribe the agent to now have a valid DEA number, and physician assistants will no longer be able to prescribe gabapentin because they do not possess the authority to prescribe controlled substances in Kentucky.3 Additionally, prescriptions may only include up to five refills, and the prescription will expire in 6 months after the date of issuance. These prescriptions also cannot be pre-signed or post-dated. Other general prescription requirements that must be met include patient’s name and address, practitioner’s name and address, drug name, strength, quantity, dosage form, and directions.4 The data for gabapentin dispensing must also be reported and appear in KASPER reports.5

dispensing gabapentin with the other III-V controlled substance prescriptions, for at least five years.7 As far as the physical storing of gabapentin, it may still be dispersed among the rest of the non-controlled pharmacy inventory, as are other III-V controlled substances.

In determining validity of gabapentin prescriptions pre-

4. Office of the Commissioner. “For Patients – Learn About Your

To prevent and catch illegitimacy of prescriptions there are many precautions that can be taken by pharmacists to evaluate the validity of controlled prescriptions, and time should be taken to do so in order to fulfill one’s responsibilities as a pharmacist.

References: 1. “Prescription Drug Information for Patients: History.” US Food and Drug Administration. Accessed November 14, 2017. https:// www.fda.gov/downloads/AdvisoryCommittees/ CommitteesMeetingMaterials/ RiskCommunicationAdvisoryCommittee/UCM150262.pdf 2. Patient package inserts for oral contraceptives. 21 CFR § 310.501 (2012).

3. Patient package inserts for estrogens. 21 CFR § 310.515 (2012).

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Medicines” US Food and Drug Administration Home Page. Accessed Pharmacy Law Brief Continued...

November 14, 2017. https://www.fda.gov/ForPatients/ While such guidance can provide valuable assistance to ucm412663.htm 5. Center for Drug Evaluation and Research. “Drug Safety and Availability – Medication Guides. US Food and Drug Administration Home Page. Accessed November 14, 2017. https:// www.fda.gov/Drugs/DrugSafety/ucm085729.htm 6. Medication Guides for Prescription Drug Products. 21 CFR § 20 (2010).

professionals when engaged in patient care decisionmaking, their appropriate legal role should be taken into account by those developing them as well as by those using them.

References: 1. Field MJ, Lohr KN (Eds.). Clinical Practice Guidelines: Directions for a New Program, Institute of Medicine, Washington, DC: National Academy Press, 1990.

7. “A Brief Overview of Risk Evaluation &Mitigation Strategies (REMS).” US Food and Drug Administration. Accessed November 14, 2017. https://www.fda.gov/downloads/aboutfda/transparency/ 2. National Heart, Lung and Blood Institute, National Institutes of basics/ucm328784.pdf Health, Bethesda, MD. 8. “Approved Risk Evaluation &Mitigation Strategies (REMS).” US Food and Drug Administration Home Page. Accessed November 14, 2017. https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm

Submit Questions: jfink@uky.edu

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

The Campaign for Kentucky’s Pharmacy Future

SAVE THE DATE: 141st KPhA Annual Meeting and Convention June 20-23, 2019 Lexington |47| www.KPHANET.org

Annual Meeting & Convention Scenes from around the 2018 KPhA Annual Meeting & Convention

Attendees participate in the pharmacy continuing education session.

Pharmacy students discuss an answer in the Self Care Championship.

Speaker Clark Kibodeaux engages with the audiences during his session.

KPhA Director Matt Carrico and KPhA Past President Chris Clifton connect during the KPPAC reception.

Jody Jaggers addresses the students during the Self Care Championship.

Members of the Reference Committee hard at work.

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KPERF Chair Bob Oakley connects with KPhA Lobbyist Shannon Stiglitz during the Presidents Reception.

William “Pat” Mattingly along with his family during the President’s Reception.

Chair Trish Freeman passes the Chair gavel to Chris Harlow.

Check out more photos on the KPhA Facebook Page.

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2018—2019 KPhA BOARD OF DIRECTORS

HOUSE OF DELEGATES Tyler Stephens, Lexington Speaker of the House stevens.tyler@uky.edu

Chris Harlow, Louisville cpharlow@gmail.com

Chair

Chris Palutis, Lexington chris@candcrx.com

President

Don Kupper, Louisville donku.ulh@gmail.com

President-Elect

Brooke Hudspeth, Lexington brooke.hudspeth@kroger.com

Secretary

Bob Oakley, Louisville rsoakley21@gmail.com

Chair

Duane Parsons, Richmond dandlparsons@roadrunner.com

Treasurer

Clark Kebodeaux, Lexington clark.kebodeaux@uky.edu

Secretary

Joel Thornbury, Pikeville jthorn6@gmail.com

Past President Representative

Duane Parsons, Richmond dandlparsons@roadrunner.com

Treasurer

Chris Palutis, Lexington chris@candcrx.com

President, KPhA

Directors Angela Brunemann, Union Angbrunie@gmail.com

KPERF BOARD OF DIRECTORS

Kimberly Croley kscroley@yahoo.com

Matt Carrico, Louisville* matt@boonevilledrugs.com

Kevin Lamping klamping@riteaid.com

Jessika Chilton—Chinn, Beaver Dam jessikachilton@ymail.com Dharti Patel, Lexington dharti.patel2@uky.edu

Ben Mudd, Lebanon Vice Speaker of the House bpmu222@gmail.com

University of Kentucky Student Representative

Chad Corum, Manchester pharmdky21@gmail.com

Paul Easley, Louisville rpeasley@bellsouth.net Sarah Lawrence, Louisville slawrence@sullivan.edu Kelly Smith, Lexington ksmit1@email.uky.edu

Cassy Hobbs, Louisville cbeyerle01@gmail.com Stephen Drog, Louisville sdrog5833@my.sullivan.edu

Sullivan University Student Representative

Chris Killmeier, Louisville cdkillmeier@hotmail.com Jeff Mills, Louisville jeff.mills@nortonhealthcare.org Richard Slone, Hindman richardkslone@msn.com James "Blake" Wiseman, Benton blake.wiseman@gmail.com *At-Large Member to Executive Committee

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

KPhA/KPERF HEADQUARTERS 96 C Michael Davenport Blvd., Frankfort, KY 40601 502.227.2303 (Phone) 502.227.2258 (Fax) info@kphanet.org www.kphanet.org www.facebook.com/KyPharmAssoc www.twitter.com/KyPharmAssoc www.twitter.com/KPhAGrassroots

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“On Tuesday, July 30th, employees of the Kentucky Pharmaceutical Association and the Kentucky Board of Pharmacy devoted the entire day to emptying shelves, cleaning out drawers and packing up to move their offices to the lovely new Pharmacy Building on Highway 127 near Frankfort.”

- From The Kentucky Pharmacist, August 1968, Volume XXXI, Number 8

Frequently Called and Contacted Kentucky Pharmacists Association 96 C Michael Davenport Blvd.

Frankfort, KY 40601 (502) 227-2303 info@kphanet.org www.kphanet.org Kentucky Board of Pharmacy State Office Building Annex, Ste. 300 125 Holmes Street Frankfort, KY 40601 (502) 564-7910 www.pharmacy.ky.gov Pharmacy Technician Certification Board (PTCB) 2215 Constitution Avenue Washington, DC 20037-2985 (800) 363-8012 www.ptcb.org

Kentucky Society of Health-System Pharmacists P.O. Box 4961 Louisville, KY 40204 (502) 456-1851 x2 (502) 456-1821 (fax) www.kshp.org info@kshp.org Kentucky Regional Poison Center (800) 222-1222 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 SUCOP 2100 Gardiner Lane Louisville, KY 40205 (502) 413-8638 www.sullivan.edu

KPhA Staff Mark Glasper Executive Director mglasper@kphanet.org Sarah Franklin Director of Communications & Continuing Education sarah@kphanet.org Angela Gibson Director of Membership & Administrative Services agibson@kphanet.org Jody Jaggers, PharmD Director of Pharmacy Emergency Preparedness jjaggers@kphanet.org

KPhA Remembers KPhA desires to honor members who are no longer with us. Please keep KPhA informed by sending this information to info@kphanet.org.

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

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THE

Kentucky PHARMACIST 96 C Michael Davenport Blvd.

Frankfort, KY 40601

www.kphanet.org