The Kentucky Pharmacist March/April 2018 by Kentucky Pharmacists Association

Vol. 13 No. 2 March/April 2018

THE KENTUCKY

PHARMACIST Official Journal of the Kentucky Pharmacists Association

INSIDE: Board of Director Elections Annual Meeting & Convention

TABLE OF CONTENTS FEATURES Annual Meeting & Convention |4| KPhA Board of Director Candidates |5|

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

On the Cover 

Kentucky Delegation at the Capitol

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Ben Mudd Meeting with Representative James Comer

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KY delegation (Sullivan students and Cathy Hanna) with KY Rep. John Yarmuth.

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

IN EVERY ISSUE President’s Perspective |3| My KPhA Rx |10| Advocacy Matters |14| Continuing Pharmacy Education |16| Pharmacy Law Brief |34| Pharmacy Policy Issues | 36|

Managing Editor: Sarah Brandenburg 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|8| PTCB |23| EPIC |35 & 36| Cardinal |38| Pharmacists Mutual |39|

|2| Kentucky Pharmacists Association | March/April 2018

PRESIDENT’S PERSPECTIVE At the APhA annual meeting in Nashville, I was reminded how lucky we are in Kentucky to have a progressive pharmacy practice act. When other pharmacists from across the nation approached me and said “Wow, tell me more about what you are doing in Kentucky,” I felt great pride. As the profession of pharmacy continues to evolve rapidly, it is essential that all pharmacists are able to adapt to the change. In all practice areas of pharmacy, we are witnessing a shift from product to patient. While for student pharmacists this may seem an obvious trend, for many pharmacists this has only been a theory particularly in the community setting. The challenges faced today with reimbursement have proved to be a wake-up call. We must all quickly adapt to the evolution of pharmacy before it’s too late. As I have mentioned before, we have serious issues to overcome to make sure pharmacists remain as integral members of the healthcare team and receive appropriate payment for both products and services provided. KPhA will never stop advocating for you. Your patients value you as a pharmacist, there is no doubt about that. We are fighting hard to make sure payors value “As the profession of you just as much. Pharmacists are the providers, and it’s pharmacy continues to evolve clear that the healthcare system relies on essential clinical pharmacy services. This is true in both the community and rapidly, it is essential that all health-system practice settings.

pharmacists are able to adapt

While we continue to advocate for proper reimbursement to the change. “ for clinical pharmacy services, I want to encourage all of you to embrace the opportunities to practice at the top of your license. We have exciting opportunities in Kentucky, and I hope you find this as encouraging as I do. I love my profession and I feel blessed to be a pharmacist in today’s healthcare system. Today, we are setting the stage for clinical pharmacy practice in the community setting and expanding opportunities in ambulatory care. We are fortunate to have two amazing Colleges of Pharmacy in Kentucky that work with KPhA to advance our mission and embrace a pharmacy practice we can all take pride in calling our own. KPhA wants to see you offer the best patient care and hopes you find your professional fulfillment. We are also hopeful for the future generation of pharmacists. Student pharmacists are graduating every year with the goal of finding their “dream position”. As we continue the evolution of pharmacy practice, KPhA will not stop advocating for what we believe and is our vision: We are a unified pharmacy profession empowered to maximize patient and public health as fully integrated members of the healthcare team. KPhA sends email announcements weekly. If you aren’t receiving: eNews, Legislative Updates, Grassroots Alerts and other important announcements, send your email address to info@kphanet.org to get on the list. |3| www.KPHANET.org

KPhA Annual Meeting & Convention Join us for the 140th Annual KPhA Annual Meeting & Convention 

Thursday night - family-friendly reception at the Newport Aquarium...all access to see and touch the exhibits

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ACPE accredited continuing education activities

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Student's Only Session - interactive CV writing workshop

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CPR training

and more...

Support KPERF on Thursday, June 14 at the KPERF Golf Scramble Don't miss this opportunity to support the Kentucky Pharmacy Education & Research Foundation and KPhA and join friends, new and old, for an afternoon of fun and networking!

|4| Kentucky Pharmacists Association | March/April 2018

Board Elections 2018-2019 KPhA Board of Directors Candidates for Election President-Elect Don Kupper, BS Pharm. M.B.A. FACHE It would be an honor and a privilege to serve the Profession of Pharmacy and the many Members of The Kentucky Pharmacist Association as their President-elect,President and Chairperson of the Board,if you select me during the 2018 KPhA election process. My name is Don Kupper,I am a Registered Pharmacist, with a Masters in Business Administration. I graduated from The University of Kentucky College of Pharmacy in 1981,and immediately went to work with my father Ken Kupper a 1937 graduate of The Louisville College of Pharmacy and my grandfather Robert Fihe a 1924 graduate of The Louisville College of Pharmacy in their Independent Pharmacy in Shively, Kentucky. Having the opportunity to literally grow up in a Pharmacy is becoming unique in our lifetime. The foundation I was able to develop during that period in my life has assisted me in the many endeavors I have choose to do since the 1980's. Having the opportunity to serve on behalf of the Kentucky Society of Health System Pharmacist in this similar capacity I am asking for your vote which would also put me in a unique position only held by a few Pharmacist in recent times, but one that prepared me to seek this position at this time. The Pharmacy profession continues to evolve regardless of your health care setting;(Hospital, Retail, Medical Office,Nursing Home,Insurance Industry, Academics, Consulting, Specialty Compounding etc.) Having our practitioners obtaining the ability to prescribe under collaborative care agreements is a huge win for our profession and one we have a unique opportunity to cultivate and grow, and we will. Protecting our ability to grow a pharmacy business and continue to serve our communities is and will be a priority. Encouraging collaboration with Health System Pharmacists should be a goal. Certainly, we can come together and work on op-

portunities to improve the patient transitions, from home to health system to assisted living, or memory care, and then tertiary nursing care; gives us ample opportunity to work together. Missing medications, wrong doses, continues to plague this process and our patients deserve better care. We have a new home for KPhA, sort of, we have occupied the building on C Michael Davenport Blvd in Frankfort, for some time now, but there is still lots to do, like any home we can/need to make it better and secure its future. We have many seasoned leaders of pharmacy working on preserving our history and a place to showcase that history in a museum. I have outlined several ideas that are on my radar. Most important though is the continue strengthening of our KPhA, our Association is on sound footing, we have a relatively new Executive Director in Mark Glasper who is getting well acquainted with our state and our members. We have many opportunities to achieve an organization that will continue for years to come. I encourage you, to ask a friend who is not a member to join and to plan now to attend our Summer Meeting in Northern Kentucky, bring your family, lets fill the house. Joel C. Thornbury, R.Ph. I am a dedicated, informed, 3rd generation pharmacist with over 25 years of experience as a registered pharmacist in Kentucky and Virginia. I have only known giving my all to our profession. I watched it my whole life, observing my dear mother and mentor, Patricia Thornbury from the time I knew what was what. She dedicated her life supporting our profession and I plan to do the same anyway possible. Previous KPhA Volunteer Experience: Past President Past Chairman of the Board Past President-elect |5| www.KPHANET.org

from the time I knew what was what. She dedicatedher life supporting our profession and I plan to do the same anyway possible. Previous KPhA Volunteer Experience: Past President Past Chairman of the Board Past President-elect Past Board of Director Past Speaker of the House Past Vice-Speaker of the House Long time member of the Organizational Affairs Committee

positive asset to the board and to KPhA’s desire to serve and protect our state’s pharmacists. The only way to progress our profession is to be an active change agent, and I feel one of the best ways I can do this is by actively participating in my state’s pharmacy organization. I am involved in many avenues to showcase and enhance the impact of pharmacists on both the local and national levels and am extremely passionate about my profession!”

Director Matt Carrico

My name is Matt Carrico and I was born and raised in Louisville, KY. From 2006 to 2010 I attended Brooke Hudspeth pharmacy school at the University of Charleston Brooke Hudspeth is a clinical diabetes care pharma- (WV). During my last two summers I interned at cist for Kroger Pharmacy and serves as the Program Walgreens corporate offices in Chicago learning Coordinator for Kroger’s American Diabetes Asso- about the business of pharmacy. Upon graduating I ciation–recognized Diabetes Self-Management Ed- began working as a staff pharmacist for Walgreens ucation Program. She received her doctor of phar- in Louisville at Algonquin Parkway and a part time macy degree from the University of Kentucky Col- pharmacist for my father’s pharmacy (Booneville Discount Drug) in Booneville, KY. In 2012 I made lege of Pharmacy in 2007. Upon graduation, Dr. the difficult career decision to leave Walgreens and Hudspeth completed a postgraduate (PGY1) resiwork full time in the wild and wonderful world of dency with an emphasis in community care with the University of Kentucky and Kroger Pharmacy. independent pharmacy. Now, I am happily a coowner and PIC for Booneville Discount Drug. Dr. Hudspeth’s practice interests include medication therapy management and disease state manFor the last six years I have had the pleasure of agement, particularly diabetes. serving as a director on the board of KPhA. This has proved to be one of the most fulfilling experiIn addition to her clinical practice activities, Dr. ences in my career thus far. In my time on the Hudspeth is Assistant Professor at the University of board I have taken full advantage of the opportuniKentucky College of Pharmacy. She serves as a pre- ty to professionally network and make friendships ceptor for the University of Kentucky College of with pharmacists, in all fields, throughout the state. Pharmacy/Kroger Community Pharmacy Residen- I have also taken part in many aspects of furthering cy Program. She also is on the faculty of the Ameri- our profession such as: testifying before a Senate can Pharmacists Association’s certificate training committee on behalf of SB 107 in 2013, serving on program The Pharmacist and Patient-Centered Dia- the Government Affairs committee, assuming the betes Care. role of chair for the Kentucky Pharmacists Political Advocacy Council (KPPAC), serving on the Exec“I feel that I would be a valued addition to the utive Committee, serving on the KPERF advisory KPhA Board. My perspective on a number of ispanel, becoming a pharmacy district coordinator sues related to our pharmacy profession would be a for Owsley and Lee counties through the Emergen-

Secretary

cy Preparedness program, establishing a needle exchange program in Owsley and Lee counties, meeting with state legislators to discuss upcoming pharmacy bills, and becoming an active member of APhA and NCPA. I am passionate about pursuing transparency and adequate reimbursement from insurance companies as well as expanding pharmacist roles within our healthcare system. Our profession has always been one of the most trusted, yet remains underutilized in the health care system. However, we are at an exciting time where we can control our destiny and our future roles in health care. Nothing would make me more proud than to be able to serve our profession again and help pave the way for all pharmacists. I would appreciate your vote, thanks.

the 2009 Preceptor of the Year for the University of Kentucky College of Pharmacy. Jessika currently serves as the KPhA Past President Liaison. Despite her commitment to our profession, Jessika's truest passions are her children Lennon Grace (16) and Preston Scott (11). Chad Corum My name is Chad Corum and I am seeking reelection to the KPhA board of directors. I graduated from the University of KY College of Pharmacy in 2012 and have been involved with KPhA ever since in various different capacities.

As a pharmacist I have worked in a variety of settings. I owned an independent pharmacy for four years, I have worked for Rite Aid/Walgreens, and most recently I accepted the position of director of Jessika Chinn pharmacy for an LTAC hospital known as ContinJessika Chilton Chinn, PharmD is a clinical phar- ue Care Hospital in Corbin, KY. I feel that I have macist with Midtown Pharmacy Express in Beaver a wide range of experience which will only help Dam, Kentucky. She earned her doctor of pharma- me to better represent the different interests of cy degree from the University of Kentucky in 1999 KPhA members from all pharmacy practice setand has over eighteen years of experience as a tings across the commonwealth. pharmacist in both community and health system I have served one term for the KPhA board of disettings. In 2014, the Owensboro Health Outparectors thus far and during my first term I have tient Pharmacy of Owensboro Health Regional served on various committees, once serving as a Hospital opened under Jessika's leadership. As the co-chair, traveled to Frankfort to support KPhA Clinical Pharmacy Manager of this transitions of legislative priorities, attended the KPhA legislative care pharmacy,Jessika and her team began pharconferences, the KPhA annual meetings each year, macist-led interdisciplinary discharge rounds, dis- and also participated in KPhA strategic planning. charge medication reconciliation, and a concierge pharmacy service for discharge patients as well as I believe pharmacy is perfectly poised to take adan ambulatory care rotation for the PGY1 residen- vantage of some tremendous opportunities in the upcoming years. As someone who is truly passioncy program. ate about the profession of pharmacy, as a whole, I Jessika's passion for our profession was kindled as hope to continue to have the opportunity to serve a student though her work in leadership roles in the KPhA membership by being elected to the the American Pharmacists Association-Academy board of directors. of Students of Pharmacy. As APhA-ASP presiBenjamin Mudd dent, Jessika fought for voting rights for students on the APhA Board of Trustees and initiated Oper- I am interested in serving on our KPhA Board of ation Immunization. She is a past president of the Directors for a number of reasons. Like many of Kentucky Pharmacists Association and was named us, I joined KPhA after graduating pharmacy

school with the intention of staying involved and paying my dues, both financially and in service, to the profession. I joined the Membership Engagement Committee soon thereafter and attempted to stay connected with the organization. In October 2016, I joined the staff at Medica Pharmacy and Wellness Center and expressed my intentions to become more involved with KPhA. My interest in KPhA aligns with Medica's mission to continue to improve the practice of pharmacy through advocacy. I believe that through its numerous initiatives and outstanding leadership, our KPhA allows Kentucky pharmacists to practice at the forefront of our profession. I want to be a part of that continued growth and feel like I can serve as an integral component to our organization. I have served 3 years on the Marion County Chamber of Commerce Board of Directors and served 2 years as the treasurer of that board. During my term on that board I helped organize, improve, and reunite our business community and the Chamber's relationship within Lebanon and Marion County. Likewise, I look forward to the opportunity to help sustain and improve an already astounding KPhA organization. I have a great appreciation for the work our peers have put forth in the past to move our profession forward. I will continue to encourage all of us to become more involved and show support of our KPhA and appreciate your consideration of my nomination on the board. James Wiseman My interest in running for a position on the Board of Directors of KPhA is very much based on nothing other than patient care. As a pharmacist our number one responsibility daily is the care we provide to our patients. The only way to better that care is to come together as one voice and advocate for the things we believe will better our ability to administer that care. Personally

I believe advocating for full provider status would be of utmost importance. As pharmacist we are underestimated in our ability to provide care verses other healthcare providers. This would be one of my top priorities if elected to this board. I believe this organization has great impact on the decisions that are made at the state and federal levels. With healthcare being such a major issue and cost being an all time high, the time is now to get involved and make our voice heard. There are multitude of other issues that need to be addressed in the pharmacy world. The current Opioid Crisis, PBM Transparency, DIR Fees, and ultimately Prescription Drug Costs are just a few. All of these need to be addressed and legislation needs to be brought forth to help combat these issues. As an organization and as one voice this can happen. It would be an honor to serve on this board and fight for pharmacist's not only in this state but across this nation. If elected to this position I can assure you I will put the interest of our patients and other pharmacist first and foremost. Thank you for your consideration.

Election Details The election will be held via electronically via the KPhA website. You must be logged in to submit your vote. Paper ballots will be mailed to the members who do not have an email address on file. The election will be open until May 4th.

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 work on YOUR behalf.

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

MY KPhA Rx KPhA Advocates for You! By Mark Glasper KPhA Executive Director/CEO The 2018 Kentucky legislative session has come to a close and pharmacy has many successes to claim. KPhA worked diligently during session with lawmakers, the Cabinet for Health and Family Services, Department for Medicaid Services, and our pharmacy partners to produce effective legislation to benefit all Kentucky pharmacists. Special thanks go to the KPhA Government Affairs Committee, chaired by Richard Slone, and our lobbyist, Shannon Stiglitz, for their tireless efforts to affect positive change for pharmacy during the 2018 legislative session. 2018 Legislative Session Highlights The following pharmacy-related bills are set to become law: SB 5 will create greater transparency and Medicaid oversight along with more appropriate dispensing fees for Kentucky pharmacists. These changes will help ease the burden of the chronic underreimbursement issues that Kentucky pharmacies are facing. An important component of SB 5 will specifically require PBMs to report fees assessed on pharmacies they own as well as those assessed on independent pharmacies. SB 5 will remove PBM authority to set reimbursement rates and give that power to the state Medicaid program. In addition, SB 5 will require the state Medicaid program to approve certain contracts, and approve new fees that MCOs or PBMs try to impose on a pharmacist. We also thank SB 5 sponsor Senator Max Wise (RCampbellsville) for his unwavering support of com-

munity pharmacy and for his efforts in championing SB 5. HB 200, Budget bill, contains increase in Medicaid pharmacy dispensing fee, including $12M in 20182019 with an amount to be determined for 20192020 from increased pharmacy dispensing fees. HB 246, sponsored by Pharmacist Representative Danny Bentley (R-Russell), builds on a regulation passed by the Kentucky Board of Pharmacy that allows pharmacists, under a prescriber approved protocol, the ability to treat patients for opioid abuse disorder. The pilot project is funded through a 2017 KORE grant that the Commonwealth received. This project will demonstrate that pharmacists are highly-trained medical professionals who can be an excellent resource in addressing some of Kentuckyâ&#x20AC;&#x2122;s greatest health care needs. SB 6 will require a pharmacist to inform persons verbally, in writing or by posted signage of methods for disposal of unused, unwanted, or expired controlled substances anytime a controlled substance is dispensed. The bill will permit a pharmacist to make available for purchase or distribute at no charge products for disposal of unused, unwanted, or expired controlled substances. HB 463 will prohibit an insurer, pharmacy benefit manager, or other administrator from requiring payment for prescription drugs in excess of certain amounts and prohibit the same from imposing a

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penalty on a pharmacist or pharmacy for complying as required. HB 463 will allow a pharmacist to discuss information relating to cost sharing or selling a more affordable alternative to the insured.

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Thanks to all the pharmacists across the Commonwealth who called, e-mailed or wrote letters to their legislators. We especially appreciate those pharmacists who traveled to Frankfort to testify or attend committee meetings. It is vital to our legislative success that we have an active and engaged audience your voice matters!

We also pressed our legislators to allow pharmacies to participate in Medicare preferred pharmacy networks in medically underserved areas, fix lingering problems with compounding regulations, and offer recommendations for stemming the opioid epidemic.

Kentucky Shines at NCPA Fly-in I joined hundreds of community pharmacists, including about 15 from Kentucky, April 11-12, 2018 in our nation's capital during the National Community Pharmacists Association's 2018 Congressional Pharmacy Summit. We discussed federal legislation that focused on prohibiting retroactive DIR fees, codifying Medicare transparency provisions regarding MAC pricing, and recognizing pharmacists as providers under the Medicare Part B program.

bursement in federal health programs. Pharmacist Provider Status Bills (S. 109/H.R. 592): Would recognize pharmacists as providers under the Medicare Part B program.

Register TODAY for KPhA Annual Meeting & Convention Registration is now open for the KPhA Annual Meeting & Convention June 14-17, 2018 at the Cincinnati Marriott at RiverCenter, Covington, KY. You won’t want to miss the outstanding CE or the great networking opportunities we have planned for you.

We will have a grand opening of the KPhA Hall of Exhibits on Friday, June 15, 2018, from 5:30-7:30 p.m. with a cash bar and hor d’oeuvres. We also have a dedicated exhibitor session on Saturday, Our Kentucky delegation met with Kentucky SenaJune 16, 2018, from 10-11:30 a.m. Please plan to tor Rand Paul and Kentucky Representatives John spend time with our exhibitors to discover the latest Yarmuth, Tomas Massie, Brett Guthrie and James and greatest in pharmacy. Comer while we also met with the staffs of KenFinally, the KPERF Golf Scramble will be held tucky Senator Mitch McConnell and Kentucky June 14 at the Devou Golf Course in Covington Representatives Andy Barr and Harold Rogers. followed by a family friendly opening night RecepWe urged our Kentucky legislators to support three tion at the Newport Aquarium to kick off the meetpriority bills: ing.  The Improving Transparency and Accuracy in Don’t forget, register TODAY for early-bird rates Medicare Part D Drug Spending Act (S. and SAVE! 413/H.R. 1038): Would end retroactive pharmacy DIR fees that push Medicare patients more quickly into the Part D coverage "donut hole." 

The Prescription Drug Price Transparency Act (H.R. 1316): Would create more transparency for generic prescription drug pricing and reim|11| www.KPHANET.org

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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.

|13| www.KPHANET.org

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. |14| Kentucky Pharmacists Association | March/April 2018

Sam Willett, RPh, Capital Campaign Donor

â&#x20AC;&#x153;

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.â&#x20AC;?

Leave a legacy by making a tax-deductible donation online at www.kypharmacyfuture.net |15| www.KPHANET.org

March CPE Article 2017 Blood Pressure Guidelines Update By: Travis Jent, PharmD Candidate, Hayley Ziegler, PharmD Candidate and Stacy Miller, PharmD, MBA, BCACP The authors declare that there are no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-0000-18-003-H01-P & T 1.5 Contact Hours (0.15 CEU) Expires 04/27/21

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

Pharmacist Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: 1. Define categories of blood pressure in adults including elevated, stage 1 and stage 2 2. State non-pharmacological treatment options for hypertension 3. State pharmacological treatment options for hypertension 4. Analyze a case scenario and select an appropriate treatment Technician Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: 1. Recognize a hypertensive patient based on blood pressure readings 2. List non-pharmacological treatment options for hypertension 3. List the primary classes of medications used in the treatment of hypertension Hypertension affects nearly one-third of the United States adult population.1 Each year, Americans spend around $48.6 billion in treatment of this condition.2 This number includes the cost of medications and healthcare services. The treatment guidelines published by the Joint National Committee (JNC) have been used in the past to help healthcare providers determine the most appropriate therapy for their patients. Data from the 2011-2012 National Health and Nutrition Examination Survey (NHANES) shows that almost 1 in 4 patients remain untreated despite having been diagnosed with high blood pressure.3 Even more unsettling is the fact that slightly over half of those treated remain uncontrolled.3 New guidelines have recently been published in the Journal of the American College of Cardiology (JACC) to update blood pressure classifications and recommendations. These guidelines are a cooperative effort of the American Heart Association (AHA), American College of Cardiology (ACC), and nine other professional societies. When using the newest definition of hypertension, found in the AHA guidelines, 46% of Americans are considered to have high blood pressure.4 This percentage is significantly higher than the 32% classified when using the hypertension definition from the JNC-7.4 Although JNC-8 was the most recent guideline prior to this update, it lacked staging of hypertension.5 Therefore, the updated guidelines are comparable to JNC-7 with the reintroduc-

tion of staging. Pharmacists and pharmacy technicians can be very valuable to patients by helping to prevent and manage this disease by understanding the classifications and treatment options. The guidelines emphasize the importance of pharmacists in the management of this disease state. Data from several randomized controlled trials and meta-analysis show that a pharmacist being part of a team-based approach has been shown to be more effective in decreasing blood pressure than a team without a pharmacist.4

Why Change the Guidelines? One of the biggest changes in the guidelines is the increase in number of patients who meet the inclusion criteria for having elevated blood pressure. This was rationalized by the increase in risk of cardiovascular disease (CVD) and stroke seen with any of these updated classifications.4 In an article by Hughes, William B. White, MD, was quoted saying â&#x20AC;&#x153;new hypertension guidelines will greatly improve the precision for diagnosing hypertension and will reduce the incidence of stroke, myocardial infarction, congestive heart failure, and death due to cardiovascular causes.â&#x20AC;?6 The hope is that nonpharmacological interventions and lifestyle modifications will be increased in patients that were previously not classified with hypertension and decrease adverse risks. There are other additions to the guidelines that are be-

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Table 1 - Diagnosis Criteria Blood Pressure Category

Systolic Blood Pressure Reading

Normal

<120 mmHg

AND

Diastolic Blood Pressure Reading <80 mmHg

Elevated

120-129 mmHg

AND

<80 mmHg

Stage 1 Hypertension

130-139 mmHg

80-89 mmHg

Stage 2 Hypertension

³140 mmHg

³90 mmHg

yond the scope of this article, but include the addition of new information such as home blood pressure monitoring and masked hypertension. Diagnosis Criteria Significant changes were made regarding diagnosis. These guidelines established the following categories in which to classify patients: normal, elevated, and stage 1 or stage 2 hypertension. These groupings are determined by the patients’ average blood pressure readings in an office setting.4 An average blood pressure is determined by averaging 2-3 blood pressure readings on 2-3 separate office visits.4 The criteria for each category of hypertension can be found in Table 1. When staging a patient, if their SBP and DBP meet different categories, the highest category should be utilized. For example, if a patient’s blood pressure is 132/79mmHg, they would be classified as Stage 1 Hypertension. Normal and Elevated Treatment and Follow-Up The type of treatment and duration of follow-up is dependent on how a patient is classified. Patients in the normal category should be evaluated yearly and are encouraged to maintain a healthy lifestyle in order to prevent the development of hypertension.4 Patients with elevated blood pressure should be reevaluated every 3-6 months.4 These patients should also be encouraged to make changes to promote a healthy lifestyle.4 (See Figure 1).

style should be recommended.4 These patients also need to be reassessed in 3-6 months.4 If the patient’s risk is greater than 10% or they have a diagnosis of CVD, diabetes, or chronic kidney disease, then lifestyle changes and one blood pressure lowering medication should be initiated.4 The patient should be re-assessed in one month to determine the efficacy of the treatment plan.4 (see Figure 1). Upon follow-up, if the blood pressure goals are achieved, the patient must be evaluated again in 3-6 months.4 If goals are not met, the provider may change the initial medication or increase the dose.4 After changes are made, monthly checks should be made until blood pressure control is acquired.4 Stage 2 Hypertension Treatment and Follow-up If a patient is determined to have stage 2 hypertension and has an average blood pressure greater than 20/10 mmHg above their target blood pressure, then promotion of healthy lifestyle and initiation of two blood pressure lowering medications should occur.4 These two medications should belong to two different classes (see Figure 1 and Table 2).4 The effectiveness of the medications should be measured in one month.4 The follow-up procedure performed in patients with stage 1 hypertension should also be utilized in those with stage 2 hypertension.4 Hypertensive Crises

There are two types of hypertensive crises that all healthcare providers should be aware of: hypertensive emergency and hypertensive urgency. Hypertensive emergency is defined as critical elevation in blood pressure, SBP >180 mmHg and/or Stage 1 Hypertension Treatment and Follow-up diastolic blood pressure (DBP) >120 mmHg, and new or The greatest change from JNC-7 to the current guidelines is worsening target organ damage.4 The rate of blood pressure seen when determining treatment and follow-up between rising could be more important than the actual blood pressure stage 1 and stage 2 hypertension. If a patient is determined to level, depending on the patient. In patients with chronic hyhave stage 1 hypertension, their 10-year risk for heart disease pertension, higher blood pressure levels can be tolerated at a and stroke must then be calculated. This is known as the 10greater extent than patients with previously normal blood year atherosclerotic cardiovascular disease (ASCVD) risk. 5 pressure levels.4 Immediate reduction of blood pressure is The ASCVD risk is determined using patient factors such as necessary in these patients to prevent further organ damage.4 age, sex, race, lipid levels, systolic blood pressure (SBP), histo- Oral hypertensive therapy is not recommended in these situary of diabetes or smoking and if the patient is currently taking tions.4 a statin, aspirin or anti-hypertensive medication.7 If the patient’s risk is less than 10%, changes to promote a healthy life|17| www.KPHANET.org

Figure 1 - BP thresholds and recommendations for treatment and follow-up

Hypertensive urgency is a critical blood pressure increase seen in otherwise stable patients without target organ damage or dysfunction.4 It is often found that these patients are noncompliant with antihypertensive therapy.4 These patients are treated by restarting or intensifying their oral antihypertensive therapy.4

even for those at risk of developing hypertension.4 These interventions include the following: 

Weight Loss: for those who are overweight or obese.4



Heart-Healthy Diet: such as the DASH (Dietary Approaches to Stop Hypertension) diet, which encourages healthy foods such as fruits, vegetables, whole grains and healthy fats.4



Sodium Reduction: optimal goal is <1500mg/day, especially in those susceptible to changes in blood pressure due to sodium, such as the elderly and African American populations.4



Potassium Supplementation: 3500-5000mg/day. In many studies, potassium intake has been shown to be inversely related to blood pressure, as a higher level of potassium reduces sodium’s effect on blood pressure.4

Management of Hypertension Although some of the classifications and terminology of hypertension have changed in the most recent 2017 guidelines, the treatment in general remains relatively similar to the previous guidelines. The primary basis of treatment for high blood pressure continues to be pharmacological agents with lifestyle modifications, as well.4 Nonpharmacological Interventions The guidelines still recommend nonpharmacological interventions for all patients in any classification of hypertension, and |18| Kentucky Pharmacists Association | March/April 2018



Increased Physical Activity: such as 90-150 minutes of dynamic aerobic exercise per week. The most well demonstrated reductions were seen with dynamic aerobic exercise4, but dynamic resistance training and static isometric exercise have been proven to lower blood pressure as well.4



Alcohol Limitation: no more than 2 drinks per day for men and no more than 1 drink per day for women.4

have increased risk factors for cardiovascular disease and help implement lifestyle modifications to prevent future events. Treatment and follow-up are dependent on many patientspecific factors. It is the responsibility of the pharmacist and pharmacy technicians to be aware of the treatment options available to these patients so that optimal outcomes can be ensured. References

Pharmacological Treatment

1. Ong KL, Tso AW, Lam KS, Cheung BM. Gender difference in blood pressure control and cardiovascular risk factors in Americans with diagnosed Antihypertensive pharmacotherapy has been shown in various hypertension. Hypertension 51(4): 1142–8. 2008.

clinical trials to effectively lower blood pressure, as well as reduce the risk of CVD, cerebrovascular events, and death.4 There are various classes of these agents available. Certain agents are preferred due to proven reduction of clinical events.4 These agents include thiazide diuretics, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), and calcium channel blockers (CCB). 4 More details about these agents can be seen in Table 2 (pg. 16).

2. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2013 on CDC WONDER Online Database, released 2015. Data are from the Multiple Cause of Death Files, 1999-2013, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program: http://wonder.cdc.gov/ucd-icd10.html. Accessed on December 5, 2017.

3. Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension Among Adults in the United States: National Health and Nutrition Examination Survey, 2011– Many factors should be taken into consideration when choos- 2012. NCHS data brief, no 133. Hyattsville, MD: National Center for Health Statistics. 2013. Available from: ing initial antihypertensive pharmacotherapy. These include age, race, concurrent medications, drug adherence, drug inter- https://www.cdc.gov/nchs/data/databriefs/db133.pdf.

actions, the overall treatment regimen, out-of-pocket costs, and comorbidities.4 If a patient’s therapy must be escalated, knowledge of each agent’s pharmacological mechanism of action is vital.4

4. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC Jr, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr, Williamson JD, Wright JT Jr. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Goals of Therapy guideline for the prevention, detection, evaluation, and management of high The primary goal of therapy is reduction of blood pressure to blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. <130/80 mmHg, for patients <65 years of age.4 The goal of therapy in patients ³65 years who are ambulatory and living in Hypertension. 2017.

the community is reduction of SBP to <130 mmHg.4 Only 5. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for SBP is utilized to diagnose hypertension in the elderly because the management of high blood pressure in adults: a report from the panel DBP gradually decreases throughout a patient’s life.4 members appointed to the eight joint national committee (JNC 8). The JourThese are lower goals than were previously desired in the JNC-8 guidelines, <140/90 mmHg in those younger than 60 years of age and <150/90 mmHg in those 60 years of age and older.5 There were many trials considered when determining this more aggressive goal, such as the Systolic Blood Pressure Intervention Trial (SPRINT).4 This trial was stopped early due to substantial reduction of the primary outcome, a CVD composite, and in all-cause mortality rate.4 Reduction of blood pressure is not the sole reason to initiate therapy. A secondary goal of treatment is prevention or reduction of development of CVD as well as secondary events that result from CVD. Treatment with the previously mentioned methods and blood pressure goals, in addition to lifestyle changes such as smoking cessation, help to control some of the modifiable risk factors for cardiovascular disease.

nal of the American Medical Association Network. https://jamanetwork.com/journals/jama/fullarticle/1791497. Published 2014 Feb 5; accessed 2017 Dec 14. 6. Hughes, S. New US hypertension guidelines: experts respond. Medscape Pharmacists. https://www.medscape.com/viewarticle/889644?nlid=119496_745&src= WNL_mdplsfeat_171212_mscpedit_phar&uac=129425AN&spon=30&imp ID=1507020&faf=1#vp_2. Published 2017 Dec 5; accessed 2017 Dec 13. 7. Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB Sr, Gibbons R, Greenland P, Lackland DT, Levy D, O’Donnell CJ, Robinson JG, Schwartz JS, Shero ST, Smith SC Jr, Sorlie P, Stone NJ, Wilson PWF. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(suppl 2):S49-S73.

Conclusion Hypertension is a disease state that affects many patients throughout the United States. With the newly updated guidelines, more patients will be considered to have elevated blood pressure or hypertension. It is important to note that not all patients under the new classifications will require medication. The inclusion of more patients will help to identify those who |19| www.KPHANET.org

Table 2 - Primary Antihypertensive Agents Class

Drug Chlorthalidone

Thiazide or Thiazide-type Diuretics

Hydrochlorothiazide Indapamide Metolazone

Clinical Pearls Chlorthalidone is preferred due to longer half-life and proven reduction of CVD4 Use with caution in patients with history of acute gout unless on uric acid lowering medication4

Benazepril Captopril Enalapril Fosinopril ACE Inhibitors

Lisinopril Moexipril Perindopril Quinapril Ramipril

Not to be used in combination with ARBs or direct renin inhibitors4 Do not use if there is patient history of angioedema with ACE inhibitors4 Avoid use in pregnancy4 Associated with increased risk of hyperkalemia, especially in patients with CKD or patients on K+ supplements or K+-sparing medications4

Trandolapril Azilsartan Candesartan Eprosartan Irbesartan ARBs Losartan Olmesartan Telmisartan Valsartan

Not to be used in combination with ACE inhibitors or direct renin inhibitors4 Associated with increased risk of hyperkalemia in CKD or patients on K+ supplements or K+-sparing medications4 Do not use if there is patient history of angioedema with ARBs. Can be used in patients with history of angioedema with ACE inhibitors beginning 6 weeks after ACE inhibitor is discontinued.4 Avoid use in pregnancy4

Amlodipine Felodipine CCBs (Dihydropyridines)

Isradipine Nicardipine SR

Avoid use in patients with HFrEF; Amlodipine or felodipine may be used4

Nifedipine LA Nisoldipine

CCBs (Nondihydropyridines)

Diltiazem SR

Do not use in patients with HFrEF4 Avoid use with beta blockers due to increased risk of bradycardia and heart block4

*ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; CKD, chronic kidney disease; CVD, cardiovascular disease; HRrEF, heart failure with reduced ejection fraction; K+, potassium; LA, long-acting; and SR, sustained release. |20| Kentucky Pharmacists Association | March/April 2018

CPE Quiz Online www.surveymonkey.com/r/CEQuizMar18

March 2018 â&#x20AC;&#x201D; 2017 Blood Pressure Guidelines Update 1. Using the definition of hypertension in the newest guidelines, what percent of Americans will be considered to have high blood pressure? A 22% B. 34% C. 40% D. 46%

6. When initiating a patient on blood pressure medication, when is the recommended time to follow up with the physician again to reassess blood pressure? A. 1 month B. 2 months C. 3 months D. 6 months

2. How many readings must be taken to diagnose high blood pressure? A. 1, if taken at an office visit B. 2-3, if taken on separate office visits C. 4-5, if taken on separate office visits D. 6-7, if taken on separate office visits

7. A patient presents to the hospital with a blood pressure of 190/125 and evidence of organ damage from this increased blood pressure. This would be classified as a hypertensive emergency. A. True B. False

3. HZ has an average blood pressure of 140/79 taken on several different office visits. What classification of hypertension does she have? A. Normal B. Elevated C. Stage 1 Hypertension D. Stage 2 Hypertension

8. Which of the following are nonpharmacological interventions that can be taken to lower blood pressure? A. Reduce sodium intake to <1500mg/day B. Incorporate a heart healthy diet such as the DASH diet C. 150 minutes of aerobic exercise per week D. All of the above

4. TJ is a 31-year-old male diagnosed with stage 2 hypertension but has no other health conditions. His average blood pressure from several different office visits is 155/95. His physician wants to initiate blood pressure lowering therapy in addition to nonpharmacological interventions. Which of the following would be most appropriate? A. Lisinopril B. Hydrochlorothiazide C. Losartan D. A and B both

9. What is the primary blood pressure goal of therapy in patients less than 65 years of age? A. <130/80 B. <135/85 C. <140/90 D. <145/95

10. If a patient is classified as having Stage 1 hypertension with an ASCVD estimated 10-year risk of 8%, it is appropriate to initially recommend nonpharmacological therapy only. A. True 5. Lisinopril would be an appropriate therapy for a pregnant B. False patient? A. True B. False |21| 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: 04/27/2021 Successful Completion: Score of 80% will result in 1.5 contact hour or .15 CEUs. TECHNICIANS ANSWER SHEET March 2018 — 2017 Blood Pressure Guidelines Update (1.5 contact hours) Universal Activity # 0143-0000-18-003-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B 7. A B 9. A B C D 2. A B C D 4. A B C D 6. A B C D 8. A B C D 10. A B 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 March 2018 — 2017 Blood Pressure Guidelines Update (1.5 contact hours) Universal Activity # 0143-0000-18-003-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 2. A B C D 4. A B C D 6. A B C D

7. A B 8. A B C D

9. A B C D 10. A B

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 Council for Pharmacy |22| Kentucky Pharmacists Association | March/April 2018

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

Have an idea for a continuing education article? WRITE IT! Continuing Education Article Guidelines The following broad guidelines should guide an author to  completing a continuing education article for publication in The Kentucky Pharmacist.  



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



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



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



Include 3 to 5 objectives using SMART and measurable verbs.

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

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Include a quiz over the material. Usually between 10 to 12 multiple choice questions. Articles are reviewed for commercial bias, etc. by at least one (normally two) pharmacist reviewers. When submitting the article, you also will be asked to fill out a financial disclosure statement to identify any financial considerations connected to your article. Articles should address topics designed to narrow gaps between actual practice and ideal practice in pharmacy. Please see the KPhA website (www.kphanet.org) under the Education link to see previously published articles. Articles must be submitted electronically to the KPhA director of communications and continuing education (info@kphanet.org) by the first of the month preceding publication.

|23| www.KPHANET.org

April CPE Article Updates in COPD Treatment Guidelines and Medications By: Emily O’Reilly, PharmD; Julie N Burris, PharmD; Sullivan College of Pharmacy The authors declare that there are no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-0000-18-004-H01-P & T 1.5 Contact Hour (0.15 CEU) Expires 4/27/2021

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

Goal: The goal of this article is to familiarize pharmacists and pharmacy technicians with the most recent chronic obstructive pulmonary disorder (COPD) guidelines, specifically the changes from the 3rd major revision in 2011 to the 4th major revision in 2017. This article will also review newly approved medications for COPD management. Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: 1. Explain how to assess severity of disease based on airflow limitation, symptoms and exacerbation history; (pharmacist and pharmacy technician) 2. Identify an appropriate treatment plan utilizing group ABCD pharmacotherapy algorithm; (pharmacist) and, 3. Recognize new COPD medications approved in 2017 and the recommended dosage, contraindications, precautions/ warnings and key counseling points (pharmacist and pharmacy technician).

Introduction Chronic obstructive pulmonary disease (COPD) is defined as a preventable disease of airflow limitation due to noxious substances damaging the airway and/or alveoli; the number one risk factor for such damage is smoking.1 COPD is the third leading cause of death in the United States, with an estimated 16 million Americans diagnosed. The cost of patientcare spending related to COPD is anticipated to increase in patient-care spending from $32 billion in 2010 to $49 billion in 2020.2 According to the 2015 Behavioral Risk Factor Surveillance System (BRFSS), the age-adjusted prevalence of COPD among adults ≥ 18 years old ranged from 3.8% to 12% among the 50 states, with Kentucky having the second highest prevalence at 11.2%.3 In response to the burden of this chronic disease, the National Heart, Lung and Blood Institute (NHLBI) partnered with the Centers for Disease Control (CDC) to create a “COPD National Action Plan.” Released in May 2017, this action plan identifies unified goals and actionable items for all stakeholders, including pharmacists. 2 One COPD National Action Plan Goal is to “improve the diagnosis, prevention, treatment, and management of COPD by improving the quality of care delivered across the health care continuum.”2 Pharmacists have the opportunity to actively help manage COPD by ensuring optimized pharmacotherapy for their patients. Pharmacy technicians are an integral part of this optimization as well, as they can identify patients that may benefit from pharmacist-led education regarding the medications being dispensed. In order to achieve this goal, it is important to be aware of the most up-to-date

COPD treatment guidelines and medications gaining FDA approval. What is new in the GOLD guidelines? The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recently released the Global Strategy for Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease 2018 Report that contains new research from January 2016 to July 2017; this is a minor revision to the 2017 report.4 The GOLD 2017 report was the 4th major revision to these guidelines and contained significant changes that impact pharmacotherapy decision-making when compared to the 3rd major revision released in 2011. Two of the most notable changes in the 2017 GOLD report for pharmacists and pharmacy technicians to be aware of include: (1) the revision of the ABCD tool used when assessing severity of disease and (2) the addition of a pharmacologic treatment algorithm. Assessing Severity of Disease A COPD assessment aims to identify level of airflow limitation, impact of the disease symptoms on a patient’s quality of life and risk for future exacerbations. While diagnosing COPD is outside of the scope of a pharmacist, it is imperative to understand the factors used to assess the severity of the disease(as outlined below) since this drives pharmacologic decision-making. Airflow Limitation Following the administration of one dose of a short-acting

|24| Kentucky Pharmacists Association | March/April 2018

bronchodilator, spirometry testing is utilized to measure airflow into and out of the lungs for patients with COPD. The patient is assigned a GOLD category 1-4, ranging from mild to very severe, based on the patient’s post-bronchodilator forced expiratory volume in one second (FEV1), or the amount of air exhaled in one second (see Table 1).1, 4

Exacerbation Risk A COPD exacerbation is classified by an acute worsening of symptoms that requires escalation of therapy for management. The strongest predictor of risk for recurrent exacerbations is a personal history of exacerbations, especially when an exacerbation led to a hospital admission for management. 1, 4

Table 1. Classification of airflow limitation in patients with COPD

Combined COPD Assessment and the Refined ABCD Assessment Tool In the 2011 GOLD report, all three of the individual assessCategory Severity Post-bronchodilator FEV1 ment components were utilized within the ABCD tool to cateGOLD 1 Mild FEV1 ≥ 80% predicted gorize a patient’s severity of disease, with “A” being the mildest and “D” being the most severe (see Figure 1a). In the 2017 GOLD 2 Moderate 50% ≤ FEV1 <80% predicted GOLD report, the categories GOLD 1 – GOLD 4, representGOLD 3 Severe 30% ≤ FEV1 <50% predicted ing the patient’s severity of airflow limitation, were removed from the ABCD assessment tool. Per this update, all patients GOLD 4 Very Severe FEV1 <30% predicted will receive a GOLD number indicating severity of airflow and a group letter indicating a patient’s symptom severity and Symptoms exacerbation risk (see Figure 1b). This change was prompted Two common validated tools can be utilized in practice to by the following shortcomings of the 2011 ABCD assessment assess patient’s symptoms. One such tool is the Modified Brit- tool: (1) it did not perform better than utilizing GOLD grades ish Medical Research Council (mMRC) questionnaire, which alone and (2) category “D” could be determined by either assesses grade of dyspnea to help predict mortality risk. A GOLD grade or exacerbation risk, which was deemed confusmMRC score ≥ 2 distinguishes between patients that are ing. 1, 4 “less” and “more” breathless. Another tool employed is the COPD Assessment Test (CAT), a more comprehensive tool Pharmacotherapy Algorithm utilizing a likert scale to assess impact of COPD beyond dysp- Corresponding to the revised ABCD assessment tool, another nea with the following categories: cough, phlegm, chest tight- major change first seen in the 2017 GOLD report was a pharness, ability to walk up one flight of stairs, ability to complete macotherapy algorithm that contains preferred escalation and activities at home, confidence leaving the house, quality of de-escalation pathways. This new proposal allows for a more sleep and energy level. A CAT score ≥ 10 indicates more fre- patient-centered approach when developing a care plan. One quent, burdensome symptoms.1, 4 limitation to this strategy is insufficient evidence supporting the recommendations for groups C and D. 1, 4 The algorithm refers to preferred drug classes; refer to Table 2 for a list of the Table 2. Maintenance medications for COPD by drug class. medications available within each class. Drug Class

Drugs

SABA

Albuterol (ProAir® HFA, ProAir RespiClick, Proventil® HFA, Ventolin ® HFA), levalbuterol (Xopenex® HFA, Xopenex® Concentrate) Ipratropium bromide (Atrovent®) Abuterol/ipratropium (Combivent® Respimat®, DuoNeb®) Arformoterol (Brovana®), formoterol (Perforomist®), indacaterol (Arcapta® Neohaler®), olodaterol (Striverdi® Respimat®), salmeterol (Serevent® Diskus®) Aclidinium bromide (Tudorza® Pressair®), glycopyrrolate (Seebri™ Neohaler®, Lonhala™ Magnair™), tiotropium (Spiriva® HandiHaler®, Spiriva® Respimat®), umeclidinium (Incruse® Ellipta®) Glycopyrrolate/formoterol (Bevespi Aerosphere®), glycopyrrolate/indacaterol (Utibron™ Neohaler®), umeclidinium/ vilanterol (Anoro® Ellipta®) Budesonide/formoterol (Symbicort®), mometasone/formoterol (Dulera®), fluticasone/ salmeterol (Advair Diskus®, Advair® HFA, AirDuo™ RespiClick®), fluticasone/vilanterol (Breo® Ellipta®) Fluticasone furoate/ umeclidinium/vilanterol (TRELEGY ELLIPTA) Roflumilast (Daliresp®) Azithromycin (Zithromax®)

SAMA SABA/SAMA LABA

LAMA

LABA/LAMA

ICS/LABA

ICS/LAMA/LABA PDE-4 Inhibitor Macrolide

When comparing the recommendations from 2011 to 2017 (see Table 3), the following differences should be noted:  Group A: Either a short-acting or long-acting bronchodilator is the preferred option for initial treatment based on a patient’s symptoms, as compared to the previous recommendation of only a short-acting bronchodilator. 1, 4  Group B: There are no differences in initial treatment of choice from the previous guidelines to the current guidelines, as either a long-acting beta2 agonist (LABA) or long-acting anti-muscaranic (LAMA) is recommended for initial therapy. One change is that a short-acting bronchodilator alone is no longer recommended as an alternative approach.1, 4  Group C: A LAMA is the preferred initial treatment of choice, and if escalation is required the preferred addition is a LABA. This differs from previous recommendations, where a LAMA or an inhaled corticosteroid (ICS) plus a LABA were equally preferred for initial therapy. This change is a result of two head-to-head trials that demonstrated the LAMA class prevented significantly more COPD exacerbations than the LABA class. The ICS class is no longer recommended for initial therapy or the preferred pathway for escalation due to the increased risk for pneumonia in some COPD patients. 1, 4  Group D: A recommendation of a LABA/LAMA combi|25| www.KPHANET.org

nation for initial therapy in this group, differs from the previously recommendation of LAMA or ICS/LABA. The preference of LABA/LAMA over a single bronchodilator (either LABA or LAMA monotherapy) is supported by the SPARK trial – which demonstrated combination bronchodilator therapy prevented more exacerbations than either monotherapy in patients with a history of exacerbations.5 The preference of LABA/LAMA over ICS/LABA is supposed by the FLAME trial – which demonstrated LABA/LAMA prevented exacerbations more so than ICS/LABA.6 Lastly, within this group if patients are uncontrolled on triple therapy and still experiencing exacerbations further escalation options include: (1) roflumilast for patients with an FEV1 <50% predicted value and chronic bronchitis and (2) a macrolide, most commonly azithromycin 250mg by mouth daily, which has shown decreased exacerbations for up to one year, with consideration for risk of developing bacterial resistance.1, 4 Although not included within the new algorithm, smoking cessation is an extremely important piece in managing COPD. Further information on brief assessments on willingness to quit and various pharmacologic options are available in chapter 3 of the GOLD guidelines. 1,4 New Medications Fluticasone furoate/umeclidinium/vilanterol Approved in September 2017, fluticasone furoate/umeclidinium/vilanterol (TRELEGY ELLIPTA) is the first triple-therapy agent combining a ICS/LAMA/LABA, respectively. Within the inhaler device are two different foil strips, one containing fluticasone furoate 100mcg per dose

and the other containing umeclidinium 62.5mcg/vilanterol 25mcg per dose. This dry powder inhaler should be dosed one inhalation once daily.7 It is contraindicated for patients with a severe hypersensitivity to milk proteins or any of the active ingredients. There is a boxed warning for increased risk in asthma-related death due to the LABA component, and it is recommended to avoid use of this medication in patients with asthma because of lack of safety and efficacy data. Other warnings and precautions include: (1) do not initiate for patients with acutely worsening COPD; (2) do not use with any other LABA to prevent overdose; (3) there is a risk for a Candida albicans infection in the mouth and pharynx due to the ICS component; (4) there is an increased risk for pneumonia in patients with COPD from the ICS component and (5) urinary retention may occur from the anticholinergic component; use cautiously for patients with benign prostatic hyperplasia (BPH).7 Other important counseling points include: (1) do not remove the inhaler from the foil package until ready for initial use; (2) discard the inhaler when the counter reads “0” or six weeks after opening the inhaler; (3) rinse mouth with water and spit (do NOT swallow) after each use to decrease risk for oral thrush.7 Glycopyrrolate nebulization solution Approved in December 2017, glycopyrrolate nebulization solution (Lonhala™ Magnair™) is the first nebulized LAMA. The inhalation solution (Lonhala™) is a unit-dose, single-use, low-density polyethylene vial. Each 1mL vial contains 25mcg of glycopyrrolate. These vials must be used with the Mag-

|26| Kentucky Pharmacists Association | March/April 2018

Table 3. Pharmacologic treatment recommendations from GOLD 2017 and GOLD 2011 reports. Current Recommendations

Initial Agent

Escalation

De-escalation

Group A

Group B

Group C

Group D

Either SA or LA bronchodilator

LABA or LAMA

LAMA

LABA and LAMA

Preferred: LABA and LAMA

Preferred: LABA, LAMA and ICS*

Alternative: LABA and ICS

Not specified

LABA and LAMA

Substitute based on symptoms

Preferred: LABA and LAMA

Stop based on symptoms

LABA or LAMA Previous Recommendations

Group A

Group B

Group C

Group D

First Choice

SABA or SAMA

LABA or LAMA

ICS and LABA or LAMA

Second Choice

LABA or LAMA or SABA and SAMA

LABA and LAMA

PDE-4 inhibitor

ICS and LABA or LAMA ICS and LAMA or ICS, LABA and LAMA or ICS, LABA and PDE-4 inhibitor or LABA and LAMA or LAMA + PDE-4 inhibitor Carbocysteine

SABA and/or SAMA

Theophylline

Alternative Choice

Theophylline

SABA and/or SAMA

*If further exacerbations after triple therapy, can consider roflumilast or a macrolide. Abbreviations: SA = short-acting; LA = long-acting; LABA = long-acting beta2 agonist; LAMA = long-acting muscarinic agent; ICS = inhaled corticosteroid; SABA = short-acting beta2 agonist; SAMA = short-acting muscarinic agent nair™ specific nebulizing device. This maintenance medication dose should be one vial twice daily.8

unused vials 7 days after opening foil pouch; (3) this nebulization solution is not for treatment of shortness of breath, rather it is a maintenance medication that should be used twice daiIt is contraindicated for patients with a severe hypersensitivity ly, every day.8 to glycopyrrolate or any of the ingredients. Other warnings and precautions include: (1) do not initiate for patients with Conclusion acutely worsening COPD; (2) discontinue medication imme- COPD is a chronic disease characterized by periods of stabildiately if paradoxical bronchospasm occurs; (3) use cautious- ity with intermittent episodes of worsening. When managed ly with patients diagnosed with narrow-angle glaucoma, as it effectively based on history of exacerbations and patient remay cause worsening; (4) urinary retention may occur, use ported symptoms, the number of exacerbations and hospitalicautiously for patients with BPH. The most common adverse zations related to COPD can be reduced. Pharmacists and effects include dyspnea and urinary tract infection.8 pharmacy technicians are well-equipped to help patients manage this disease and pharmacists can make evidence-based Other important counseling points include (1) the Lonhala™ pharmacotherapy recommendations to the patient’s provider vials should only be used with the Magnair™ device, and vice for optimized care. versa; (2) keep the vials in the foil wrapper until ready for use and store any unused vials back in the foil pouch; discard any |27| www.KPHANET.org

References 1. From the Global Strategy for the Diagnosis, Management 6. and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: 7. http://goldcopd.org. 2. National Heart, Lung and Blood Institute. COPD Na8. tional Action Plan. Bethesda, MD. U.S. Department of Health and Human Services, 2017; NIH publication no.17-HL-8031. 3. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System (BRFSS), 2015. 4. From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2018. Available from: http://goldcopd.org. 5. Wedzicha JA, Decramer M, Ficker JT, et al. Analysis of chronic obstructive pulmonary disease exacerbations with dual bronchodilator QVA149 compared with glycopyrronium and tiotropium (SPARK): a randomized, doubleblind, parallel-group study. Lancet Respir Med.

2013;1:199-209. Wedzicha JA, Banerji D, Chapman KR, et al. Indacaterol-glycopyrronium versus salmeterol-fluticasone for COPD. N Engl J Med. 2016;374:2222-2234. Trelegy prescribing information. Research Triangle Park, NC: GlaxoSmithKline; 2017 Sep. Lonhala™ Magnair™ prescribing information. Marlborough, MA: Sunovion Pharmaceuticals Inc.; 2017 Dec.

CPE Quiz Online www.surveymonkey.com/r/CEQuizAp18

April 2018—Updates in COPD Treatment Guidelines and Medications 1. GOLD grades 1-4 assess which component COPD? A. Exacerbation risk B. Symptoms C. Airflow limitation D. Hospitalization risk 2. Which patient reported outcome tool assesses the symptom dyspnea only? A. Modified British Medical Research Council (mMRC) questionnaire B. COPD Assessment Test (CAT)

6. What risk is associated with inhaled corticosteroids when used in patients with COPD? A. Tachycardia B. Pneumonia C. Urinary retention D. Hypokalemia 7. What is the best recommendation for initial therapy, given a patient is classified as GOLD 3, group D? A. Tiotropium B. Fluticasone/salmeterol C. Glycopyrrolate/indacaterol + azithromycin D. Umeclidinium/vilanterol

Use the following patient case for questions 3-5. JP is a 58yo with a history of COPD controlled with a short-acting bronchodilator as needed. JP presents to his primary care provider today for a follow-up after a recent hospital admis- 8. What long-acting antimuscarinic agent (LAMA) was the first sion for a COPD exacerbation. The patient’s pulmonary function tests show approved as a nebulization solution? an FEV1 = 54% predicted and CAT score =9. A. Aclidinium bromide B. Glycopyrrolate 3. How would JP’s COPD be classified? C. Tiotropium A. GOLD 2, Grade A D. Umeclidinium B. GOLD 2, Grade C C. Grade A 9. Which of the following is an appropriate counseling point for D. Grade C Lonhala™ Magnair™? A. Use this nebulization solution as needed for shortness of air 4. Which of the following is the best option for initial pharmaB. This nebulization solution can be used with any nebulizer cotherapy for JP? C. Discard any unused vials 7 days after opening the foil pouch A. Tiotropium D. Use this nebulization solution once daily every day B. Salmeterol C. Albuterol/Ipratropium 10. What are the active components of TRELEGY? D. Glycopyrrolate/Formoterol A. Budesonide/tiotropium/vilanterol B. Fluticasone furoate/umeclidinium/vilanterol 5. JP’s provider decides to start umeclidinium. JP returns in one C. Fluticasone furoate/aclidinium bromide/olodaterol month and still complains of dyspnea, chronic cough and sputum. D. Mometasone/umeclidinium/salmeterol The provider asks you, the pharmacist in clinic, for advice on what therapy to select next. Which of the following is the best recommendation for JP? A. Switch to tiotropium B. Add fluticasone C. Switch to budesonide/formoterol D. Add vilanterol

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Expiration Date: 4/27/2021 Successful Completion: Score of 80% will result in 1.5 contact hours or .15 CEUs. TECHNICIANS ANSWER SHEET. April 2018 — Updates in COPD Treatment Guidelines and Medications (1.5 contact hours) Universal Activity # 0143-0000-18-004-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B 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)

PHARMACISTS ANSWER SHEET April 2018 — Updates in COPD Treatment Guidelines and Medications (1.5 contact hours) Universal Activity # 0143-0000-18-004-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 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

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

The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation

Quizzes submitted without NABP eProfile ID # and Birthdate will not be accepted. |29| www.KPHANET.org

Campus Corner Welcome to the Pharmacy Family “Pharmacy is in a rather remarkable position to blaze a new trail.” Paul F. Parker It’s that time of year when graduation announcements are in the mail and rotations are coming to an end. This May, the Class of 2018 will join the legacy of those that have gone before and become a part of our prestigious pharmacy family. Through early mornings, late nights, seemingly endless hours in the lab and classroom our graduates have done the hard work. Their persistence and resilience are evident, and we are incredibly proud of what they’ve accomplished. I challenge each remember of the class of 2018 to continue our proud tradition of excellence in whatever path they take. Congratulations to you all! You've earned it.

R. Kip Guy Dean & Professor UK College of Pharmacy

What I Wish I Knew As we look back on an academic year almost complete, we thought it might be fun to see what lessons our students would want to pass along. We asked Kaitlin Musick (2020) Mency Zhu (2018) and Spencer Tungate (2020) what they wish they knew before starting pharmacy school. Here’s what they had to say.

Kaitlin: Research isn’t scary–and doesn’t have to include mice. I was scared of “research” because I was only familiar with benchtop research (i.e. test tubes, mice, etc). Thankfully, I was encouraged to pursue research that was more at the bedside, which included taking information from the electronic health records at UK HealthCare, analyzing it, and interpreting the results. This was an awesome experience! It’s never too soon to start exploring career opportunities! Start shadowing, start networking, and start researching the wide variety of pharmacy jobs that are out there. Be prepared to change your mind about 1,000 times.

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Mency: The professors at UKCOP are very accessible. They're always open to meet with students and are very willing to provide career advice. There are many different pharmacy organizations to be involved in. There are always events to participate in and it’s how I made a lot of my friends in pharmacy school during my first year.

Spencer: It’s possible to have free time while you’re in pharmacy school. It’s actually important to use free time for mental breaks and building relationships with other students! To not be afraid to get involved. Some of my best experiences at the College of Pharmacy have been from the organizations I’m directly involved with.

Save the Date MAY 9: Pharmasee Blue Tour stop in Louisville at Sullivan College of Pharmacy. For more information about dates, locations, and accreditation, please visit bit.ly/seebluetour AUGUST 25: Kentucky Preceptor Development Training at UK College of Pharmacy. An evening welcome reception will take place Friday, August 24. OCTOBER 12-14: UK Residency 50th Anniversary Weekend

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. |31| www.KPHANET.org

Campus Corner Sullivan Preceptor Highlight Featured Site: Walgreens Community Pharmacy Medication Therapy Management (MTM) Rotation Area: Community Pharmacy Preceptor: Melissa “Missy” Crews, PharmD, MBA How long have you been a preceptor? 5 years Where did you go to pharmacy school? Sullivan University College of Pharmacy (Class of 2012) Any certifications/specialty areas/residency/ fellowships?  PGY1 Ambulatory Care Residency (Center for Health & Wellness, SUCOP)  Medication Therapy Management Certification (APhA)  Teaching Certification (SUCOP)  Smoking Cessation Facilitator Certification (Cooper -Clayton  Immunization Certification (SUCOP)  MTM Facilitator Certification (APhA) How long have you offered this experience as an Advanced Pharmacy Practice Experience (APPE)? 4 years (initially it was general community with heavy focus on MTM and now I am fully listed as an MTM rotation) Highlights of the rotation: During my rotation the student gains extensive insight on how to complete MTM cases in a community pharmacy retail setting. My students are fully in charge of MTM for the month of their rotation and must meet the goal set by the store. Their focus is to complete Comprehensive Medication Reviews (CMRs) which include an in-depth work-up, phone or face-to-face consultation, Medication Action Plan (MAP) and any follow-up required. They may complete any additional Targeted Medication Reviews (TMRs) as well. The workup is the most important piece because even if the student is unable to reach the patient, they still gain experience reviewing guidelines and determining initial recommendations for the patient. I encourage students to dig deep into their patient cases reviewing for missing medications recommended by

clinical guidelines as well as making recommendations to patients and providers just like we would in an ambulatory care setting as a part of the patient’s healthcare team. The student also completes weekly topic discussions reviewing clinical guidelines of ambulatory care disease states such as diabetes, hypertension, hyperlipidemia, asthma/COPD, anticoagulation, etc., and/or MTM-related articles such as The Ashville Project. Their final presentation is a comprehensive SOAP note presentation where they will present one of their CMRs in SOAP note format and include all guidelinesupported laboratory goals (if none reported by patient) and more in-depth recommendations that we could make if in an ambulatory care setting such as lab monitoring, etc. What unique opportunities are available for a student on this rotation? As the MTM Lead for my Area here in Louisville and Southern Indiana, the student gets the unique opportunity to travel to different Walgreens locations to meet a variety of pharmacists, technicians and store managers and learn what challenges or successes they are experiencing with MTM. The student gets to help pull monthly MTM completion and opportunity reports for over 70 stores which helps them understand from a business standpoint the financial benefits of pharmacies providing MTM especially as reimbursement declines for dispensing medications. Due to my involvement with the Walgreens/Sullivan PGY1 Residency program, my students also get to interact with our community resident pharmacist which gives them insight into the differences and opportunities available if they were to pursue a community-pharmacy residency. What are some clinical services that are currently being offered? As a company, we are heavily involved with Medication Therapy Management (MTM), immunizations including Travel health vaccines, free blood pressure screenings and Specialty medications. Each store is encouraged to also partner with local businesses or senior centers to provide quarterly outreach programs. At my home store we have partnered with a local senior center at which myself and my students host bingo and provide information regarding Medicare Part D plans, immunizations, health and wellness, etc. Where are you growing or expanding services/ opportunities?

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Currently, my focus is to provide a high level of MTM services for the local area which include offering and providing any recommended vaccinations and blood pressure screenings. As a company, we are also focusing on Specialty drugs so if and when we encounter patients on these types of medications during a CMR we are able to connect them with our Local Specialty site downtown Louisville where they may receive dedicated clinical and financial support from our Specialty pharmacy team. Also, through maintaining a strong relationship with the Colleges of Pharmacy, I am hoping to build a program in which we strategically place APPE students in some of our high opportunity stores in Louisville and Southern Indiana in order to support MTM and other clinical services for our patients in these stores as well as prepare these students for the rigors of current community

pharmacy practice especially in an area where there are many underserved patient populations. What do you love about being a preceptor? I love the opportunity to grow future pharmacists. I am so passionate about this profession and I believe that my students are the key to our successes in the years to come. I also know that community pharSUCOP Pinning Ceremony On Friday, April 6, 2018 the Sullivan University College of Pharmacy (SUCOP) held its Annual Pinning Ceremony for eighty-four second professional year student pharmacists. This pinning ceremony marks the transition of the student pharmacists from their didactic learning to experiential learning. Family and friends joined our student pharmacists as they were recognized and received their SUCOP pins.

macy is vastly changing and the focus is moving away from a dispensing role to a higher level of pharmacist engagement through our patient care services. I love preparing students for a more advanced role in community pharmacy and encouraging them to push the bar even though right now we do not always have access to the full patient’s medical story. I also love working through barriers and challenges that are often presented to me initially by students who have attempted MTM before my rotation such as “no one accepts my offer for a CMR.” Having completed hundreds of CMRs successfully, I explain that it’s all in the verbiage and the key is to “make them an offer they can’t refuse!” APhA Nashville: SUCOP Students at the Leadership Training Series

phase in the PY3 year, students are encouraged to reach out to advisors and mentors for guidance in the application process. This year, SUCOP had twenty 3rd year students complete the ASHP Match Process and a 55% Match Rate. These numbers continue to grow every year! In addition, the SUCOP PGY-1 Residency Programs are excited to announce the 2018-2019 residents:

This year’s keynote speaker was Dr. Jacob Hall (SUCOP Class of 2017 alum) who provided a very timely and heartfelt message on this educational transition as well as the values of professionalism, punctuality, and perseverance.

SUCOP/Center for Health and Wellness

Post-Graduate Training at SUCOP

SUCOP/Frankfort Regional Medical Center

Sarah Banday – University of Illinois Chicago, Abigail Krabacher – Butler University, Hayley Ziegler – Sullivan University College of Pharmacy

With the growing trend toward completing post-graduate Alonna Greene – Sullivan University College of Pharmacy training, SUCOP continues to educate students on the value SUCOP/Passport of seeking opportunities, and to provide guidance and support to those who wish to pursue these options. Chris Quenelle – Drake University During the PY1 year, students are introduced to the concept SUCOP/Walgreens of post-graduate training and encouraged to begin building Chikodili “Kodi” Udemgba – University of Mississippi their curriculum vitae. In the PY2 year, an Introduction to Residency elective course is offered to students who are considering post-graduate training. This course is designed to give an overview of life as a resident, assist students in creating a strong CV and choosing appropriate references, and develop interview skills to increase chances of being selected for postgraduate training positions. During the interview and ranking |33| www.KPHANET.org

Pharmacy Law Brief Vaccinating Pharmacists and the National Vaccine Injury Compensation Program 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: I read somewhere about a federal fund to compensate patients who suffer damages from the process of being vaccinated. Is that source of funds available to patients suffering adverse consequences when a pharmacist is doing the vaccination? Response: The National Vaccine Compensation Program represents a no-fault approach to handling injuries from certain vaccines. This program was created during 1986 with enactment of the National Childhood Vaccine Injury Act. It was enacted because there was a threat of vaccine shortages and reduced vaccination rates due to lawsuits in this area. Coverage of the legislation was expanded by the 21st Century Cures Act enacted during the December, 2016.

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

tion or surgery; or [3] resulted in death. Parents or legal guardians can file claims for children or disabled adults or deceased individuals. Immunizations completed by pharmacists would be covered; the focus is on the vaccine, not on the health professional providing the service.

The best, most up-to-date information about program eligibility and coverages in available on the program website -Some data may help put this in perspective. From https://www.hrsa.gov/vaccinecompensation/. 2006 to 2015 over 2.8 billion doses of vaccines in- The National Vaccine Injury Compensation Procluded in the program were administered. During gram is administered by the Health resources and that same time period, 4,374 petitions for compen- Services Administration, a division of the U.S. Department of Health and Human Services. sation were filed with this program and, of those, 2,847 payments resulted. So, for approximately Submit Questions: jfink@uky.edu every 1 million doses of vaccine administered there was one compensation payout. Program promotional materials emphasize that the U.S. has the most effective vaccine supply in history. The vast majority of administrations cause no side effects but as with any medication, there is always that possibility. To be eligible to file a petition for compensation the effects of the injury must have: [1] lasted for more than six months after the vaccination; [2] resulted in inpatient hospitaliza|34| Kentucky Pharmacists Association | March/April 2018

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Pharmacy Policy Issues Transparency Laws and Drug Product Pricing Author: Chelsea King, a native of Burkesville, Kentucky, is a PY3 student at the University of Kentucky College of Pharmacy. She completed her pre-professional education at Lindsey Wilson College with a B.S. in Biology. She is concurrently pursuing an MBA degree from the UK Gatton College of Business and Economics hike. In theory, this law seems to be a good option to decrease medication costs. If manufacturers don’t want to supply financial information to the public, then they must keep their drug price increases to a minimum; however, there are several issues with this type of transparency law. First, Discussion: There have been many attempts to there is no available force behind the law; even if decrease drug prices over the last few years. Those the price increase was deemed to be unacceptable attempts include: pay-for-delay settlements, inand inappropriate, drug companies still have the creasing generic competition via the Lower Drug right to determine what they should charge for a Costs Through Competition Act, eliminating medication under current federal regulations. SecREMS (Risk Evaluation and Mitigation Strategy) ond, there are no set criteria for what is acceptable delay tactics via the Creating and Restoring Equal and appropriate so this creates an issue with differAccess to Equivalent Samples (CREATES) Act, ing opinions. Third, the Vermont law only gives the Fair Drug Pricing Act, Ohio’s Drug Price Rethe authority to obtain information on 15 drugs lief Act and New Jersey’s and Massachusetts’ legisannually. This information on such a small numlation preventing discounts and rebates when a ber of drugs will only be marginally informative lower cost generic is available. Some of these atand effective. These three main issues are key inditempts have been somewhat successful, but most cators of why other states have not passed similar have failed to be enacted at the state or national laws. level, which does not bode well for future legislaThe United States House and Senate both have tive proposals. pending bills, currently in committee as of this The next trend in the search for a solution to lower writing -- S.1131 and H.R.2439 -- which address prescription drug prices is transparency laws. To transparency with drug manufacturers and are simdate there has only been one state, Vermont, which ilar to the Vermont law. The future of these and has passed a transparency law. The Vermont law other similar bills are uncertain but strategies for states that the board can identify up to 15 prescriplowering prescription drug prices will continue to tion drugs annually on which the state spends sigbe pursued. Although transparency laws are not nificant health care dollars and on which wholesalgoing to be the golden ticket to lowering drug pricers’ acquisition cost increased by 50 percent or es and making medication affordable to all pamore in the past five years or by 15 percent or tients, these laws are a step in the right direction. more in the past year (S. 216 Act 165) and summon them to provide justification for the price Issue: Recently, there has been a lot of discussion about the use of transparency laws to prevent astronomical price increases for prescription medication. What are these and are transparency laws really the cure for high drug prices?

|36| Kentucky Pharmacists Association | March/April 2018

Welcome to KPhA! We’re so happy to have you! The list reflects new memberships received from January 1, 2018— February 28, 2018 Marilyn Belt (T) Marion

Rushabh Shah Lexington

Anthony Brown Louisville Kari Riddle Madisonville

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

Sara Sauer (T) Lexington

MEMBERSHIP MATTERS: To YOU, To YOUR Patients

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KPhA BOARD OF DIRECTORS Trish Freeman, Lexington trish.freeman@uky.edu

Chair

Tyler Stephens, Lexington Vice Speaker of the House stevens.tyler@uky.edu

Chris Harlow, Louisville cpharlow@gmail.com

President

KPERF BOARD OF DIRECTORS

Chris Palutis, Lexington chris@candcrx.com

President-Elect

Brooke Hudspeth, Lexington brooke.hudspeth@kroger.com

Secretary

Duane Parsons, Richmond dandlparsons@roadrunner.com

Treasurer

Jessika Chinn, Beaver Dam jessikachilton@ymail.com

Past President Representative

Directors

Clark Kebodeaux, Lexington clark.kebodeaux@uky.edu

Secretary

Duane Parsons, Richmond dandlparsons@roadrunner.com

Treasurer

Chris Harlow, Louisville cpharlow@gmail.com

President

Paul Easley, Louisville rpeasley@bellsouth.net

Sarah Lawrence, Louisville slawrence@sullivan.edu

Matt Carrico, Louisville* matt@boonevilledrugs.com University of Kentucky Student Representative

Kelly Smith, Lexington ksmit1@email.uky.edu

KPERF ADVISORY COUNCIL

Chad Corum, Manchester pharmdky21@gmail.com

Matt Carrico, Louisville matt@boonevilledrugs.com

Cassy Hobbs, Louisville cbeyerle01@gmail.com Nathan Hughes, Louisville nhughe1030@my.sullivan.edu

Chair

Melinda Joyce, Bowling Green MBJoyce@chc.net

Angela Brunemann, Union Angbrunie@gmail.com

Jaclyn Ochsner, Lexington jaclyn.Ochsner@uky.edu

Bob Oakley, Louisville rsoakley21@gmail.com

Sullivan University Student Representative

Chris Killmeier, Louisville cdkillmeier@hotmail.com Don Kupper, Louisville donku.ulh@gmail.com Jeff Mills, Louisville jeff.mills@nortonhealthcare.org Richard Slone, Hindman richardkslone@msn.com Sam Willett, Mayfield willettsam@bellsouth.net

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

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

*At-Large Member to Executive Committee

HOUSE OF DELEGATES Amanda Jett, Louisville Speaker of the House ajett@sullivan.edu

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K.PH.A. BREAKS GROUND FOR BUILDING “The American Pharmaceutical Association lauds President Johnson’s concern for improving the health of American citizens and endorses the five major goals outlined in the President’s Health Message, Executive Director William S. Apple stated recently.“ - From The Kentucky Pharmacist, April 1968, Volume XXXI, Number 3

Frequently Called and Contacted Kentucky Pharmacists Association 96 C Michael Davenport Blvd. Frankfort, KY 40601 (502) 227-2303 www.kphanet.org Kentucky Board of Pharmacy State Office Building Annex, Ste. 300 125 Holmes Street Frankfort, KY 40601 (502) 564-7910 www.pharmacy.ky.gov 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 Brandenburg Director of Communications & Continuing Education sbrandenburg@kphanet.org Angela Gibson Director of Membership & Administrative Services agibson@kphanet.org Jody Jaggers, PharmD Director of Pharmacy Emergency Preparedness jjaggers@kphanet.org Elizabeth Ramey Receptionist/Office Assistant eramey@kphanet.org

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

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THE

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

www.kphanet.org |42| Kentucky Pharmacists Association | March/April 2018