Editorial Continuing Education
Editorial
Vaccine Recommendations for HIV-Infected Individuals
Student Pharmacists’ Developments with MPhA
Maryland Pharmacist’s Role in Preventing and Treating Sexually Transmitted Infections
AL SE as
WINTER 2018
PRSRT STD U.S. POSTAGE HARRISBURG PA PERMIT NO. 533
2018
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Contents
COVER STORY MPhA Midyear Meeting
DIVERSITY , AdvisoRY COUNCIL
President’s Pad 4 MPhA News
5 | Member Mentions & News You Can Use
5 | Welcome New MPhA Members 6 | Interview: Lieutenant Chris Charles
8 | Student Pharmacists’ Developments with the Maryland Pharmacists Association
23 | Thank You Corporate Sponsors Editorial
19 | Maryland Pharmacist’s Role in Preventing and Treating Sexually Transmitted infections
ADVERTISERS INDEX
23 Corporate Sponsors
2 Smith Drug Company 21 | Holiday Party Photos 7 Independent Pharmacy 21 | Foundation Donors Buying Group Continuing Ed EPIC bi EPIC 11 | Vaccine Recommendations for HIV-Infected Individuals
22 HD Smith Executive Director’s Message 23
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«Sr, 188% MARYLAND PHARMACISTS ASSOCIATION
MPhA OFFICERS 2017-2018
Kristen Fink, PharmD, BCPS, CDE, Chairman
Cherokee Layson-Wolf, PharmD, CGP, BCACP, FAPhA, President
Chai Wang, PharmD, BCPS, AE-C, Vice President
Matthew Shimoda, PharmD, Treasurer
Samuel Lichter, Honorary President (posthumous)
HOUSE OFFICERS
Richard Debenedetto, PharmD, MS, AAHIVP, Speaker
Matthew Balish, PharmD, RPh, Vice Speaker
MPhA TRUSTEES
Kerry Cormier, PharmD
Darci Eubank, Pharm
Sadhna Khatn, PharmD
Anne Lin, PharmD
Amy Nathanson, PharmD, BCACP, AE-C,
Wayne VanWie, RPh
Patricia Dieso, ASP Student Representative — Notre Dame of Maryland University School of Pharmacy
EX-OFFICIO TRUSTEES
Rondall Allen, PharmD, Dean University of Maryland Eastern Shore School of Pharmacy
Natalie Eddington, PhD, Dean University of Maryland School of Pharmacy
Paul R. Holly, PD, MPhA Foundation
John Lee, University of Maryland School of Pharmacy
Divya Vepuni, University of Maryland Eastern Shore School of Pharmacy
PEER REVIEWERS
Kerry Cormier, PharmD
Tosin David, PharmD
Nicole Groves, PharmD
G. Lawrence Hogue, BSPharm, PD Frank Nice, RPh, DPA, CPHP
STAFF
Aliyah N. Horton, CAE, Executive Director
Shawn Collins, Membership Services Coordinator
Carole Miller, Operations and Program Associate
CONTRIBUTORS
NASPA Services Company, LLC, Editorial
Katy Pincus, PharmD, BCPS
Special thanks to Graphtech, Advertising Sales and Design
Maryland Pharmacists Association, 9115 Guilford Road, Suite 200, Columbia, MD 21046, call 443.583.8000, or email aliyah.horton@mdpha.com.
President’s Pad
Dear MPhA Members: Tis the season...For Advocacy!
When we think of the word advocacy, those of us in Maryland think of the numerous Maryland Pharmacy Coalition Legislative Days we've had over the years. The truth is that advocacy for pharmacy does not only happen that day, but it can happen every day in various ways. We know that many of you may not be able to join us on Legislative Day for various reasons, but please know that your efforts
do not go unnoticed, and every action, no matter how small, can make an impact, but
you do have to make a choice to act. It is simply amazing what we can accomplish when everyone can contribute their support to pharmacy.
I have been fortunate over the years to be involved in various legislative efforts for pharmacy, from immunizations to point of care testing, and all along the way I have had the support of my colleagues
at MPhA. They joined me at hearings, testified alongside me, worked to review proposed regulations, attended work groups, and educated legislators about various issues. What has always amazed me about this process was it really started
with people believing in a cause and giving
what they could to support it in any way they could. The efforts we have made
to become #ProviderReady did not start just a few years ago, but actually a few decades ago, and our current experience tells us that Provider Status will not come easy. It will take a few years for the idea to take hold, but now is the time to help us establish those roots that will ensure that as a profession we will be ready to take on that responsibility serving our patients at a higher level. Reimbursement continues to be a challenging issue
for many of our members, and we are working to ensure that the impact of those issues is being shared and discussed with various stakeholders. To continue to support successes and address practice challenges, here are some ways you can help advocate:
¢ Be informed: Knowing the issues that affect practice will help you understand your role further in helping support the various efforts of MPhA and our pharmacy colleagues.
e Tell your story: We are surrounded by amazing practitioners here in Maryland who are already serving their patients and communities in many ways. Sharing what you do will help others understand the role of the pharmacist in providing care, and understanding what impact establishing pharmacists formally as providers will have on health care in Maryland.
e Contact your legislators: As Maryland residents, our legislators represent us and can only know us if we are sharing with them on a regular basis. It is likely that our issues also impact their other constituents as well, so serving as a resource can have an amazing impact.
¢ Be present: If you are able, join us at
events like MPC Legislative Day, testify at hearings, or join us for work groups. It is helpful for us to share how various issues impact our membership as a whole, and
MPhA can only know that if you join us to share and talk. Supporting your pharmacy colleagues will help show that we are unified in our mission to strengthen our profession.
The MPC Legislative Day is February 20th! Register today to join us either in the morning for meetings with legislators and their aides or at the evening reception from 6:30-8:30pm. Please
visit marylandpharmacist.org for more information.
While we have entered our Maryland
Legislative season, advocacy efforts take place all year long. I hope that you can join MPhA in our efforts all year long to support the profession of pharmacy! @
Kindest regards,
Cherokee Layson-Wolf President
Member Mentions & News You Can Use
McPherson Named Visionary in Hospice and
Palliative Medicine Maryland Students Elected to Mary Lynn McPherson, PharmD, MA, MDE, BCPS, CPE, APhA-ASP
professor and executive director of advanced post- graduate education in palliative care in the Department of Pharmacy Practice and Science (PPS) at the University of Maryland School of Pharmacy has been named a Visionary in Hospice and Palliative Medicine by the American Academy of Hospice and Palliative Medicine (AAHPM).
“This program recognizes key individuals who have been critical in building and shaping our field over the past 30 years,” says Steve R. Smith, MS CAE, chief executive officer for AAHPM. “These individuals APh A ASP represent thousands of other health care professionals we
in this country who provide quality medical care and ee E RUS Ste ORAS LS Tea eae
a, ' ACADEMY OF STUDENT PHARMACISTS support for those living with serious illness — each and every day.”
Two students from Maryland were elected as APhA-ASP Region 2 Delegates: Elodie A. Tendoh from University of Maryland and Seth Weinstock from the University of Maryland Eastern Shore. Elodie and Seth were elected as delegates at the Midyear Regional Meeting in Pittsburgh this past
November. Congratulations Elodie and Seth!
Congratulations Mary Lynn!
New Addition to the MPhA Pharmily!
Congratulations to Deanna Tran and Chai Wang, who welcomed their first child, daughter, Cassandra Hope Wang on December 15th at 10:58am. She weighed in at a healthy 7 lbs, 6 oz.
WELCOME NEW MPhA MEMBERS
Mir Karamat Ali Stormi Gale Sheshu Mettu Pratap Rikka Aileen Altman Arwa Ghabra Maureen Minot Lisa Sanderoff Regine Beliard Mangesh Y. Joglekar Yasir Y. Naroo Elisabeth Setzler Anupam Bhavsar Sherine Joseph Christina Trang Nguyen Syed A. Shah Maureen Cutright Pascal Kemelong Sanjaykumar Ranchhoddas Patel Ajay Sharma Vinay Reddy Dasani Naveen Khambum Hetalben Patel Mahesh Tickle George N. Fotis Joey Lyons Syam K. Potluri Archana Zala
Bhupendra Gadani Neil Patrick McGarvey Julie Preis Kevin McGill
MARYLANDPHARMACIST.ORG 5
interview: Lieutenant Chris Charles
By Miaka Huynh, PharmD Candidate 2018, Notre Dame of Maryland University, MPhA APPE Rotation Student
Eight months ago, Chris Charles, PharmD, BCPS, AE-C, an active member of Maryland Pharmacists Association (MPhA) moved across the United States and settled in South Dakota. Chris joined Indian Health Service within the United States Public Health Service (USPHS) and is now known as Lieutenant (LT) Charles. He is currently serving on the Pine Ridge Indian Reservation, home
to the Oglala Lakota Sioux Nation. In 2000, the United States Census Bureau reported an employment rate of 57% on the reservation with 61% of individuals living below the poverty level. It goes without saying that LT Charles’ knowledge and skills are greatly needed. As busy as he is with work and family (with a new baby on the way), he graciously made time for an interview with MPNA.
What inspired you to join the Indian Health Service (IHS)?
When I was in pharmacy school, about 11 years ago,
I met CAPT James Bresette. He was there to doa presentation on the cool things that pharmacists could do within the Corps [United States Public Health Service]. From there, I learned that the Indian Health Services (IHS), and more generally, the Corps, gives you the opportunity to do more and practice to the top of your license. The IHS give you an opportunity to work ina variety of areas and that’s what inspired me to join.
Being far from resource rich urban centers, you are needed more and it gives you the opportunity to do more. Because we have so many different areas, we dont have to work just as outpatient pharmacists. | don't have to be a specialist to go to work in a broad range of clinical settings.
Where is your post/location?
At the Pine Ridge Reservation, our hospital has
40 beds and we serve about 20,000 people. The hospital has acute care, emergency department, optometry, dental, physical therapy, outpatient primary care clinic, mid-wife clinic, ENT (Ear, Nose, and Throat) clinic, behavioral health clinic, dietary clinic, cardiology clinic, and orthopedic clinic. We also do minor, general, and dental surgery. When we receive a patient that we dont have the staff or technology to help, we fly them out to the nearest hospital, about 95 miles to the north in Rapid City.
6 MARYLAND PHARMACIST | WINTER 2018
Lt. Chris Charles is second from the right.
What do you love best about your job with the IHS?
I love the variety of areas and specialties I get to work in. Because we have so many clinics and different areas like acute and primary care, I get to work with the providers on those teams collaboratively. For example, the outpatient clinic is more clinical than a traditional community chain pharmacy. At big chain pharmacies, all we have is the patient's prescription, but here, I have the full EHR (electronic health record). We are expected to look at drugs more closely and call the doctor
based on the patient's disease state, other medications, allergies, labs, etc. We access all of that before we fill the prescription. That gives us the opportunity to better serve the patient.
There is also a lot of opportunity for involvement with other professions. I have been able to give in-service presentations to the nursing staff. We have a cafeteria that everyone loves to eat in and we basically all eat together. It gives a chance to build relationships and rapport with the whole healthcare team.
There is also opportunity to be involved with the Corps, even though you are stationed in a remote area. I still get email from the Corps PharmPac and Commissioned Officers Association (COA). They have a lot of opportunities to get involved, develop yourself, and take on leadership positions. I am currently the APhA House of Delegates alternate delegate for the Corps, and Treasurer for the local COA branch.
Continued on page 18
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Student Pharmacists’ Developments with the Maryland
Pharmacists Association
By Lee J, Dieso P, Vepuri D, Aung L, Nguyen V.
There is no denying that the profession of pharmacy is undergoing a rapid evolution,
as there have been significant advancements in pharmacists’ roles and professional responsibilities. Due to the continuous changes
in the professional landscape, it is vital for student pharmacists — the incoming generation of pharmacists — to be engaged in the discussions and practices regarding the profession's directions. Within the Maryland Pharmacists Association (MPhA), a commitment to the future is evident as student pharmacists are given a seat at the table (both literally and figuratively) when it comes to discussing challenges and solutions to these challenges.
With the president of the American Pharmacist Association — Academy of Student Pharmacists (APhA-
ASP) from each Maryland school
of pharmacy represented in MPhA, student pharmacists are playing an active role in their state association's decision-making to shape the profession. On a rotating basis,
one of the student representatives serves as a voting member on the MPhA Board of Trustees. These opportunities are unique and rewarding as echoed by this year's ASP representative, Patricia Dieso from the Notre Dame of Maryland University. According to Dieso,
“being an ASP student representative
for MPhA this semester has shown me how involved pharmacists
are with evolving their roles in pharmacy. At many meetings, we have discussed supporting pilot runs of changes to help improve a
pharmacist's work load to give them more patient interaction. It’s great to be a part of this as the roles of pharmacists are always changing.” Student involvement extends beyond APhA-ASP representatives as well, as numerous student pharmacists serve on various committees. Some activities over the past few years have included helping plan/create events, creating advertisement material, and even having one member, Andrew Wherley, serve as the technician network co-chair. Wherley states, “As the technician network co-chair I've had the opportunity to work with a
“As the technician network co-chair I've had the opportunity to work with a lot of different members to provide a voice for technicians at MPhA. Being trusted with this responsibility as a student has helped me improve many of my communication skills.
It truly goes to show how much emphasis the MPhA members place on educating and mentoring the next generation of pharmacists.”
— Andrew Wherley
Students attend a poster presentation from a student-peer on his research conducted at the Notre Dame of Maryland University.
8 MARYLAND PHARMACIST | WINTER 2018
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Students from all three pharmacy schools in Maryland attend the inaugural Spring Into Your Career event, co-hosted by MPhA, NDMU, UMSOFP,
and UMES.
lot of different members to provide a voice for technicians at MPhA. Being trusted with this responsibility as a student has helped me improve many of my communication skills. It truly goes to show how much emphasis the MPhA members place on educating and mentoring the next generation of pharmacists.” Through the different roles that student pharmacists serve in MPhA, the common theme amongst students is the impact that their actions hold in directing the trajectory of pharmacy careers.
MPhA also emphasizes student growth through the Professional Development Committee. Chaired by two University of Maryland School of Pharmacy alumni, Virginia Nguyen and Lynn Aung, the Professional Development Committee supports student initiatives and brings programming events to the pharmacy schools in Maryland. In just the past two years, the Professionalism Development Committee has overseen numerous initiatives such as the first MPhA pharmacist roundtable event
and the first ever collaborative event involving all three Maryland schools of pharmacy: Spring Into Your Career. Within the past year, Maryland student pharmacists listened to topic discussions from two distinguished pharmacists,
participated in a networking roundtable event, and engaged ina student poster presentation session. The concept of collaborative programming continued beyond the event, as the 2017 Fall saw another program developed by all three schools, Clinical Aspects of Medical Marijuana, presented by guest speaker Dr. Kari Franson. The students’ benefits from MPhA‘s focus on their development have been unlike any previous years. Co-chair
DIVERSITY ADVISORY COUNCIL
UMB VALUES
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Professional Development Committee Chair, Virginia Nguyen, greets a student pharmacist prior to the first MPhA pharmacist roundtable event.
Virginia Nguyen states, as new practitioners, we vividly remember how overwhelming it can be to navigate through pharmacy school and develop clinical and professiona skills. What we wanted to do with the Professional Development Committee is help students prepare for a constantly changing pharmacy
landscape. Through our roundtables or professionalism forums, we wanted to ensure that each student goes from ‘sitting on the sidelines to becoming better stew profession and practic doubt, the sustained development of programming, partnerships
and relationships amongst the schools in Maryland is a testament to the Professional Development Committee's dedication to fostering student growth
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As the pharmacists’ role advances, student pharmacists are able
to actively support their fellow classmates by providing these various opportunities and more by having an active role through MPhA. These opportunities are what help shape the careers
of our future pharmacists and provide them with new and evolving information they may need to advance their careers. @
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Continuing Ed
Vaccine Recommendations for HIV-infected Individuals
By Sumit Gandotra, PharmD Candidate 2019, Neha S. Pandit, PharmD, AAHIVP, BCPS
Learning Objectives
After completion of this activity, the participants will be able to:
Keywords CD4 count
HIV vaccination
1. Discuss how HIV infection affects the efficacy and safety of vaccinations
2. State current ACIP guidelines for vaccination in HIV-infected individuals
Introduction Human Immunodeficiency Virus
(HIV) attacks and depletes CD4 cells,
compromising both cell-mediated and humoral immunity. Untreated HIV can progress to Acquired Immu- nodeficiency Syndrome (AIDS) de- fined as a CD4 count <200 cells/ mm, leading to an increased risk of infections. Vaccinations can help ease this burden. However, as vaccine efficacy is highly dependent ona functioning immune system, a reduced antibody response may be seen as the CD4 counts decline. Vaccines contain either living material that is significantly weak- ened (live vaccines) or inactive material important in causing an infection but unable to do so on its own (inactivated vaccines). At low CD4 counts there is a risk of live vaccines causing active infections, therefore only administration of inactivated vaccines are recommended in the HIV- infected population*
Despite the widespread knowledge of the risks associated with preventable diseases, the rates of vaccinations in the HIV- infected population leaves something to be desired. The Advisory Committee on Immunization
Practices (ACIP) outlines recommended vaccinations for HIV-infected patients
HPV MM
Vaccination
Influenza Tdap Pneumococcal
Meningococcal conjugate | Inactivated
Hepatitis B
Varicella/Herpes
[Table 1].* Studies have shown vaccination rates of 50% for >3 doses of hepatitis B vaccine, 40% for annual flu vaccine, and 30%
for meningococcal or tetanus, diphtheria, and acellular pertussis (Tdap) vaccines in eligible HIV- infected patients.°*° Some studies have identified mild adverse events (AEs) to inactivated vaccines and increased AEs to live vaccines in the HIV-infected population.’ It is clear that the overall rate of vaccination among the HIV-infected population is very low.
The lack of knowledge regarding vaccine eligibility, efficacy and safety differences, and the consistently evolving ACIP guidelines may be contributing factors to the low rates of adherence to best immunization practices in this population. This article aims to review the available information on the efficacy and
Table 1: ACIP vaccination recommendations for HIV-infected adults?
Live or CD4 >200 cells/mm? | CD4 <200 cells/mm? inactivated | and/or CD4% >15% | and or CD4% <15%
Inactivated Inactivated Inactivated
safety of vaccinations for the HIV- infected population.
Influenza
HIV-infected and uninfected individuals are equally at risk for contracting influenza. However, the severity of illness may be increased in the HIV population, leading to higher rates of hospitalization, morbidity, and mortality.® IlIness severity can be minimized with vaccination but the antibody response to vaccination is almost absent with CD4 counts <100 cells/ mm: with no improvements seen with booster or increased dosages. Annual vaccination improves prevaccination antibody titers in HIV-infected patients with CD4 counts >300 cells/mm?
ACIP recommends the use of annual trivalent inactivated influenza vaccine (IIV3) for those that are
v
MARYLANDPHARMACIST.ORG 11
Continuing Ed
>6 months of age, regardless of CD4 count.’ Data shows IIV3 to
be 27-78% effective in preventing influenza in HIV-infected individuals with a CD4 count >100 cells/mm compared to 11% in those with CD4 counts <100 cells/mm%.?*° The safety of IIV3 in HIV-infected individuals was of concern after conflicting reports of increases in HIV RNA levels and decreases in CD4 counts after vaccine administration.? These results were found to be transient and lacked clinical significance.
There is limited efficacy data
for the live attenuated influenza vaccine (LAIV) in the HIV-infected population. One study showed that children with a median CD4 count of 645 cells/mm? and HIV RNA of 20 copies/mL had similar immune responses compared to uninfected children given the LAIV."* Due to the limited data, ACIP continues to recommend against the use of LAIV in the HIV-infected population. Meningitis
The incidence of invasive meningococcal infection (IMI) fluctuates from 0.5-1.5 cases per 100,000 population annually to 3.4-6.6 cases in the HIV-infected population.” The overall risk of IMI in HIV-infected patients continues to rise as CD4 counts decline and HIV RNA levels increase with the highest risk in patients with a
CD4 count of <200 cells/mm*?.57¢ Regardless of HIV status, the highest incidence of IMI is seen in the infant population. With the increased incidence of IMI seen in the HIV- infected population, ACIP updated their recommendations to routinely vaccinate for meningococcal disease as of 2016.4 Six serogroups (A, B, C, W-135, X, and Y) are responsible for most IMIs with B,
C, W, and Y causing the majority
of infections in the HIV-infected population within the United States.¥2
Currently two conjugated meningococcal vaccines exist against serotypes A, C, W, and Y (Menactra and Menveo). ACIP recommends that the primary series in HIV-infected individuals that are <2 years old receive a series of Menveo at ages 2, 4, 6, and 12-15 months. If the HIV-infected individual is >2 years old, both Menactra and Menveo can be given as a two series 8-12 weeks apart.’
The efficacy of the meningococcal vaccine is highly dependent on one’s CD4 percentage (CD4%), yet, antibodies seem to diminish over time for HIV-infected individuals. The proportion of HIV-infected patients with an adequate amount of antibody titers to serogroup C decreased from 65% at 4 weeks
to 21% at 72 weeks after one dose of MenACWY-D (Menactra) in those with a CD4% >15%. A similar decrease from 83% to 63% was seen for serogroup Y. With a 2nd dose of the vaccine given at 24 weeks to the same population, the proportion of patients with adequate titers went from 59% to 35% for serogroup C and 73% to 71% for serogroup Y, 4 weeks and 72 weeks post vaccination. For those with a CD4% <15 the overall response to the vaccine was decreased even with a 2nd dose. The proportion
of patients with adequate titers in this population decreased from 22% to 6% for serogroup C and 30% to 28% in serogroup Y, four and 72 weeks post vaccination.® Due to the finding of diminishing antibodies over time in the HIV-infected population, a booster vaccination every 5 years is recommended [Table 2].%*
Serious adverse events after meningococcal vaccine administration were seen in 2.2- 6.5% of patients within six weeks of vaccine administration. The rates of these events are inversely related to CD4%.4
12 MARYLAND PHARMACIST | WINTER 2018
Tetanus, Diphtheria, and Pertussis
Due to vaccination efforts, from 2001-2008 the incidence of tetanus within the U.S. was 0.1 cases per million population annually; from 2004-2015 only two cases of diphtheria were reported; however, in 2015 over 20,000 cases of per- tussis were reported in the U.S.”
HIV-infected individuals had similar antibody responses to uninfected patients for tetanus, however a decline in tetanus titers over time was seen even in patients who were previously vaccinated.°*° A lower antibody response was seen to diphtheria after vaccination, especially with CD4 counts <300 cells/mm?.!6* A similar decline in pertussis antibody concentrations was seen 24 weeks post booster vaccination in children with a CD4% >15% with a minimal response seen in CD4% <15%.* The diminished protection to tetanus, diphtheria, and pertussis lead to the belief
that booster vaccinations may be necessary sooner than every 10 years for HIV-infected patients, though more frequent boosters
are not currently recommended by ACIP [Table 3].°°
Diphtheria, tetanus, and pertussis vaccinations (DTaP) are made with inactivated material. Adverse events associated with DTaP were similar between vaccinated and unvaccinated HIV-infected children with the most common events mostly attributed to the patients’ antiretroviral therapy.”° There is limited data on Tdap in HIV-infected individuals, however, results are suggestive to be similar to DTaP.©
Pneumococcal Diseaseonia
Between 1996-2011, the burden
of invasive pneumococcal disease (IPD) in adult HIV-infected individuals was 160 cases compared to eight cases per 100,000 person-years in uninfected individuals. Recurrence,
Table 2: Meningococcal Vaccines in HIV-infected individuals and their Dosage, Administration, and Schedule**5
| Site | Schedule
IM IM SQ
Age 55 Two-dose series given ¢ If <7 years from previous years old 12 weeks apart series: Give additional dose
2 months | Four-dose series at 2, 4, 6, and 12-15 months of age. Two-dose series with the second dose administered in the second year of life and at least three months after the
7-23 months
first dose
Two-dose series given years old 8-12 weeks apart
3 years after primary series; boosters every 5 years thereafter
If >7 years from previous series: Give additional dose 5 years after primary series; boosters every 5 years thereafter
>56 Single Dose
Table 3: Tetanus, Diphtheria, and Pertussis vaccinations for HIV-infected individuals*
Schedule 5 dose series: age 2, 4, 6 months then at 15-18 months and then at 4—6 years Single dose (if not fully vaccinated)
Single dose (if no record of vaccination) Every 10 years
Age 6 weeks-—6 years
7-10 years
>11 years
@Pregnant women—Single dose during 3rd trimester for each pregnancy
morbidity, and mortality of IPD is more common in HIV-infected individuals, however antiretroviral therapy (ART) has shown to minimize the incidence of IPD.**
The inactivated conjugate (PCV13) vaccine provided protective antibody response to HIV-infected individuals with a CD4 count
>200 cells/mm? who had prior vaccination with the pneumococcal polysaccharide vaccine (PPSV23).°° Moreover, a recent study indicated that HIV-infected adults with CD4 count >200 who never received
a pneumococcal vaccination had higher antibody protection at weeks 8 and 28 from PCV13 followed by PPSV23 over PPSV23 alone. Similar studies have also shown that delaying the PPSV23 until six months after antiretroviral medication initiation did not improve immune response.*©
For those naive to pneumococcal vaccination, ACIP recommends PCV13 at time of HIV diagnosis regardless of CD4 count followed by PPSV23 vaccination >8 weeks later. A second PPSV23 dose can be given after five years if the HIV- infected individual is <65 years old. The third and final dose of PPSV23 can be given either at 65 years old or after five years from prior PPSV23 vaccination. If a patient has already received PPSV23, PCV13 should be administered >1 year later with a repeat of PPSV23 after five years. If the patient is not yet 65, they can receive one final PPSV23 vaccination at 65 years old or after five years from the 2nd dose of PPSV23.°” HIV-infected individuals with CD4 counts of <200 cells/mm can defer receiving PPSV23 until their count rises above 200.2 PCV13 and PPSV23 have been deemed safe for use in the HIV-infected population.”
Hepatitis B Virus
It is estimated that close to 40%
of HIV infected patients are also co-infected with hepatitis B virus (HBV), with the incidence of chronic HBV infection close to 10%.2° One study has shown that 15% of deaths in HIV-infected adults can be attributed to liver disease.*? HBV is a common cause of liver disease and it is well known that AIDS leads to faster progression to hepatocellular carcinoma.*°
HBV vaccination differs in effectiveness when given to HIV- infected individuals (18-68% effective) as opposed to uninfected individuals (60-95% effective).”® Completing the HBV vaccination series before contracting HIV confers similar protection against HBV as in HIV-uninfected individuals.
MARYLANDPHARMACIST.ORG 13
Continuing Ed
Therefore, it is optimal to begin HBV vaccination before or at the time of HIV diagnosis.’® If a delay occurs, duration of protection is decreased in HIV-infected individuals, declining to 70% protection after 12 months
to 30% after 24 months.*° For HIV-infected individuals who fail
to seroconvert (<10 mIU/mL) after receiving all immunizations within
a series, double-dose (40ug) HBV vaccination have been proposed
as follow-up. Seroconversion rates have been reported at 51-77% with better response in those who are taking combination ART and have higher CD4 counts (>350 cells/ mm.,,).'° Furthermore, double-
dose immunizations may confer durability. At 72 weeks post- vaccination, 56% of those who received a single dose immunization lost response whereas only 23%
lost response in the double-dose group.*! [Table 4] provides further information.****
The HBV vaccination series is well tolerated in both single and double- dose trials with local reactions being more prevalent in double- dose immunizations.*! The HBV vaccination series has received endorsement from the WHO Global Advisory Committee on Vaccine Safety (GACVS).°°
Human Papillomavirus
Human Papillmoavirus (HPV) is the most common sexually transmitted disease with an estimated preva- lence of 45% in the general popula- tion and rates as high as 73% in the HIV-infected population.’®* HIV- infected patients with HPV also have a higher incidence of infections with oncogenic serotypes also known as high-risk HPV (HR-HPV).*° Despite the increased prevalence, it is estimated that only 17.2% of men who have sex with men, aged 18-26 years, receive >1 HPV vaccination.*°
There. is limited data on the inactivated vaccine Gardasil-9 and
0.5m
Table 4: HBV vaccine administration, dosing and schedule for Recombivax HB and Engerix-B in HIV-infected individuals****
O and then
IM 11-15 years Maca tie 0, 1, and ae Ovens 6 months
Schedule
Age
Birth-19 years
aAdolescents can receive either two or three dose series
its immunogenicity and safety
in HIV-infected individuals. ACIP, - however, recommends Gardasil-9 for HIV-infected individuals regardless of CD4 count, advising a three dose series (0, 1-2, and 6 months) for females and males between the ages of 9-26.°° If an individual has HPV, they should still receive the vaccine to prevent against infection with other oncogenic HPV serotypes.
Measles, Mumps, Rubella
The incidence of measles, mumps, and rubella (MMR) in the general population is low due to continued vaccination efforts. In 2014, the number of new cases per 100,000 population were 0.21, 0.38, and 0, respectively.”” Early studies have shown that mortality rate for HIV- infected patients with measles is as high as 40%, however a lower rate was seen in those that were vaccinated.*®
A cross-sectional analysis assessed the humoral immune response to
a measles vaccine between HIV- infected and uninfected individuals. There were no differences three months after vaccination. However, at one year 34% of the HIV infected patients remained seropositive compared to 80% in the uninfected population. This same study also assessed adaptive immune response to measles which included a positive IgG measles ELISA and/or a positive
14 MARYLAND PHARMACIST | WINTER 2018
cellular proliferative response after vaccination. The results did not find any difference between the two groups 12 months after vaccine administration.*?
All three of these organisms are administered as one live vaccine. Due to the risk of measles pneu- monitis after MMR vaccination, HIV-infected individuals are only eligible for this vaccine once their CD4 count is >200 cells/mm? or >15%."° Safety data suggests the MMR vaccine is well-tolerated in children and adults.*°*# Reports have shown transient increases in HIV-1 RNA levels with a return to baseline 6-8 weeks after
MMR vaccination but the long-term consequences of this increase
is unknown.*?
Varicella and Herpes Zoster
Varicella zoster virus (VZV) is the etiological cause of chickenpox whereas the herpes zoster virus (HZV) is a reactivation of latent VZV. VZV infection in HIV-infected individuals can increase HIV viral loads.** HZV has a higher prevalence in the elderly population but is
also 10-30 times more likely in HIV-infected patients, regardless of age.** In the general population, the VZV vaccine is recommended for children starting at 12 months of age whereas the HZV vaccine is recommended in those >60 years of age.*°
VZV vaccine efficacy in HIV-infected children, 1-8 years old, had antibody responses of 59%-72% at 20 weeks of vaccine series completion, which declined to 43%-65% one year after. In contrast, VZV vaccine efficacy
in healthy children is >85%.4° VZV vaccine has been shown to be
well tolerated with local injection site reactions being the most noted.** Nevertheless, HIV-infected individuals are at a higher risk for developing complications including pneumonia and encephalitis and are subsequently associated with a 25- fold higher risk of death. Therefore,
a series separated by >3 months and a CD4 count of >200 cells/mm: is recommended for those that lack immunity.’
HZV, however, is an endogenous infection for persons that have been exposed to VZV primary infection. HZV vaccine, therefore, must act to alter the host-
virus relationship by boosting immunity in order to decrease
Patient Case:
illness severity.*® The HZV vaccine contains 14 times the amount
of VZV in it.”? The effectiveness
of this vaccine was close to 37%
in the inmunocompromised patient population, but this
was not specifically looking at HIV-infected patients. HZV is
also administered as a single
dose injected subcutaneously.’ Protection declines precipitously after five years.°° Data regarding the safety and efficacy of HZV vaccine in HIV-infected individuals is lacking. A study, evaluating 295 HIV-infected patients with a CD4 >200 cells/mm found that HZV vaccine was safe and immunogenic in HIV-infected individuals but was not powered
to evaluate efficacy.*? A new HZV vaccine (Shingrix, GlaxoSmithKline) was approved by the FDA for use
in adults >50 years in October
2017. There is limited data to date on the use of this new product in HIV-infected subjects. The vaccine is considered to be a non-live recombinant.°?
Conclusion
In conclusion, the likelihood of vaccine efficacy within the HIV population is dependent upon a functioning immune system. For the most part, this is defined to be a CD4 count >200 cells/mm and
a CD4% >15%. It is recommended that vaccines be administered
as early as possible, especially if the vaccines are live. Inactivated vaccines, however, have been shown to be effective with lower CD4 counts and can thus be given at any time. It should be noted that inactivated vaccines are not devoid of adverse effects and that caution Should be taken during all vaccine administrations. Finally, in instances such as PPSV23, vaccination can be delayed until the CD4 count rebounds to above 200 for optimal efficacy. @
HM is an 18-year-old CM that has come to the pharmacy to pick up his prescription. He has agreed to get the influenza shot but has questions about other immunizations he needs before he starts college. After getting his medical history, you find out that HM has been HIV-infected for the past year. He is adherent to his medications and has claimed that his last viral load was determined to be undetectable. Additionally, his last reported CD4 count was 300 cells/mm. He has received his MMR, Tdap, and Varicella vaccines in the past. When asked about allergies, HM noted that he had trouble moving his arm last time he received the influenza vaccine.
Case Questions:
_L.If Menactra is supplied in your pharmacy, how would you schedule HM’s doses(s)?
a. Single dose
b. Two doses spaced 10 weeks apart
c. Four dose series
d.HM is not indicated for Men-
~actra since his CD4 cell count is too low
2.What other vaccinations is HM indicated for?
a. Pneumococcal
b. Hepatitis B
c.A &B
d.None of the above
3.HM wants to receive the HPV vaccine. What can you tell him?
a. HPV vaccine is not recom- mended for males
b. He is too young to receive the vaccination
c. He can receive the vaccine as long as his CD4 count is above 200 cells/mm?
d.He can receive the vaccine regardless of CD4 count
Answers on page 16
MARYLANDPHARMACIST.ORG_ 15
Continuing Ed
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Bailey CL, Smith V, Sands M. Hepatitis B vaccine: a seven-year study of adherence to the immunization guidelines and efficacy in HIV-1 positive adults. Int J Infect Dis 2008;12(6):e77-83.
Durham MD, Buchacz K, Armon C, et al. Seasonal influenza vaccination rates in the HIV outpatient study-United States, 1999- 2013. Clin Infect Dis 2015;60(6):976-7.
Setse RW, Siberry GK, Moss WJ, et al. Meningococcal Conjugate and tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccination among HIV-infected youth. Pediatr Infect Dis J ZUG S5\b)-eloc-/
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Kroon FP, van Dissel JT, de Jong JC, Zwinderman K, van Furth R. Antibody response after influenza vaccination in HIV-infected individuals: a consecutive 3-year study. Vaccine 2000;18(26):3040-9.
Centers for Disease Control and Prevention. Influenza (Flu). Who needs a flu vaccine and when. https://www.cdc.gov/ flu/consumer/vaccinations.htm. Published Aug 25, 2016. Accessed Sept 9, 2017.
Atashili J, Kalilani L, Adimora AA. Efficacy and clinical effectiveness of influenza vaccines in HIV-infected individuals:
a meta-analysis. BMC Infect Dis 2006;6(138):1-6.
Fine AD, Bridges CB, De Guzman AM, et al. Influenza A among patients with human immunodeficiency virus: an outbreak of infection at a residential facility in New York City. Clin Infect Dis. 2001;32(12): 1784- or
Weinberg A, Curtis D, Ning MF, et al. Immune responses to circulating and vaccine viral strains in HIV-infected and uninfected children and youth who received the 2013/2014 quadrivalent live-attenuated influenza vaccine. Front Immunol 2016;7: Article 142.
Harrison LH. Epidemiological profile of meningococcal disease in the United States. Clin Infect Dis 2010;50(S2):S37-44.
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Menactra® [package insert] Swiftwater, PA: Sanofi Pasteur Inc; 2016
Menveo® [package insert] Cambridge, MA:
Novartis AG; 2010
Crum-Cianflone NF, Wallace MR. Vaccination in HIV-infected adults. AIDS Patient Care STDs. 2014;28(8):397-410.
Centers for Disease Control and Prevention. Tetanus surveillance — United States, 2001 — 2008. MMWR. 2011; 60(12):365-369.
Centers for Disease Control and Prevention. Diphtheria; for clinicians. https://www.cde.gov/diphtheria/clinicians. html. Published Jan 15, 2016. Accessed Jul 12, 2017
Centers for Disease Control and Prevention. Pertussis (whooping cough). https://www.cdc.gov/pertussis/surv- reporting/cases-by-year.html. Published Jan 10 2017. Accessed May 15 2017.
Rosenblatt HM, Song LY, Nachman SA, et al. Tetanus immunity after diphtheria, tetanus toxoids, and acellular pertussis vaccination in children with clinically stable HIV infection. J Allergy Clin Immunol 2005;116(3);698-703.
Kroon FP, van Dissel JT, Labadie J, van Loon AM, van Furth R. Antibody response to diphtheria, tetanus, and poliomyelitis vaccines in relation to the number of CD4+ T lymphocytes in adults infected with human immunodeficiency virus. Clin Infect Dis 1995;21(5): 1197-1203.
Abzug MJ, Song LY, Fenton T, et al. Pertussis booster vaccination in HIV- infected children receiving highly active antiretroviral therapy. Pediatrics 2007;120(5):e1190-202.
Marcus JL, Baxter R, Leyden WA, et al. Invasive pneumococcal disease among HIV-infected and HIV-uninfected adults in a large integrated healthcare system. AIDS Patient Care STDs. 2016;30(10): 463-70.
Jordano Q, Falco V, Almirante B, et al. Invasive pneumococcal disease in patients infected with HIV: still a threat in the era of highly active antiretroviral therapy. Clin Infect Dis 2004;38(11):1623-8.
Glesby MJ, Watson W, Brinson C, et al. Immunogenicity and safety of 13-valent pneumococcal conjugate vaccine in HIV- infected adults previously vaccinated with pneumococcal polysaccharide vaccine. J Infect Dis 2015; 212(1): 18-27.
16 MARYLAND PHARMACIST | WINTER 2018
26.
eu
28.
oo
30.
ANSWERS
1. Answer: B For HIV-infected individuals who are between the ages of 2-55 years old, Menactra is recommended as a two-dose series given 12 weeks apart. Menactra is an inactivated polysaccharide vaccine that is recommend for HIV-infected patients regardless of current CD4 count.
2. Answer: C HM is an 18-year-old Caucasian male that is HIV positive. He is indicated to receive both Pneumococcal and Hepatitis B vaccinations.
3. Answer: D HPV is an inactivated vaccination that is recommended to boys and girls ages 9-26. Therefore, he can receive the vaccine regardless of CD4 count.
Sadlier C, O'Dea S, Bennett K, Dunne J, Conlon N, Bergin C. Immunological efficacy of pneumococcal vaccine strategies in HIV-infected adults:
a randomized clinical trial. Sci Rep 2016;6:32076.
Bennett NM, Whitney CG, Moore
M, Pilishvili T, Dooling KL. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2012;61(40): 816-19.
Chun HM, Fieberg AM, Hullsiek KH, et
al. The epidemiology of hepatitis B virus infection in a U.S. cohort of HIV-infected individuals during the last 20 years. Clin
Infect Dis 2010;50(3):426-436.
The Antiretroviral Therapy Cohort Collaboration. Causes of death in HIV-1-— infected patients treated with antiretroviral therapy, 1996-2006: collaborative analysis of 13 HIV cohort studies. Clin Infect Diseases 2010;50(10):1387-96
Mena G, Garcia-Basteiro AL, Bayas JM. Hepatitis B and A vaccination in HIV- infected adults: A review. Hum Vaccin Immunother 2015;11(11):2582-98.
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Rey D, Piroth L, Wendling Md, et al. Safety and immunogenicity of double- dose versus standard-dose hepatitis B revaccination in non-responding adults with HIV-1 (ANRS HB04 B-BOOST): a multicentre, open-label, randomised controlled tral. Lancet Infect Dis 2015;15(11):1283-91.
Recombivax HB® [package insert] Whitehouse Station, NJ: Merck & Co., INC; 2017
Engerix-B® [package insert] Rixensart, Belgium: GlaxoSmithKline; 2016
McQuillan G, Kruszon-Moran D, Markowitz LE, Unger ER, Paulose-Ram R. Prevalence
of HPV in adults aged 18-69: United States,
2011-2014. NCHS Data Brief 2017;280: 1-8.
Oliver SE, Hoots BE, Paz-Bailey G, Markowitz LE, Meites E. Increasing human papillomavirus vaccine coverage among men who have sex with men-National HIV behavioral surveillance, United States, 2014. J Acquir Immune Defic Syndr 2017;75:S370-S374.
Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination — updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2016; 65:1405-08.
National Center for Health Statistics. Health, United States, 2016: With Chartbook on Long-term trends in Health. Hyattsville, MD 2017. https://www.cdc.gov/ nchs/data/hus/hus16.pdf#033
. Kaplan LJ, Daum RS, Smaron M,
McCarthy CA. Severe measles in immunocompromised patients. JAMA 1992;267(9):1237-41.
. Belaunzaran-Zamudio, PF, Garcia-Leon
ML, Wong-Chew RM, et al. Early loss of measles antibodies after MMR vaccine among HIV-infected adults receiving HAART. Vaccine 2009;7(50):7059-64.
. Coetzee S, Morrow BM, Argent AC. Measles
in a South African paediatric intensive care unit: Again! J Paediatr Child Health 2014;50(5):379-385.
. Singh HK, Chiu YL, Wilkin T. Measles,
mumps, and rubella serostatus and response to MMR vaccination among HIV- infected adults. AIDS Patient Care STDs 2015; 29(9):461-464.
. Obaro SK, Pugatch D, Luzunaga, K.
Immunogenicity and efficacy of childhood vaccines in HIV-1-infected children. Lancet Infect Dis 2004;4(8):510-518.
. Levin MJ, Gershon AA, Weinberg A, Song
LY, Fentin T, Nowak B. Administration
of live varicella vaccine to HIV-infected
children with current or past significant depression of CD4(+) T cells. J Infect Dis 2006; 194(2):
247-255.
. Grabar S, Tattevin P, Selinger-Leneman
H, et al. Incidence of herpes zoster in HIV-infected adults in the combined antiretroviral therapy era: results from the FHDH-ANRS C04 cohort. Clin Infect Dis 2015;60(8):1269-77.
. Centers for Disease Control and
Prevention. Immunization Schedules. https://www.cdc.gov/vaccines/schedules/ hep/imz/adult.html Published February 6, 2017. Accessed August 31, 2017.
. Seward JF, Marin M, Vazquez M. Varicella
vaccine effectiveness in the US vaccination program: A Review. J Infect Dis. 2008; 197 (S2): S82-S89.
. Marin M, Guris D, Chaves SS, Schmid
S, Seward JF. Prevention of varicella. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007;RRO4L1-40. https:// www.cdc.gov/mmwr/preview/mmwrhtmV mr5604ai.htm.
. Oxman MN. Zoster vaccine: current status
and future prospects. Clin Infect Dis. 2010; 51 (2):197-213.
. SD Shafran. Live attenuated herpes zoster
vaccine for HIV-infected adults. HIV Med 2016; 17(4): 305-310.
. Centers for Disease Control and
Prevention. Herpes Zoster Vaccination. https://www.cdc.gov/vaccines/vpd/ shingles/ncp/hcp-vax-recs.html. Published Sept 11 2015. Accessed May 16, 2017.
. Benson CA, Hua L, Anderson JW, et al.
for the ACTG A5247 Team. Zostavax is generally safe and immunogenic in HIV+ adults virologically suppressed on ART: results of a Phase 2, randomized, double- blind, placebo-controlled trial. 19th CROI, 5-8 March 2012, Seattle. Oral abstract 96.
. Shingrix® [package insert] Rixensart,
Belgium: GlaxoSmithKline; 2017.
CONTINUING EDUCATION QUIZ
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education. A continuing education credit will be awarded
within six to eight weeks.
MPhA Members may retrieve FREE CE for this article up (1) to one-year after the program release date.
Program Release Date: 1/29/2018
Program Expiration Date: 1/29/2021
This program provides for 1.0 contact hour (0.1) of continuing education credit. Universal Activity Number (UAN) 0798-9999-18-017-H06-P and (UAN)
0798-9999-18-017-H06-T
The authors have no financial disclosures to report.
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Click on “Obtain Your Statement of CE Credits for the
(2) Scroll down to Homestudy/OnDemand CE Credits and select the Quiz you want to take.
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MARYLANDPHARMACIST.ORG 17
Interview: Lieutenant Chris Charles continued from page 6
How is practicing within the Indian Health Service different from other experiences that you have had?
The main thing is the variety of areas I get to work in. I'm not only the outpatient pharmacist, I'm also the inpatient and clinic pharmacist. I have a broad scope of practice here. I also enjoy full access to patients’ EHRs.
What is your day-to-day responsibility?
The pharmacy team starts the day by making sure
that the ScriptPro is working. We do about 1,200-1,400 prescriptions a day, so ScriptPro has to be working. We run the refill list and start to process the prescriptions. As the processing pharmacist, we will park ourselves at the computer because most of our scripts come through electronically from the clinics. We check them for interactions, look through the patient EHR, screen for immunizations, and call the doctors as needed.
As the filling pharmacist, I'm at the back with the ScriptPro, making sure that it is stocked with bottles, filling prescriptions, and listening to Chinese on my headphones because I'm learning Chinese. As the clinic pharmacist, I jump right in: I counsel patients, provide recommendations to the providers, and review labs. As the narcotics pharmacist, I focus our day on narcotics stewardship work — we handle all the narcotics for the hospital. Lastly, as the acute care pharmacist I manage
800-965-EPIC | EPICRX.COM
all the pharmaceutical needs and many of the clinical needs of our patients admitted to the inpatient ward.
What tips would you give to anyone who is interested in joining the Indian Health Service?
¢ The very first thing would to decide whether you want
to be Corps or civilian because to work for the IHS, you don't have to be Corps. You still qualify for loan repayment as a civilian.
Be open-minded as to where you want to go.
Get a good pair of hiking boots because you will be out and about.
Visit the site, if you can, or at least talk to people that work there. Every site is different.
Lastly, get ready for adventure. For students — pass your boards and get your license!
What do you miss about being in Maryland?
I miss my friends. I miss the MPhA family. And I miss the variety of restaurants in Baltimore. I miss the short commute. There is beautiful scenery here, but the drive
can be a bit drawn out. And it is cold here! We have seen
temperatures below 10 degrees already (late October) and several flurries. @
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Maryland Pharmacist’s Role in Preventing and Treating Sexually
Transmitted Infections
By Elisabeth Liebow, MPH, Policy and Program Associate Center for STI Prevention, Maryland Department of Health
Maryland pharmacists can play a critical role in addressing the significant public health burden of sexually transmitted infections through an intervention known as Expedited Partner Therapy (EPT). EPT is the voluntary clinical practice of treating the sex partners of patients diagnosed with certain sexually transmitted infections (STIs), without an intervening medical examination of the partners. EPT has been shown to decrease the likelinood of repeat infection in the index patient. The Centers for Disease Control and Prevention (CDC) recommends EPT as a useful chlamydia and gonorrhea treatment option for heterosexual partners who are unlikely or unable to obtain timely testing, counseling and treatment.t* The CDC also encourages consideration of EPT for partner treatment of trichomoniasis.* Numerous national organizations endorse the practice. In Maryland, the Maryland Pharmacists Association, along with all major chapters of medical societies and the medical boards, endorse EPT.
Burden of STIs in Maryland
Rates of chlamydia and gonorrhea are at record high levels nationally and have risen significantly in Maryland.*4 From 2015 to 2016, reported cases of chlamydia in Maryland
increased 11.6%. In 2016, there were 30,658 cases reported, PIII GORI a ra Pe pet ee Or arate of 510.4 per 100,000 population. Reported cases of ST i S i n M a ry j a n d gonorrhea rose an alarming 38.9% from 2015 to 2016. There were 9,523 cases of gonorrhea reported in 2016, a rate of 158.5 per 100,000 population. While preliminary 2017 year-
end data indicate the dramatic increase appears to have 1 1 . 6 % 30,6 be 8 slowed, increases are still occurring (unpublished surveillance data, Maryland Department of Health). The CDC estimates that trichomoniasis is the most prevalent non-viral STI nationwide, though the true burden of disease cannot be measured since trichomoniasis is not a reportable disease.” Like chlamydia and gonorrhea, untreated trichomoniasis can
Cause severe sequelae, especially in females, including pelvic inflammatory disease, infertility and ectopic pregnancy.
EPT in Maryland 510.4 38.9%
_ Rate per 100,000 | Percent of increase
RAC, hw
eaPercent of increases: Amount of
In Maryland, EPT can legally be prescribed and dispensed for partner treatment of chlamydia and gonorrhea as of June 1, 2015, and trichomoniasis as of October 1, 2017. Pharmacists are authorized to dispense EPT as prescribed. See Maryland Health-General, Code Ann. § 18-214.1 (2017)5. For practitioners and pharmacists implementing EPT, Maryland law and implementation regulations specify the following:*°
* All EPT prescriptions must include the designation ) 9 5 2 3 1 5 S e 5
“Expedited Partner Therapy” or “EPT;”
a Amount of cases of ate per 100,000 * Separate EPT prescriptions must be issued for each partner; ary oa reported | of gonorrhea cases |
If asex partner's name is unknown, the written designation “EPT” is sufficient for the pharmacist to fill the prescription.
MARYLANDPHARMACIST.ORG 19
Though not required, this information can be obtained when the patient or partner drops off or picks up the partner's prescription;
¢ EPT prescriptions may not be refilled;
« Pharmacists (and prescribers) must provide written informational materials to patients and each partner. The accompanying information must include advice for the partner to seek medical care even after taking EPT; information about the infection; medication instructions; warnings about allergic reactions; and advice to abstain from sex for seven days post-treatment.
e Chlamydia and gonorrhea informational materials for patients and partners are available for downloading on the Maryland Department of Health's EPT web site at http:// bit.ly/EPTMaryland. New materials for trichomoniasis are in production and will be available shortly. Alternatively, comparable educational materials may be used.
EPT Treatment Regimens for Partners
e Chlamydia treatment delivered via EPT — 1 gm azithromycin orally once.
¢ Gonorrhea treatment delivered via EPT — dual oral treatment with 400 mg cefixime once PLUS 1 gm azithromycin once.
o Note: Due to the emergence of resistance to oral cephalosporins, the CDC-recommended in-office treatment of gonorrhea is 250 mg ceftriaxone once IM PLUS 1 gm azithromycin orally once.
¢ Trichomoniasis treatment delivered via EPT — 2 gm metronidazole orally once OR 2 gm tinidazole orally once.
Operationalizing EPT
¢ Paying for EPT: (1) If the partner’s name is on the prescription, the medication may be paid for out of pocket by the person picking up the prescription (the patient or the partner), or by the partner's health insurance. (2) If a prescription is issued to “EPT” with no partner name included, the medication must be paid for out of pocket, or the unnamed partner wishing to have his insurance cover medication costs must provide identification to the pharmacist. Pharmacists should not bill the partner's prescription to the index patient's insurance.
¢ Creating profiles for unnamed partners: Patients most often know and disclose sex partners’ names to their clinicians. And, pharmacists have an additional opportunity to ask for the partner's name for those prescriptions simply issued to “EPT.” Unnamed prescriptions, though legally permissible, pose challenges.
o Consider creating a patient profile called “EPT Partner.” If your computer system requires additional patient
20 MARYLAND PHARMACIST | WINTER 2018
demographic information, use your professional judgment as to what makes sense, such as creating a unique identifier and a default birthdate.
o Alternatively, consider designating a sequential numeric identifier as the first name on each unnamed prescription, “EPT” as the last name on each, and a default birthdate, resulting in numerically identifiable prescriptions for unnamed partners. First unnamed | prescription: 001 (first name), EPT (last name), 01/01/2000 (DOB); the next unnamed EPT prescription would be 002 (first name), EPT (last name), 01/01/2000 (DOB); etc.
o Consider assigning “EPT” to your Facility field for tracking all EPT prescriptions.
Adverse Events
Among 41 states in which EPT is legally permissible, there have been no known reported instances of serious allergic reactions to EPT, nor any lawsuits known to have arisen from the provision of EPT. Notably, California, the first state to authorize EPT (in 2001), received no calls to its toll-free EPT adverse events hotline. In Maryland, patients and partners with concerns about serious allergic reactions to EPT are advised to contact the Maryland Department of Health at 410-767-6690.
Resources
In addition to fact sheets, Maryland's EPT law, implementa- tion regulations and provider guidance can be found on the EPT website. Additional EPT information can be found at: https://www.cdc.gov/std/ept/default.htm. @
REFERENCES
1. Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta, GA: U.S. Department of Health and Human Services; 2006. Accessible at: https:// www.cdc.gov/std/treatment/eptfinalreport2006.pdf. Accessed December 6, 2017,
2. Centers for Disease Control and Prevention. Atlanta: U.S. Department of Health & Human Services. 2015 STD Treatment Guidelines. Web site. Accessible at: https://www.cdc.gov/std/tg2015/default.htm. Updated January 25, 2017, Accessed December 6, 2017.
3. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2016. Atlanta: U.S. Department of Health and Human Services; 2017. Accessible at: https://www.cdc.gov/std/stats. Updated: October 17, 2017. Accessed December 6, 2017.
4. STI Data and Statistics. Maryland Department of Health website. Accessible at: https://phpa.health maryland.gov/OIDPCS/CSTIP/Pages/STI- Data-Statistics.aspx. Updated: May 21, 2017. Accessed December 6, 2017.
5. Md. Code Ann., Health-Gen. §18-214.1. Accessible at: http://mgaleg. maryland.gov/webmga/frmStatutesText.aspx?article=ghg§ion=18- 214.16ext=html&session=2018RS&tab=subject5. Accessed December 6, 2017
6. Md. Code Regs. 10.06.01.17. Accessible at: http://www.dsd.state.md.us/ comar/SubtitleSearch.aspx?search=10.06.07*. Accessed December 6, 2017.
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| Evander Frank Kelly ($500-$999) Matthew Shimoda Darci Eubank Cynthia Boyle John Spain Janet Feldman in memory of David
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B. Olive Cole ($100-$499) John VanWie Abimbola Adebowale Wayne VanWie
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Randy Chiat Supporter ($25-$99) Kristen Fink Mr. and Mrs. Paul Albert in memory of Gerard, Herpel David Serpick Mr. and Mrs. Barry Hoffman in
Berry Hecht : memory of David Serpick
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Butch Henderson
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of David Serpick Amy Nathanson Brian Hose John Beckman Mr. and Mrs. Barry Rothberg in Nelson Kline : nick Jeffrey Bray memory of David Serpick Cherokee Layson-Wolf Mr. and Mrs. Howard Schiff in
James Bresette ; ; oral Mr. and Mrs. Neil and Dixie Leikach ” C | Pier Om son Gavic Se1 ic) Sean ce Amy Uhlfelder in memory of David
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Executive Director’s Message
Happy New Year! As we kick off 2018, I wish you a year full of meaning, happiness and prosperity!
For those of you new to MPhA ... Welcome!
The MPhA Board of Trustees, commit- tee leaders and its members are committed to you. We continually work to shine a light on you,
so that the public knows the contributions you make in enhancing patient access to health care and improved patient outcomes.
We continue to work toward achieving the goals of our strategic plan,
with an emphasis on membership value, recruitment and retention.
A critical area identified in the strate- gic plan is advocacy. This time of year, includes the kickoff of the 2018 legislative session in Annapolis. Your support of MPhA provides resources for that advocacy. At the forefront are our efforts to advance the profession and to protect sectors within our community that come under assault. Over the last few years, we have generated significant recognition
in Annapolis. This has been an investment of time and resources of leadership, staff and members.
The 2018 session is looking to be another barnburner, with bills focused on pharmacy reimbursements,
MAC pricing, PBM issues and prescription drug pricing. Our Advocacy Committee is finalizing details related to pursing legislation
to expand pharmacists’ medication administration. As members of the
General Assembly look to address the opioid epidemic and revise the oversight of the production and dispensing of medicinal cannabis, we will support efforts that maintain the pharmacist's ability to assist in achieving positive outcomes for patients, and will fight against any unfunded mandates and exclusion of pharmacists from providing medication expertise.
Please be ready to make calls, send emails and provide testimony. Your support will be needed.
As we focus on membership recruitment and retention, we
are hosting focus groups and reaching out to segments of our community to determine how we can better serve your needs. These efforts will result in more focused investment of MPhA’s resources.
Thank you again for you membership.
I look forward to seeing you at the MidYear Meeting on February 18 and at Legislative Day on February 20. Please feel free to reach out to me with your ideas and suggestions at 443-583-8000 or aliyah.horton@ mdpha.com. @
Lye —
Aliyah N. Horton, CAE Executive Director
A critical area identified in the strategic plan is advocacy. Your support of MPhA provides resources for that advocacy. At the forefront are our efforts to advance the profession and to protect sectors within our community that come under assault. Thank you again for your membership.
Thank you 2018 Corporate Sponsors 44 pharmacists’
© Clarion
Ly mutual
TOMORROW. IMAGINE THAT.
MARYLANDPHARMACIST.ORG 23
FEBRUARY.18 |) ANNAPOLIS ©.
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MARYLAND PHARMACY COALITION
LEGISLATIVE DAY & RECEPTION
TUESDAY, FEBRUARY 20, 2018 ANNAPOLIS
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GOELEAGUE TODAY! DEADLINE APRIL 2
Editorial Mid-Year Meeting MPhA News Continuing Education
2018 Legislative The Role of Professional Falls Prevention in Session Recap Thank you to all Pharmacy Organizations and Older Adults who attended! Its Impact on the Profession
of Pharmacy.
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5 | Member Mentions & News You Can Use
9 | The Role of Professional Pharmacy Organizations and Its Impact on the Profession of Pharmacy
10 | Welcome New MPhA Members 11 | MPhA 2018 Mid-Year Meeting 22 | Thank You Corporate Sponsors
ADVERTISERS INDEX
22 Corporate Sponsors 7 | 136th Annual Convention: Rising to the Future 2 Smith Drug Company
8 Independent Pharmacy Buying Group 12 Cardinal Health ZO AERC 25.2) Smith 13 | Falls Prevention in Older Adults ZLREDPIG 28 Pharmacists Mutual
20 | Pharmacy Time Capsule
24 | Reflections, Rhythms and Rewards of Haiti Medical Missions: Five Times and Four Years Later
21 | Legislative Update
MARYLANDPHARMACIST.ORG 3
MARYLAND PHARMACISTS ASSOCIATION
MPhA OFFICERS 2017-2018
Kristen Fink, PharmD, BCPS, CDE, Chairman
Cherokee Layson-Wolf, PharmD, CGP, BCACP, FAPhA, President
Chai Wang, PharmD, BCPS, AE-C, Vice President
Matthew Shimoda, PharmD, Treasurer
Samuel Lichter, Honorary President (posthumous)
HOUSE OFFICERS
Richard Debenedetto, PharmD, MS, AAHIVP, Speaker
Matthew Balish, PharmD, RPh, Vice Speaker
MPhA TRUSTEES
Kerry Cormier, PharmD
Darci Eubank, Pharm
Sadhna Khatri, PharmD
Anne Lin, PharmD
Amy Nathanson, PharmD, BCACP, AE-C,
Wayne VanWie, RPh
Patricia Dieso, ASP Student Representative — Notre Dame of Maryland University School of Pharmacy
EX-OFFICIO TRUSTEES
Rondall Allen, PharmD, Dean University of Maryland Eastern Shore School of Pharmacy
Natalie Eddington, PhD, Dean University of Maryland School of Pharmacy
Paul R. Holly, PD, MPhA Foundation
John Lee, University of Maryland School of Pharmacy
Divya Vepun, University of Maryland Eastern Shore School of Pharmacy
PEER REVIEWERS
Kerry Cormier, PharmD
Tosin David, PharmD
Nicole Groves, PharmD
G. Lawrence Hogue, BSPharm, PD Frank Nice, RPh, DPA, CPHP
STAFF
Aliyah N. Horton, CAE, Executive Director
Lauren Williams, Director of Programs and Membership Engagement
Shawn Collins, Membership Services Coordinator
CONTRIBUTORS
NASPA Services Company, LLC, Editorial
Katy Pincus, PharmD, BCPS
Special thanks to Graphtech, Advertising Sales and Design
Maryland Pharmacists Association, 9115 Guilford Road, Suite 200, Columbia, MD 21046, call 443.583.8000, or email aliyah.horton@mdpha.com.
President’s Pad
Congratulations to our soon-to-be graduates
... MPhA is an important resource for you as you continue your professional development after graduation.
RE a
Dear MPhA Members:
When we last saw each other, we were on the brink of Maryland Pharmacy Coalition's Legislative Day and as I write this, the 2018 legislative season has come to an end — but there is still work to be done to advocate for the profession.
Nothing is more inspiring than seeing pharmacists and student pharmacists from across the state descending upon Annapolis to help our legislators learn about pharmacy related issues. The excitement is palpable as participants make their way to the legislative visits to meet with delegates and their aides. There is no doubt that we left an indelible mark with our delegates and amongst each other who participated that day. Thank you to
all the MPhA members who came to Legislative Day, as well as those who helped plan and contributed long hours to make the event a success. We are so fortunate to have a dedicated membership that volunteers so much of their time to support pharmacy — that is one of the great things I love about being a member of MPhA!
As Imentioned in the Winter journal, advocacy is a year-round activity. Take the time to share your story about how you impact your community and your patients.
Just a few weeks ago was the APhA 2018 Annual Meeting in Nashville, TN. We had an amazing number of MPhA members in attendance and the Maryland Pharmacy Night
on Saturday night was also a hit. It was great to catch up with our Maryland pharmacy colleagues and enjoy each other's company. I know that many of us returned home from the meeting inspired, with many new ideas to implement in our practices.
Spring is finally here, and we're getting ready for the MPhA 136th Annual Convention
in Ocean City, MD from June 29—July 2! The Meetings Planning Committee and MPhA staff are hard at work to bring you an amazing group of speakers to learn about different topics, earn continuing education credits, make new connections, and enjoy the beach. It's another fantastic opportunity to prepare you to be #ProviderReady! I can't wait to see everyone there.
Be sure to follow us on Facebook and Twitter, and check your inbox for the Monday Message to stay up to date with all MPhA events and any pharmacy-related news and updates.
As we round out the spring, it is time for our soon-to-be graduates to finish out their training and join the ranks as pharmacists. Congratulations to you on this hard-fought journey of pharmacy school. Know that we're rooting for you and are excited to see what you'll accomplish in practice. MPhA is an important resource for you as you continue
your professional development after graduation — you are an important part of our membership and our work will continue with your support! We look forward to seeing you at MPhA events and New Practitioner activities. Congratulations to the Class of 2018! @
Kindest regards,
Cherokee Layson-Wolf President
f : f ;
MPhA News
Member Mentions & News
You Can Use
Maryland at APhA2018
It was great to see so many Maryland pharmacists, technicians, and students in Nashville at the APhA Annual Meeting!
Special thank you to the hardworking MPhA members representing Maryland in the APhA2018 House of Delegates! Thank you for your service!
Award Recognition Congratulations to the following MPhA members who were recognized with awards during the meeting:
¢ Tolani Adebanjo — APhA Foundation Boyle Family Scholarship
¢ Jim Bresette — Phi Lambda Sigma Advisor of the Year
m®
Magaly Rodriguez DeBittner
Joey Mattingly
And Congratulations to MPhA Members on These Recent Appointments
CARE Pharmacies Cooperative recently named MPhA Past President Christine Lee-Wilson to it’s 2018 Board of Directors. Lee-Wilson holds a Doctor of Pharmacy degree from St. Johns University, New York and currently owns Professional Pharmacy in Baltimore. Congratulations Christine!
Lincy Abraham, past MPhA rotation student, was selected to be the 2018-2019 National Association of Chain Drug Stores Foundation's Executive Fellow.
Dr. Yen Dang of the University of Maryland Eastern Shore School of Pharmacy was appointed to the Maryland statewide immunization commission for a 3-year term as the pharmacist member. Her term ends in 2020.
Cynthia Boyle — Phi Lambda Sigma National Leadership Award
Brian Hose — APhA-APPM Immunizing Pharmacists Special Interest Group award
Cherokee Layson-Wolf — APhA-APPM Immunizing Pharmacists Special Interest Group award
Joey Mattingly — Elected Speaker-Elect by the APhA House of Delegates
Ashley Moody — APhA-APPM Immunizing Pharmacists Special Interest Group award
¢ Magaly Rodriguez DeBittner — Sworn in as APhA Trustee
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Maryland's 2018 APhA House of Delegates representatives
A New Member to the MPhA Phamily!
Congratulations to MPhA Board Chair Kristen Fink and husband Andrew Wherley who welcomed their third son Cole Alexander on Thursday, April 5.
MPhA Member as Panelist on Opioid Series
MPhA Member Dr. Thomas Cargiulo appeared as a Subject matter expert panelist on Maryland Public Television's “America Addicted" program summarizing PBS News Hour's opioid epidemic series on February 9, 2018. Full video can be found on Maryland Public Television's website. @
MARYLANDPHARMACIST.ORG 5
2017 Recipients of the “Bowl of Hygeia” Award
4
Larry Presley John McGilvray Alan Barreuther Sue Frank Pierre Del Prato Mary Petruzzi Noel Rosas Goar Alvarez Alabama Alaska Arizona Arkansas California Connecticut Delaware Florida
id
Hewitt Ted Matthews Ed Cohen Ahmed Abdelmageed Tim Becker Merlin McFarland Melody Ryan Gregory Poret Greg Cameron Georgia Illinois Indiana lowa Kansas Kentucky Louisiana Maine
Denise Frank David French David Farris Minnesota Mississippi Missouri
Cynthia Boyle Anita Young Dennis Princing Maryland Massachusetts Michigan
+
Hubert Hein Thomas F.X. Bender, Jr. David Lansford New Hampshire New Jersey New Mexico
Matthew Bowman Gary Rihanek Mark Decerbo Montana Nebraska Nevada
My John T. McDonald III Steve Caiola Tim Weippert Debra Parker Ben Allison Mercy Chipman Jerry Musheno Marisa Carrasquillo New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico
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) fe ¥ Gary Kishfy Terry Blackmon Tim Tucker Chris Alvarado Kurt Price Pat Resto Rhode Island South Carolina Tennessee Texas Utah Virginia In Memoriam: Rob Loe
South Dakota
Keith Campbell Washington ~
Daneka Lucas Kevin Yingling Thad Schumacher Joe Steiner 4 Washington DC West Virginia Wisconsin Wyoming
The Bowl of Hygeia award program was originally developed by the A. H. Robins Company to recognize pharmacists across the nation for outstanding service to their communities. Selected through their respective professional pharmacy associations, each of these dedicated individuals has made uniquely personal contributions to a strong, healthy community. We offer our congratulations and thanks for their high example. The American Pharmacists Association Foundation, the National Alliance of State Pharmacy Associations and the state pharmacy associations have assumed responsibility for continuing this prestigious recognition program. All former recipients are encouraged to maintain their linkage to the Bowl of Hygeia by emailing current contact information to awards@naspa.us. The Bowl of Hygeia is on display in the APhA History Hall located in Washington, DC.
FOUNDATION
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136™ Annual Convention:
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Une 29-July 2, 2018. Ocean City, MDa mt a lat . ee a ee ee —— = = ie emcees ee a $2 ~j ina " tects _ Wehope you will come join us for a on ne ; —————— ae = four-day convention at the beach with ig - eoice . . Tae ae i ee See i ample opportunities to broaden your os knowledge in the pharmacy profession. eee : ti ae a : Highlights,include; ° rages gage how Te cc eUp,to.17.CEU.on the most current -~ “—— told 0) of me | C—O trends in the pharmacy profession “2 SRG GiGe (0 O) G1) Co | ee Ge Ge ooo
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e New Drug Update
e Job Burnout , : ee 1 e Cardiovascular Benefits of Diabetes Reg istration Is Open for MPhA‘s
Medication 136th Annual Convention e OTC Jeopardy in Ocean City, MD! Pharmacists, pharmacy technicians, and student pharmacists from Opportunities to network, connect, the surrounding regions convene, learn, and re-connect with your peers network and engage with colleagues and peers at our biggest event of the year!
¢ Opioids vs. NSAIDs Debate, and more
Chances to gain new perspectives from our dynamic speakers Recognition of professional Look for Friday afternoon &
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The Role of Professional Pharmacy Organizations and its Impact on the Profession of Pharmacy
By Enaefe Ziregbe, PharmD Candidate 2018, Howard University College of Pharmacy and MPhA Rotation Student
Pharmacy organizations have been heavily involved in shifting the focus of the pharmacy profession from traditional dispensing to pharmacists as an integral part of the health care team. The American Society of Hospital Pharmacists (ASHP) Hilton Head Conference
in South Carolina in 1985 established the groundwork for pharmacy being recognized as a clinical profession. This conference led the ASHP Foundation to fund parallel state and regional programs leading to the widespread reexamination of the professional mission by hospital pharmacists and the creation of plans to transform their departments into clinical enterprises. The American Association of Colleges of Pharmacy (AACP) delegates in 1990 endorsed a paper that declared that the mission of pharmacy practice
is to render pharmaceutical care.This was backed up by
the American Pharmacists Association (APhA) in 1991 when
it adopted a policy that stated “that the mission of pharmacy
is to serve society as the profession responsible for the appropriate use of medications, devices and services to achieve optimal therapeutic outcomes.” That same year, the ASHP
House of Delegates voted unanimously to endorse the concept of pharmaceutical care. These examples from national pharmacy organizations show the importance and impact of pharmacy organizations in the practice of pharmacy.*
The Maryland Pharmacists Association (MPhA),
established in 1882, has been pivotal in advancing the practice of pharmacy in the state of Maryland.
MPhA is the only state- wide professional society representing all practicing pharmacists and is affiliated with APhA, the National Community Pharmacists Association (NCPA), and the Academy of Managed Care Pharmacy (AMCP). The mission of MPhA is to strengthen the profession of pharmacy, advocate for all Maryland pharmacists and promote excellence in pharmacy practice.
MPhA has an umbrella organization, the Maryland Pharmacy Coalition (MPC), whose purpose is to
provide a forum for discussion and understanding between Maryland's pharmacy associations on issues impacting the practice of pharmacy and public health. MPC strengthens relationships between pharmacy associations in the state and encourages collaborative
efforts to benefit pharmacists and patients in Maryland. Members of the MPC include the Maryland Pharmacists Association, American Society of Consultant Pharmacists (Maryland chapter), Maryland Pharmaceutical Society, Maryland Society of Health System Pharmacists, University of Maryland Baltimore School of Pharmacy Student Government Association, University of Maryland Eastern Shore School of Pharmacy Student Government Association, and Notre Dame of Maryland University School of Pharmacy Student Government Association.*
Colleges of pharmacy vary in their educational offerings to students related to advocacy, and the annual MPC Legislative Day is an important day for pharmacists,
MARYLANDPHARMACIST.ORG 9
The Role of Professional Pharmacy Organizations continued
student pharmacists, and pharmacy technicians to
join together to educate legislators and staff about the importance of pharmacy practice to the public health for the state of Maryland.* The most recent Legislative Day held on February 20, 2018 saw student pharmacists from University of Maryland, Notre Dame of Maryland University, and University of Maryland Eastern Shore Schools of Pharmacy come together to establish their stance on bills that had been introduced in the General Assembly. Students were divided into their various districts and spoke with their district delegates and senators on how these bills could positively or negatively affect the profession of pharmacy. For example, a Maryland house bill, HB601: Public Health — Opioids- Dispensing Requirement that was introduced required ‘a drug classified as an opioid to be dispensed with a nontoxic composition designed to permanently and chemically sequester or deactivate the drug and be used for disposal of the drug.” The bill was opposed
by MPC because it served as an unfunded mandate; was ambiguous regarding who would bear the cost and potentially legislated market share to the company advocating for the bill. Students spoke to the delegates regarding the cost concern since insurance companies were not obligated to pay for it. Students also informed delegates on the other options available for
the disposal of opioids, like the National Prescription Drug Take-Back Day events, DEA-authorized collection sites, and pharmacies that have free on-site opioid disposal programs.
MPhA works with all pharmacists, regardless of practice area, to establish a stance on the bills proposed in the General Assembly and works with a lobbyist to facilitate getting its positions to the appropriate legislators. Written testimony supporting or opposing pharmacy-related bills are collected through MPhA and are presented to elected leaders on hearing days and as part of the ongoing advocacy process. Pharmacists who are interested in providing oral testimonies in support or opposition to a bill go through MPhA, who registers them to speak on hearing days. On March 8, 2018, there was a hearing
on several bills that impacted independent pharmacies like HB1349: Pharmacy Benefits Managers-Revisions that affected Maximum Allowable Cost (MAC) lists, MAC appeals, and protection from retaliation among other issues related to PBMs. These issues have had a major impact on independent pharmacies in the past year and are causing some pharmacies to stop carrying certain medications due to below-cost reimbursement rates. A substantial number of pharmacists attended the hearing on this day to speak about their experiences with the unfair treatment by PBMs, who they believe reimburse PBM-owned pharmacies higher than independent pharmacies. Legislators heard the concerns raised
by pharmacists during their testimony, and ultimately passed the bill with an effective date six months earlier than originally proposed.
It is important to recognize the chasm that would
exist between pharmacists and lawmakers if MPhA
was not present to help communicate the issues that pharmacists face while bills are being considered. MPhA helps lawmakers understand the impact that these bills have on pharmacists and provides pharmacists with a solid platform to express their issues.
The importance of pharmacy organizations in the advancement of the profession of pharmacy cannot
be overemphasized. These organizations not only strengthen the profession of pharmacy, but also provide a unified voice for pharmacists to come together to brainstorm innovative ways to improve the current practices in place, while providing the best care for their patients. @
REFERENCES
1. Zellmer, William A. “The Role of Pharmacy Organizations in Transforming the Profession: The Case of Pharmaceutical Care.” Pharmacy in History, 1 Jan. 2001, www.jstor.org/stable/41112050
2. Maryland Pharmacy Coalition (MPC) http://www. marylandpharmacist.org/?page=MPC Date accessed: March 20th, 2018
3. Maryland Pharmacist Association (MPhA) http://www. marylandpharmacist.org/ Date accessed: March 9th, 2018
Prince Adekoya
Kafi Agboola Waheed Aziz
Tawfik Beshir Michael Bochniewicz
WELCOME
Rajkamal Brahmanapalli Melinda Burke Chaitanya Chittimalla
10 MARYLAND PHARMACIST | SPRING 2018
Parnab De Brittany Eisemann Tanisha Gooden Marcelle Gossan Ajay Khanna Sarah Maksimovic Lauren Mayfield Renee McCarthy
Darryn Naylin Opeyemi Obayemi Norah Osian Dipen Patel Vaibhav Patel Manish Shah Monica Smith Simona Williams
Mid-Year Meetina wUUrToar MICCUIIY
Sunday, February 18, 2018 Thank you to all who attended the MPhA 2018 Mid-Year Meeting!
And a special thank you to Clarion Brands, Pharmacists Mutual, Compliant Pharmacy Alliance, HealthSource
Distributors, QS1, the Maryland Board of Pharmacy, Pfizer, and the University of Maryland School of Pharmacy for their support of this meeting! @
MARYLAND PHA
FEBRUARY 18 ANNAPOLIS
MARYLANDPHARMACIST.ORG 11
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Continuing Ed
Falls Prevention in Older Adults
Review of Fall Risk Increasing Drugs (FRIDs) and the Role of the Pharmacist
By Jazmin Turner, PharmD, BCGP, Notre Dame of Maryland University School of Pharmacy
Pharmacist Learning Objectives
After completing this activity, the participants will be able to:
1. Recognize the prevalence and disease burden of falls in older adults in the United States
2. Identify intrinsic, extrinsic, and situational risk factors for falls 3. Identify medications that can cause falls and describe how they cause falls 4. Identify three ways pharmacists can help prevent falls in older adults
Pharmacy Technician Learning Objectives 1. Recognize the prevalence and disease burden of falls in older adults in the United States 2. Identify medications that can cause falls and describe how they cause falls
Introduction
A fall is defined as unintentionally coming to rest on the ground,
floor, or other lower surface." It
does not need to cause an injury; however, the general public typically associates a fall with that outcome. Due to this misperception, approximately 75-80% of falls without injury go unreported.* Every minute of every day, an older adult suffers a fall and one in four adults over the age of 65 falls on an annual basis, according to the Centers for Disease Control and Prevention (CDC).* This makes falls the leading cause of injury, both fatal and nonfatal, in older adults.* A senior dies from a fall every 19 minutes; however, less than half talk to their doctors about falling.*° In Maryland in 2014, 83% of fatal falls occurred amongst older adults and fall-related hospitalization costs totaled $253 million®
Falls can cause head injuries and arm, ankle, wrist, and hip fractures. Over 95% of hip fractures are caused by falls and the risk of a fracture increases with age. After sustaining a fracture, many older adults are no longer able to live independently and may have to
be institutionalized.’ Head injuries in older adults are especially concerning due to a higher prevalence of comorbidities that predispose them to bleeding and the use of anticoagulants and antiplatelet agents. Warfarin users have a mortality rate six times that of non-warfarin users and antiplatelet users have a three times increase in mortality.? Older adults who have fallen often retain a fear of falling, which leads to physical deconditioning, muscle weakness, and social isolation which, in turn, further increases the patient's risk of falling.*
The purpose of this article is to review the various pharmacologic and non-pharmacologic causes of falls in older adults and provide strategies for pharmacists to become involved with falls prevention in the community.
Non-Pharmacologic Fall Risk Factors
Falls are typically multi-faceted
in nature — they occur due to a combination of intrinsic (patient- specific), extrinsic (environmental), and situational factors.* Pharmacists should be knowledgeable about
Keywords «Falls prevention
Fall risk increasing drugs (FRIDs)
eOlder adults
these risk factors so they can make holistic recommendations to their patients.
Intrinsic Risk Factors
While age itself is a risk factor
for falling, physiologic changes associated with aging also contribute to a patient's risk of falling. Adults greater than age 85 were four times as likely to suffer from a fall than adults ages 65-74. There are normal gait changes associated with aging: slower walking speed, stiffer movements, impaired balance. There are also pathological gait changes associated with neurological conditions such as Parkinson's disease. Both types of gait changes are associated with a higher risk of falls. Other conditions such as visual impairment, depression, heart rhythm disorders, vitamin D deficiency, vestibular dysfunction, and cognitive impairment are additional intrinsic factors that pharmacists should screen their patients for when doing a fall risk assessment.?
Extrinsic Risk Factors
Hazards in the home increase a patient's risk for having a fall. Poor lighting coupled with clutter in
MARYLANDPHARMACIST.ORG_ 13
Continuing Ed
the home and objects such as unsecured throw rugs, can be dangerous for an older patient. Completing modifications, such
as installing grab bars, railings, and increasing lighting, can make the home safer.’ Proper footwear is
also important. Wearing slippers, walking barefoot, walking with socks, or wearing high-heeled shoes all increase a patient's fall risk. It is recommended that older adults wear properly fitted shoes with hard, slip-resistant soles and a heel height of less than 2.5 centimeters (less than one inch).?
Situational Factors
A common scenario would include something similar to the following: a patient waking up in the middle of the night due to polyuria or nocturia caused by diuretic medications subsequently slipping on a throw rug or tripping over furniture due to poor lighting and clutter.
Fall Risk Increasing Drugs (FRIDs)
Anticholinergic Drugs Anticholinergic medications are listed on the Beers Criteria for their myriad of adverse effects such as dry mouth, constipation, confusion, ataxia, dizziness, mydriasis, delirium, cognitive impairment, and falls [Table 1].2°* Approximately 8-37% of older adults utilize anticholinergic medications, due in part to their over-the-counter availability.! Scales such as the Anticholinergic Cognitive Burden Scale (ACB) and Anticholinergic Risk Scale (ARS) rank the anticholinergic activity
of medications into groups with scores of one, two, and three; the higher the score, the higher the anticholinergic load and the greater the risk of side effects.
Studies have shown that anti- cholinergic medications are asso- ciated with a decline in lower
limb and overall physical function, slowed gait speed and reaction time.
Table 1. Examples of Anticholinergic Medications”
Medication Class. 3 |au
They also have been associated with cognitive impairment, which is independently associated with falls.* In a study by Rudolph and colleagues, it was estimated that
an ARS score of three would likely result in at least two anticholinergic adverse effects in more than 70% of their study population.»
Cardiac Drugs
There are conflicting reports regarding whether antihypertensives increase the risk of falls and the doses at which they are more likely to cause falls. The proposed mechanism is through hypotension and syncope. Antihypertensive therapy should not be withheld from older adults due to concerns about falls because studies, such as the Hypertension in the Very Elderly trial, have shown that therapy decreases the risk of death from stroke and death from any cause. Patients newly prescribed antihypertensive therapy seem to be at a higher risk of falling when compared to chronic users. This
is particularly true for diuretic medications. Thiazide diuretics appear to have the highest risk of causing a fall within the first few weeks of therapy initiation. This may be due to polyuria leading to
14 MARYLAND PHARMACIST | SPRING 2018
First generation Diphenhydramine, chlorpheniramine antihistamines hydroxyzine Antiparkinson agents Benztropine, trinexyphenidyl
First Generation: Chlorpromazine, thioridazine Second Generation: Clozapine, olanzapine Tricyclic Antidepressants (TCAs): Amitriptyline, nortriptyline
Selective Serotonin Reuptake Inhibitors (SSRIs): paroxetine
Antispasmodics Dicyclomine, scopolamine Skeletal muscle relaxants | Cyclobenzaprine, orphenadrine Oxybutynin, trospium
Examples
a AY nw ny ee ‘ a Py ¢ Tee ot Oe we nl 3 airs, ‘
a reduction in plasma volume and orthostasis.’©” Loop diuretics pose the greatest risk within the first week of initiation.’® Additionally, a study by Lipsitz and colleagues showed that patients taking either an ACE inhibitor (ACE-I) or an angiotensin receptor blocker (ARB) have a lower risk of falls than patients not taking these medications.!
Psychoactive Medications Antipsychotic medications are commonly prescribed in older adults to treat behavioral and psychological symptoms of dementia (BPSD). In addition to the warnings about increased risk of death when used in this manner,
a study by Fraser and colleagues found that newly prescribed antipsychotics were correlated with a 52% increased risk of a serious
fall and a 50% increased risk of a nonvertebral osteoporotic fracture.” Food and Drug Administration (FDA) labeling on many antipsychotics have been updated to include warnings about the increased risk of falls and both first and second generation antipsychotics carry this risk. The proposed mechanisms are: anticholinergic adverse effects, extrapyramidal symptoms, sedation, and hypotension.”
Benzodiazepines and sedative- hypnotics increase fall risk by causing confusion, sedation, slowed reflexes, and cognitive impairment. According to the Beers Criteria, short-acting benzodiazepines do not carry a lower risk of falls than long acting ones.’° According
to a study of Medicare patients
by Tom and colleagues, use of zolpidem, not eszopiclone, led to an increased risk of hip fracture and traumatic brain injury which necessitated hospitalization. The low utilization of zaleplon in this study made it underpowered to detect the true risks associated with it. Therefore, more studies are needed to determine if there are key differences among sedative hypnotics in increasing fall risk in older adults.*!
Depression is a risk factor for
falls through several potential mechanisms. Cognitive deficits and inattention coupled with psychomotor changes leading
to gait instability can all make a patient unsteady on their feet and more likely to trip over hazards. Depression also leads to lower amounts of exercise which causes muscle weakness. A fear of falling due to a history of falls can be disabling to patients and can cause social isolation, which can worsen depression. It can also cause the patient to change their gait, which increases their likelihood of falling. Antidepressants have also been associated with an increased fall nisk.2245
Selective serotonin reuptake inhibitors (SSRIs) were initially thought to be safer alternatives to tricyclic antidepressants (TCAs) due to limited anticholinergic affects (except for paroxetine). However, there is mounting evidence that SSRIs can cause falls as well.“
The risk of falling appears to be
the highest within the first several weeks of therapy initiation.** Current studies have focused on TCAs
and SSRIs, with limited studies on other classes of antidepressants
and limited information on specific medications and doses.** As a clinician, one must weigh the risks of depression itself with the risks and benefits of antidepressants when looking to treat a patient's psychiatric condition while not exacerbating the risk of falls.
Treating seizures in older patients poses a challenge, as clinicians must balance the risk of falls during seizure episodes with the adverse effects of anticonvulsants, which include ataxia, dizziness, and unsteady gait. The Study on Male Osteoporosis and Aging (SOMA) found that anticonvulsant therapy was associated with a 2-3-fold increased risk of a falling.*° Anticonvulsant drugs are also associated with an increased fracture risk, with patients who take more than one anticonvulsant and/or an enzyme-inducing anticonvulsant at a higher risk.?°
Analgesics
Sedation and impaired coordination are the primary mechanisms by which opioids can cause falls. These effects are likely dose-related. A Canadian population-based cohort study found that the mean prescribed opioid dose exceeded the adult dosing recommended by the World Health Organization by 50%.*’ Due to physiologic changes associated with aging, opioid therapy should be initiated in doses that are 25-50% lower than that of younger, healthy adults.*® This sharp contrast is appropriate compared
to actual dosing combined
with concurrent psychoactive medications which places older adults at a higher risk of adverse effects. A meta-analysis found
that patients who were prescribed opioids had a 38% higher risk of fracture when compared with those who were not prescribed opioid therapy.*? While all opioids pose risks to older adults, meperidine and pentazocine specifically should be avoided.”°
When looking at other analgesia options, NSAIDs have also been associated with an increased risk
of falls. This medication class has not been studied as intensely as opioids when analyzing fall risk; however, it is important to consider as approximately 20-30% of older adults take NSAIDs on a daily basis. NSAIDs, particularly indomethacin, can cause adverse CNS effects because they cross the blood-brain barrier.°° For mild to moderate pain, a patient can take acetaminophen, salsalate, ibuprofen, or naproxen
if they have an eGFR greater than 30 mL/min and do not have heart failure; these should be given with a proton pump inhibitor to reduce the risk of a gastrointestinal bleed.**
Hypoglycemic agents are not always listed as FRIDs, but they are important to scrutinize as there are studies that correlate hypoglycemia with an increased risk of falls. Recognizing hypoglycemia in older adults poses difficulties due to the presence of cognitive impairment and decreased autonomic symptoms, such as tachycardia and sweating, in response to low blood glucose. Hypoglycemia is often underreported to healthcare providers, which can be dangerous if a patient's diabetes regimen needs to be adjusted. It was found that the 4.7% of older adults with type 2 diabetes and a documented hypoglycemic episode within the past year had a 70% increased chance of a fall-related fracture. Patients who were prescribed insulin were found to be ata higher risk of falls than patients prescribed only oral agents. Among oral agents, sulfonylureas had
the highest risk of hypoglycemia. While thiazolidinediones, such as pioglitazone, do not increase the risk of hypoglycemia, they do increase the risk of fractures. Therefore, the risks of therapy must be balanced as microvascular complications from uncontrolled diabetes, such as peripheral neuropathy, diabetic
MARYLANDPHARMACIST.ORG 15
Continuing Ed
foot ulcers, and retinopathy can also increase falls.*
Guidelines & Screening Tools
The American Geriatrics Society has specific guidelines for the prevention of falls. It is recommended that patients are asked the following questions at least annually:
1. Have you had 2 or more falls in the past 12 months?
2.Are you presenting with an acute fall?
3.Do you have difficulty with walking or balance?
If the patient has a positive response to any of the screening questions, then that is a trigger for further evaluation and assessment of fall- related risk factors. The guidelines specifically mention medication
PATIENT CASE
minimization as a potential inter- vention to reduce a patient's risks. Psychotropic medications in particular are targeted and it is advised to withdraw those types
of medications, if possible, or
to reduce the dose if medical conditions necessitate chronic psychotropic therapy. The guidelines also aim at addressing intrinsic and extrinsic risk factors, such as visual impairment, arrhythmias, vitamin
D supplementation, and home hazards. They recommend Vitamin D 800 IU in all older adults at risk of falls.*4 |
The CDC Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative has materials for both healthcare providers and patients and it has three main components: screen, assess, and intervene. The Stay Independent
brochure can be completed by a patient; a score > 4 should trigger
a multi-factorial assessment. Patients are separated into three categories: low risk (a score less than 4), moderate risk, and high
risk and each category has different interventions.** The American Society of Consultant Pharmacists and the National Council on Aging have paired together to create a Falls Risk Reduction Toolkit, which is a companion to CDC STEADI. This toolkit provides a more in- depth medication evaluation in order to identify medication-related problems that may be contributing to falls.**
Beasley and colleagues created a Medication Fall Risk Score tool that separates classes of medications into high risk (3 points), moderate risk (2 points), and low risk (1 point)
Mrs. Roland is a 67-year-old patient who presents to your medication management clinic after being referred by her primary care provider for a medication review. She had a fall last month and was treated at the emergency department for a right arm fracture. Mrs. Roland has a past medical history which includes: type 2 diabetes, generalized anxiety disorder, hypertension, mild Alzheimer's disease, and dyslipidemia. All labs are within normal limits. She is currently prescribed: metformin 1000 mg PO BID, clonazepam 1 mg PO TID, lisinopril 5 mg PO daily, and atorvastatin 40 mg PO daily. She describes feeling tired and lightheaded right before she stumbled, slipped on a throw rug, and fell in the kitchen in the middle of the night. In the emergency room, she was prescribed oxycodone/acetaminophen 10/325 mg 1 tablet PO Q6H PRN.
1. What intrinsic risk factor does Mrs. Roland have that increases her risk of a fall?
a. Dyslipidemia b. Throw rug
c. Mild Alzheimer's disease
d.Poor lighting in the kitchen
. What is an issue you have identified with this medication in terms of her fall risk?
a. Dosing frequency b. Risk of constipation
c. Risk of nausea d.High dose
3. What would you recommend for the primary
care provider to prescribe to treat her anxiety?
a. Duloxetine 30 mg PO daily b. Duloxetine 90 mg PO daily c. Fluoxetine 20 mg PO daily d.Sertraline 25 mg PO daily
. Mrs. Roland would also like to know if there is anything that she can take over the counter to
reduce her risk of falling. You reference the AGS guidelines and recommend:
a. Vitamin D 400 IU b. Vitamin D 800 IU c. Vitamin D 1000 IU d. Vitamin D 2000 IU
16 MARYLAND PHARMACIST | SPRING 2018
Answers on page 18
Table 2. Therapeutic Alternatives for Several Classes of FRIDs”°
Medication Class Alternatives
First generation antihistamines
¢ Intranasal normal saline e Second-generation antihistamine
¢ Intranasal steroids
Anticholinergic ¢ Carbidopa/levodopa antiparkinson agents
Anticonvulsants
e New-onset epilepsy
o Lamotrigine, levetiracetam (newer drugs)
preferred
Oo Calcium/vitamin D supplementation o Bisphosphonate e Neuropathic pain o Serotonin norepinephrine reuptake inhibitors (SNRIs)
Oo Gabapentin oO Pregabalin
Oo Topical capsaicin o Lidocaine patch
Benzodiazepines
e Anxiety:
Non benzodiazepine
hypnotics 0 SNRI
o Buspirone
e Sleep — non-pharmacologic options such as: oO Behavioral therapy o Sleep hygiene
Long acting e Short-acting sulfonylureas (glipizide sulfonylureas
Tricyclic antidepressants SSRIs
oO SNRI
¢ Depression:
o Bupropion
¢ Neuropathic pain
o SNRI
o Gabapentin o Pregabalin
o Topical capsaicin o Lidocaine patch
medications. Scores > 6 indicate that the patient is at a higher risk of falls and this should trigger a more in-depth medication review.® In addition to completing these risk assessments, the pharmacist can also measure patients’ blood pres- sure and alert their providers if they observe orthostatic hypotension as a method of screening for falls.
Role of the Pharmacist
Pharmacists are trained to be aware of drug-drug, drug-food, and drug- disease interactions, understand issues such as anticholinergic burden and potentially inappropriate medications, and apply the concepts of aged-related physiologic
changes. This makes them uniquely positioned to help prevent falls as members of the interdisciplinary team. Understanding how an
older adult's comorbidities and
medications interact with the physical, psychological, and pharmacokinetic/pharmacodynamic changes of aging is essential. The CDC created a pharmacist-specific falls prevention training in March 2017 and the National Council on Aging (NCOA) specifically mentions pharmacists as having a role in reducing falls in their 2015 Falls Free Strategic Plan*°*” As pharmacists are being nationally recognized
as members of the healthcare
team that can help prevent falls,
it is essential to get involved. By conducting medication therapy management and comprehensive medication reviews, pharmacists can uncover medication-related problems that increase the risk of falls and address these issues with the prescriber [Table 2].
In a study by Casteel and colleagues, patients of 32 community pharmacists in North Carolina were recruited for medication reviews based on age and number of medications, more specifically psychoactive medications. Pharmacists reviewed the regimens of 73 patients and made *! recommendations for medication changes. While overall provider acceptance was low (24.4%), this study demonstrates how many interventions pharmacists can make to reduce falls.*° In a 2011 paper by Flores and colleagues, the pharmacists’ role in an interdisciplinary falls clinic was described: obtaining an accurate and detailed medication history, evaluating regimen difficulties, counseling on adherence and proper medication administration, and evaluating high risk medications and drug interactions.*’ Ina retrospective observational study that took place in a rehabilitation center, the number of falls among older adults was measured before and after pharmacy intervention. The post-intervention group had a 47% reduction in falls.*°
MARYLANDPHARMACIST.ORG_ 17
Continuing Ed
Deprescribing is defined as the supervised withdrawal of potentially inappropriate medications to minimize polypharmacy and improve health outcomes.*!** In
a non-randomized controlled study, cognitive improvement, fall reduction of up to 66% and fracture reduction of up to 10% were seen in patients whose benzodiazepines and other psychotropic medications were reduced or discontinued. Deprescribing has also been
shown to reduce costs, improve adherence, and produce positive health outcomes in older adults.*?
A prospective cohort study showed that deprescribing FRIDs was associated with a reduction in falls.43 Pharmacists can have major involvement with deprescribing by identifying potentially inappropriate medications, recommending
safer alternatives, counseling, and monitoring patients as medications are reduced and eventually discontinued.
Conclusion
Older adults are at a risk of falling due to a complex interrelationship between physiologic effects of aging, changes in pharmacokinetics and pharmacodynamics, comorbidities, and polypharmacy. Clinicians must balance properly treating a medical condition while minimizing the risk of falls from various medications. Pharmacists are in a unique position to identify FRIDs, consult with prescribers
on medication changes, monitor deprescribing efforts, and counsel patients on falls prevention Strategies. @
REFERENCES
1. Lipsitz LA, Habtemariam D, Gagnon M et al. Reexamining the Effect of Antihyertensive Medications on Falls in Old Age. Hypertension. 2015; 66;183-9.
2. Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: A Review of the Literature. Maturitas. 2013;75(1):51-61
3. Centers for Disease Control and Prevention. Take Steps to Prevent Older Adult Falls.
Available at: https://www.cdc.gov/steadi/pdf/
10.
ANSWERS
1. Answer: C Answers B and D are both extrinsic risk factors. Patients with Alzheimer’s disease have been shown to alter their gait pattern and have decreased gait stability. Dyslipidemia has not been shown to be associated with falls. Mrs. Roland expresses concerns about her new oxycodone/acetaminophen prescription because she’s afraid about becoming addicted. She’s never taken an opioid before and when she took the first dose she felt very sedated. She requests for you to go over the risks
and side effects with her.
2. Answer: D The dosing frequency of the oxycodone/acetaminophen is appropriate. Constipation and nausea have not been correlated with falls. The dose is too high for an initial dose for an opioid naive, geriatric patient and increases the risk of adverse effects that could lead to another fall. After talking about the risks of benzodiazepines in older adults, Mrs. Roland is hesitant to discontinue because she's been taking the medication for 10 years. She doesn't believe anything else would be effective for treating her anxiety, although she is afraid of having another fall. You ask for her primary care provider come in and discuss the risk of benzodiazepines with the patient as well and she eventually agrees to a slow taper
over the course of several months.
3. Answer: A Fluoxetine and sertraline are both SSRIs and they have been shown to increase fall risk. This does not mean that SSRIs are always inappropriate, but they are not first-line for patients at risk of falls. Duloxetine is an SNRI, which is listed as a potential alternative, but 90 mg is too high for a starting dose. An initial 30 mg dose
would be the most appropriate.
3. Answer: B The AGS Falls Prevention Guidelines recommend Vitamin D 800 IU to
prevent falls in older adults.
STEADI_ClinicianFactSheet-a.pdf Accessed August 9, 2017.
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National Council on Aging. Falls Prevention Facts. Available at: https://www.ncoa.org/ news/resources-for-reporters/get-the-facts/
falls-prevention-facts/. Accessed August 9, 2017.
Falls in Older Adults. Available at: https://phpa. health.maryland.gov/ohpetup/Shared%20 Documents/EIP-RESOURCE/FallsOlderAdults. pdf. Accessed August 14, 2017.
Centers for Disease Control and Prevention. Important Facts About
Falls. Available at: https://www.cde.gov/ homeandrecreationalsafety/falls/adultfalls. html. Accessed August 14, 2017.
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Menant JC, Steele JR, Menz B, et al. Optimizing footwear for older people at risk of falls. J Rehabil Res Dev. 2008; 45(8): 1167- 1181.
Fick DM, Semla TP, Beizer J, et al. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication
Use in Older Adults. J Am Genatr Soc. 2015;63(11):2227-2246.
18 MARYLAND PHARMACIST | SPRING 2018
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Aging Brain Program of the Indiana University Center for Aging Research. Aging Brain Care. Available at: http://www.agingbraincare.org/
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Glab KL, Wooding FG, Tuiskula KA. Medication-Related Falls in the Elderly: Mechanisms and Prevention Strategies. Consult Pharm. 2014; 29: 413-417.
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Emst D. Monthly Prescribing Reference. New Warning Added to Antipsychotic Drug Labeling. Available at: http://www.empr. com/safety-alerts-and-recalls/antipsychotic- medication-warning-somnolence- hyoptensior/article/640400. Accessed October 30, 2017.
Tom SE, Wickwire EM, Park Y, et al. Nonbenzodiazepine Sedative Hypnotics and Risk of Fall-Related Injury. Sleep. 2016; 39 (5): 1009-1014.
Iaboni A, Flint AJ. The Complex Interplay
of Depression and Falls in Older Adults: A Clinical Review. Am J Geriatr Psychiatry. 2013; 21(5): 484-492.
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Kenny RA, Rubenstein LZ, Tinetti ME. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-157.
Masud T, Frost M, Ryg J. Central nervous system medications and falls risk in men aged 60-75 years: the Study on Male Osteoporosis and Aging (SOMA). Age and Ageing. 2013;42:121-124.
Carbone LD, Johnson KC, Robbins J, et al. Antiepileptic Drug Use, Falls, Fractures, and BMD in Postmenopausal Women: Findings From the Women's Health Initiative (WHI). J Bone Miner Res. 2010; 25(40: 873-881.
CONTINUING EDUCATION QUIZ
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education. A continuing education credit will be awarded
within six to eight weeks.
MPhA Members may retrieve FREE CE for this article up to one-year after the program release date. (2)
Program Release Date: 5/7/2018 Program Expiration Date: 5/7/2021
This program provides for 1.0 contact hour (0.1) of continuing education credit. Universal Activity Number (UAN) 0798-9999-18-075-H04-P and (UAN)
0798-9999-18-075-H04-T
The authors have no financial disclosures to report.
ah;
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Do
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Chau DL, Walker V, Pai L. Opiates and elderly: Use and side effects. Clin Interv Aging. 2008:3(2) 273-278.
Heckenbach K, Ostermann T, Schad F. Medication and falls in elderly outpatients: an epidemiological study from a German Pharmacovigilance Network. Springerplus. 2014 Aug 29;3:483.
Findley LR, Bulloch MN. Relationship Between Nonsteroidal Anti-inflammatory Drugs and Fall Risk in Older Adults. Consult Pharm. 2015;30:346-351.
Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications
in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug—Disease Interactions in the Elderly Quality Measures. J Am Genatr Soc. 2015; 63: e8-e18.
Malabu U, Vangaveti VN, Kennedy RL. Disease burden evaluation of fall-related events in
the elderly due to hypoglycemia and other diabetic complications: a clinical review. Clin Epidemiol. 2014:6 287-294
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American Society of Consultant Pharmacists. ASCP-NCOA Falls Risk Reduction Toolkit. Available at: https://www.ascp.com/default. asp?page=fallstoolkit. Accessed on October 31, 2017
Beasley B, Patatanian E. Development and Implementation of a Pharmacy Fall Prevention Program. Hosp Pharm. 2009;44(12):1095-1102.
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Casteel C, Blalock SJ, Ferreri S, Roth MT, Demby KB. Implementation of a community pharmacy-—based falls prevention program. Am J Geriatr Pharmacother. 2011;9:310319
Flores EK, Henry R, Stewart DW. Pharmacist’s Role in an Interdisciplinary Falls Clinic. South Med J. 2011;104:143146.
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Ailabouni N, Mangin D, Nishtala PS. Deprescribing anticholinergic and sedative medicines: protocol for a Feasibility Trial (DEFEAT-polypharmacy) in residential aged care facilities. BMJ Open 2017;7 (4): e013800.
Lee JY, Holbrook A. The efficacy of fall- nsk-increasing drug(FRID) withdrawal for the prevention of falls and fall-related complications: protocol fora systematic review and meta-analysis. Syst Rev. 2017; 6(1):33.
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MARYLANDPHARMACIST.ORG 19
Second Quarter 2018: Pharmacy Time Capsule
By: Dennis B. Worthen, PhD, Cincinnati, OH
1993
e NABP Task Force on Pharmacy Technicians issued final report. One recommenda- tion was to standardize the term pharmacy technician as a uniform title
1968
e Successful
human parenteral hyperalimen- tation first described.
1943
Microbiologist Selman A. Waksman discovers the antibiotic streptomycin, later used in the treatment of tuberculosis and other diseases
1918
Prior to 1918, pharmacy services in
PHS hospitals were provided through contract services or by
1893
e Virginia
University College of Medicine Department
of Pharmacy formed (became
Federal civilian part of the employees. In Medical College 1918, a reserve of Virginia in corps composed 1913). @
designating personnel that assist the pharmacist in the practice of pharmacy.
Institute of the History of Pharmacy,
the contributions of your profession
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State Legislative Update
The 2018 Maryland legislative Session was once again an active session with a host of pharmacy-related bills. A more comprehensive bill chart can be accessed here: https://bit.ly/2Htbzyp
HB 736/ SB 576
Pharmacy Benefits Managers — Pharmacies and Pharmacists — Information on and Sales of Prescription Drugs
PASSED
Eliminates the “pharmacists
gag rule.” Prohibits a pharmacy benefits manager from prohibiting a pharmacy or pharmacist from discussing with or providing a beneficiary with information on the retail price of a prescription drug
or the amount of the cost share
for a prescription for which the beneficiary is responsible.
HB 1349/SB 1079
Pharmacy Benefits Managers — Revisions
PASSED
The bill provides the Commissioner of the Maryland Insurance Administration (MIA) broader authority to request information from PBMs. PBMs may not reimburse a pharmacy or pharmacist less than it reimburses itself or an affiliate for the same product or service, with some restrictions. Clarifies the definition of the MAC List and determines that the MAC fee does not include dispensing fees. MAC list must be accessible in an electronic format with immediate updates used to calculate payments to pharmacies. PBMs are required to have designated personnel to address questions related to appeals within three business days. Upheld appeals will be adjusted to appealing pharmacies with no reverse and rebill, with corrections made to
similarly contracted pharmacies on second remittances; and notices sent to others in the network. Appeal denials must include
the NDC and the name of the wholesaler where the product was available on the date the claim was adjudicated at or below the MAC price. Bill clarifies MIAs regulatory and enforcement authority and is effective June 2018.
HB 1558
Pharmacists — Dispensing of Prescription Drugs — Single Dispensing of Dosage Units PASSED
Authorizes a pharmacist to dispense in a single dispensing a 30-day prescription with two refills (90-day fill) without physician authorization.
HB 407/SB 232
Public Health — General Hospice Care Programs — Collection and Disposal of Unused Prescription Medication
PASSED
Requires general hospice care programs to establish a program for medication collection and disposal.
HB 1452 /SB 1223 Controlled Dangerous Substances Registration — Authorized Providers — Continuing Medical Education
PASSED
Amended bill requires prescribers and dispensers to complete two CE on opioid prescribing or dispensing prior to initial CDS registration or
the first renewal on or after October 1, 2018. MPhA opposed underlying bill and provided input on amended language. This is a one-time occurrence and is intended to stop the annual submission of legislation requiring health providers to take opioid training.
HB 2/SB 1 Medical Cannabis Commission Reform Act
PASSED
The bill as introduced included several reforms related to diversity and number of permits for cannabis growers and dispensers. MPhA successfully amended the House bill to maintain a pharmacist seat on the Cannabis Commission.
HB 115/SB i3
Electronic Prescription Records Cost Saving Act of 2018
PASSED
Initial bill required all dispensers of a prescription drug to submit dispensing information to CRISP. The House bill was successfully amended to require the Maryland Health Care Commission, in consultation with interested stakeholders, to assess the benefits and feasibility of developing an electronic system to allow health care providers to access a patient's prescription medication history, requires the Commission to report its findings to the Governor and the General Assembly on or before January 2020.
MARYLANDPHARMACIST.ORG 21
HB 591/SB 549
Health Occupations — Physician Assistants — Dispensing of Drugs Under a Delegation Agreement
PASSED
Allows physician assistants (PA)
to dispense medications under
a delegation agreement with a physician who has a dispensing permit. MPhA felt the expansion of scope was too broad, with unanswered concerns regarding PA dispensing of opioids and their requirements related to updating the PDMP. MPhA was the only group in opposition to this expansion of scope.
HB 601/SB 1255 — Public Health — Opioids — Dispensing Requirement FAILED
The bill as introduced required dispensing of an opioid antagonist product with all opioid prescriptions. However, the mandate was
only for pharmacists and not all dispensers. We fought against it and its various iterations as it was an unfunded mandate on pharmacies and patients and violated MPhA's policy against mandatory patient counseling in legislation and regulations.
HB 1194/SB1023 — Health — Drug Cost Review Commission
FAILED
This bill was Phase II of the medication affordability initiative spearheaded during the 2017 legislative session. As introduced the Commission would have reviewed prescription drug costs and reported back recommendations to the state. The bill was amended significantly and watered down the intent. As we go to print, a federal appeals court declared last year’s price gouging law unconstitutional.
Federal Legislative Update
MPhA participated in the NCPA Congressional Advocacy Summit, April 11-12 in Washington, DC. We visited with the Maryland Congressional delegation with pharmacists and student pharmacists to encourage support for federal
provider status for pharmacists and the prohibition of DIR fees in Medicare Part D.
HR 592/S 109
Pharmacy and Medically Underserved Areas Enhancement Act
Recognizes pharmacists as providers under the Medicare Part B program. If passed, pharmacists would be
able to perform and be paid for services for patients consistent
with their state’s scope of practice
if their pharmacy is located ina
medically underserved area, health professional shortage area, or medically underserved population. Nineteen out of 24 counties in Maryland are considered to be medically underserved. The majority of the MD Congressional Delegation are cosponsors of this bill, except for Reps. Steny Hoyer (D-5) and Andy Harris (R-1).
Thank you
HR 1038/S 413
Improving Transparency and Accuracy in Medicare Part D Spending Act
Prohibits retroactively reducing payment on clean claims submitted by pharmacies under Medicare Part D. Reps. Joh Sarbanes (D-3) and Jamie Raskin (D-8) are cosponsors. @
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Reflections, Rhythms and Rewards of Haiti Medical Missions: Five Times and Four Years Later
By Hoai-An Truong, PharmD, MPH, FAPhA, FNAP and Yen H. Dang, PharmD, CTTS-M
“My children, I give you a mission... to relieve suffering” are the lyrics
of a song that our driver, and
also the pastor and leader of the Carcasse community in the remote southwestern region of Haiti, led
us In Singing as we drove into the sunset with mountain and ocean on either side of rugged roads on the journey back to Jeremie, one-third of the way back to Haiti's capital Port-au-Prince, after a weeklong medical mission. The 4-hour bumpy ride through rough terrain made several stops on pitch black roads
as Pere [Father] Verdieu examined the tire for a potential flat. We found hope and comfort as we gazed into the sky with shining stars to say a quick prayer. Another SUV was close behind with the other half of our team members, including healthcare professionals and interpreters both from the U.S. and Haiti who worked together to care for Haitians during Our medical mission, and perhaps relieve some human suffering.
Jessica Wearden with children.
Despite the many hardships that Haiti has faced, there is hope and a vision for the future that exists among many of the Haitian people I met. I came away from the experience with new friends, new perspective, and a new hope for the future of collaborative global health.
— Scott Baker, Pharmacy Student (Haiti Medical Mission 2018)
Our team consisted of our fearless leader Mrs. Pat Labuda, who
has traveled to Haiti for over 30 years and speaks Haitian Creole, supported by Dr. Frank Nice, founder of this Haiti medical mission, two physicians, two nurse practitioners, two nurses, two University of Maryland Eastern Shore (UMES) faculty pharmacists, three UMES student pharmacists, and four interpreters. Together we conducted a 5-day primary care clinic, seeing 1,011 patients, treating
Maheder Dachew.
24 MARYLAND PHARMACIST | SPRING 2018
1,307 medical conditions, and dispensing 1,877 prescriptions. With limited medications and supplies, we managed to last through five full days, working from 8 a.m. to
7 p.m. We had the opportunity to serve patients ranging from 9 days old to 96 years old by providing general physical assessments,
lab tests, medication dispensing, and hosting a focused women’s health education session. It was
a humbling experience knowing some patients had to walk many miles, and in some cases over mountains from another town, to wait in long lines in the heat on dirt ground for hours to receive the only medical care for the year, or years, and then return home with medications and a sense of comfort.
We found our sense of comfort in knowing that while we had
left our daily lives with our family and paying jobs for this volunteer opportunity, the gratitude of our
Visiting the hospital pharmacy.
It was astonishing to see how many people needed medical attention but were not able to receive it due to distance and money. There were days we worked past clinic hours to attend to as many patients as we could knowing that we were their only source of medical attention for
a while. It was humbling to see many of their diseases are so prominent solely due to lack of nutrition, hygiene, and education, all of which we take for granted here in the United States.
— Thomas Tran, Pharmacy Student (Haiti Medical Mission 2018)
fellow Haitian brothers and sisters was beyond our comprehension. The words of appreciation from the priest and interpreters, as we gathered to reflect and relax on Our last night under the star-filled Carcasse sky surrounded by the rhythms of musical and dance performances, touched our hearts. It was peaceful and comforting as we held hands with our Haitian friends and danced to the music — the universal language of humanity. As our minds wandered into the cadence of the night, with the sounds of crickets, insects, cow, and even early-rising roosters,
our thoughts traveled back to 4 years ago during the inaugural UMES medical mission to Haiti in May 2014.12
No one tells you how much you will fall in love with the country and the children you meet and how a piece of you will always stay with them.
— Jessica Wearden, Pharmacy Student (Haiti Medical Mission 2016)
Time flies as we capture memories of global health services. UMES
has partnered with St. Francis of Assisi Catholic Church and received fundraising support from non-profit organizations, including Health and Education for Haiti and International Community Initiatives, for five medical missions to Haiti from
2014 to 2018 providing ‘beyond the classroom global health experiences for more than 30 pharmacy, physical therapy, and physician assistant students in the real-world.t? The impact on our students to provide compassionate, cultural, and competent health care for diverse patient populations in a developing country is immeasurable.
This trip was a perfect mixture of overcoming challenges and serving a patient population that is in need.
— Truptiben Sindhi, Pharmacy Student (Haiti Medical Mission 2018)
In addition to applying their aca- demic knowledge and skills, students enhanced their abilities in communication, cultural
Orphanage mission team and children.
competence, health literacy, leadership, and providing compassionate care. Besides appreciating the necessities of life - food, water, and shelter — we were challenged to work with limited resources and live in the community of our patients. Such challenges included antibiotic substitutions, pre-natal vitamins usage for all who needed multivitamins, and cutting up bottles as inhaler spacers
We were able to swim in the river near the orphanage and enjoy some simple pleasures like skipping stones, right next to some of the local children. It was a settling experience, contrasted by the devastation we have seen in patients and in the country’s infrastructure.
— Marc McDonald, Physical Therapy Student (Haiti Medical Mission 2016)
We managed to control our emotions while facing extreme poverty, worked creatively with what we had, and slept when we could at the end of the long days. We walked along the trails with children, dipped our feet into the ocean, and hiked through the Haitian mountains — all in an attempt to relax and recharge after tough days. We left Haiti with a sense of fulfillment and gratefulness for what we have in life. While our mission to relieve suffering is not complete, our fifth UMES medical mission was a rewarding experience, with many of us promising to return to Haiti again. @
REFERENCES 1. Dang YH, Nice FJ, Truong HA. Academic- community partnership for medical missions
Lessons learned and practical guidance for global health service-learning experiences Journal of Health Care for the Poor and Underserved. 2017;28.1:8-13
2. Truong HA. Inaugural Haiti health mission: an academic-community and interprofessional collaboration for global community service and lessons beyond the classroom. Maryland Pharmacist. 2014; 90(3):8-10
MARYLANDPHARMACIST.ORG 25
Executive Director’s Message
Some days it seems a little hard to tell, but Spring is easing its way in. With it brings MPhAss participation in annual national pharmacy events, longer days, fresh perspectives and new opportunities.
The APhA Annual Convention is always a wonderful time to gather with our Maryland Phamily! With sponsorship from our three schools of pharmacy, we welcomed nearly 150 attendees at our annual “must attend” Maryland Pharmacy Night. In Nashville, we were able to reconnect and celebrate the achievements of Maryland colleagues and students. I also recently participated in NCPA‘s Congressional Advocacy Summit with several pharmacy owners and students. We educated congressional leaders about on-the-ground pharmacy issues and advocated for bills that impact pharmacy practice
and provider status. I also advocate for my own profession and participated in
the American Society of Association Executive's Association Advocacy Day with other leaders of professional societies and non-profits. Our goal was to educate members of Congress about the power of associations, and how potential modifications to tax legislation could impact the work
we do.
Spring brings a new round of graduations. It is an exciting time. The Class of 2018 will soon join
the profession. They have been trained on the latest and greatest
in pharmacy practice, leadership, and professionalism. They have experienced various practice
settings and cultivated long-lasting relationships with their peers, professors and employers. I was pleased to have renewed MPhA‘s commitment to professional development by serving as a rotation site. We had wonderful students who contributed to our work and learned how important MPhA‘s role is in advocating for the profession. MPhA continues to push to ensure that
the scope of practice in Maryland is up-to-date so seasoned professionals and new graduates can practice at the height of their degrees. As I think
about the upcoming graduations, I am
reminded of a quote by Arthur Ashe: “Start where you are; use what you have; do what you can.” And so to our newest new practitioners, I say: Start at your workplace, residency
or fellowship, be empowered that you are working in a profession that is one of the most trusted in the healthcare industry. Utilize your skills and your network (you earned it!). Do what you can to stay up-to-date and connected to your colleagues by maintaining your membership and/ or investing your time and talent in an MPhA activity or committee. The connections and opportunities you gain will benefit you far beyond your contributions.
Spring also means the end of another legislative session. The
2018 session was full-throttle. We successfully advocated for bills that will provide greater transparency, regulation and enforcement of PBMs and limited opportunities for drug diversion. We watered down bills that would have added extensive additional CE requirements and killed bills that would have forced unfunded mandates on pharmacists and patients. Legislative session is a bargaining game. Spring gives us an opportunity to reflect on the session, think about new opportunities and refresh strategies for the next go- around. As we get closer to the summer recess, I encourage you to invite your General Assembly and Congressional representatives to your practice site. These connections build their familiarity with you and pharmacy-related topics.
What's new? We have introduced a new Advocacy Focus Group Webinar series to help you learn about and give feedback on issues that impact different practice settings. We are also bringing back the New Practitioner
26 MARYLAND PHARMACIST | SPRING 2018
Spring gives us
an opportunity to reflect on the session, think about new opportunities and refresh strategies for the next go-around.
Happy Hour, with connection points in different parts of the state. We hope our new practitioners will
take advantage of these networking opportunities.
As always, I look forward to the 136th Annual Convention, where
we will bring our families together to soak up some sun, learn, and celebrate professional contributions to MPhA and Maryland pharmacy. We will be back in Ocean City! We are working hard to enhance the Annual Convention with new programming, while maintaining our favorite MPhA traditions.
Looking forward to seeing you soon! @
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Aliyah N. Horton, CAE Executive Director
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Contents
19 MPhA COVER STORY MPhA Excellence in Pharmacy Awards
in Pharmacy Awards
FOR ALL! atin namin rat com | 5 A | (NGlale President’s Pad 4 Maryland MPhA News Pha rmacy 6 | Member Mentions & News You Can Use G rad uates! 8 | Phi Lambda Sigma and the Maryland Pharmacists Association Reunite ] 4 10 | History: How and When MPhA Was Formed 11 | Welcome New MPhA Members 14 | Graduating Members ADVERTISERS INDEX 16 | Save the Dates 30 Corporate Sponsors 19 | Convention Wrap Up erik DHISCamaay 30 | Thank You Corporate Sponsors EPIC Editorial IPBG 11 | Pharmacy Time Capsule I3._ HD.Smith/AmerisourceBergen 12 | Spring Ahead in Your Pharmacy Career 1f R.J. Hedges lé Cardinal Health Advocacy 22 EPIC Pharmcies, Inc. 17 | Rx and the Law: Animal Patients 31 Compliant Pharmacy Alliance Continuing Ed
Pharmacists Mutual
NO
23 | Chronic Obstructive Pulmonary Disease Treatment Update: Review of Recent Guideline Changes and Recommendations
Executive Director’s Message 31
MARYLANDPHARMACIST.ORG 3
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MARYLAND PHARMACISTS ASSOCIATION
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MPhA OFFICERS 2018-2019
Cherokee Layson-Wolf, PharmD, CGP, BCACP, FAPhA, Chairman
Chai Wang, PharmD, BCPS, AE-C, President
Richard DeBenedetto, PharmD, MS, AAHIVP., Vice President
Mark Lapouraille, PD, Treasurer
Betty Sanford, Honorary President
HOUSE OFFICERS
Matthew Balish, PharmD, RPh, Speaker
Lauren Lakdawala, PharmD, BCACP, Vice Speaker
MPhA TRUSTEES
Kerry Cormier, PharmD
Darci Eubank, PharmD
Sam Houmes, PharmD, BCACP
Anne Lin, PharmD
Amy Nathanson, PharmD, BCACP., AE-C,
Cory Duke, ASP Student Representative — University of Maryland School of Pharmacy
EX-OFFICIO TRUSTEES
Rondall Allen, PharmD, Dean, University of Maryland Eastern Shore School of Pharmacy
Jackie Phan, University of Maryland Eastern Shore School of Pharmacy
Yaritza Velez Burgos, Notre Dame of Maryland School of Pharmacy
PEER REVIEWERS
Kerry Cormier, PharmD
Tosin David, PharmD
Nicole Groves, PharmD
G. Lawrence Hogue, BSPharm, PD Frank Nice, RPh, DPA, CPHP
STAFF
Aliyah N. Horton, CAE, Executive Director
Lauren Williams, Director of Programs and Membership Engagement
Shawn Collins, Membership Services Coordinator
CONTRIBUTORS
NASPA Services Company, LLC, Editorial
Katy Pincus, PharmD, BCPS
Special thanks to Graphtech, Advertising Sales and Design
Maryland Pharmacists Association, 9115 Guilford Road, Suite 200, Columbia, MD 21046, call 443.583.8000, or email aliyah. horton@mdpha.com.
President’s Pad
| look forward to engaging
each of you to bring
your ideas forward and
transform our association
through innovation.
Let us become imagineers
and see what we can build together.
Dear MPhA Members,
Thank you for giving me the opportunity to serve as your association president. lam very appreciative of the support and guidance that our member volunteers continue to provide. As I prepare to share my vision for MPhA with you, I am inspired by your energy and excitement, and I look forward to serving you as we work to achieve our strategic plan priorities and increase membership value.
As I put pen to paper to draft these remarks, I reflected upon my own MPhA journey which started as a first-year student pharmacist. I remember my first visit to the Kelly Building, where pharmacists talked as friends and worked to improve the future of the profession amidst a 1950s pharmacy exhibit. These trailblazers were passionate about their involvement, and it was their vision that led to exciting developments like the MTM summit and our permanent home at 9115 Guilford Road.
This home, like our meetings and events, is the product of creative ideas driven by passion and hard work. MPhA has a rich history of major accomplishments because members like you are given a voice. Through an environment that stimulates
and facilitates member participation, everyone can make a meaningful impact by contributing their ideas and interests. With your support, we can shape the association through this year’s theme of “Imagineering: Transforming MPhA through Innovation.”
Imagineering, which combines imagination with engineering, is the process of implementing creative ideas in a practical way. It is this concept that will serve our association well as we build the infrastructure for a stimulating environment that supports member participation. It starts by laying the foundation for the MPhA of tomorrow by reflecting upon our past and engaging the present.
I envision a vibrant member community actively increasing the value proposition for joining our association, creating a place where pharmacists, technicians, student pharmacists, and friends can have fun by volunteering their time, sharing ideas, and participating in events. To jumpstart this effort, I have refreshed our committees with new leadership to pull in that energy from all aspects of our membership and take advantage of unique experiences. These committees will not only plan events, but also encourage member contributions. In addition, you will notice a concerted effort to engage our Past Presidents on each committee, tapping into their knowledge and experience. We also are supporting first-time trustees through a mentorship program to ensure we have a strong pipeline of future leaders.
With this foundation, MPhA will have greater capacity to shift ideas into production, thereby generating membership value through rapid yet sustainable growth. The association will examine value in the non-traditional sense in order to provide educational entertainment, a multitude of convenient touchpoints connecting you
Continued on next page
800-965-EPIC | EPICRX.COM
President’s Pad continued
with the organization, and ensuring you are personally and professionally satisfied with the membership experience.
We will work to ensure MPhA is responsive to your interests and promotes events in different venues across the state and through mobile and web-based technology. By working together, Let us work together and create the meaningful experiences that make
fun MPhA memories. Transforming MPhA through innovation is not limited to events — this is also an opportunity to consider new approaches to achieve our strategic goals. We will be looking to enhance our membership offerings to make it easier to become a member. By placing a focus on family and community engagement, we can bring additional value to your
membership. And through organizational development,
we will plan major association events like our conventions with additional lead time to maximize attendance.
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* EPIC Pharmacy Network, Inc. (EPN) membership fee included at no cost — access to third-party contracts
* Clinical services tools, including expert assistance from our in-house pharmacist and access to custom PrescribeWellness offerings and EQuIPP™
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You are essential to the success of this association. Your ideas will drive the MPhA of tomorrow. If you have not yet had the opportunity to volunteer on a committee and would be interested in doing so, let us help you become connected so you can help make a difference.
With that, I want to thank everyone again for their support this upcoming year. I look forward to engaging each of you to bring your ideas forward and transform our association through innovation. Let us become imagineers and see what we can build together. @
Thank you,
Chai Wang, PharmD, BCPS, AE-C President, Maryland Pharmacists Association 2018-2019
MARYLANDPHARMACIST.ORG 5
Member Mentions & News
You Can Use
MPhA Members Honored with AACP Award
Dr. Nicole Culhane, Assistant Dean, Experiential Education, Notre Dame of Maryland University School of Pharmacy, received the Excellence in Experiential Education Award from the American Association of Colleges of Pharmacy Experiential Education Section at the annual meeting in July 2018.
Toney Appointed to BOP
Congratulations to Rhonda M. Toney, who was recently elected as Secretary of the Maryland Board of Pharmacy. Toney was appointed as an at-large representative on the Board, and is serving her first term through 2021.
With Sympathy
Delegate Ted Sophocleus passed away on June 8. Sophocleus was one of the longest serving public officials in Anne Arundel County history and the only pharmacist serving in the Maryland General Assembly. Our condolences to the family, friends and colleagues of Del. Sophocleus. A funeral service was held on Friday, June 15. Donations may be made to Opportunity Builders, Inc. of Millersville in Sophocleus’ memory.
Reminder: PDMP Mandated Use as of July 1
Effective July 1, 2018, Maryland law requires controlled substance prescribers and pharmacists to request and assess data from the prescription drug monitoring program (PDMP) in certain prescribing and dispensing situations. The below materials detail when you are required to check the POMP and where exceptions exist — both clinical and technological — and how to appropriately document your actions.
The Maryland Department of Health (MDH) anticipates no issues related to PDMP access. However, if you encounter any challenges, you should use reasonable clinical judgment in deciding whether to prescribe or dispense an opioid or benzodiazepine. An inability to view PDMP data does not legally prevent you from prescribing or dispensing.
6 MARYLAND PHARMACIST | SUMMER 2018
The Proceedings of the Maryland State Pharmaceutical Association Digitization Project is Complete!
With support from the MPhA Foundation, the History Committee has been working on several projects
to highlight the contributions of MPhA to Maryland pharmacy history. One effort of the project was to digitalize documents held at the University of Maryland. MPhA proceedings from 1985-1955 are now available in the University of Maryland Baltimore's Digital Archive.
MPhA Helps Launch RALI MD
MPhA has joined as a founding partner of the Rx Abuse Leadership Initiative (RALI) of Maryland. It is an alliance of more than a dozen local, state, and national organizations committed to finding solutions to end the opioid crisis in Maryland. RALI focuses on raising awareness about appropriate drug disposal.
The program was launched at MPhA member Neil McGarvey's pharmacy, Annapolis Professional Pharmacy, with Maryland House Speaker, Delegate
Mike Busch. Education events have also been held at community meetings with members of the Maryland General Assembly. RALI is developing future events in Western Maryland and on the Eastern Shore.
Aliyah N. Horton, Neil McGarvey and MPnhA President Cherokee Layson-Wolf
Changes to General Assembly Committee Leadership
Delegate Joseline Pena-Melnyk will become the Vice Chairman of the House Health and Government Operations (HGO) Committee. Delegate Pena- Melnyk has served in the House and on the Health
& Government Operations Committee since 2007, and as the Public Health & Minority Health Disparities Subcommittee Chair since 2015.
Delegate Pena-Melnyk has been a strong advocate for the pharmacy profession. She has supported efforts related to enhancing collaborative practice authority, pharmacy technician registration waivers for pharmacy students, and contraceptive prescriptive authority, among others. She will replace Delegate Eric Bromwell who will become the Vice Chairman of the House Economic Matters Committee.
Both House and Senate Committees that oversee realthcare issues are seeing significant turnover. On the House side, at least seven members of HGO Committee ost their primaries or chose not to run for reelection. In the Senate, the Senate Finance Committee chair, Senator Mac Middleton, lost his primary, and the vice chair, Senator John Astle, chose not to run. And the Education, ealth, and Environmental Affairs Committee chair, Senator Joan Carter Conway, also lost her primary.
MPhA will engage in outreach and education to get the new members of these important committees up-to- speed on pharmacy practice issues.
2017 Price Gouging Law
The U.S. 4th Circuit Court of Appeals issued a ruling denying the Attorney General's request for a rehearing to uphold Maryland's 2017 prescription drug anti-price- gouging law. It is unclear at the time of publication, whether State Attorney General Brian Frosh will seek a Supreme Court appeal. In the meantime, Members of the General Assembly are holding town hall meetings across the state to discuss prescription affordability. These town halls will inform how the Delegates proceed on the issue during the 2019 Session.
Maryland Technician Consensus Conference
We Work for Health Maryland Summit
As a co-chair/partner of We Work for Health (WWFH) Maryland, MPhA works with a diverse mix of Maryland organizations to promote the social and economic value of the biopharmaceutical and life sciences sectors in Maryland. Our partners include biotechnology
and pharmaceutical companies, as well as state and local chambers of commerce, academic and research institutions, labor and patient advocate groups, physicians, and healthcare providers. Annually, MPhA participates in a WWFH summit with other state partners in Washington, DC. The summit included meetings with the Maryland congressional delegation. The collective Maryland team had meetings with the offices of the entire 10-member delegation and MPhA staff participated in eight.
MPhA staff and members participated in the development and implementation of the Maryland Pharmacy Technician Consensus Conference. The conference was held on June 21. MPhA served as a sponsor of the event, along with
the Maryland Board of Pharmacy, Maryland Association of Chain Drug Stores, Maryland Pharmacy Coalition, MPhA, Maryland Society of Health-System Pharmacy, Notre Dame of Maryland University School of Pharmacy, University of Maryland School of Pharmacy, and University of Maryland Eastern Shore School of Pharmacy.
Attendees included a broad swath of professionals and stakeholders engaged in the education,
hiring, and supervision of pharmacy technicians. The consensus conference aimed to identify the optimal knowledge, skills, and abilities pharmacy technicians need; educational requirements; and potential regulations related to how technicians practice. MPhA members and leadership were well represented and provided key perspectives from various practice settings.
The consensus conference report is under development and will be made available to the membership upon its release.
Continued on next page
MARYLANDPHARMACIST.ORG 7
Saniya Chaudhry, President, NDMU Phi Lambda Sigma Delta Beta Chapter James Bresette, PharmD, UMES School of Pharmacy, Phi Lambda Sigma Delta Nu Chapter Co-Advisor
2, 2018, Phi Lambda Sigma welcomed ents to the Notre
On Saturday June 41 pharmacists and pharmacy studer
Dame of Maryland University School of Pharmacy. Phi seucclaters Sigma partnered with MPhA and the MPhA
Foundation to bring graduates another opportunity to excel at the Multi-State Pharmacy Jurisprudence Exam (MPJE). The 7-hour review session was planned and implemented by the three school Phi Lambda Sigma chapters with Dr Andrew York, PharmD, J.D., Phi Lambda Sigma alumnus and MPhA member instructing. This partnership marks the second consecutive year that ete recent graduates and pharmacists entering
ryland pharmacy practice were presented content on
pharmacy law, oe ient studying techniques and how to cel when taking the MPJE. The three chapters planned
this powerful one-day session through 3 months of
weekly teleconferences. The planning committee is also working to improve the available options by offering a recording of the live session and supplemental podcasts to augment the live session. These content options will be available for all MPhA members through the website.
This year’s MPJE workshop brought in 33 new MPhA members and the overall satisfaction with the MPJE session was rated as highly or very highly satisfied, receiving 4s and 5s on all aspects of the course.
Phi Lambda Sigma and the MPhA Foundation aim to continue this partnership, offering the MPJE preparation course again in 2019. Phi Lambda Sigma, the MPhA Foundation and MPhA will continue to work together to successfully prepare all pharmacists seeking Maryland licensure to pass the MPJE and demonstrate the value and benefit of MPhA membership. @
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nedetto participated in a press conference with Representative John Sarbanes to thank and Delegate Eric Bromwell for their sponsorship of the legislation that bans the
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HEALTH CARE FOR ALL!
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l 0 0 | l ) PHARMACISTS ASSOCIATION NATIONAL
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History: How and When MPhA
Was Formed
Murhl Flowers, RPh, Co-Chairman, MPhA History Committee
MPhA History Committee
In April 2016, MPhA formed a History Committee to research and produce a written history of MPhA. The committee's goal is to preserve MPhA history with written documentation chronicling the history of the Maryland Pharmacists Association. This has proven to be quite a challenge. The original name of the association, established in 1883, was the Maryland Pharmaceutical Association. Our journal was not established until 1925; consequently, we only have information from 1925 to the present. It is extremely difficult to find the activities and proceedings from 1883 to 1925.
The committee is primarily composed of past MPhA presidents but participation is open to any interested member. So, if you are interested in joining, please let the office know.
Association Establishment
The Maryland College of Pharmacy was organized in 1841, making it the fourth school of pharmacy in the United States. Many of the school's graduates and other Maryland pharmacists were instrumental in the founding of the American Pharmaceutical Association (APhA) in 1852. Annual meetings of APhA were held in Baltimore in 1856, 1863, 1870, and 1898.
One of APhA’s outstanding efforts was to encourage the formation of state and local pharmaceutical associations. Efforts were made by the Maryland College of Pharmacy in 1868 to form a state association in Maryland. However, there was not enough support from the ranks to sustain an association at that time.
On October 5, 1882, at a meeting of the Maryland College of Pharmacy, the following resolution to form a state association was produced:
WHEREAS, the general progress and well-being of our profession demand that the Pharmacists everywhere be thoroughly organized, and
WHEREAS, the business relations existing between Pharmacists and Wholesale and Manufacturing Druggists are and ought to be of the most intimate and confidential character, and
WHEREAS, the Pharmacists, the Wholesale and the Manufacturing Druggists have thus far had no organization in this State for their mutual
10 MARYLAND PHARMACIST | SUMMER 2018
protection, benefit and the general advancement of pharmaceutical interests and knowledge:
THEREFORE, BE IT RESOLVED, that a committee of fifteen be appointed to correspond with and invite every Pharmacist, Wholesale and Manufacturing Druggist in the State to meet in the city of Baltimore on the second Tuesday of May next to organize an association for the purposes set forth in the preamble.
BE IT FURTHER RESOLVED, that the said committee be and are hereby instructed to draft a suitable Constitution and By-Laws, to be submitted to the proposed association for their consideration, and that they do such other work as will, in their judgement, be useful to, and facilitate the speedy organization of said proposed association.
BE IT FURTHER RESOLVED, that we cordially tender to the Pharmacists, the Wholesale and the Manufacturing Druggists of the State the use of the College Building as a place of meeting.
In November 1882, the committee created by the resolution sent the following invitation to the pharmacists, chemists, and the wholesale and manufacturing druggists in the State:
The undersigned Committee, acting in behalf of the Maryland College of Pharmacy, cordially invite you to meet in the city of Baltimore on the second Tuesday of May next at 11 o'clock A.M. at the hall of said college, for the purpose of organizing an Association of the Pharmacists, the Chemists, the Wholesale and the Manufacturing Druggists of the State, for the general advancement of the science of Pharmacy and the promotion of mutual interests. Be Kind enough to advise the Committee if they may count upon
your presence and hearty cooperation. Your atten- tion is respectfully called to a series of resolutions under authority of which this call is issued.
The meeting was held on May 8, 1883, in the Hall at the Maryland College of Pharmacy. The resolutions, a draft constitution, and draft by-laws were presented to the attendees and subsequently approved. A slate of Offi- cers was nominated, presented, and passed. The officers elected and committees established were as follows: President: John J. Thomsen, Baltimore
Ist Vice President: C. W. Crawford, Gaithersburg
2nd Vice President: Thomas. W. Shryer, Cumberland
Continued on page next page
Third Quarter 2018: Pharmacy Time Capsule
By: Dennis B. Worthen, PhD, Cincinnati, OH
— 1993 1968 1943 1918 1893
¢ ACPE released e Fentanyl, ¢ Bulletin of the ¢ Beginning of « New Mexico proposed developed by American Society the Spanish flu formed state standards and Janssen and of Hospital pandemic. pharmacy guidelines for marketed by Pharmacists association. @ the PharmD as McNeil, was first published. the professional approved as an Later renamed entry-level IV analgesic. American Journal degree. of Health-System
Pharmacy.
New Mexico passed legislation to address a
shortage of ; primary care One of a series contributed by the American Institute of the History of Pharmacy,
providers a unique non-profit society dedicated to assuring that the contributions of your making vine profession endure as a part of America’s history. Membership offers the satisfaction of first state to let helping continue this work on behalf of pharmacy, and brings five or more historical
specially trained publications to your door each year. To learn more, check out: www.aihp.org pharmacists
provide primary patient care.
EST. 1982 MARYLAND PHARMACISTS ASSOCIATION
© MPhA MWlelconesr our NEWEST MEMBERS
Michael P. Ferris Sapana Patel Robert Rapier Judy Sim
Ilene Harris Raj Pingili Lauren Ru Lindsay Wagner Lisa Valerio Heber Pamela Ann Piotrowski Sheel Shah Anna Marie Woods Rajendra Kamma Heidi Polek Salem Shah Michael Yapp
Lisa Kao
History: How and When MPhA Was Formed continued
3rd Vice President: Hugh Duffy, Hillsboro Initially, there were 25 members who paid an initiation Secretary: John W. Geiger, Baltimore fee of $1.00 and annual dues of $2.00. Treasurer: E. Walton Russell, Baltimore
Executive Committee: Samuel Mansfield, Baltimore THE MARYLAND PHARMACEUTICAL ASSOCIATION Joseph B. Boyle, Westminster
Henry A. Elliott, Balttumore
WAS OFFICIALLY FORMED ON MAY 8, 1883, 135 YEARS AGO
Committees Established: Committee on Legislation Committee on Pharmacy Committee on Trade Interests Committee on Business
MARYLANDPHARMACIST.ORG_ 11
Spring Ahead in Your Pharmacy Career
By John Lee, PharmD Candidate 2019; Shelby Holstein, PharmD Candidate 2019; Patricia Dieso, PharmD Candidate 2019
On April 21, 2018, the pharmacy schools of Notre Dame of Maryland University (NDMU), the University of Maryland Baltimore (UMB), and the
University of Maryland Eastern Shore (UMES) partnered with the Maryland
Pharmacists Association (MPhA)
to hold the second annual Spring Ahead in Your Pharmacy Career event. In the spring of 2017 these four groups originally partnered to create the novel event under the guidance of MPhA‘s Professional Development Committee, led by then-chairs, Dr. Amy Nathanson and Dr. Virginia Nguyen. The event was a significant undertaking, as it required constant communication and planning amongst all three pharmacy schools and MPhA. The efforts proved worthwhile. Student
participants learned valuable lessons
in email etiquette and conflict management and had ample opportunities for networking. The feedback from participants was so positive that the four groups chose to host the event again this year.
In its second year of planning, Maryland Schools of Pharmacy student representatives partnered with MPhA‘s Professional Develop- ment Committee, this year headed by Dr. Virginia Nguyen and Dr. Lynn Aung. After several months of discussion and planning, the event was revamped to feature two new
topics reflective of Maryland student
pharmacists’ areas of interest. The first session was presented by Tim Baker of Script Financial. Mr. Baker covered the often overlooked,
yet ever-important subject of managing student loans and debt, and discussed several financial management tips and strategies for students to consider when
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paying back their loans. The second new session featured Dr. Brandon Biggs of Kaiser Permanente, who presented a workshop on how to draft proper letters of intent. Every student pharmacist in the room, knowing they would have to write letters of intent in their near future, found this workshop positive and useful. Afterwards, students were
treated to an APPE Student Panel led
by the three-immediate past APhA- ASP Presidents in Maryland, and original collaborators of the Spring Ahead event, Tola Adebanjo, Rachel Lumish, and Mayrim Millan-Barea.
“What started as a pilot collaboration
between the three schools of pharmacy, has now transformed into an annual event that benefits so many students. It is rare that students from all three schools come together, so I'm looking forward to seeing this professional development opportunity evolve each year,” Rachel Lumish commented on the success of the event. Additionally, 12 practicing pharmacists in the Maryland area were present to meet with student attendees and conduct mock
12 MARYLAND PHARMACIST | SUMMER 2018
interview sessions. “As a student, it is encouraging to engage in mock interview sessions. The feedback that I received from the mock interview at MPhA will help me build better responses that reflect my strengths in future career interviews,” attendee and 3rd
year pharmacy student Stephanos Gozali noted.
The second annual collaborative event proved to yet again be a success. As student pharmacists
in Maryland, it is rewarding to see the continual development and growth of our profession, and the collaborative efforts of all student pharmacists throughout the state work together. It is extremely encouraging to see the support and energy that Maryland pharmacists invest in student pharmacists for our professional development and preparation. Thank you to these mentors and the association — with your help, student pharmacists within MPhA are better prepared to be “Provider Ready.” @
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Graduating Members
Notre Dame of Maryland University School of Pharmacy
Olufunmilola Adebanjo
Janet Akinduro Michtta Andre
Cesar Bejarano-Garcia
Charlene Chatzistrati Yu-Wei Chen Abidemi Dada Harriet Daraja Fritz Demanou Lyndsay D'Intino Linda Duong Alyssia Dyett Nahed Elias Obehi Esene Kyle Gundlach Quynh-Nhu Ha Shannon Haar
]
KA
Miaka Huynh Fatemeh Khayatian Louzon
Sandrine Mbouyo
University of Maryland Eastern Shore School of Pharmacy & Health Professions
Lincy Abraham Tolani Adebanjo Constance Ambele Rosa Ayele
Albert Ayernor
Etchi Awu Ayuk-Nkem
Manyo Ayuk Scott Baker Amber Benitez Michelle Benton Bryce Bristow Brittney Brooks-Grey Matthew Coco Carolyn Cooper Marco Dela-Cruz Raissa Fodjo Careen-Joan Franklin Bernadette Frunjang Aneesha Garg
Beth Hatton
Amber Haynes
Olivia Chizua Akubuilo
Michelle Alejandro Aamira Tabassum Ali Peter Nyarko Ansong
Mayrim Millan Barea Ki Moon
Fortunate Mwanaka Chibuike Nduanya Binh Nguyen
Vy Nguyen
Phuong Nguyen Uyen Nguyen Muhammad Obaid Jeffrey Oboite Jasmine Offoha Alexander Olumese Michaela Palma Sonya Park
Tue Phan
Allison Plummer Josette Pono
Jie Ying Qiu
Zainab Raza
Bella Sarjoh
Tiffany Sherod-Harris Dorlette Somtia Monique Spears
Joyce Kiama
Yoon Jung Kwon Chukwuka Maduako Harris Ngokobi
Vu Nguyen Terrance Nkunbuma Adeline Noumssi Olufisayo Oluwafemi Kamal Patel
Waldon Remington Truptiben Sindhi Solange Sirri
Alexis Smith Matthew Smithmyer Shadow Spiers David Sproul Katherine Syphard Mesay Teklu Thomas Tran Shahrzad Vasy Alberta Wacka
Stephanie Ifeoma Anyanwu
John Alan Arthur Daniyal Bashir Amy Lorraine Batdorf
14 MARYLAND PHARMACIST | St
“4 » 4]
Yaharn Su Shelby Tomaselli Huan Vuong Syria Wesley
Tai Wang Jessica Wearden
University of Maryland School of Pharmacy
Farinaz Beniesfahany
Matthew Joseph Borrison
Margaret Brill
Alexander Brett Britcher
Jessica Wiley Alexander Wong Melody Yun
Winfield Whittington Alora Wilson
Eric Murray Britton Mary Kathryn Brunk Priya Brunsdon Jamila Erin Chaudry
Kelechi Olariche Chikeka
Eunice Choi
Rohini Choudhuni
Teyrra D. Crawford
Priya Davey
Maxwell Scott Ditlevson
Christina Do
Vee Do
Kenneth Doan
Rachid Douglas Louis
Dorian Edwards
Ugochukwu Okwudini Eze
Fahim Faruque
Mark Andrew Ferenc
Anne Elise Fulton
Maggie Fung
Yechezkel Gabaie
Mena Gaballah
Sheriff Oluwaseun Gbadamosi
Markos Kidane Gebru
Meryam Sima Gharbi
Bahareh Ghorashi
Sadia Goheer
Oshrah Golfeiz
Jillian Granados Gutierrez
Alyssa Theresa Henshaw
Jessica Hodge
Bashir Abdallah Hassan Idris
Oluwatoyin Yewande Ikujuni
Elias Carr Inscoe
Jeehyun Jang
Syra Jang
Lynn Kayali
Didi Honey Kim
Emmanuel Kim
Grace Eunhae Kim
Lena Kyuhee Kim
Esther Ruguru Kimani
Alexandra Daphna Kirsch
Heather Ashley Kirwan
Abigail Marie Klutts
Philip Ling-Fat Kong
Alina Jane Kukin
Neha Kumar
Dana Eun Lee
Jin Yi Lee
Minseok Lee
Tommy D. Lee
Class of 2018 Outstanding
Student
Achievement Award Winners
Matthew Brian Levit
Ashley Lim
Hongzhuo Lin
Kevin Loh
Kari Ann Louk
Rachel Allison Lumish
Sophia Ma
Joseph Robert Martin
Stephen Louis Meninger
Katherine Elizabeth Mersinger
Dorinne Alexandra Mettle- Amuah
Robert Andrew Mix
Thamar Laurianne Kinkeu Momo
Ana Luisa Moreira Coutinho
Shannon Cristine Morrow
Hildred Mildred Moyo
Kelly May Murphy
Sruthi Nandakumar
Anh-Tuan Thanh Nguyen
Christine Nguyen
Jenny Diep Nguyen
Kelvin Nguyen
Kristin Elizabeth Nichols
Gaelle Annick Ngadeu Njonkou
Marian Akamin Nkeng
Elizabeth Atemnkeng Nkengasong
Heejung Stacey Noh
Tolani Adebanjo University of Maryland Eastern Shore School of Pharmacy
Jacqueline Elizabeth North
Richard Sean O'Dell
Victor Oluwatobi Olalekan
Chibundu Eziafa Osakwe
Hannah Osemudiamen Oseghale
Christian Amoah Osei
Kayla Lynn Otto
Akosua Adoma Owusu- Dommey
Jordan Bethany Paavola
Chinsu Pak
So Yeon Park
Dharti Vinodbhai Patel
Vinh Pham
Hyo Chan Phee
Arielle Veronica Pietron
Kaitlyn Eve Pinkos
Aimee Catherine Porter
Rumsha Qaiyumi
Alaina Marie Robey
Vincent Rosel
Joshua David Rubel
Leila Sasanpour
Erika Kimberly Saunders
Stephanie Schmersahl
Akil Joseph Shambourger
Seongbin Shin
Garrett Evan Sinnott
Jason Ronald Smith
Mehak Nawaz Suddle
Monalee Diane Swale
Meryam Gharbi University of Maryland School of Pharmacy
Rachel Hope Switzer
Melissa Teng
Tenkang Ernest Tiendi
Jason Minhtan Tran
Triet Minh Tran
Vivian Tran
Cynthia Uche
Chukwukadibia Jideofor Udeze
Jessica Chioma Jeremiah Uwandu
Dana Traniece Valentine
Mudit Verma
Lan Uyen Sylvie Vu
Sokleap Vuth
Catherine Wang
Yoo Min Han Warner
Brandi Lauren Wian
Anne McKnight Collins Williams
Christian Anthony Wolfe
Benjamin Shiang Wu
Yan Ting Wu
Irene Xue
Wenye Yang
Kar-Yue Alvin Yee
Ahrang Yoo
Han Sol Yoo
SeJeong Yoon
Pamela Younes
Melissa Vanna Yuen
Victoria Luo Zhu
Miaka Huynh Notre Dame of
Maryland University School of Pharmacy
MARYLANDPHARMACIST.ORG 15
_
ay. HE
QUESTIONNAIRE y
Medicare Questionnaire
MEDICARE
re f
MPhA headquarters unless otherwise indicated.
Sunday, September 16 — Do You Believe In MAGIC?
Thursday, December 13 — MPhA Holiday Party
For the most up-to-date schedule of MPhA activities visit www.marylandpharmacist.org. All activities are at
Notre Dame of Maryland University, Baltimore, MD
A one-day event designed for new practitioners
and student pharmacists highlighting hot
topics involving Mentorship, Advocacy, Growth, Innovation and Collaboration within the pharmacy
profession.
| Thursday, September 27 — Public Board of Trustees Meeting
Thursday, October 18 — Public Board of Trustees Meeting
Thursday, November 15 — Public Board of Trustees Meeting
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Thursday, January 17, 2019 — Public Board of Trustees Meeting
Sunday, February 10, 2019 — 2019 MPhA Mid-Year Meeting
College Park Marriott Hotel and Conference Center, Hyattsville, MD
MPhA’s annual one-day meeting for pharmacists, pharmacy technicians, and students from all practice settings. The meeting will feature
hot topic continuing education sessions and networking opportunities.
Rx and the Law: Animal Patients
By Don R. McGuire Jr., R.Ph., J.D
The pharmacist at Anytown Pharmacy had prepared prescriptions for two pets and placed them in the refrigerator awaiting pickup. When Butch’'s owner came in to pick up his prescription, the owner was given another dog's prescription. Upon administration, the dog became lethargic and Butch’s owner took him to the vet. Unfortunately, Butch’s symptoms couldn't be reversed and he died as a result of the incorrect drug's effects. Butch’'s owner subsequently made a claim for damages against the pharmacy.
What damages is Butch’s owner entitled to recover?
In the majority of states, pets and other animals are considered personal property. As such, the owner is not entitled to recover damages for emotional pain and suffering or mental anguish, no matter how close the owner is to the pet or how much a part of their family they consider the pet to be. This can make these types of claims difficult to settle because the owner feels that the bond with their pet is not being considered. Under the law, they are correct. The bond with their pet is not compensable.
What is compensable is the market value of the animal and other costs resulting from the incident. These other costs could be the cost of treatment by a vet or in extreme cases, the cost of burial or cremation of the animal. The market value of an animal includes a number
of factors, such as the original purchase price, the cost of replacement, and
other elements that can enhance the animal's value. For example, if the animal patient is a prize-winning race horse, the owner would be entitled to recover lost stud fees and other income derived from the horse's performances. The cost to replace a winning race horse can also be substantial.
The potential vet bills for an injured pet could also be substantial. Because of the bond with their pet, the distraught owner might be willing to try any treatment, even those with only a small chance of success. It would not be unusual for vet bills to exceed the market value of an animal.
Because animals are considered property under the law, some states may have
different procedures for these types of claims. States that have damage caps in medical negligence cases may not apply them here. These caps are generally applied to the injured patient's damages for pain and suffering. Because animal claims are property claims and there are no emotional damages, these caps do not apply. Also, because these claims are property claims, they may not be eligible for the Medical Review Panel process if that
is in place in your state. In the Medical Review Panel process, the negligence claim is reviewed and evaluated by a panel of practitioners before the case can go to court. The case then only goes to court if one of the parties disagrees with the panel's decision.
Pharmacists may not think much about the financial risks from an animal claim because there are no damages for emotional distress. While this is true, the other exposures can still be significant. Market values for race horses that have died as the result of prescription errors can reach six figure settlements. This can be multiplied if more than one animal is killed or injured. A case in Florida in 2009 resulted in the deaths of 21 polo ponies from a compounded nutritional supplement. A jury awarded the owners of the horses $2.5 million.
Pharmacists are health care providers because they want to help their patients. This is true whether the patient is human or an animal. The differences in the law for damages as the result of an error should not influence the way that a pharmacist approaches the care that they provide. There are groups advocating in several states for changes in these laws to allow for the owner to recover emotional damages. Pharmacists will need to verify the law in their state. All patients deserve the same processes and safeguards. As with any aspect of their practices, pharmacists should be well informed of the standards and risks for any activity undertaken. This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and your State Pharmacy Association through Pharmacy Marketing Group,
Inc., a company dedicated to providing quality products and services to the pharmacy community.
© Don R. McGuire Jr., R.Ph., J.D., is General Counsel, Senior Vice President, Risk Management & Compliance at Pharmacists Mutual Insurance Company.
This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly.
MARYLANDPHARMACIST.ORG_ 17
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Convention Wrap-Up
Thank you to all who attended MPhA’s 136th Annual Convention in Ocean City, MD! And thank you to the Meeting Planning Committee, led by Darci Eubank and Sadhna Khatri, for putting together a great program of continuing education, networking, and fun!
RECOGNITIONS 2018-2019 Board of Trustees
MPhA OFFICERS 2018-2019 Cherokee Layson-Wolf, Chairman; Chai Wang, President; Richard DeBenedetto, Vice President; Mark Lapouraille, Treasurer; Betty Sanford, Honorary President
HOUSE OFFICERS Matthew Balish, Speaker; Lauren Lakdawala, Vice Speaker
MPhA TRUSTEES Kerry Cormier, Darci Eubank, Sam Houmes, Anne Lin, Ashlee Mattingly, Amy Nathanson, Cory Duke, Natalie Eddington
EX-OFFICIO TRUSTEES Rondall Allen, Jackie Phan, Yaritza Velez Burgos
SPONSORS
And thank our generous sponsors for supporting the convention: EPIC Pharmacies, Inc. RALI Maryland MPhA Foundation Shea Moisture Middletown Valley Bank Shoppers Pharmacy National Association of Chain Drug Stores Snyder Cohn University of Maryland School of Pharmacy P3 Program Whitesell Pharmacy PEER Wolfe & Fiedler Professional Pharmacy Your Community Pharmacy
2018 EXCELLENCE IN PHARMACY AWARDS
All winners and honorees are pictured with MPhA President, Cherokee Layson-Wolf. Photography courtesy of Marci Strauss.
Bowl of Hygeia Award presented to Dixie Honorary President Award presented to Betty Sanford, pictured with Mark Leikach, RPh, MBA, FACA Sanford, PD, RPh, MBA
MARYLANDPHARMACIST.ORG 19
Convention Wrap-Up continued
POLICY ACTIONS
The following policies were approved by the 2018 MPhA House of Delegates. A proposed policy on opioid dispensing was referred back to the committee for further refinement and will be brought back up at the 2019 Mid-Year Meeting. Thank you to the members of the Resolutions Committee: Matthew Balish, Chair and Richard Debenedetto, Ashley Moody, Hoai-An Truong, Jim Bresette, Chai Wang, Jim Dvorsky, Cherokee Layson-Wolf and students Adit Shah and Douglas Wienchedji.
Maryland Pharmacists Association supports the public health efforts for treatment and cure of Hepatitis Cin all patients, regardless of stage of liver damage. Pharmacists are prepared to provide timely treatment, education and adherence support in order to ensure treatment cure.
Maryland Pharmacists Association supports access to all appropriate medication disposal efforts and education programs in order to reduce medication misuse. MPhA
MPhA Mentor Award presented to Deanna Tran, PharmD, BCACP
Shown at far right,
Pharmacist Advocate Award, sponsored by Buy-Sell-A Pharmacy, presented to Surinder K. Singal, RPh, accepted on his behalf by
Thomas Wieland, RPh
Shown at right,
Excellence in Innovation Award, sponsored by Upsher-Smith Laboratories and the MPhA Foundation, presented to Jill A. Morgan, PharmD, BCPS, BCPPS
20 MARYLAND PHARMACIST
encourages pharmacists and pharmacies to provide medication disposal options and support medication disposal events. MPhA also encourages pharmacists and pharmacies to utilize all available resources to implement and expand education and disposal
programs within pharmacies.
Maryland Pharmacists Association supports confidential referral to the contracted Maryland Board
of Pharmacy Rehabilitation Services program for recovery
Distinguished Young Pharmacist Award, sponsored by Pharmacists Mutual Companies, presented to Richard A. DeBenedetto, PharmD, MS, AAHIVP by Adam Pietlock, PhMIC Field Representative
and assistance for pharmacists, pharmacy technicians, and pharmacy students afflicted with
a substance use disorder and encourages compliance with the duty to report requirement of the pharmacy practice act. Additionally, the Maryland Pharmacists Association supports legislation that will allow the Board of Pharmacy to support the operation programs that meet the needs of impaired pharmacists, pharmacy technicians and pharmacy students. @
MPhaA Seidman Distinguished Achievement Award presented to Joseph A. DeMino, PD
Convention Wrap-Up continued
= =e a
Outgoing Speaker of the House
Outgoing President Recognition
Recognition presented to Richard presented to Cherokee Layson- “nme . A. DeBenedetto, PharmD, MS, Wolf, PharmD, CGP, BCACP, FAPhA ; AAHIVP presented by Chairman Kristen Cardinal Health Generation Rx Champions Award, sponsored by rant : Cardinal Health Foundation, presented to Mary Lynn McPherson,
PharmD, MA, MDE, BCPS, CPE by Leah Bonnes, Cardinal Health Representative
=
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Outgoing MPhA Foundation Incoming President Recognition President Recognition presented presented to James (Chai) Wang to Paul R. Holly, PD, BSPharm PharmD, BCPS, AE-C
Outgoing Treé PharmD
Welcome 2018-2019 MPhA Board of Trustees
MARYLANDPHARMACIST.ORG 21
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Continuing Ed
Chronic Obstructive Pulmonary Disease Treatment Update
Review of Recent Guideline Changes and
Recommendations
Angeo Rey Belen, PharmD Candidate 2019, University of Maryland School of Pharmacy; Kathleen J Pincus, PharmD, BCPS, University of Maryland School of Pharmacy
After completing this activity, the pharmacist will be able to:
1. Compare and contrast the updated 2011 and 2017 Global Initiative for Obstructive Lung Disease (GOLD) guidelines
. Identify subjective and objective data used for assessment of chronic obstructive pulmonary disease (COPD)
. Recognize medication classes central to treatment of COPD
. Given a clinical case for a patient with COPD, select appropriate pharmacological treatment options for initial and step-up
management
Introduction
Chronic obstructive pulmonary disease (COPD) is a progressive inflammatory lung disease characterized by obstructed airflow and respiratory symptoms such as shortness of breath and chronic cough. According to the World Health Organization, COPD is recognized as the fourth leading cause of death in the world with 3.2 million lives claimed in 2015." Within the United States, COPD has been diagnosed in more than 15.7 million Americans and stands as the primary contributor to chronic lower respiratory disease, a leading cause of death in the country.** The Global Initiative for Obstructive Lung Disease (GOLD) has published reports based on scientific literature which guide the diagnosis, assessment, and treatment of COPD. While the 2011 GOLD Report received yearly updates from 2013 to 2016, the treatment paradigm remained mostly unchanged.* Then in November 2016, GOLD published its 2017 report which includes changes to severity assessment
and treatment recommendations.°
able to:
After completing this activity, the pharmacy technician will be
1. Identify ways in which Global Initiative guidelines influence patient needs at the pharmacy level . Recognize medication classes central to treatment of COPD
. Recognize potentially clinically significant information relative
consultation.
This article will review the updated guidelines and discuss selection between treatment options.
Pathophysiology
COPD is characterized by chronic inflammation, increased presence of inflammatory cells within the lungs, and structural damage to
the pulmonary system. Cigarette smoking or exposure to other noxious particles such as chemical fumes or air pollution can trigger inflammatory processes in the lungs leading to development of these pathologies. This structural damage leads to decreased expiratory capacity and trapping of gases in the lungs. The resulting hyperinflation of the lungs combined with
altered pulmonary function, leads to shortness of breath, the most common symptom of COPD.
Assessment
Airflow Limitation
Due to its noninvasiveness, repro- ducibility, and availability, spirometry is used by the updated 2011 and 2017 GOLD guidelines as the standard objective measurement
to COPD patients that should be referred to the pharmacist for
Keywords: chronic obstructive pulmonary disease, bronchodilators, inhaled corticosteroids
of airflow limitation in COPD patients. Spirometry measures the volume of air forcibly exhaled after maximal inspiration (forced vital capacity, FVC) and the volume
of air forcibly exhaled during the first second of this maneuver (forced expiratory volume in one second, FEV1). These values can be measured after administration of
a bronchodilator such as a short- acting beta2-agonist, a short-acting anticholinergic, or a combination of the two. The chronic inflammation and narrowing of the peripheral airways in the lungs results ina decreased FEV1 and FEV1/FVC ratio. More specifically, a calculated post-bronchodilator ratio of FEV1/ FVC < 0.70 confirms the presence of airflow limitation per the GOLD guidelines.
While this result is necessary to clinically diagnose COPD, both versions of the GOLD guidelines recommend using symptoms
and exacerbations as additional parameters for diagnosis. Indeed, a study published after the 2011 GOLD guidelines were released showed poor correlation between
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lung function, symptoms, and exacerbation frequency. In addition, the results of spirometry can be affected by patient-specific factors such as age and location. For example, a study focusing on elderly patients aged > 65 years found
that using an FEV1/FVC < 0.70 as
the sole diagnostic criterion led to over-diagnosis of COPD.’ Another study found that after adjusting for height, age, and sex, FEV1 values can differ substantially between global regions, further impacting COPD classification and management
in various geographical areas.® Regardless, both the updated
2011 and 2017 GOLD guidelines recommend using the post- bronchodilator FEV1 cut-off values given in Table 1 to classify patients into GOLD grade 1 — 4 based on the severity of airflow limitation.
Symptoms
Dyspnea, or shortness of breath,
is one of the most common symptoms in COPD and is associated with increased disease severity, increased risk of COPD exacerbation, and increased risk of mortality in a severity-dependent manner.” ?° Thus, due to its significance, both versions of the GOLD guidelines recognize the value of assessing breathlessness
in COPD. More specifically, the Modified British Medical Research Council Questionnaire (mMMRC) is discussed in the guidelines as a way for patients to rate their sensation of breathlessness. MMRC grading can range from 0 to 4 with a higher
grade corresponding to increased impact of breathlessness on patient quality of life.
Another tool discussed in both guidelines that more comprehen- sively assesses the impact of COPD on patient health status is the COPD Assessment Test (CAT).
This 8-item instrument has been discussed in multiple publications as a widely-available and simple tool for clinicians to predict risk of exacerbation, deterioration of health Status, depression, and mortality - in COPD patients." CAT scores can range from 0 to 40 with a higher score corresponding to increased health status impact. Ultimately, CAT scores do not correspond with mMRC grades and vice-versa, though both are useful for objectively characterizing the severity of COPD symptoms.
Both screening tools are available on the GOLD website at
https://goldcopd.org.
Other common symptoms seen
in COPD include chronic cough (usually the first symptom), wheezing, chest tightness, and sputum production. As the disease progresses and becomes more severe, additional symptoms include fatigue, weight loss, and anorexia. However, these more severe symptoms can be caused by other diseases and should be investigated.
Exacerbation Risk
Both versions of the guidelines define COPD exacerbation as an acute worsening of respiratory symptoms which leads to
Table 1: Airflow Limitation Severity Classification in COPD
Based on Post-Bronchodilator FEV-,
In patients with FEV1/FVC < 0.70:
GOLD 1
GOLD 4
FEV, > 80% predicted
50% < FEV-, < 80% predicted
GOLD 3 30% < FEV-, < 50% predicted
FEV, < 30% predicted
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medication changes. Exacerbations can be caused by infections, air pollutants, or be idiopathic in nature. A recent literature review found that COPD exacerbations can be linked to short- and long- term clinical implications including accelerated lung function decline, decreased quality of life, and
even increased risk of death.” Interestingly, studies have found that one of the strongest predictors for future COPD exacerbation is prior history of exacerbations. Thus, exacerbation history is an important consideration for exacerbation risk and overall COPD severity.3
Combined COPD Assessment
As discussed, spirometry data and clinical symptoms should both be used when assessing COPD status in a patient: spirometry allows for an objective assessment of lung function while symptoms allow for a subjective assessment of clinical impact. With the release of the 2011 GOLD guidelines, both types of data were used to classify patients in an "ABCD" system which corresponded to COPD severity. Within the system, group A is considered the least severe and group D the most severe of the four groups. However, the 2011 and 2017 guidelines begin
to diverge when discussing how spirometry should be incorporated.
Within the 2011 guidelines and its subsequent updates until 2016, if post-bronchodilator FEV1 values are available to classify patients into GOLD grade 1 — 4, this grading can then be used as a predictor
of COPD exacerbation risk: GOLD grade 1 and 2 patients have low risk for exacerbation and GOLD grade
3 and 4 patients have high risk for exacerbation. If this spirometry value is not available, exacerbation risk can also be predicted using the patient's history of exacerbations within the past year: 0 or 1 exacerbation not leading to hospital admission is considered low risk while > 2 exacerbations or > 1
“TA 1
CAT <10 CAT 210 Symptoms
mMRC 0-1 mMRC 2 2 Breathlessness
Risk
(GOLD Classification of Airflow
exacerbation leading to hospital admission is considered high risk. If risk assessment leads to conflicting results (for example, low risk via GOLD grading and high risk via exacerbation history), the higher risk is chosen.
In addition to risk assessment, symptom assessment using MMRC grading or CAT scores can be used to determine symptom burden:
a CAT score < 10 or amMRC grading of 0 to 1 is considered low symptom burden while a CAT score > 10 oramMEC grading > 2 is considered high symptom burden. Risk assessment and symptom assessment are then combined to assign patients into GOLD group
A — D. To summarize, assessment of a COPD patient involves assigning a number which corresponds
to airflow limitation and a letter which corresponds to symptom burden and exacerbation risk. For example, a patient with FEV1 of 40% predicted who has had zero COPD exacerbations in the past year and a CAT score of 15 would be considered GOLD grade 3 group C per the 2011 version of the guidelines.
Updated GOLD 2011 leat fae INL
Figure 1: Combined COPD Assessment Based on the 2011 and 2017 Guidelines
GOLD 2017 Combined Assessment
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