June/July 2014

PalmettoThe Official Journal of the South Carolina Pharmacy Association • Vol. 53, Num. 5

Palmetto Pharmacist • Volume 54, Number 3 1

PharmacistThe Official Journal of the South Carolina Pharmacy Association • Vol. 54, Num. 3

Palmetto

2 Palmetto Pharmacist • Volume 54 Number 3

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SDC_collage_Final.indd 3 4/11/13 12:00 PM

Palmetto PharmacistVolume 54, Issue 3 June/July 2014The Palmetto Pharmacist, the official publication of the South Carolina Pharmacy Association, is distributed to association members as a membership service. Statements of fact and opinion are made by the authors alone and do no imply an opinion on the part of the officers or members of SCPhA. For advertising rates and other information, contact SCPhA.

What’s Inside...

5 My Year As President President Steve McElmurray reflects on his time as President of SCPhA

8 Opportunities for Students Laura Jeffcoat, SCCP Student and Junior Board Member, discusses upcoming opportunities for students

10 Expanding Scope of Practice for Pharmacists in South Carolina: A Student’s Perspective How pharmacists in South Carolina can increase their role 13 Compounding Competition SCCP succeeds with compounding competition

Regular Columns 13 SCCP 27 Classifieds

Advertisers 2 Smith 4 Pharmacists Mutual 24 Display Options 24 Mutual Drug 26 PACE 27 JonWallace, AttorneyatLaw 28 QS/1


Palmetto PharmacistVolume 53, Number 3 June/July 2013 The Palmetto Pharmacist, the official publication of the South Carolina Pharmacy Association, is distributed to association members as a membership service. Statements of fact and opinion are made by the authors alone and do no imply an opinion on the part of the officers or members of SCPhA. For advertising rates and other information, contact SCPhA.

Board of Directors

President/Chairman of the Board

Steve McElmurray, RPh

Immediate Past President John Pugh, PharmD, RPh

President-Elect Bryan Amick, PharmD, RPh

Treasurer Pamela Whitmire, PharmD, RPh

Low Country Region Kristy Brittain, PharmD, RPh

Pee Dee Region Jarrod Tippins, PharmD, RPh

Midlands Region Patti Fabel, PharmD, RPh

Upstate Region Ed Vess, PharmD, RPh

At-Large DirectorWilliam Wynn, PharmD, RPh

Speaker, House of Delegates Michael Gleaton, PharmD, RPh

Speaker-Elect, House of Delegates Sarah Braga, PharmD, RPh

CEO Craig Burridge, MS, CAE

REGION DELEGATESLow Country Region Midlands Region Don Neuroth, RPh Craig Harmon, RPhDavid Proujan, RPh Sarah Braga, PharmD, RPh Tray Till, RPh Lynn Connelly, RPhWayne Weart, PharmD Kevin Brittain, PharmD, RPh Brian Clark, PharmD, RPh Upstate Region Pee Dee Region David Banks, RPh Jim Shuler, RPhSteve Greene, PharmD, RPh Kelly Jones, PharmD, RPh Walter Hughes, RPh Dan Bushardt, RPh Linda Reid, RPh

SCPhA STAFF Craig Burridge Chief Executive Officer Laura Reid Director of EventsKeenan Grayson Director of Membership Cassandra Hicks-Brown Director of Operations/ACPELauren Sponseller Director of CommunicationsJon Wallace, BS Pharm, JD SCPhA General CounselCecily DiPiro, RPh PPN Network Coordinator

PALMETTO PHARMACIST STAFF

Jennifer Simmons Layout/Design/ContentCraig Burridge Managing Editor

What’s Inside...

5 Metathesiophobia President Steve McElmurray discusses the irrational fear of change

7 State Phair 2013 A look at SCPhA’s 2013 Annual Convention

16 Legislative Wrap Up At the close of the legislative session, see how things tied up 21 A Perspective on Pet Medications Information on veterinary medications

25 My SCPhA Rotation Journal SCCP Student Michelle Nations discusses her rotation with SCPhA

33 Pharmacy Camp Attracts Young Audience A special camp at SCCP provides a unique experience for students

Regular Columns 18 SCCP 32 Financial Forum 36 Journal CE 33 Classifieds

Advertisers 2 Smith 4 Pharmacists Mutual 15 Mutual Drug of North Carolina 34 Display Options 42 PACE 43 Jon Wallace, Attorney at Law 44 QS1

MeganMontgomery,PharmD,RPh

General CounselJonWallace,BSPharm,JD



Board of Directors


















What’s Inside...










Board of Directors


















What’s Inside...








LaurenPalkowski


EdVess,RPh


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It’shardtobelievethatmyyearasSCPhAPresidentiscomingtoanend-whatanamazingexperienceithasbeen!ServingtheAssociationinthiscapacityhasbeenmorethanrewarding,andIamgratefulthatIwasgiventheopportunity.

2013wasgoodtous.Letmetakeamomenttore-capthesuccessesthatSCPhAhasexperiencedoverthepastyear.

TheAssociation’smembershipissteady,andwehavefocusedalargeamountoftimeandenergyonbuildingourrelationshipwithstudents,astheyarethefutureofpharmacy.Learningwhatisimportanttothem,andsharingissuesthatwillaffectlawsandregulationsimpactingtheirfutureissuchavaluableexperienceforeveryone.Wewillcontinuetobuildthisrelationshipwitheachofthemsothattheyun-derstandthebenefitofmembershipwithSCPhA.

Inmyopinion,SCPhAhadoneoftheirbestyearsofeventsthroughouttheyear.Recordnumbersofat-tendeesweresetatAnnualConvention,andweweresoldoutattheSoutheasternGirlsofPharmacyLead-ershipWeekend,aswellasseveralofthePharmacyNightsacrossthestate.PharmacyDayattheCapitolwasexpandedthisyearasSCPhAopenedtheinvita-tiontootherpharmacy-relatedorganizations,result-inginawidervarietyofpharmacyrepresentatives.

WehavealsohadtremendousfeedbackinregardstotheAll-PharmacyConferencethatwasstartedinOctoberoflastyear.Oursecondmeetinghadoversixtyattendeeswhorepresentedallareasofphar-macy,schoolsofpharmacy,stateagencyrepresenta-tives,payers,andPhRMA.ThenextmeetingdateisMay22,2014,andwelookforwardtoitbeingjustassuccessful!

Aswithanynewgrowth,therearegrowingpains,andliketheoldsayinggoes,“Onestepforward,twostepsback.”Ourgrowthinthepharmacyindustryisnodifferent.TherehavebeensignificantissuessurroundingPBM’sandreimbursementsasitrelatestoMACpricinginparticular.AsreportedtomebyourCEO,thispromptedameeting,organizedbyourmostablelobbyingteamofRichardDavisandAnnieWilson.RichardandAnnieassembledagroupofPBMlobbyistsandinsomecases,theirPublic

PRESIDENT’S PLATFORM

AffairsofficialsandweallmetinSenatorRonnieCromer’soffice,whoactedasourmostgracioushost.Themeetingwasveryamenable.WediscussedourFairMACPricinglegislationwiththosepresentandwhatthePBM’scouldlivewith,ornotlivewith.Granted,thisisnotetchedinstone,butitdidallowpharmacytodiscussourconcernsaboutthewayretailpharmaciesaretreated,especiallywhentheycontactaPBMtoappealaMACprice.Toooften,theyaretold,“Itiswhatitis!”SCPhA’slegislationtriestorectifythatone-sidedattitudeandbringsomefairnesstoretailpharmacies.Iftheycandecreaseagenericpriceonthesameday,thenwhycan’ttheyincreaseagenericpriceevenmonthsafteritsin-crease?We’dalsolikeforaPBMwhorejectsapriceappealtorespondbackwiththeNDCnumber(s)thatwentintodecidingthatprice.Weunderstandthatitmaybeanaverageofmultipleprices,butitshouldbeamultipleofgenericsthatarewidelyavailabletoretailpharmacies.WearguedthatcertaingovernmentprogramsrequireA/Bratedgenerics,sothatlessergenericsshouldnotbeincludedinthepricingmeth-odology.Thesameapplieswithpotentiallyusinganationalchain’s‘fulfillment’contractpricingforcertaingenerics,knowingthesepricesarenotavail-abletoanyofthatchain’scompetitors.Infact,thosegenericsbythatmanufactureraregenerallyonlyavailableatmuchhighercoststocompetingpharma-cies.WearenotcallingforthePBM’smethodology,justsometransparencyasto‘whatNDC’swereused’


PRESIDENT’S PLATFORM

My Year As President, In Review

sothatpharmaciescangooutandbuythosegenericsthatwillsavethehealthcaresystemmoneywithoutthepharmacytakingabath.

TheSCPhABoardofDirectorswillbelookingatthemodifiedlegislation(postmeeting)toseeifithasenoughteethinittoprovidepharmacywithsomeresemblanceofatrulyfree-marketsystemwherereim-bursementsarebasedon‘real’free-marketpricesandnotsomemadeupnumbertoharmcompetitorstomailorder.

It’stimetopassthetorch;timetostartoveragain;timeformorechange.We’rereadyhereatSCPhA.Areyou?



SCPHA’S ANNUAL CONVENTION

IS RIGHT AROUND THE CORNER!

JUNE 19-22, 2014

MARRIOTT RESORT & SPA HILTON HEAD ISLAND, SC

THEME: ROARING 20S

REGISTER AT WWW.SCRX.ORG

Scpha’s annual convention • June 19-22, 2014 Marriott Resort and Spa • Hilton Head Island, SC

Non-Member Registration Early Bird Registration Regular Registration Before May 10 After May 10 VIP Package □ $389 □ $439 Includes t-shirt, Awards Dinner ticket and Alumni Lunch ticket. Select your Awards Dinner choice: □ Beef □ Chicken Select your Alumni Lunch choice: □ PC □ South □ MUSC □ USC Please select your shirt size: □ S □ M □ L □ XL □ XXL Full Registration □ $279 □ $329 Please select your shirt size: □ S □ M □ L □ XL □ XXL Single Day Registration Thursday Only □ $89 □ $109 Friday Only □ $109 □ $129 Saturday Only □ $109 □ $129 Sunday Only □ $89 □ $109

Member Registration Early Bird Registration Regular Registration Before May 10 After May 10 VIP Package □ $339 □ $379 Includes t-shirt, Awards Dinner ticket and Alumni Lunch ticket. Select your Awards Dinner choice: □ Beef □ Chicken Select your Alumni Lunch choice: □ PC □ South □ MUSC □ USC Please select your shirt size: □ S □ M □ L □ XL □ XXL Full Registration □ $219 □ $269 Please select your shirt size: □ S □ M □ L □ XL □ XXL Single Day Registration Thursday Only □ $69 □ $89 Friday Only □ $89 □ $109 Saturday Only □ $89 □ $109 Sunday Only □ $69 □ $89

Student Registration Does not include Alumni Lunch or CE. □ Student Registration $99Select your Awards Dinner choice: □ Beef □ Chicken Please select your shirt size: □ S □ M □ L □ XL □ XXL Please select your school: □ USC □ MUSC □ South □ PC Grad Year: ________________

Registration Information Name_________________________________________________________________ □ Technician □ Pharmacist □ Student □ Other Nickname__________________________________ NABP eID#_________________________________Birthdate (MM/DD) _____________________ Email_______________________________________________________________________________Phone _____________________________________ Address________________________________________________________________________________________________________________________ Do you have any special dietary, learning or accessibility accommodations? _____________________________________________________

Payment Information Total Amount Due: $___________________ Credit Card Type: □ MC □ Visa □ AMEX □ Discover Name on Card________________________________________________ Card #___________________________________________________________________Exp. Date________________________CVV________________ Billing Address __________________________________________________________________________________________________________________ Cancellations will only be accepted if received more than 5 business days before the event. If applicable, a refund will be issued less a $25 processing fee. Please note that the threat of inclement weather is not considered sufficient to override our cancellation policy.

Complete this form and return, with payment, to SCPhA, 1350 Browning Road, Columbia, SC 29210 or fax to 803.354.9207. Visit www.scrx.org to register online. Questions? Call 803.354.9977.

Please check all optional (and free!) activities that you plan to attend: □ Phun Run □ Golf Tee Times □ Welcome Reception □ Sunrise Service □ I would like to sing in the Sunrise Service Choir. □ Trivia (students only) □ Student Programming (students only, topics tbd)

Add A Guest Does not include Alumni Lunch or CE.□ Guest Registration $219 Guest Name: _________________________________________________ Select Guest’s Awards Dinner choice: □ Beef □ Chicken Select Guest’s shirt size: □ S □ M □ L □ XL □ XXL

Student Sponsorships □ Full Sponsorship ($250) □ Partial Sponsorship ($100) □ Other Amount: ________________

The South Carolina Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Continuing education credits will be available to participants who fully attend theprogram and then complete an online educational activity evaluation. A unique code given at each activity must beprovided in the evaluation to receive credit. Grievances regarding the education program must be submitted in writing tothe SCPhA ACPE Administrator immediately following the program.

Additional Options Alumni Lunch tickets ($49 ea.) USC: Qty. ___ MUSC: Qty. ___ South: Qty. ___ PC: Qty. ___

Awards Dinner tickets (Adult: $79 ea.; Child: $29 ea.) Adult, Beef: Qty. ___ Adult, Chicken: Qty. ___ Child: Qty. ___

Roaring 20’s Event tickets: (Adult: $49 ea.; Child: $19 ea.) Adult: Qty. ___ Child: Qty. ___


Scpha’s annual convention Marriott Resort and Spa

Hilton Head Island, SC June 19-22, 2014

Registration Types Full Registration • 15+ hours of Continuing Education available • Welcome Reception Thursday, Breakfast Friday-Sunday • Ticket to Foundation event (includes dinner) • Ticket to Exhibit Hall (includes lunch) • Event T-Shirt VIP Registration • All of the items listed above in the Basic Full package • Ticket to the Awards Dinner • Ticket to PC, South, MUSC or USC Alumni Luncheon Student Registration • Access to all CE programming (CE credit not included) • Student specific events, including student trivia night • Welcome Reception Thursday, Breakfast Friday-Sunday • Ticket to Foundation event (includes dinner) • Ticket to the Awards Dinner • Ticket to the Exhibit Hall (includes lunch) • Event T-Shirt STUDENT SCHOLARSHIPS ARE AVAILABLE! Apply today at www.scrx.org.

Guest Registration • Access to all CE programming (CE credit not included) • Welcome Reception Thursday, Breakfast Friday-Sunday • Ticket to Foundation event (includes dinner) • Ticket to the Awards Dinner • Ticket to Exhibit Hall (includes lunch) • Event T-Shirt Daily Registration • Credit for continuing education programs for the day(s) you attend • Breakfast for the day(s) you attend • Friday attendees receive ticket to Foundation event (includes dinner) • Saturday attendees receive ticket to Exhibit Hall (includes lunch)

Hotel Information Marriott Resort and Spa 1 Hotel Cir., Hilton Head Island, SC 29928

SCPhA’s group rate of $199 per night will be available until May 19 or until rooms sell out, whichever comes first.

Reserve your room today by calling 843.868.8400.

Questions? Call SCPhA at 803.354.9977.

Scpha’s annual convention • June 19-22, 2014 Marriott Resort and Spa • Hilton Head Island, SC

Non-Member Registration Early Bird Registration Regular Registration Before May 10 After May 10 VIP Package □ $389 □ $439 Includes t-shirt, Awards Dinner ticket and Alumni Lunch ticket. Select your Awards Dinner choice: □ Beef □ Chicken Select your Alumni Lunch choice: □ PC □ South □ MUSC □ USC Please select your shirt size: □ S □ M □ L □ XL □ XXL Full Registration □ $279 □ $329 Please select your shirt size: □ S □ M □ L □ XL □ XXL Single Day Registration Thursday Only □ $89 □ $109 Friday Only □ $109 □ $129 Saturday Only □ $109 □ $129 Sunday Only □ $89 □ $109

Member Registration Early Bird Registration Regular Registration Before May 10 After May 10 VIP Package □ $339 □ $379 Includes t-shirt, Awards Dinner ticket and Alumni Lunch ticket. Select your Awards Dinner choice: □ Beef □ Chicken Select your Alumni Lunch choice: □ PC □ South □ MUSC □ USC Please select your shirt size: □ S □ M □ L □ XL □ XXL Full Registration □ $219 □ $269 Please select your shirt size: □ S □ M □ L □ XL □ XXL Single Day Registration Thursday Only □ $69 □ $89 Friday Only □ $89 □ $109 Saturday Only □ $89 □ $109 Sunday Only □ $69 □ $89

Student Registration Does not include Alumni Lunch or CE. □ Student Registration $99Select your Awards Dinner choice: □ Beef □ Chicken Please select your shirt size: □ S □ M □ L □ XL □ XXL Please select your school: □ USC □ MUSC □ South □ PC Grad Year: ________________

Registration Information Name_________________________________________________________________ □ Technician □ Pharmacist □ Student □ Other Nickname__________________________________ NABP eID#_________________________________Birthdate (MM/DD) _____________________ Email_______________________________________________________________________________Phone _____________________________________ Address________________________________________________________________________________________________________________________ Do you have any special dietary, learning or accessibility accommodations? _____________________________________________________

Payment Information Total Amount Due: $___________________ Credit Card Type: □ MC □ Visa □ AMEX □ Discover Name on Card________________________________________________ Card #___________________________________________________________________Exp. Date________________________CVV________________ Billing Address __________________________________________________________________________________________________________________ Cancellations will only be accepted if received more than 5 business days before the event. If applicable, a refund will be issued less a $25 processing fee. Please note that the threat of inclement weather is not considered sufficient to override our cancellation policy.

Complete this form and return, with payment, to SCPhA, 1350 Browning Road, Columbia, SC 29210 or fax to 803.354.9207. Visit www.scrx.org to register online. Questions? Call 803.354.9977.

Please check all optional (and free!) activities that you plan to attend: □ Phun Run □ Golf Tee Times □ Welcome Reception □ Sunrise Service □ I would like to sing in the Sunrise Service Choir. □ Trivia (students only) □ Student Programming (students only, topics tbd)

Add A Guest Does not include Alumni Lunch or CE.□ Guest Registration $219 Guest Name: _________________________________________________ Select Guest’s Awards Dinner choice: □ Beef □ Chicken Select Guest’s shirt size: □ S □ M □ L □ XL □ XXL

Student Sponsorships □ Full Sponsorship ($250) □ Partial Sponsorship ($100) □ Other Amount: ________________

The South Carolina Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Continuing education credits will be available to participants who fully attend theprogram and then complete an online educational activity evaluation. A unique code given at each activity must beprovided in the evaluation to receive credit. Grievances regarding the education program must be submitted in writing tothe SCPhA ACPE Administrator immediately following the program.

Additional Options Alumni Lunch tickets ($49 ea.) USC: Qty. ___ MUSC: Qty. ___ South: Qty. ___ PC: Qty. ___

Awards Dinner tickets (Adult: $79 ea.; Child: $29 ea.) Adult, Beef: Qty. ___ Adult, Chicken: Qty. ___ Child: Qty. ___

Roaring 20’s Event tickets: (Adult: $49 ea.; Child: $19 ea.) Adult: Qty. ___ Child: Qty. ___


2014 Convention Schedule At-A-Glance

Thursday, June 19 3:00 PM-6:00 PM Registration Open 4:00 PM-5:00 PM The Triple Aim Journey: Pharmacists as Collaborative Partners Robert (Bob) E. Davis, PharmD, FAPhA and Paul Fleming, PharmD 5:00 PM-6:00 PM Immunization Update 2014 Patti Fabel, PharmD, BCPS 6:00 PM-7:00 PM Flexible Leadership: A Tool for Pharmacy Human Resource Management Bryan Ziegler, PharmD, MBA 7:00 PM-8:00 PM Welcome Reception Friday, June 20 7:00 AM-4:00 PM Registration Open 7:30 AM-7:45 AM House of Delegates Reference Committee Hearing 7:45 AM-9:00 AM House of Delegates 8:30 AM-9:30 AM Breakfast 9:30 AM-11:30 AM New Drug Update part 1 Wayne Weart, PharmD, FAPhA, FASHP, BCPS 11:30 AM-1:00 PM MUSC, USC or PC Alumni Lunch 1:00 PM-2:00 PM Social Media – Effective Utilization Strategies for Pharmacy Practitioners Bryan Ziegler, PharmD, MBA and Katie Pennington, PharmD Candidate 2:00 PM-4:00 PM 2014 Legal Issues for the Pharmacy Practice Jon A. Wallace, BS Pharm, JD 4:00 PM-5:00 PM Student CE: Pharmacists Guide to Financial Peace of Mind John Dohn; Marketing Executive 5:00 PM-6:00 PM Student CE: A Glimpse Into Independent Pharmacy Ownership Phil Piercy, sales manager, and Eden Sulzer, director, Women in Pharmacy 7:30 PM-9:30 PM Roaring 20s benefitting the SC Pharmacy Foundation 10:00 PM-11:00 PM Student Trivia Saturday, June 21 7:00 AM-4:00 PM Registration Open 7:00 AM-8:00 AM Breakfast 7:00 AM-8:00 AM Former President’s & Foundation Board of Trustees Breakfast 8:00 AM-10:00 AM Keynote Address: SC's Response to the Prescription Drug Epidemic Panelists: Christie Frick, RPh; Joseph Shenkar, JD; Adam Roberson; and Ronald Delfidio 10:00 AM-1:30 PM Exhibit Hall 10:00 AM-1:30 PM Scavenger Hunt 11:30 AM-1:00 PM Munch and Mingle 1:30 PM-3:30 PM NASPA/NMA Student Pharmacist Self Care Championship 3:30 PM-4:30 PM Sunrise Choir Rehearsal 4:00 PM-5:00 PM Student CE: How YOU Can Make an Impact for the Pharmacy Profession L. Megan Montgomery, PharmD and Betsy Blake, PharmD, BCPS 5:30 PM-6:00 PM Awards/Installation Rehearsal 6:00 PM-6:30 PM Photos 6:30 PM-7:00 PM President’s Champagne Reception 7:00 PM-11:00 PM Awards Dinner & Entertainment Sunday, June 22 6:30 AM-7:30 AM Sunrise Service 7:00 AM-8:00 AM Registration Open 7:00 AM-8:00 AM Breakfast 8:00 AM-10:00 AM New Drug Update part 2 Wayne Weart, PharmD, FAPhA, FASHP, BCPS 10:00 AM-10:15 AM Break 10:15 AM-12:15 PM Chronic Pain and Pain Management Ezra B. Riber, MD Immediately upon closing 2014-2015 Board of Directors Meeting and Lunch 10 Palmetto Pharmacist • Volume 54 Number 3

Students

Students,areyouamemberofSCPhA?YES,youare!!!SCPhAprovidescomplimentarymember-shiptoallstudentpharmacistsattendingapharmacyschoolwithinthestateofSouthCarolina.Thatleadsmetothequestion,areyouanACTIVEmemberofSCPhA?IfyouansweredYES,SCPhAalongwithmewouldliketosay“ThankYou!”Wealsoaskthatyoushareyourexperienceswithourfellowstudentsandencouragethemtobecomeinvolved.IfyouansweredNO,pleasetakejustafewmoreminutestofinishreadingthisarticletolearnwhatSCPhAhastoofferyou.

SCPhAlovesstudentpharmacistsandiseagertohelpyoudevelopintoayoungprofessional.SC-PhA’sAnnualConventionisablasteachandeveryyear!WhileatConventionwehavethechancetoattendstudentprogrammingwithtopicsrangingfrom“StepstoGettingLicensed”to“StudentorPharma-cistSalary–FinancialTips.”Wealsohavetheop-portunitytocompeteintheSelfCareBowl,whichisaJeopardystylecompetitionwherethefourpharma-cyschoolcampusesinthestatecompeteagainsteachother.I’mproudtosaySouthCarolinaCollegeofPharmacy–UniversityofSouthCarolinaCampusisthereigningchampion!EachyearSCPhAprovidesseveralstudentscholarshipstotheAnnualConven-tiontohelpcutdownonthecostsforus.

PharmacyNights,acontinuingeducationprogramhostedbySCPhAintownsalloverSouthCarolina,arehugenetworkingopportunitiesforus.Pharma-cistsfromaroundthestateofSouthCarolinaattendthesetoreceiveCEcreditaswellasvisitwithstu-dentsandfriendsintheprofession.

HaveyouheardoftheAllPharmacyConference?Thisisaprofessionalgatheringforpharmacistsinallaspectsofthecareertoattend.Thevoiceofeachspecialtycanbeheardwhilesittingatthesametableasotherspecialties.Thisconferenceprovidesstudentswiththechancetoseehowotherspecialtiesfeelaboutlegislationorspecifictopicsthatmayim-

pacttheprofes-sion.Everyothermonthofeachyear,SCPhAholdstheirBoardofDirectorsmeetings.ThesemeetingsarethecoreofSCPhAandhowdeci-sionsaremadeon SCPhA’s behalf.BoththeAll Pharmacy ConferenceandBoardofDirec-torsmeetingswelcomestudentattendance.

AlloftheopportunitiesSCPhAhastoofferstudentsareimportant,butmyfavoriteisbeingaJuniorBoardMember.Eachyear,SCPhAselectsseveralstudentsfromeachpharmacyschoolcampustobeaJuniorBoardMember(JBM).AsaJBM,wearepartneredwithanactualBoardMemberformentoringpurposesaswellasguidanceoncompletingourJBMproject.WeattendalltheBoardmeetingsandareabletohaveourvoicesheardonmattersthatareimportanttoourcareer.AsaJBM,wealsoserveonseveralSCPhAcommitteeswhichallowustohaveinputoncontinuingeducationtopicsandstayup-to-dateonlegislativetopicsthatmayimpacttheprofessionofpharmacy.ThesearejustafewopportunitiesSCPhAhastooffer.SCPhAandIlookforwardtoseeingyouatoneofourupcomingevents!

Laura Jeffcoat is a PharmD Candidate at the South Carolina College of Pharmacy at the University of South Carolina Campus, Columbia. Laura served as a SCPhA Junior Board member for the 2013-2014 year.

Opportunities for StudentsBy: Laura Jeffcoat, PharmD Candidate 2014 South Carolina College of Pharmacy – University of South Carolina Campus



$50 gift cards will be awarded to: Best Dressed (Man) Best Dressed (Woman) Best Dressed Student (Man) Best Dressed Student (Woman)

Join us for a Costume Contest!

When: Friday, June 20 at the Roaring 20s event

Why: why not?! Plus, there’s prizes!

Free Vacation Voucher

Free Vacation Voucher

Follow SCPhA on Social Media Networks

Go ahead...we know you want to! Like or follow us on Facebook, Twitter, Instagram and Pinterest– we’re there!

Make sure that you aren't missing out on the most up-to-date information related to pharmacy in South Carolina and beyond!

Friends and Followers receive the following: Invitation for exclusive savings on event

registrations Cool facts related to your profession Contests to win great prizes (We offer "Pharmacy Bucks" to use towards future

membership or registrations and cool SCPhA paraphernalia!) Notifications that you can't find elsewhere!

https://www.facebook.com/scpha https://twitter.com/yourSCPhA

http://www.pinterest.com/scpha follow us on Instagram @scpha



Twocurrenttopicsinpharmacypoliticsincludeexpandingthescopeofpracticeforpharmacistsandgrantingpharmacistsnon-physicianproviderstatusundertheSocialSecurityAct.Althoughthesetwotopicsarefrequentlytalkedaboutinconjunctionwithoneanother,itisimportanttonotethattheyaretwoseparatelegisla-tivemovements.Thisarticlewillfocusonexpand-ingthescopeofpracticeforpharmacists in SouthCarolina.Thepurposeofthismovement,howlegislativemovementsliketheseareenacted,andwhereSouthCarolinaisintheprocesswillbeexplained. Thereareseveralreasonsforex-pandingthescopeofpracticeforpharmacists.Twomainreasonsareincreasingpatientaccessibilitytohealthcareservicesandreducinghealthcarespendingassociatedwithchronicdiseasemanagement.AccordingtoareportreleasedbytheAssociationofAmericanMedicalColleges,therewereonly3,660primarycarephysiciansinthestateofSouthCarolinaasof2012.1Atthistimethestatepopulationwasreportedtobe4,723,723people.Thesenumbersreflectarateof77.5primarycarephysiciansper100,000peoplecomparedtothena-tionalrateof90.1primarycarephysiciansperevery100,000people,suggestingaprimarycareshortage

inSouthCarolina.RevisingSouthCarolinastatestatute40-43-30toallowpharmaciststoparticipateincollaborativepracticeagreementswithphysicianswouldpermitpharmaciststoassistphysiciansinthepost-diagnosticdrugtherapymanagementinchronic

diseasessuchasdiabetes,hyperlipid-emia,hypertension,asthma,preventa-tivemedicineandsimilarconditions.Thiswouldnotonlyincreasepatientaccesstoprovidersforchronicdiseasemanagement,butitwouldalsofreeupphysicianstotreatpatientsforacuteillnessesinatimeliermanner.

Thesecondrea-sonforexpandingscopeofpracticeforpharmacistsistodecreasehealthcarecosts.Therehavebeenseveralstudiesconductedtodem-onstratethatphar-macistscaneffec-tivelycontributeto

improvingthecost,quality,andaccessibilityofthehealthcaresysteminwaysotherthanjustdispensingmedications.2,3,4Thesestudiesrepeatedlyshowphar-macistsnotonlyimprovepatientoutcomes,butalsoreduceoverallhealthcarespending.OneexampleistheAshevilleProject.2Thisprojectevaluatedhowpharmacist-ledpatientcareprogramsaffectedpatientoutcomesandhealthcarespendinginvariouschronicdiseasestates.Servicesprovidedinthesepatientcareprogramsincludedpatienteducation,assessment,monitoring,andfollowupcare.Oneoftheoutcomes

Expanding Scope of Practice for Pharmacists in South Carolina: A Student’s Perspective

By Lisa Leary, PharmD Candidate, Class of 2016, Presbyterian College School of Pharmacy

Students


shownintheAshevilleProjectincludedthereduc-tionofhealthcarespendingandimprovedpatientoutcomesindiabeticpatients.Thecostreductionforthesepatientsrangedfrom$1,200to$1,872perpatientyear.2Atthistime,stepsarebeingtakentochangethecurrentscopeofpracticetosupportphar-macists’involvementinthesenon-dispensingroles.

InSouthCarolina,thescopeofpracticeforphar-macistsisdefinedbystatecodesection40-43-30,thereforeanyrevisionstothecurrentscopemustbedonethroughstatelegislation.TheSouthCarolinaPharmacyAssociationandotherpharmacyorganiza-tionswithinthestatearecurrentlyintheprocessofdraftingproposedrevisionstoexpandthecurrentscopeofpractice.Currentdraftedrevisionsincluderedefiningpatientcaretoallowpharmaciststheabil-itytoorderandassesslabsonceadiagnosisismade,adjustdrugdosagesinaccordancetopre-formulatedprotocols,andinitiatepatientphysicalassessments,suchasbloodpressuremeasurementsandcertainpointofcaretests.Oncetherevisionsareperfected,thenewproposalwillbepresentedaslegislationforapproval.Whileamendingtheproposalandawait-ingthebestopportunitytopresentthebill,pharmacyorganizationssuchastheSouthCarolinaPharmacyAssociationareworkinghardtopromotethemove-mentandgainsupportfromstakeholdersandlegisla-tors.Formoreinformationonthistopic,pleasevisitwww.scrx.orgorattendasubcommitteemeeting.

References1. AssociationofAmericanMedicalColleges.2013StatePhysicianWorkforceDataBook:CenterforWorkforceStudies[Internet].Washington,D.C.2013Nov[accessed2014Apr25].11p.Availablefrom:https://www.aamc.org/download/362168/data/2013statephysicianworkforcedatabook.pdf2. CranorCW,BuntingBA,ChristensenDB.TheAshevilleProject:Long-TermClinicalandEco-nomicOutcomesofaCommunityPharmacyDia-betesCareProgram.JAmPharmAssoc[Internet].2003Mar[accessed2014Apr25];43(2)173-84.Availablefrom:http://www.theashevilleproject.net/research3. TheAmericanPharmacistsAssociation.PharmacistsandtheHealthCarePuzzle:ImprovingMedicationuseandReducingHealthCareCosts[In-ternet].Washington,D.C.2008[accessed2014Apr25].Availablefrom:http://c.ymcdn.com/sites/www.chronicdisease.org/resource/resmgr/cvh/pharm_&_hc_puzzle.pdf4. GibersonS,YoderS,LeeMP.ImprovingPa-tientandHealthSystemOutcomesthroughAdvancedPharmacyPractice:AReporttotheU.S.SurgeonGeneral[Internet]Dec2011[accessed2014Apr25]40p.Availablefrom:http://www.usphs.gov/corps-links/pharmacy/documents/2011AdvancedPharmacyPracticeReporttotheUSSG.pdf

Thank You for

Attending Pharmacy Day at the

Capitol

We would like to thank each of you who made our Pharmacy Day at the Capitol a success! With more than 100 participants representing all

branches of the pharmacy profession, we were able to, once again, show that we are here to serve the citizens of our great state!

We’re already excited to have the date for next year’s event, February 19, 2015. Hope to see you there!


SCCP

TworecentcompetitionsillustratedtheSouthCaro-linaCollegeofPharmacy(SCCP)’scommitmenttocommunitypharmacy,aswellasshowcasingtheabil-ityofourstudents.

OnMarch22-23,ateamofstudentpharmacistsfromtheUniversityofSouthCarolina(USC)campustookfirstplaceintheRegulatoryComponentoftheNa-tionalStudentPharmacistCompoundingCompetition(SPCC).TheyalsowontheTeamSpiritAward.ThefourthannualSPCCtookplaceMarch22-23attheUniversityofFlorida.

MichaelScruggs,KatieBastugandGregRegancom-petedonbehalfoftheCollege’sUSCcampus.BarretDuncan,E.DestineHooverandKristinaN.FerrellrepresentedtheSCCPcampusfromtheMedicalUni-versityofSouthCarolina(MUSC),whichfinishedinthetop10.TheSCCPteamsviedagainst19otherpharmacycollegeteamsfromaroundthecountry.TheCollege’sparticipatedinthenationalcompound-ingcompetitionforthefirsttimethisyear.Facultyandstudentsreportedsatisfactionandvalueintheexperience.

“Ibelievethatthecompoundingcompetitionre-kindledtheexcitementinthepharmacystudentsforcompoundingandittooktheircompoundingskillstoahigherlevel,”saidKathyQuarles-Moore’86,labcoordinatorandthefacultymemberhandlingtheon-campuscompetitionatUSC.ClinicalpharmacyandoutcomessciencesassociateprofessorRonNickelcoordinatedtheMUSCcompetition.BothfacultymembersaccompaniedtheteamstoFloridaasadvi-sors.

Thecompetitionconsistedofregulatory,qualitycompounding,andpracticalcompoundinglabcom-ponents.FacultyadvisorspresentatthecompetitionvotedontheTeamSpiritAwardandrewardedtheteamthatdisplayedthemostunityasateam,sports-manship,andprofessionalism.

Inadditiontothebenefitsthestudentsexperiencedbyparticipating,theSCCPfacultywasabletoengageincompoundingdiscussionswithfacultyfromallaroundthecountryandbringbackideastoincorpo-rateintothecurriculum,Nickelsaid.

Compounding Competition by Joseph DiPiro, Executive Dean SCCP CompoundingsupplierMediscasponsoredtheevent,whichhasbecomeverytimelyinlightofanationaloutbreakoffungalmeningitisin2012.Theoutbreakwastracedtocontaminationofcompoundedsterilepreparations(CSPs)andattractedanewlevelofattentiontoCSPsandcompoundingpharmacyingeneral.Foundedjusttheyearbefore,thenationalstudentcompoundingcompetitioncreatedanoppor-tunityforstudentsinterestedinthisspecialtytointer-actwitheachotherandwithpracticingcompounders.“TheSPCCismorethanjustacompetition;itisanastoundingeducationalexperiencethatexposespharmacystudentstothehigheststandardsincom-poundingpharmacypractice,inordertostrengthentheintegrityoftheprofession,”Mediscaannouncedinareleaseaboutthecompetition.

Thenationalcompetitioncertainlycatalyzedinter-estattheCollege.Scruggs,BastugandReganwentupagainst11otherqualifiedteamsinthefirstUSCcampuscompoundingcompetitiononJanuary10.AsimilarcompetitionwasheldJanuary17todeterminetheteamofDuncan,HooverandFerrellfromMUSC.“Ithinkallthestudentsgreatlyenjoyedtestingourskillsandknowledgeagainsteachotherinthisuniqueandcompetitiveenvironment,”saidCarolineArnette’16.“Competitionssuchasthisareagreatwaytoallowstudentstoimplementskillssuchasteamwork,communication,improvising,andcom-pounding.”

Priortotheschoolwidecompetition,studentswererequiredtocomposeapreliminaryessaytonarrowparticipantsto12teamsofthreestudentseach.Once12qualifiedteamswereestablished,studentswererequiredtowriteanadditionalessayaboutrecentcompoundinglegislationattheU.S.SenateandU.S.HouseofRepresentatives.Inadditiontotheresearchandessayinvolved,thestudentsparticipatedinahands-oncompetitionusingmaterialsandguidelinesprovidedbyMedisca.

Thesecondcompetitionisahighly-successfulCollege-wideeventinitssecondyear.

OnApril12,theKennedyPharmacyInnovationCenter(KPIC)heldthesecondannualKPICBusi-nessPlanCompetition.KatieBastug,PhilippMon-terroyo,GregReganandMichaelScruggs--known


asFoothillsPharmacy--tookfirstplaceandwonscholarshipsaswellastripstoCardinalHealth’sRetailBusinessConferenceandtheNationalCom-munityPharmacistsAssociation(NCPA)AnnualConvention.

ThesecondplaceteamofSallyBell,BlakeCogdillandRyanJohnsonwon$1,000scholarshipsandthethirdplaceteamofZachJordan,JolindaSchreiber,KevinThompsonandKaylieWallerwon$500scholarships.

FoothillsPharmacywillgoontorepresenttheCol-legeinthenationalNCPAStudentBusinessPlanCompetition.FinalistswillbeannouncedattheAmericanAssociationofCollegesofPharmacy(AACP)AnnualMeetinginJuly;winnerswillbean-nouncedduringtheGeneralOpeningSessionoftheNCPAAnnualConventioninOctober.


Medical Reserve Corps

Pharmacistsarevaluableprofessionalsthatare“re-markablyunderutilizedintheU.S.healthcaredeliv-erysystemgiventheirlevelofeducation,training,andaccesstothecommunity”(Gibersonetal,2011).Notonlycanpharmacistscontributeintraditionalhealthcaresettings,buttheycanalsobeanimportantassettopublichealthentities.TheMedicalReserveCorps(MRC)offerspharmacistsopportunitiestoutilizetheiruniqueskillsetstosupportthehealthandsafetyoftheircommunities.

TheMedicalReserveCorpsisanetworkofover200,000volunteers,organizedinalmost1,000lo-calunitsacrosstheUnitedStates,withamissiontostrengthenpublichealth,improveemergencypre-parednessandresponsecapabilities,andbuildcom-munityresilience.MRCvolunteerscancontributetoarangeofactivities,suchasprovidingfluvaccina-tions,promotingobesitypreventionandhealthylife-styles,teachingneighborshowtoprepareadisasterkit,andassistingwithemergencyresponses.

MRC’svolunteerpharmacistshavedemonstratedtheirvaluetolocalcommunitiesonmanyoccasions.Forinstance,MRCpharmacistshaveprovidedas-sistanceandinformationatprescriptiondrugtake-backevents,administeredvaccinationsinresponsetoHepatitisAoutbreaks,joinedhealthcareteamstoprovidepreventivehealthcareandhealtheducationtovulnerablemembersofsociety,guidedtheproperidentificationandlabelingofmedicinesinprepara-tionformassprophylaxisevents,staffedfunctionalneedsshelters,andvaccinatedneighborsandothercommunitymembersagainstinfluenza-includingalarge-scaleresponsetotheH1N1influenzaepidemicin2009-2010.

TheMRCcanalsoconnectpharmacistmemberstovaluabletrainings,oftentimeswithcontinuingeduca-tioncredits.Thistrainingimprovesthepharmacists’capacitytoassistandincreasestheircomfortinbeinginvolved.Forinstance,researchhasindicatedthatnon-traditionalvaccineproviders,includingphar-macists,havelessexperienceadministeringvac-cinesandhaveindicatedthattheyarelessconfident

Pharmacists and the Medical Reserve CorpsBy Capt. Rob Tosatto, Director, Division of the Civilian Volunteer Medical Reserve Corps

inrespondingduringanemergency.Astudyof800vaccineprovidersinCaliforniarevealedthatalackoftrainingforemergencyresponsesituationsreducedtheirlikelihoodandcomfortlevelwithrespondingtoemergencies.Thestudyauthorssuggestedthatad-ditionaltrainingopportunitieswouldallowthesenon-traditionalvaccineproviderstofeelmorecomfort-ablerespondingduringasurge(Seibaetal,2012).TheMRCprovidesawaytotrainthevolunteers,increasetheirabilitytorespond,andreducerisks.Thetrainingsmaycoveravarietyoftopics,includingPointofDispensing(POD)andStrategicNationalStockpileprocedures,IncidentCommandSystem,PsychologicalFirstAid,andrespondingtoradiologi-calevents.

TofindoutmoreabouttheMedicalReserveCorps,pleasevisithttp://1.usa.gov/1gYz5cz.The“FindMRCUnits”pageisagreatplacetostart.YoucanalsocontacttheMRCProgramOffice(OfficeoftheSurgeonGeneral/DivisionoftheCivilianVolunteerMedicalReserveCorps)[email protected].

References:Giberson, S., Yoder, S., & Lee, M. (2011). “Improv-ing patient and health system outcomes through advanced pharmacy practice.” A report to the U.S. Surgeon General. Office of the Chief Pharmacist, U.S. Public Health Service. Retrieved from http://www.accp.com/docs/positions/misc/improving_pa-tient_and_health_system_outcomes.pdf.

Seiba, K., Barnett, D., Weiss, P., Omer, S. “Vaccine-related standard of care and willingness to respond to public health emergencies: A cross-sectional sur-vey of California vaccine providers.” 2012. Vaccine. 31: 196–201.


Medical Reserve Corps State/Territory # Pharmacists # Nurses Total # MRC VolunteersAK 0 1 21AL 92 1208 5867AR 8 75 564AS 0 0 17AZ 57 570 2444CA 309 3343 10645CO 13 329 1351CT 22 843 2867DC 4 400 1388DE 27 157 501FL 220 2864 9177FM 0 0 20GA 35 609 3415GU 0 9 18HI 17 277 845IA 9 316 893ID 64 953 2986IL 115 2468 6736IN 95 1310 3143KS 9 263 1034KY 93 1092 3029LA 22 374 1412MA 207 5495 16184MD 221 1391 4999ME 1 18 79MI 13 219 1063MN 117 2932 8587MO 55 837 2660MP 1 85 165MS 6 192 745MT 0 99 246NC 67 756 2413ND 12 590 1397NE 20 289 996NH 19 223 778NJ 116 1975 5061NM 12 104 865NV 15 175 589NY 338 4246 13973OH 245 3511 11575OK 63 2564 5766OR 45 750 1602PA 181 1528 5370PR 26 411 2887PW 2 10 21RI 67 450 1441SC 18 342 918SD 0 24 46TN 109 1525 19634TX 85 2157 15092UT 45 373 2048VA 309 3775 13173VI 0 11 66VT 1 40 124WA 52 955 2905WI 1 65 542WV 67 898 2121WY 3 32 225Grand Total 3750 56508 204729


Where would you prefer to have your HIPAA training?

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Assessing Your Pharmacy’s HIPAA Policies & Procedurescreated by Craig Burridge, MS, CAE, CEO, South Carolina Pharmacy Association Goals and Objectives:1. Identify the laws covering confidentiality and their lead up to HIPAA.2. Recognize the standard principles governing confi-dentiality as it relates to patient records.3. Identify the need for and responsibilities of a pri-vacy officer and workforce training requirements.4. Differentiate between the proper uses and disclos-ers of protected health information and permitted uses and disclosures.5. Recognize when authorization is necessary for protected information.6. Identify the requirements for the distribution of Privacy Practices Notices.7. Know how to develop an electronic protected health information policy.8. Recognize how to mitigate and notify affected individuals in case of a breach of protected health information.9. Identify the expanded HIPAA requirements under the Health Information Technology for Economic and Clinical Health Act (HITECH)

Fees:SCPhA Members: $15\Non-Members: $25Please note that this is required in order to obtain 2 hours of CE Credit.

The South Carolina Pharmacy Association is accredited by the Accreditation Coun-cil for Pharmacy Education as a provider of continuing pharmacy education. This home study is approved for 2 contact hours of continuing pharmacy education credit (ACPE UAN: 0171-0000-13-074-H03-P). This CE credit expires 8/08/2016.

Register online at www.scrx.org, or follow the QR code to the right!

Independent Pharmacy


This is the sixth of a series of topics covering primar-ily the physical attributes that lead to greater suc-cess. These are described in more detail in my new book “Independent Pharmacy Steps to Greater Suc-cess” which can be previewed at www.independent-pharmacy101.com. I will now discuss a few impor-tant merchandising tips that I have learned through personal trials and cases studies by ISP.

MERCHANDISING AlthoughmostindependentpharmacieshavelimitedOTCdepartments,thereareseveralminorthings,whencombined,thatcanmakeabigdifferenceintheoutcome.DuringmyseveralyearsofmembershipinISP(InstituteofStorePlanners),Ilearnedmanymerchandisingtipsthroughcasestudies.Ialsoopenedanex-perimentalpharma-cyinthemid-1980’sforthepurposeofcomparingdiffer-entconceptstoseehowpeoplereact.Throughtrialander-rorIwillsharewhatIhavelearnedthatbroughtaboutthebestresults.

1. Depart-mentsthatrelatetoeachothershouldbeadjacenttoeachother.Wecallthatdepartmentalization.Asimpleexamplewouldbecoughandcoldbesideallergyproducts,etc.becausedoingsomakesiteasierforthecustomertolocatetheitemandoftenresultsinanextrasale.Vitaminsandsupplementsshouldbenexttonutritionalproducts,etc.

2. Departmentsshouldbemerchandisedverti-callyratherthanhorizontally.Habitually,theeyesweepshorizontallyandfromlefttorightsoitmakes

iteasierforthecustomertofindaspecificitem.Positioningtheshelvesatadifferentlevelwhereonecategoryendsandanotherbeginsalsohelps.Therearesomeexceptionswithverysmalldepart-mentslikeeyeandearcare.Thelargestsizeshouldbepositionedtotherightofthesmalleronessotheeyemovementstopsonthelargersize.Studieshaveshownanincreaseinsalesbyutilizingthissimpleinitiative.

3. Ibelievethateveryshelfshouldhavebuilt-inticketmoldingforlabelsthatservemorethanonepurpose:thepriceoftheitemcanbeshownandeasiertoscanforinventorycontrol.EverythingintheOTCareashouldeitherhavethepriceontheitem,

thelabelorboth.

4. Displaysur-facesunderorbe-hindmerchandiseshouldnotdrawattention.ThatiswhyIneversug-gestdarkcoloredbacksorshelvesthatmaydrawmoreattentiontothedisplaythanthemerchandise.Ialsodiscourageusingslatwallbehindmosthealth-relatedmerchandisewiththeexceptionof

diabeticshoes,homehealthcareandperhapsanun-usualdepartmentusedtodrawattentiontoaspecificarea.Slatwallnotonlycostsmorebutitcanbeadeterrentinsellingmoremerchandise.Ibelieveallcostsshouldprovideagoodreturnoninvestment.Thedisplaythatyieldsthebestresultsisonethatbasicallygoesunnoticedsothatthecustomer’satten-tionisdrawntothemerchandiseandnotthedisplay.

5. Idiscouragepositioningthetopshelfonis-

Creating a Competitive Strategy for Independent Pharmacy Success By Roland Thomas

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This manual outlines the regulatory envi-ronment and essential elements of a com-pliance program and, in Part II, includes sample policies and procedures that may be useful to pharmacies in developing or updating their compliance programs. Be-yond this manual, however, each pharmacy must undertake a detailed risk assessment and self-audit to ensure that its particular compliance program is properly tailored to its business.

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landshelvingatornearthetopofthefixturebacking.Thetopshelfshouldbeatleast6”belowthetopofthedisplayorwherethetallestitemdoesnotextendabovethefixtureitself.Weoftenuse60”opposedto54”highislandsectionstohelpinsurethatmerchan-diseisnotabovethebacking.Astraightline,op-posedtoajaggedone,ismuchmoreappealingwhencustomerslookacrossthecustomerarea.

6. Ihighlyrecommendaminimumof3itemsofmostproductsondisplay.Imagineshoppingatagrocerystorethatonlyhadoneortwofacingsofeachitem.Youcertainlydonotwanttohaveyourmoneyinvestedininventorythatdoesnotbringaboutthebestreturn.However,theideaofdisplayingoneortwofacingsisnottheanswer.Itgivesthecus-tomertheimpressionthattheitemdoesnotsellverywell.Mostofthebigstoresdonotinvestmorethannecessarybutstudieshaveshownthatskimpingoninventorysellsfewerproducts.Inmyopinion,withfewexceptions,islandenddisplaysservenousefulpurposeinasmallpharmacy.However,Idosuggestthatanendpaneloneachendofanislanddisplayhelpsconcealthefactthatthemerchandisedisplayedisnotverydeepwhenlookingattheendofanopenislandunit.

7. Asoutlinedinapreviousarticle,IpersonallydonotthinkitisinthebestinterestoftheIndepen-dentPharmacytodisplayhouseholdproducts,dollaritemsorotherproductsthatconveytoyourcustomersthatyouaresimplyasmallversionofthechaindrugstore.Therearesomeorganizationsandbusinessesencouragingpharmaciestoaddgreetingcards,gifts,jewelryandothernon-healthcategoriesbutItotallydisagreeifyouhaveasmallpharmacy.Again,thesediminishtheprofessionalimagethatdifferentiatesyourpharmacyfromyourcompetition.

Inthenextarticle,Iwilloffermyproposalregard-inghowIndependentPharmaciescanincreasetheirso-called“front-end”volumebutnotbyaddingmorenon-health-relateddepartments.

Roland G. Thomas is a Pharmacy Planning Spe-cialist with Rx Planning Solutions – a division of Display Options in Charlotte, NC. Roland has had the privilege of working with pharmacists all over the Southeast United States, planning and design-ing pharmacies for over 40 years. Independent and multiple location owners have relied on his expertise in this field.


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Objectives1. Describeposttraumaticstressdisorder(PTSD)anditsassociatedsymptomsaccording toDSM-5diagnosticcriteria2. ReviewmedicationsthatmaybeusedtotreatPTSDbasedonNICEandVA/DoDtreatmentguide-lines3. Discussthemechanismofaction,dosing,andcommonsideeffectsofvariousmedicationsusedinthetreatmentofPTSDindetailalongwithspecificpatienteducationcounselingpoints

AbstractObjective: Afterreadingthisarticle,thereadershouldbeabletodescribesymptomsassociatedwithPTSD,listmedicationsusedintreatment,andbeabletoeducatepatientsonimportantcounselingpointswithregardtothesemedicationsinthetreatmentofPTSD.

Summary:Itisestimatedthatthelifetimeprevalenceofposttraumaticstressdisorder(PTSD)amongadultAmericansis6.8percent.Inveterans,thispercentageincreasesupto30percent.

TheDiagnosticandStatisticalManual,5thedition(DSM-5)discussesthesymptomclustersofPTSDwhichcanincludeintrusionsymptoms,avoid-ance,negativealterationsincognitionsandmood,andalterationsinarousalandreactivity.AccordingtoVA/DoDandNICEtreatmentguidelines,first-linetreatmentoptionsmayincludesertraline,fluoxetine,paroxetine,venlafaxine,mirtazapine,prazosinforPTSD-relatednightmares,andpsychotherapy.Otherpharmacologicoptionsthathaveshownsomebenefitincludephenelzine,nefazodone,andtricyclicantide-pressants(TCAs).Thereisinsufficientevidencetorecommenduseofothertreatmentssuchasanticon-vulsantsorantipsychoticsforadjunctivetherapyinPTSD.Finally,thereisevidenceagainsttheuseofbenzodiazepines(BZDs)inthetreatmentofPTSD.Withantidepressantmedications,severalsideeffectsmayoccursuchasanxiety,headache,nausea,diarrhea,antidepressantdiscontinuationsyndrome,andsexual

JOURNAL CEA Review of Pharmacotherapy for Posttraumatic Stress Disorder (PTSD) By Jennifer Houser, PharmD, BCPPNote that this article appeared in the previous issue of the journal, but was incorrectly attributed to a dif-ferent author.

dysfunction.Itisimportantthatpatientsareeducatedonthesesideeffectsandthetreatmentstrategiestoalleviatethem.

Conclusion:ThetreatmentofPTSDcaninvolveavarietyofpharmacologicalandnon-pharmacologicalapproaches.Inorderfortreatmenttobemostsuccessful,patienteducationiskey.

Keywords: PTSD, antidepressant, prazosin, SSRI

Introduction Posttraumaticstressdisorder(PTSD)isoneofthemostcommonpsychiatricdisordersamongnationalmilitarypersonnel.Although50to90percentofthegeneralpopulationmaybeexposedtoatraumaticeventdur-inghisorherlifetime,mostindividualsdonotdevelopPTSD.1,2

TheNationalComorbiditySurveyReplication(NCS-R)estimatedthelifetimeprevalenceofPTSDamongadultAmericanstobe6.8percent.3Itisestimatedthatupto20percentofveteransoftheIraqandAfghanistanwars(OperationsIraqiandEnduringFreedom),10percentofGulfWar(DesertStorm)veterans,and30percentofVietnamveteranshavePTSD.1

ThereareseveralfactorsthatcanincreasetheriskofdevelopingPTSD.Someoftheseincludeifapersonwasdirectlyexposedtothetraumaasavictimorwitness,ifthetraumawasverysevereorlong-lasting,orifapersonhadaseverereactionduringtheevent,suchasshakingorfeelingapartfromthesurroundings.4,5TherearealsoseveralcomorbiditiesassociatedwithPTSDincludinggeneralizedanxietydisorder(GAD),majordepressivedisorder(MDD),substanceusedisorder,andalcoholabuseordependence.3Ithasbeenshownthat60to80percentofVietnamveteransseekingPTSDtreatmenthaveanalcoholuseproblem.6Thereasonforthishighpercentageislikelyduetothedepressanteffectsofalco-hol.AlthoughthepathophysiologyofPTSDisnotquiteunderstood,thereareseveraltheories.Theoriesinclude:alteredglutamatergicprocesseswithrespecttoinforma


JOURNAL CEtionprocessing,alteredmemoryfunction,abnormalincreasesinsympatheticnervoussystemactivity,dys-regulationofthehypothalamic-pituitary-adrenalaxis(HPA),andabnormalserotonin(5-HT)activity.7

Symptoms of PTSDIntheUnitedStates,theDiagnosticandStatisti-calManual(DSM)servesasageneralguideforthediagnosisofpsychiatricdisorders.IthasrecentlybeenupdatedandwasreleasedinMay2013.8ThereweresomemajorchangeswithregardtothediagnosticcriteriaforPTSD.First,PTSDisnolongerconsideredananxietydisorder.Itisnowlistedunder“TraumaandStressor-RelatedDisorders.”InsteadofPTSDconsist-ingofthreesymptomclustersasitdidinDSM-IV,theupdatedDSM-5dividesitintofoursymptomclusters.Theseincludeintrusionsymptoms(e.g.distressingmemories,dreams,orflashbacks),avoidance(e.g.avoidingplacesorpeoplethatremindthepersonofthetraumaticevent),negativealterationsincognitionsandmood(e.g.inabilitytorememberanimportantaspectoftheevent,feelingdetachedfromothers,ornega-tivebeliefs),andalterationsinarousalandreactivity(e.g.irritablebehavior,hypervigilance,problemswithconcentration,recklessbehavior,orsleepdisturbance).Symptomsinthelastclustermaybesimilartosymp-tomsconsistentwithbipolardisorderorattention-deficit/hyperactivitydisorder(ADHD).Therefore,itisimportantthatthesediagnosesberuledoutbeforeadiagnosisofPTSDismade.

Inadditiontoassessingforsubjectivesymptomsasnotedabove,itcanalsobehelpfultoadministerthePTSDChecklist(PCL).9,10TherearedifferentversionsofthePCLincludingacivilianandamilitaryversion(PCL-CorPCL-M).Thisscaleisa17-item,standard-izedself-reportratingscalethattakesonlyfivetotenminutestocomplete.ItcanbeusedtodeterminetheseverityofPTSDoverallortodeterminewhichsymp-tomclustersaremostbothersome.Ifdesired,treatmentcanbeguidedbythepatient’sPCLscore.Overall,atento20pointchangefrombaselineisconsideredclini-callysignificant.Aclinicallysignificantchangemeansthatthetreatmentbeingutilizediseffective.

TreatmentThereareseveraltreatmentguidelinesforPTSD.TheseincludetheAmericanPsychiatricAssociation(APA)(2004),theBritishAssociationforPsychopharmacol-ogy(2005),CanadianPsychiatryAssociation(2006),WorldFederationofSocietiesofBiologicalPsychiatry(WFSBP)(2008),VeteransAssociationDepartmentof

Defense(VA/DoD)(2010),andtheNationalInstituteforHealthandClinicalExcellence(NICE)(2011)treatmentguidelines.TheremainderofthediscussionwillfocusontreatmentsforPTSDaccordingtoboththeVA/DoDandNICEguidelinesasthesearethemostcurrent.11,12

AntidepressantsMosttreatmentguidelineslistantidepressants,suchasselectiveserotoninreuptakeinhibitors(SSRIs),asfirst-linetreatmentconsideringtheseagentsareeffec-tiveforallsymptomclustersofPTSD.IntheVA/DoDguidelines,fluoxetine,sertraline,andparoxetinehavethelargestcollectionofevidencedemonstratingtheirefficacy.13Inaddition,venlafaxine,aserotonin-norepi-nephrinereuptakeinhibitor,isanotherfirst-lineagentandcanalsotreatallfoursymptomclusters.13,14 With regardtonon-pharmacologicaltreatment,psychotherapyisconsideredtobefirst-linealoneorinconjunctionwithpharmacotherapy.Theevidence-basedpsychotherapeu-ticoptionsforPTSDthataremoststronglysupportedbyrandomizedcontrolledtrialsincludeprolongedexpo-sure(PE),cognitiveprocessingtherapy(CPT),andeyemovementdesensitizationandreprocessing(EMDR)orstressinoculationtraining.11IfpatientsdonotrespondtoaspecificSSRIorvenlafaxine,theprovidershouldswitchtoanotheragent(e.g.,analternativeSSRIorven-lafaxine)and/oraddpsychotherapy.Ifthepatientfailstoclinicallyrespond,theprovidercanswitchtomirtazap-ineand/orpsychotherapy.Finally,ifthepatientisstillnotrespondingtotreatment,thelaststepistoswitchthepatienttophenelzine,nefazodone,oratricyclicantide-pressant(TCA)andaddpsychotherapy.Mirtazapine,phenelzine,nefazodone,andTCAshavebeenshowntobeeffectiveforallsymptomsclusterswiththeexceptionofavoidance.11

Interestingly,theNICEguidelinesdonotrecommendpharmacologicaltreatmentasfirst-linetherapyunlesstheindividualrefusestrauma-focusedpsychologicaltreatment(e.g.trauma-focusedcognitivebehavioraltherapy[CBT]orEMDR).Iftheindividualdecidestoproceedwithpharmacologicaltreatment,paroxetineormirtazapinearethepreferredagentsifprescribedbyageneralprovider.Amitriptylineorphenelzinemayalsobeanoption,buttheseagentsshouldonlybeprescribedbyamentalhealthspecialist.12 InitialandmaximumdosesoftheseagentsalongwiththeirtitrationschedulesarelistedinTable1.Patientsshouldbeeducatedonan-tidepressanttherapypriortoinitiation.Educationshouldincludepotentialsideeffectsandstrategiestoalleviatethesesideeffects,thedelayinonsetofactionandtheamountoftimeneededtoachievearesponse,andthe


JOURNAL CEriskofdiscontinuation/withdrawalsyndrome.

Mechanism of Action and Side Effects of Antide-pressants SSRIs/SNRIs15,16Selectiveserotoninreuptakeinhibitors(SSRIs)actontheserotonintransporter(SERT)pump.InhibitionoftheSERTresultsinanincreaseofserotonininthe

body.Serotonin-norepinephrinereuptakeinhibitors(SNRIs)actinasimilarfashion,howevertheyalsoinhibitthereuptakeofnorepinephrineinadditiontoserotonin.

ThemainsideeffectsofSSRIsandSNRIsincludenausea,diarrhea,headache,dizziness,sexualdys

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Table 1: Doses of Medications Commonly Used in the Treatment of PTSD11,12,16

Antidepressant Generic (Brand)

Initial dose (mg/day)

Titration Maximum dose (mg/day)

Fluoxetine (Prozac) 10 10 – 20 mg every2weeks 60

Sertraline (Zoloft) 25 Increase by 50mg within1week, thenby 25– 50mg every 1 – 2weeks

200

Paroxetine (Paxil) 10 10 mg every 2weeks 60

Venlafaxine(Effexor or EffexorXR)

37.5 Increase to75mg within the first week,thenby 37.5 – 75 mg every 2 weeks

375(IR) 225 (XR)

Mirtazapine(Remeron) 15 15mg every 2weeks 60

Phenelzine(Nardil) 15 15mg every4days as tolerated 75

Nefazodone(Serzone) 200 100 – 200 mg (in2divideddoses) everyweek

600

Amitriptyline(Elavil) 25– 100 25– 50mgeveryweek 300

Desipramine(Norpramin) 100 – 200 100 mg everyweek 300

Nortriptyline(Pamelor) 50 25– 50mg everyweek 150

Prazosin(Minipress) 1 Days 1 – 3:1mg Days 4 – 7:2mg Week2: 4 mg Week3: 6 mg Week4: 10 mg *After week4,thedose canbeincreasedby 5mg incrementsuntilsymptoms are resolved *Iftherapyisinterruptedfor3ormoredays,thenreinitiateatthelowestdoseandre-titrateaccordingtoschedule

20 (or higherif

needed/tolerated)

*IR=immediaterelease;XR=extendedrelease


JOURNAL CEfunction,and/orwhatisknownas“jitterinesssyn-drome.”JitterinesssyndromemayoccurwheninitiatingaSSRI/SNRIandincludesshakinessortremor,in-creasedanxiety,andinsomnia.17Somecommontreat-mentstrategiesforjitterinesssyndromeincludeusingalowerinitialdoseorslowertitration.

Therearespecificsideeffectsassociatedwitheachantidepressantmentionedpreviously.Fluoxetineiscon-sideredtobethemoststimulatingSSRI.Therefore,forsomepatients,thisagentcanpotentiallyworsenanxietyorirritability.Itisimportantthatfluoxetineisadminis-teredinthemorningasitcancauseinsomniaifdosedatbedtime.Inaddition,fluoxetineanditsmetabolitehavelonghalf-livesandtherefore,taperingisnotnecessarywhendiscontinuationofthisagentoccurs.Sertralinehasbeenshowntohaveahigherriskofgastrointestinaldiscomfort(e.g.,diarrhea/nausea)incomparisontootherSSRIs.Takingsertralinewithfoodmayhelpallevi-atethissideeffect.Paroxetinehasthehighestriskofsexualdysfunction,weightgain,andanticholinergicsideeffectssuchasdrymouthandconstipation.Italsohastheshortesthalf-lifeandcanleadtomorepronouncedwithdrawalsymptomsifthepatientmissesadose.TheSNRI,venlafaxine,mayalsobestimulatingforpatientsreceivinghigherdosesresultinginanxietyorirritabil-ity.Venlafaxinemayleadtoelevatedbloodpressureduetoanincreaseinnorepinephrine.Atlowerdoses(e.g.75mg/day),venlafaxineactsmostlyonserotonergicreceptorsversusadrenergicreceptorsandmaynotaffectbloodpressureascomparedtohigherdoses(e.g.150to225mg/day).Itisimportanttomonitorbloodpressureateachvisitifapatientisonvenlafaxine.Similartopar-oxetine,venlafaxinehasashorthalf-lifewhichcanleadtowithdrawalsymptomsuponabruptdiscontinuation.Therefore,thisantidepressantshouldbetaperedupondiscontinuation.

Sexualdysfunctionisaparticularlyconcerningsideef-fectthatcanoccurinupto70percentofpatientstakinganSSRI.18,19However,itisimportanttonotethatdepressionoranxietyitselfcancausesexualdysfunctionalongwithavarietyofotherhealthconditionsinclud-ingsmoking,alcoholuse,cardiovasculardisease,anddiabetes.Tohelpguidetreatment,aprovidershouldaskthepatienttodescribetheirsexualdysfunctioninmoredetail.Forexample,ifapatientishavingdifficultywithejaculation,phosphodiesterase-5(PDE-5)inhibitorswillnotbebeneficialastheseagentsareprimarilyeffectiveforerectiledysfunction(ED).Thesexualsideeffectsthatcanoccurwithantidepressanttherapyincludedelayedorgasm,anorgasmia,problemswithejaculation(e.g.,

delayedejaculation),anderectiledysfunction.Thereareseveralapproachestothetreatmentofsexualdysfunc-tion.18,19Oneapproachtotreatmentisthe‘watchandwait’strategy.Withinsixmonths,ithasbeenshownthatroughlytenpercentofpatientsreportremissionofsexualdysfunctionandimprovementmaybenotedinupto15to20percentofpatients.Loweringthedoseoftheantidepressantmaybeconsidered,althoughthereisariskofworseningPTSDand/ordepressivesymptoms.StudiesonPDE-5inhibitorsandbupropionareconflict-ing,however,aprovidermayaddeitherasanadjunc-tivetherapeuticoption.Anotherstrategytoconsiderisswitchingtheantidepressanttoonewithalowerriskofsexualdysfunction(e.g.,bupropion,mirtazapine,ornefazodone).Ofnote,bupropionisastimulatingantide-pressantthatmayleadtoworseningofPTSDsymptoms.Inaddition,thereisaninsufficientamountofliteraturesupportingitsuseinPTSD.Finally,sincethereisariskofseizureswithbupropion,itisnotrecommendedinpatientswithahistoryofseizuredisorder.AsummaryofantidepressantsideeffectsandtreatmentapproachescanbefoundinTable2.

Other Antidepressant Agents15,16

OtherantidepressantsthatcanbeusedinthetreatmentofPTSDincludemirtazapine,phenelzine,nefazodone,ortricyclicantidepressants(TCAs).Throughnegativefeedback,mirtazapineincreasesthelevelsofserotoninandnorepinephrinebyblockingpre-synapticalpha-2receptors.Mirtazapinealsoactsasanantagonistatserotonin-2Aand2C(5-HT2Aand5-HT2C),sero-tonin-3(5-HT3),andhistamine-1(H1)receptors.Duetotheblockadeof5-HT2and5-HT3receptors,5-HT1mediatedtransmissionisenhanced.MirtazapinehasalowerriskforsexualdysfunctionascomparedtoSSRIsandSNRIswhichisbelievedtobeattributedtoitsef-fectson5-HT1and5-HT2receptors.Inaddition,duetothepotentblockadeoftheH1and5-HT2Creceptors,mirtazapinecanbequitesedating,mayincreaseappe-tite,andcauseweightgain.Thisagentshouldbedosedatbedtime.Interestingly,whenmirtazapineisusedatlowerdoses(e.g.,7.5mg/day),itismorelikelytocausesedationandweightgaincomparedtohigherdoses(e.g.,15-30mg/day).Thehigherdosesofmirtazapinetendtobelesssedating,lesslikelytocauseweightgain,andmorelikelytobeefficaciousformood.Phenelzineisamonoamineoxidaseinhibitor(MAO-I).ThisagentinhibitstheactivityoftheMAOenzyme,whichbreaksdownmonoamineneurotransmittersincludingnorepinephrine,dopamine,andserotonin.IfapatientisinitiatedonaMAO-I,astrictdietmustbefollowedinwhichfoodshighintyraminecontentmust


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belimitedoravoidedaltogether(e.g.,agedcheese,processedmeats).Tyraminecantriggeracascadewhichmaycauseariseinnorepinephrineinthebody.There-fore,ifapatientdoesnotadheretothisdiet,thenahy-pertensivecrisiscanresult.Inaddition,priortostartinganMAO-I,awash-outperiodof14daysisusuallyrec-ommendedifapatientisbeingswitchedfromanotherantidepressant.Sincefluoxetinehasalongerhalf-life,itisrecommendedtowaitatleastfiveweeksafterstop-pingthisagentpriortoinitiatingaMAO-I.OthersideeffectsofMAO-Isincludedrymouth,constipation,orthostatichypotension,andinsomnia.Nefazodoneisanantidepressantthatissimilartotra-zodoneintermsofitsmechanismofaction,howeveritalsoactsuponnoradrenergicreceptors,hasaloweraffinityforalpha-1receptors,andlackshistamineactivity.Nefazodoneincreaseslevelsofserotoninandnorepinephrine,antagonizes5-HT2andslightlyantago-nizesalpha-1receptors.Asaresult,thereisalowerriskforbothsexualdysfunctionandposturalhypotension.Thereisablackboxwarningforhepatotoxicitywhich

warrantsthemonitoringofliverfunctionperiodicallythroughouttreatment.Nefazodoneisalsoapotentinhibi-torofCYP3A4,therefore,potentialdrug/druginterac-tionsshouldbemonitored.Tricyclicantidepressants(TCAs)includeagentssuchasamitriptyline,imipramine,nortriptyline,anddesipramine.Withregardtotheirmechanismofaction,theseagentsareverysimilartoSNRIsastheycanincreasebothsero-toninandnorepinephrinelevels.TheTCAsaremetabo-lizedtosecondaryandtertiaryamines.Thesecondaryamines(desipramineandnortriptyline)aremorepotentatnoradrenergicreceptorsandarethoughttohavealowerincidenceofsideeffectsascomparedtotertiaryamines.TCAsalsoactonseveralotherreceptorsincludingH1,alpha-1,andacetylcholinereceptors.Severalsideeffectscanresultfromthisreceptorbindingprofileincludingsedation,orthostatichypotension,blurredvision,drymouth,andconstipation.Inaddition,thereisawarningforpotentialcardiacsideeffectssuchasventricularar-rhythmiasandtachycardia.Duetothesevariousreasons,TCAshavethepotentialtobetoxicinoverdoseand

25

Table 2: Side Effects Associated with Antidepressants and Treatment Strategies17-19

Side Effect

Strategy

Anxiety Startwith a lowerdose and titrateslowly

Insomnia or sedation Adjusttimeof day that patient takesthemedication

Headache Take atbedtime.Ofnote,antidepressantsmay causeinsomniaif dosedatbedtime.

Nausea Take withfood

Diarrhea May go away withcontinuedtreatment;however,may needtoswitch to another antidepressant

Sexual dysfunction “Watch andwait” Reduce thedose ofthe antidepressant Switchtoanother antidepressant that haslower riskof

sexual dysfunction(e.g.,mirtazapine,bupropion,ornefazodone)

Adjunctivetherapy withaPDE-5inhibitorifthe issue iserectiledysfunction;adjunctivetherapy with bupropion


JOURNAL CEareusuallynotrecommendedinpatientswithsuicidalideation.

Time to Effect for AntidepressantsItisimportantthatpatientsareeducatedonthelengthoftimeitcantakeforanantidepressanttobeeffective.Contrarytothebeliefthattheseagentsworkimmedi-ately,itmaytakeuptofourtosixweeksatanadequatedosetoseemoodimprovement.15,16Anadequateantide-pressantdosecanbelooselydefinedastheminimallyeffectivetolerateddosethathasbeenshowntoimprovesymptomsinclinicaltrials.15Therefore,anadequatedoseofanantidepressantmaybedifferentforeachindividual.Theinitialdoseofanantidepressantisnotlikelytobeanadequatedoseandshouldbeincreasedifneeded/toler-ated.

Almostimmediatelyhowever,patientsmaynoticesideeffectssuchasdiarrhea,nausea,oranxiety.15,16Thesesideeffectsusuallydissipatewithinafewdaystoaweek.Thisisanimportantcounselingpointsincepatientswhostartanantidepressantmaydevelopsideeffectsearlyon,butshownoimprovement.Patientsmaydiscontinuetheirmedicationbecausetheybelieveitisnoteffective.WithdrawalsymptomsmayoccurandmayalsoleadtopoorcontrolofPTSD.

Antidepressant Discontinuation SyndromePatientsshouldbecounseledtoavoidabruptdiscon-tinuationofanantidepressantmedicationasitcanleadtowhatisknownasantidepressantdiscontinuationorwithdrawalsyndrome.Symptomsofthissyndromeincludenausea,flu-likesymptoms,tremor,anxiety,and/or“electricshock”sensationsthroughoutthebodyandhead.20Thissyndromeismostcommonwithantidepres-santsthathaveashorterhalf-lifesuchasparoxetineandvenlafaxineandleastlikelytooccurwithfluoxetinetherapy.

Other Medications Used in the Treatment of PTSDOtherclassesofmedicationsthatarecommonlyusedinthetreatmentofPTSDincludeantipsychoticsandanti-convulsants.Ofnote,noneoftheagentsintheseclassesareFDAapprovedforthetreatmentofPTSD.

Second Generation Antipsychotics (SGAs)IntheVA/DoDtreatmentguidelines,secondgenerationantipsychotics(SGAs)asadjuncttherapiesarelistedas“unknownbenefit.”TheNICEguidelineslistrisperidoneandolanzapineashaving“limitedevidence”asadjuncttherapy.Therehavebeentenpublishedrandomizedcontrolledtrialsexaminingolanzapineandrisperidone

andtwotrialsexaminingquetiapineasadjuncttherapyinPTSD.21-32Oneofthemaindrawbacksofthesetrialsisthesmallnumberofpatientsstudied(n=15to48).Inaddition,notallofthetrialsinvolvethecombatveteranpopulation.Insummary,theresultsofthesestudiesarevariableandthedetailscanbeviewedelsewhere.11,21-32

Onerandomized,multicenterdouble-blind,placebo-controlledVAstudyinvolvingnearly300patientswasperformedin2011.27ThiswasthelargestcontrolledtrialtodateexaminingaSGAasadjunctivetherapyinPTSD.Veteransreceivedrisperidoneupto4mgperdayasadjunctivetherapyversusplaceboforchronicmilitaryservice-relatedPTSD.TheprimaryendpointwasachangeinClinician-AdministeredPTSDScale(CAPS)scorefrombaselineto24weeks.Achangeof15pointsintheCAPSscorewasconsideredtobeclinicallysignificant.TheresultsofthisstudyfoundthatrisperidonewasnobetterthanplaceboinreducingPTSDsymptoms.Afterthisstudy,anupdatewasmadetotheVA/DoDtreatmentguidelineswhichnowspecificallylistrisperidoneas“nobenefit”versusotherSGAswhichstillarelistedas“unknownbenefit.”BothVA/DoDandNICEtreatmentguidelinesconcludethatthereisinsufficientevidencetorecommendtheuseofanySGAasadjuncttherapyinthetreatmentofPTSD.ItshouldalsobenotedthatpatientswithPTSDmayhavepsychoticfeaturesasapartofthissyndrome.Thereisalackofsufficientdatainthisarea.PsychoticsymptomsmustfirstbedifferentiatedaspartofPTSDorduetoacomorbidpsychoticdisorder.IfthesymptomsarethoughttobepartofPSTD,thetreatmentofchoiceisaSSRI.IfapatientfailstorespondtoSSRItherapy,aSGAmaybeusedtoaugmenttherapy.11Nodataareavailableontheuseoffirstgenerationanti-psychotics(FGAs)inthetreatmentofPTSD.IfPTSDisthoughttobeacomorbidconditionwithapsychoticdisorder,anantipsychotic(eitherSGAorFGA)shouldbeinitiated.11

TherearesomestudiesexaminingtheuseofSGAsforthetreatmentofinsomniaornightmaresinPTSD.How-ever,datasupportingtheuseofSGAsforthetreatmentofnightmaresinPTSDissparsecomparedtoprazosin.Onestudyexaminedprazosinversusquetiapine.33 This cohort studyinvolving237veteransfoundthatthetwodrugshadsimilarefficacywhichwasdefinedassymptomaticimprovementoverthecourseofsixmonths(61%versus62%,p=0.54).However,ahigherpercentageofpatientscontinuedonprazosinlong-term(threetosixyears)ver-susthosetakingquetiapine(48%versus24%,p<0.001).Patientsweremorelikelytodiscontinuequetiapineduetolackofefficacy(13%versus3%,p=0.03)andadverse


effects(35%versus18%,p=0.008)comparedtoprazosin.

Overall,thereareseveralrisksassociatedwithSGAs,includingweightgain,elevationsinlipidandbloodglu-coselevels,hypotension,cardiaceffects,andmovementdisorders.15,16Therefore,SGAsarereservedasalast-linetreatmentoptionforPTSDthathasnotrespondedtofirstlinetherapiesortotreatcomorbidpsychoticsymptomsinPTSD.

Anticonvulsants TheVA/DoDandNICEtreatmentguidelinesstatethereisinsufficientevidencetorecommendananticonvulsantasadjunctivetherapyforthetreatmentofPTSD.How-ever,moodstabilizersmayhaveapossibleroleinPTSDforpatientswhohavespecificintrusionsymptoms,suchasre-experiencingandhyperarousal,andmayevenhelptreataffectiveinstability.11,12Therehavebeenseveralopen-labelandrandomizedcontrolledtrialsexamin-ingdivalproex,carbamazepine,lamotrigine,topiramate,lithium,andphenytoinwhichhavedemonstratedmixedorlimitedefficacy.Itappearsthatdivalproexhasthemostliterature,althoughresultsarevaried.34,35Ameta-analysiswasperformedin2007whichexamineddivalproexasadjuncttherapyforthetreatmentofPTSD.Itinvolvedonesingle-blindedstudy,fouropen-labelstudies,andthreecasereports.Theanalysisdemonstratedthatdi-valproexcouldbebeneficialinreducinghyperarousal,improvingirritability,angeroutburstsandmood.36 Un-fortunately,thesestudiesweresmallinnumberanddidnotincludeanydouble-blindtrials.Thedoserangedfrom1250–1400mgperday,butthedoseistypicallybasedonweight(target10-15mg/kg/day).Adverseeffectsmayincludesedation,nausea,weightgain,thrombocytopenia,alopecia,andpancreatitis.16

BenzodiazepinesAllguidelinesrecommendagainsttheuseofbenzodiaz-epines(BZDs)inPTSD.ThereisnoevidencethatBZDsreducecoresymptomsofPTSD.Theuseoftheseagentscaninterferewiththeextinctionoffearconditioningandworsenrecoveryfromtrauma.11Fearconditioningisabehavioralmodelinwhichpeoplelearntopredicthostileevents.PatientswhohavePTSDoftenhavealterationsinarousalandreactivity.Therefore,theymaymisinterprettheirsurroundingsasahostileenvironment.Benzodiaz-epinescaninterruptrestructuringofthisthoughtpro-cess.11Inaddition,thereisahighpercentageofpatientswithPTSDwhoalsohaveasubstanceusedisorderand/orhistoryofatraumaticbraininjury(TBI).3,6This is con-cerningbecauseanincreasedriskofrespiratorydepres-sionmayoccurwhencombiningBZDswithalcoholoropioids.InpatientswhohaveahistoryofTBI,BZDs

cancauseparadoxicalagitation/aggression.37IntheVA/DoDtreatmentguidelines,BZDsarelistedas“nobenefit/harm.”Unfortunately,ifapatientisalreadyonaBZD,itcanbedifficulttowithdrawtheagent.ThediscontinuationofaBZDcanresultinanxiety,sleepdisturbances,rage,hyperalertness,increasednight-mares,andintrusivethoughts.Thesewithdrawalsymp-tomshavebeenreportedafteraslittleasfiveweeksoftherapy.16ABZDshouldneverbediscontinuedabruptly.WhendiscontinuingaBZD,thetapersched-uledependsonthelengthoftimethepatientwasontheBZD.Forexample,ifapatientwaspreviouslyonaBZDforgreaterthanoneyear,thetapercanoccurovertwotofourmonths.Ageneralruleofthumbfordiscon-tinuationtoavoidwithdrawalistoreducethedoseby50percentthefirsttwotofourweeksandmaintainthatdoseforonetotwomonths.Then,reducethedoseby25percenteverytwoweeks.38

Prazosin for the Treatment of NightmaresPatientswhoexperiencetheintrusionsymptomofnightmareswithPTSDshouldbetriedonprazosinther-apy.Thisagentisconsideredtobethefirst-lineoptionforPTSD-relatednightmaresandhasbeenshowntobemoreeffectiveversusquetiapineasnotedabove.33 In combat,arushofadrenalineornorepinephrinecanoc-curandhelpsoldiersstayalert.Unfortunately,thismaybecomepersistentandmaladaptiveinnormalsituationsinwhichthisrushofadrenalineisnotneeded.Prazosincannormalizethearousalresponsetonorepinephrineinlowthreatenvironments.39Itisacentrallyactivealpha-1adrenergicantagonistthatisFDAapprovedforthetreatmentofhypertension.16Prazosinisthoughttobethemosteffectivealphaantagonistduetoitshighli-pophilicity.Ithastheabilitytopenetratethebloodbrainbarriertoagreaterextentthandoxazosinandterazosinwhichcrossthebloodbrainbarrierpoorly.40 However,prazosinhasashorthalf-life(twotothreehours)anditsdurationofactionrangesfromsixtotwelvehours.16 As aresult,morefrequentdosingmaybeneededtoman-agehyperarousalsymptomsduringtheday.

PrazosinwasoriginallyexaminedbyDr.Raskindin1995.ItwasfirstthoughtthatPTSD-relatednightmaresweretheresultofageneraladrenergiceffect.However,itwasnotedthatwhenpropranololwasadministered,abeta-adrenergicantagonist,nightmaresbecameworse.Incontrast,whenprazosinwasadministered,itwasquiteeffective.41Intheopen-labelcasestudythatwasperformed,fourcombatveteranswithPTSDweretreatedfor8weekswithprazosin.42 NightmareseveritywasmeasuredusingthenightmareitemfromtheCAPSandClinicalGlobalImpressionof

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of5mgperdayofprazosin.Thesepatientsmarkedlyimprovedandhadcompleteresolutionofnightmares.Theothertwopatientsreceived2mgdailyduetohavinglowbloodpressureatbaseline.Thepatientsthatreceivedthelowerdoseofprazosinmoderatelyimprovedandhadatleasta50percentreductioninnightmareseverity.Therehavebeenseveralstudiessinceinvolvingprazo-sinthathavedemonstratedbothsafetyandefficacyintrauma-relatednightmares,sleepdisturbances,andover-allPTSDseverityandfunction.43-45DespitethefactthatprazosinhasbeenshowntobehelpfulforglobalPTSDsymptoms,thegoalofthestudieswastoevaluatethetargetedsymptomsofnightmaresandsleepdisturbances.Therefore,theVA/DoDtreatmentguidelinescurrentlylistprazosinas“unknown”forthetreatmentofglobalPTSDsymptoms.

BasedonthestudiesfromRaskindetal.,theinitialdoseofprazosinshouldbe1mgatbedtime,andtheaveragedoserangesfrom9to13mgperday.Althoughthemaxi-mumdoseislistedas20mgperdayforhypertension,somepatientsmayrequireahigherdoseifneededandtolerated.Divideddosingofprazosintomanagedaytimehyperarousalsymptomsiscurrentlybeingstudied.Sideeffectsofprazosinincludehypotension,dizziness,andheadache.16Aslowtitrationcanhelptoreducetheseadverseeffects.Oncethedoseisincreasedupto6mgatbedtime,patientsareusuallyabletotoleratehigherdoseswhentitrated(seeTable1).Animportantcounsel-ingpointforpatientsistotakeprazosinonadailybasis,notasneeded.Ifpatientsdiscontinueprazosin,thenightmaresandhyperarousalsymptomsusuallyreturn.Finally,inorderforprazosintobemosteffective,thedreamsshouldbetraumanightmaresthatreenacttheeventandincludesympatheticarousal(e.g.,sweating,racingheart)versusnormalbizarredreams.Prazosinwillnoteliminatedreamsaltogether,butchangestraumaticnightmarestonormaldreams.41 Onemajordruginteractiontobeawareofisthecombi-nationofprazosinandanotheralphaantagonistsuchasterazosinordoxazosinoftenusedforbenignprostatichypertrophy(BPH).16,46Thiscombinationisconsideredtobeaduplicationintherapy.Tomanagethisdrug/druginteraction,itisrecommendedtoswitchfromterazosinordoxazosintoprazosinmonotherapy.Theconversionis1:1forterazosintoprazosin,and1:1fordoxazosintoprazosin(except4mgdoxazosin=5mgprazosin).However,fordosesgreaterthan4or5mg/dayfordoxa-zosinandterazosin,oneshouldstartwithprazosin5mgatbedtimeandtitrateupifneeded.16

Other Medications for the Treatment of PTSD-Relat-ed Nightmares ThereareseveralothermedicationsthatmaybeusedinthetreatmentofPTSD-relatednightmares,butthedataarelowgradeandsparse.Potentialtreatmentsincludetrazodone,SGAs,topiramate,fluvoxamine,phenelzine,gabapentin,cyproheptadine,clonidine,andTCAs(LevelCevidence–assessmentissupportedbylowgradedatawithoutthevolumetorecommendmorehighlyandlikelysubjecttorevisionwithfurtherstudies).47 Withregardtocyproheptadine,afewopen-labeltrialssuggestthatthisantihistaminemaybeapotentialop-tionfornightmares.48,49CyproheptadineactsasaH1and5-HT2receptorantagonist.Ithasbeenshownthat5-HT2antagonistsincreasestagesofslow-wavesleepwithoutalteringtotalsleeptimeandcanimprovesleepout-comes.50,51Mostoftheothertrialsexaminingcyprohep-tadinearesmallandopen-label.52-54Thedosecanrangefrom4mgto24mgatbedtimeandresultsareusuallyseenwithinafewdaysoftreatment.Sideeffectsincludedizziness,increasedappetite,andsedation.Intheory,thereissomeconcernthatcyproheptadinecanreversetheeffectsofaSSRI,althoughthishasnotbeenclinicallydemonstratedinstudies.

Clonidineisanalpha-2agonistthatisthoughttoworkbydecreasingcentrallymediatedadrenergicactivitywhichmayhelpalleviatePTSDarousalsymptoms(LevelCevidence).47Inanopen-labeltrialperformedin2007,thedoseof0.2to0.6mgdailyimprovedintrusivesymptoms,startle,anger,vigilance,andnightmares.55Commonsideeffectsofclonidineincludelowbloodpressure,reboundhypertension,drymouth,andsedation.16

ConclusionInsummary,althoughthereisclearevidencefortheuseofcertainantidepressantsandprazosininthetreatmentofPTSDandPTSD-relatednightmares,respectively,thereislimitedevidencewithregardtootheragentsincludingantipsychoticsandanticonvulsants.PrazosinmaynotonlybehelpfulintreatingPTSD-relatednightmaresbutalsoforhypervigilanceduringthedayandimprovingoverallglobalPTSDsymptoms.Theroutineuseofprazo-sinforthelatterindicationswilldependonfuturestudies.Thereareseveralimportantcounselingpointswitheachmedicationthatpatientsshouldbemadeawareofifanyoftheseagentsareprescribed.Ifpatientsknowwhattoexpectwithvarioustreatments,theyaremorelikelytobeadherentwiththeirmedicationsandultimatelyimprovetheirhealth-relatedoutcomesforPTSD.

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References1. Kessler, RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52(12):1048-60.2. Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry. 1998;55:626–32. 3. Kessler RC, Berglund P, Delmer O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.4. Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, Marmar CR, et al. Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. J Trauma Stress. 1992;5(2):321-22.5. Tanielian T, Jaycox L. editors. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica: RAND Corporation; 2008.6. Evans K, Sullivan JM. Treating addicted survivors of trauma. New York: Guilford Press 1995. 7. Vieweg WV, Julius DA, Fernandez A, Beatty-Brooks M, Hettema JM, Pan-durangi AK. Posttraumatic stress disorder: clinical features, pathophysiology, and treatment. Am J Med. 2006 May;119(5):383-90.8. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013.9. Weathers FW, Huska JA, Keane TM. PCL-C for DSM-IV. Boston: National Center for PTSD – Behavioral Science Division; 1991.10. Weathers F, Litz B, Herman D, Huska J, Keane T. The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. Paper presented at the An-nual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX. October 1993.11. Veterans Health Administration, Department of Defense. VA/DoD clinical practice guideline for the management of post-traumatic stress. Washington (CD): Veterans Health Administration, Department of Defense; 2010 Oct. Avail-able online at http://www.healthquality.va.gov/PTSD-FULL-2010c.pdf. Accessed July 6, 2013.12. National Collaborating Centre for Mental Health commissioned by the National Institute for Clinical Excellence. Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. Na-tional Clinical Practice Guideline Number 26; 2005. Available online at http://www.nice.org.uk/nicemedia/pdf/CG026fullguideline.pdf. Accessed July 6, 2013.13. Stein DJ, Ipser JC, Seedat S. Pharmacotherapy for post traumatic stress disorder. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD002795.14. Davidson J, Baldwin D, Stein DJ, Kuper E, Benattia I, Ahmed S, et al. Treatment of posttraumatic stress disorder with venlafaxine extended release: a 6-month randomized controlled trial. Arch Gen Psychiatry. 2006;63(10):1158-65. 15. Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines. 10th ed. London, England: Informa Healthcare; 2010.16. Micromedex Healthcare Series. [Internet]. Greenwood Village: Thomson Reuters (Healthcare) Inc. Version 5.1 Available from: http://www.thomsonhc.com and http://www.micromedexsolutions.com/micromedex2/librarian/.17. Sinclair LI, Christmas DM, Hood SD, Potokar JP, Robertson A, Isaac A, et al. Antidepressant-induced jitteriness/anxiety syndrome: a systematic review. Br J Psychiatry. 2009 Jun;194(6):483-90.18. Taylor MJ, Rudkin L, Hawton K. Strategies for managing antidepressant-induced sexual dysfunction: a systematic review of randomized trials. J Affect Disord. 2005; 88:241-54.19. Worsham J, Bishop JR, Ellingrod VL. Antidepressant-associated sexual dysfunction: a review. JCPNP [internet]. 2006 Sept. [cited 2007 Jan 16]:1-28. Available from: http://cpnp.org/_docs/resource/jcpnp/sexual-dysfunction.pdf.20. Warner CH, Bobo W, Warner C, Reid S, Rachal J. Antidepressant discon-tinuation syndrome. Am Fam Physician. 2006 Aug 1;74(3):449-56.21. Butterfield MI, Becker ME, Connor KM, Sutherland S, Churchill LE, Da-vidson JR. Olanzapine in the treatment of post-traumatic stress disorder: a pilot study. Int Clin Psychopharmacol. 2001;16(4):197-203.22. Petty F, Brannan S, Casada J, Davis LL, Gajewski V, Kramer GL, et al. Olanzapine treatment for post-traumatic stress disorder: an open-label study. Int Clin Psychopharmacol. 2001;16(6):331-7.23. Stein MB, Kline NA, Matloff JL. Adjunctive olanzapine for SSRI-resistant combat-related PTSD: a double-blind, placebo-controlled study. Am J Psychia-try. 2002;159(10):1777-9.24. Hamner MB, Deitsch SE, Brodrick PS, Ulmer HG, Lorberbaum JP. Que-tiapine treatment in patients with posttraumatic stress disorder: an open trial of adjunctive therapy. J Clin Psychopharmacol. 2003b;23:15-20.25. Sokolski KN, Denson TF, Lee RT, Reist C. Quetiapine for treatment of refractory symptoms of combat-related post-traumatic stress disorder. Military Med. 2003;168(6):486-9.26. Bartzokis G, Lu PH, Turner J, Mintz J, Saunders CS. Adjunctive risperidone in the treatment of chronic combat-related posttraumatic stress disorder. Biol Psychiatry. 2005;57:474-9.27. Krystal JH, Rosenheck RA, Cramer JA, Vessicchio JC, Jones KM, Vertrees JE, et al. Adjunctive risperidone treatment for antidepressant-resistant symptoms of chronic military service-related PTSD: a randomized trial. JAMA. 2011 Aug 3;306(5):493-502.28. Hamner MB, Faldowski RA, Ulmer HG, Frueh BC, Huber MG, Arana GW.

Adjunctive risperidone treatment in post-traumatic stress disorder: A preliminary controlled trial of effects on comorbid psychotic symptoms. Int Clin Psycho-pharm. 2003a;18:1-8. 29. Monnelly EP, Ciraulo DA, Knapp C, Keane T. Low-dose risperidone as ad-junctive therapy for irritable aggression in posttraumatic stress disorder. J Clin Psychopharmacol. 2003;23:193-6.30. Padala PR, Madison J, Monnahan M, Marcil W, Price P, Ramaswamy S, Din AU, Wilson DR, Petty F. Risperidone monotherapy for post-traumatic stress disorder related to sexual assault and domestic abuse in women. Int Clin Psycho-pharm. 2006;21:275-80.31. Reich DB, Winternitz S, Hennen J, Watts T, Stanculescu C. A preliminary study of risperidone in the treatment of posttraumatic stress disorder related to childhood abuse in women. J Clin Psychiatry. 2004;65:1601-6. 32. Rothbaum BO, Killeen TK, Davidson JR, Brady KT, Connor KM, Heekin MH. Placebo-controlled trial of risperidone augmentation for selective serotonin reuptake inhibitor-resistant civilian posttraumatic stress disorder. J Clin Psychia-try. 2008;69:520-5.33. Byers MG, Allison KM, Wendel CS, Lee JK. Prazosin versus quetiapine for nighttime posttraumatic stress disorder symptoms in veterans: an assessment of long-term comparative effectiveness and safety. J Clin Psychopharmacol. 2010;30(3):225-9.34. Davis LL, Davidson JR, Ward JC, Bartolucci A, Bowden CL, Petty F. Dival-proex in the treatment of posttraumatic stress disorder: a randomized, double-blind, placebo- controlled trial in a veteran population. J Clin Psychopharmacol. 2008 Feb;28(1):84-8.35. Hamner MB, Faldowski RA, Robert S, Ulmer HG, Horner MD, Lorberbaum JP. A preliminary controlled trial of divalproex in posttraumatic stress disorder. Ann Clin Psychiatry. 2009 Apr-Jun;21(2):89-94.36. Adamou M, Puchalska S, Plummer W, Hale AS. Valproate in the treat-ment of PTSD: systematic review and meta analysis. Curr Med Res Opin. 2007;23:1285-91. 37. Arciniegas DB, Anderson CA, Topkoff J, McAllister TW. Mild traumatic brain injury: a neuropsychiatric approach to diagnosis, evaluation, and treat-ment. Neuropsychiatr Dis Treat. 2005 December;1(4):311–27. 38. Shelton RC. Steps following attainment in remission: discontinuation of antidepressant therapy. Prim Care Companion J Clin Psychiatry. 2001;3:168-74.39. Boehnlein JK, Kinzie JD. Pharmacologic reduction of CNS noradrenergic activity in PTSD: the case for clonidine and prazosin. J Psychiatr Pract. 2007 Mar;13(2):72-8.40. Menkes DB, Baraban JM, Aghajanian GK. Prazosin selectively antagonizes neuronal responses mediated by alpha1-adrenoceptors in brain. Naunyn Schmie-debergs Arch Pharmacol. 1981;317:273–5.41. Keller DM. Prazosin relieves nightmares and sleep disturbance in PTSD. EPA 2012: 20th European Congress of Psychiatry: Abstract P-1094. Presented March 6, 2012. Available from: http://www.medscape.com/viewarticle/760070. 42. Raskind MA, Dobie DJ, Kanter ED, Petrie EC, Thompson CE, Peskind ER. The alpha1-adrenergic antagonist prazosin ameliorates combat trauma night-mares in veterans with posttraumatic stress disorder: a report of 4 cases. J Clin Psychiatry. 2000;61(2):129–33.43. Raskind MA, Peskind ER, Kanter EV, Petrie EC, Radant A, Thompson CE, et al. Reduction of nightmares and other PTSD symptoms in combat veteran by prazosin: a placebo-controlled study. Am J Psychiatry. 2003;160:371-3.44. Raskind MA, Peskind ER, Hoff DJ, Hart KL, Holmes HA, Warren D, et al. A parallel group placebo controlled stud of prazosin for trauma nightmares and sleep disturbance in combat veterans with post-trauamtic stress disorder. Biol Psychiatry. 2007;61(8):928-34.45. Taylor FB, Martin P, Thompson C, Williams J, Mellman TA, Gross C, et al. Prazosin effects on objective sleep measures and clinical symptoms in civilian trauma posttraumatic stress disorder: a placebo-controlled study. Biol Psychia-try. 2008;63(6):629-32.46. VA Pharmacy Benefits Management Services, Medical Advisory Panel, and VISN Pharmacist Executives. Alpha-blocker combination therapy in PTSD and BPH: recommendations for use. June 2012. Available from: www.pbm.gov. 47. Aurora RN, Zak RS, Auerbach SH, Casey KR, Chowdhuri S, Karippot A, et al. Best Practice Guide for the Treatment of Nightmare Disorder in Adults. J Clin Sleep Med. 2010 Aug 15;6(4):389-401.48. Brophy MH. Cyproheptadine for combat nightmares in post-traumatic stress disorder and dream anxiety disorder. Mil Med. 1991;156:100–1.49. Harsch HH. Cyproheptadine for recurrent nightmares (letter). Am J Psy-chiatry. 1986;143:1491– 2.50. Idzikowski C, Mills F, Glennard R. 5-Hydroxytryptamine-2 antagonist increases human slow wave sleep. Brain Res. 1986;378:164–8.51. Adam K, Oswald I. Effects of repeated ritanserin on middle-aged poor sleepers. Psychopharmacology (Berl). 1989;99:219–21.52. Gupta S, Popli A, Bathurst E, Hennig L, Droney T, Keller P. Efficacy of cyproheptadine for nightmares associated with posttraumatic stress disorder. Compr Psychiatry. 1998 May-Jun;39(3):160-4.53. Ahmadzadeh G, Asadolahi G, Mahmodi G, Farhat A. Effect of cyprohepta-dine on combat related PTSD nightmares. Ann Gen Psychiatry. 2006 Feb 5(Suppl 1):S159.54. Clark R, Canive J, Calais L, Qualls C, Brugger R, Vosburgh T. Cypohepta-dine treatment of nightmares associated with posttraumatic stress disorder. J Clin Psychopharmacol. 1999;19:486-7.55. Boehnlein JK, Kinzie JD. Pharmacologic reduction of CNS noradrener-gic activity in PTSD: the case of clonidine and prazosin. J Psychiatr Pract. 2007;13(2):72-8.

JOURNAL CE


A Review of Pharmacotherapy for Posttraumatic Stress Disorder (PTSD)Correspondence Course Program Number: 0171-9999-14-047-H01-P 1.Completeandmailentirepage.SCPhAmemberscantaketheJournalCEforfree;$15fornon-members.Checkmustaccompanytest.Youmayalsocompletethetestandsubmitpaymentonlineatwww.scrx.org.2.Mailto:PalmettoPharmacistCE,1350BrowningRoad,Columbia,SC29210-6309.3.ContinuingEducationstatementsofcreditwillbeissuedwithin6weeksfromthedatethequiz,evaluationformandpaymentarereceived.4.Participantsscoring70%orgreaterandcompletingtheprogramevaluationformwillbeissuedCEcredit.Participantsreceivingafailinggradeonanyexaminationwillhavetheexaminationreturned.Theparticipantwillbepermittedtoretaketheexaminationonetimeatnoextracharge.

SouthCarolinaPharmacyAssociationisaccreditedbytheAccreditationCouncilforPharmacyEducationasprovidersforcontinuingphar-macyeducation.Thisarticleisapprovedfor1contacthourofcontinuingpharmacyeducationcredit(ACPEUPN0171-9999-14-047-H01-P).ThisCEcreditbegins5/05/2014;expiration5/05/2017CEcreditswillbeuploadedtotheCPEMonitorSystem.

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LEARNING ASSESSMENT QUESTIONS:

1.WhichofthefollowingisNOTasymptomclusterofPTSD?a.Intrusionsymptomsb.Avoidancec.Psychosisd.Negativealterationsincognitionsandmood

2.Allofthefollowingmedicationsareconsideredtobereason-ableoptionsasmonotherapyforthetreatmentofPTSDaccordingtoNICEandVA/DoDtreatmentguidelinesEXCEPT:a.Sertraline b.Bupropionc.Venlafaxine d.Mirtazapine

3.Youareapharmacistreviewingordersandrealizethatapro-viderenteredanorderforprazosin1mgQHSfornightmares,butthepatientisalreadytakingterazosin2mgQHSforBPH.Whatdoyourecommend?a. Discontinueprazosinasthisisduplicatetherapyanditcannotbeusedb. Startprazosinincombinationwithterazosinbutmonitorbloodpressurecloselyc. Discontinueprazosinandincreaseterazosinslowlyuntileffectivefornightmaresd. Switchterazosintoprazosinasa1:1conversionandtitrateprazosinasneeded/tolerated

4.Aprovidercomestoyouandsays,“IreallywouldliketotryanantipsychoticformypatientwhohasPTSDandishavingalotofdifficultywithirritabilityandre-experiencing.Whichoneisthebest?”Althoughthereislimitedevidencefortheuseofantipsy-choticsforthetreatmentofPTSD,whichagentshouldNOTberecommendedpertheVA/DoDtreatmentguidelinesduetoalargestudypublishedin2011?a.Risperidone b.Quetiapineec.Olanzapine d.Aripiprazole

5.Apatientistakingsertraline200mg/dayandisexperiencingsexualdysfunction.Theprovidercallsyouandaskswhatthebestoptionwouldbe.Yourespond:a. Ifirstneedtoknowwhatthepatientisactuallyexperi-encingasthiswillguidethetreatmentb. Increasethedoseto250mg/dayaslowerdosescancausemoresexualdysfunctionc. Addonsildenafil50mg/dayifneededforsexualdys-functiond. Switchthepatienttoparoxetine40mg/day

6.ApatientcallsyouandexplainsthatshemissedtwodosesofherantidepressantthatshetakesforPTSDbecauseshewentawayfortheweekend.Shedescribesthatshefeelsshock-likesensationsalloverherbody,isveryanxious,andistremulous.Whatdoyouthinksheisexperiencingandwhichantidepressantisthepatientmostlikelytaking?a.Allergicreaction,fluoxetineb.Allergicreaction,paroxetinec.Antidepressantdiscontinuationsyndrome,fluoxetined.Antidepressantdiscontinuationsyndrome,paroxetine

7.AdoctorcallsyouafterreadingasummaryoftheVA/DoDtreatmentguidelinesandisconcernedabouthispatientwhohasPTSDandhasbeentakingalprazolam1mgBIDforabout2years.Hewouldliketodiscontinuethismedicationandasksyouhowtodoso.Howwouldyoureply?a. Decreasethedoseofalprazolamby1mgeverydayandthendiscontinueb. Decreasethedoseto1mgQHSfor4–8weeks;de-creaseagain0.25mgTIDfor2weeks,then0.25mgBIDfor2weeks,then0.25mgQHSfor2weeks,thenstopc. SwitchalprazolamtoclonazepamasthisagentismoreeffectiveinPTSDd. Continuealprazolam1mgBID.TheNICEguidelinesstatethatbenzodiazepinesmaybeeffectiveinPTSD.

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602 Rutledge Avenue ♦ Charleston, SC 29403 ♦ (843) 266-2626 ♦ [email protected],Charleston,SC29403•DirectDial(843)266-2625•[email protected]


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