PalmettoThe Official Journal of the South Carolina Pharmacy Association • Vol. 53, Num. 5
Palmetto Pharmacist • Volume 54, Number 2 1
PharmacistPalmetto
The Official Journal of the South Carolina Pharmacy Association • Vol. 54, Num. 2
The Student Issue
• Convention • Student Board Review • Student Trivia • Student-Written Articles • And More!
2 Palmetto Pharmacist • Volume 54 Number 2
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Palmetto PharmacistVolume 54, Issue 2 March/April 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 Inspire Passion; Inspire Students President Steve McElmurray talks about how we can inspire students
7 One Profession. One License. One Voice. CEO Craig Burridge discusses unification in pharmacy
14 Palmetto Pharmacist Network Cecily DiPiro encourages members to get involved in the PPN
23 A Call to Action The What, Why, and How of Antimicrobial Stewardship
25 Transitioning the Role of the Pharmacist A look at the past, present, and future of pharmacy
Regular Columns 12 SCCP 13 PCSP 31 Financial Forum 33 Journal CE 43 Classifieds
Advertisers 2 Smith 4 Pharmacists Mutual 24 Display Options 24 Mutual Drug 26 PACE 43 JonWallace, AttorneyatLaw 44 QS/1
Palmetto Pharmacist • Volume 53, Number 3 3
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
Palmetto Pharmacist • Volume 53, Number 3 3
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
Palmetto Pharmacist • Volume 53, Number 3 3
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
LaurenPalkowski
Palmetto Pharmacist • Volume 54, Number 2 3
EdVess,RPh
4 Palmetto Pharmacist • Volume 54 Number 2
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Passion rebuilds the world for the youth. It makes all things alive and significant.
-Ralph Waldo EmersonRalphWaldoEmersonwasawiseman.Whenwehavepassionforwhatwedoandwhatwelove,wenotonlycreateabetterworldforourselves,wealsocreateabetterworldforfuturegenerations.
Severalofmypredecessors,includingKellyJonesandWayneWeart,toutedthissamemessage.Iwanttoemphasizethisaswell.Whatwedonowiswhatwillbuildafutureforgenerationsofpharmaciststocome.
OnethingthatI’mveryproudofisthefactthatoverthepastfewyearswehavetrulytakenstridestoengageourstudentmembers.WehaveseenahugeincreaseinattendanceatourAnnualConvention.WehaveseenmoreandmorestudentsinattendanceatHouseofDelegatesmeetings,Regionmeetings,andmore.
Thisincreasedengagementdidnothappenspontane-ously.Ithasbeenthroughagreatdealofhardworkanddedicationfromourmembers.ThroughoutmyservicetoSCPhA,I’veseenourleaderstimeandtimeagainreachouttohelpourfuturepharmacists.Fromformalprograms,suchastheJuniorBoardMemberprogram,toinformalhelpsuchasmerelynetworkingatevents,I’veseenourentiremember-shipstepupandreallyencouragestudentmemberstogetinvolved.
Whilewehaveallmadegreatstridestoencour-agestudentparticipationandengagement,Iknowthatwecanstilldomore!Firstofall,ifyouareapreceptor,encourageyourstudentstogetinvolved.BringstudentswithyoutoAssociationmeetingsandevents.Encouragethemtoattendwhenyoucan-not.Filltheminonthelatestissuesimpactingtheprofession.
Anotherwaythatyoucanhelpoutisbyfollowing
PRESIDENT’S PLATFORM
inthefootstepsoftheSCPharmacyFoundation.Recently,theFoundationdecidedthatprovidingad-ditionalfundsforstudentscholarshipstotheAnnualConventionwasapriority.TheFoundationagreedtohelpsendevenmorestudentstoConvention.
Youcanhelpaswell!WhiletheadditionalfundsfromtheFoundationwillhelptosendmorestudentstoConvention,wecouldalwaysuseadditionalsup-port.StudentsthatattendtheSCPhAconventionaremorelikelytobecomemembersofSCPhAaftergraduationandareoftenmorelikelytoenterintoleadershiproles.
Wehopethatyouwillconsidercontributingtoourstudentscholarshipstohelpshowyoursupportofthefutureofpharmacy.Itisagreatwaytoshareyourpassionofpharmacy,investinthefuture,andinspirestudentstocontinuetobuildthisprofession.
Palmetto Pharmacist • Volume 54, Number 2 5
PRESIDENT’S PLATFORM
Inspire Passion; Inspire Students
SCCP
6 Palmetto Pharmacist • Volume 54 Number 2
Thepublicdependsonpharmacistsfortheproductionofsafemedications,andsometimessuffertheconsequencesofunacceptableworkplaceconditions,inadequateatten-tiontostandardprocedureandpoorqualitycontroloverproducts.Theharmcausedbythecontaminatedmedica-tionsproducedbytheNewEnglandCompoundingCen-ter(NECC)wasadramaticexampleofhowtheseissuescanhavetragicconsequences.
Theprofession’sresponsehasbeenswiftandappropri-ate.UnsafesterilecompoundingtechniquewasattheheartoftheNECCoutbreak,inwhichtaintedsteroidinjectionsledtomorethan750fungalinfections,includ-ingafewcasesinSouthCarolina,and64deathsnation-wide.Intheaftermath,theInstituteforSafeMedicationPracticesissuedaclarioncallforadditionalmonitoringandregulationsofsterilecompounding--currentlybeingimplementedfollowingapprovaloftheDrugQualityandSecurityAct--andagreateremphasisonhands-ontraining.
Aspharmacyeducators,wehavetheresponsibilityofprovidingthattraining.Safesterilemedicationcom-poundingrequireshighlyspecifictraininginanenviron-mentnotreadilyavailabletomanypharmacists.Drugshortagesandspecializedmedicationshaveincreasedtheneedforcompoundedproducts,whichincreasestheneedforproperly-trainedpharmacistswhocansafelymakethemforpatients.
Lastmonth,theSouthCarolinaCollegeofPharmacy(SCCP)attheUniversityofSouthCarolinaopenedastate-of-the-artsterilemedicationcompoundingfacilitythatisoneofthefewofitskindinthecountry.
Createdtohelpassurethatpharmacistslearnthehigheststandardsforcompoundingofmedications,theAsepticCompoundingExperience(ACE)LaboratoryenablestheCollegetoofferoneofthenation’sfewUniversity-affiliatedsterilemedicationcompoundingprogramswithhands-ontraining,videotechnologies,coachingandendproduct-testing.
TheACELab,whichwilloffercontinuingeducation(CE)coursesaswellastrainingforourPharmDstudents,isinthelowerleveloftheCokerLifeSciencesBuildingontheuniversity’sColumbiacampus.“Whatmakesthislabuniqueisthecombinationofthesterilefacilitywiththewaytheeducationalmaterialispresented,usingtheoutreachandcapabilitiesofboththeKennedyPharmacyInnovationCenter(KPIC)andthe
College,”saidBobDavis,KennedyprofessoratUSC’sKPIC.“Thereareveryfewsterilecompoundinglabsatuniversitiesanywhereinthecountryandnoneweknowofofferingthiscompleteprogram.”
Aseptictechniquetrainingwillbethroughcorecur-riculumintheSCCPwhileadvancedtrainingwillbethroughKPICcontinuingeducationcoursesandelec-tives.Duringthenextfiveyears,morethan500phar-macystudentsandmorethan1,000pharmacistsandpharmacytechnicianswillgettrainingintheACELab.
“Thereisaprofoundlearningbenefittotraininginafa-cilitywhereyouproduceahands-onsterilecompound,incompliancewiththehigheststandards,thatyoucanthentest,”saidBryanZiegler,KPICexecutivedirec-torandSCCPassistantprofessorofclinicalpharmacyandoutcomessciences.“Theadvancedtechnologyalsoallowsustotrainlargergroupswithlivedemonstration,recordingandcoaching,andvideocaptureanddistribu-tion.Itwillrevolutionizesterilecompoundingtraining.”
AftertheNECCtragedy,industryandregulatoryagen-cieshavetohelprestorethepublic’sconfidencethatmedicationsarepreparedtothehigheststandards.Col-legesofpharmacycanhelprestorethattrustbyeducat-ingpharmacistswhoapplyproperstandardstotheirwork.
AstudyintheAmericanJournalofHealth-SystemPharmacistsfoundthatonly13percentofdeansatthenation’s130pharmacycollegesbelievedtheirstudentsgraduatedwithadequatetraininginsterilecompound-ing.
Ourgraduateshavealwaysreceivedtraininginsterileandnon-sterilecompounding.TheACELabenablesustoprovideasterilecompoundingexperienceonparwithanyinthecountrynotonlyforourstudents,butalsoforpracticingpharmacistsinSouthCarolinaandthroughoutthecountry.TheACELabiscompliantwiththehighestnationalindustrystandardsforsterilecompounding.
FormoreinformationonCEcourses,visittheKPICWebsiteatwww.kennedycenter.sc.edu.
“Weknowofnosimilartrainingprogramanywhereinthenation,”Davissaid.“TheultimatebenefitofthenewACELabisnotonlybettertrainingoffuturephar-macists,butalsoitsexponentialimpactonimprovedpatientsafetyandhigherqualityoflife.”
Sterile Compounding at SCCP
Whenspeakingtoapharmacist,weoftenask:“Wheredoyoupractice?”Theresponseisoften,I’mahospitalpharmacist,LongTermCarepharmacist,orIworkforachainorindependentpharmacyandthen,whotheyworkfor.Toooften,pharmacistsdefinetheirprofessionbythelimiteddefinitionofwheretheypractice.Isuspectthisiswhypharmacyhassomanynationalpharmacyorganizationsandamorelimitednumberofcompetingstatepharmacyorganizations.
FACT CHECK: Takeoutyourpharmacistregistrationandreadit.Doesitsayyouareregisteredasachainpharmacist?Maybeahospitalpharmacist?Or,doesitjustsayyou’rearegisteredpharmacistinthestatewhereyoupractice?I’mbettingonthelatter.Whydoyoudothis?Whathasfrustratedmeasapharmacyassociationexecutiveformorethan22yearsisthis‘we’and‘they’attitudeamongthislearnedprofessionwecallpharmacy.Itisn’tthefirsttimeIfacedthistypeofdivisionamongthesame.Istartedmyassociationmanagementcareer27yearsagoastheCEOoftheNYSAssociationofRenewalandHousingOfficials.Wetoohadfourcompetinggroupsinthestate.TheboardandIbroughtthesefourgroupstogethershortlyafterIjoinedtheorganization,andbecamethelargeststatehousingandrenewalassociationinthenation.Whenwedidthat,thestatepumpedoutmorepaper(meaninglettersofsupportoroppositiononfederalandstatelegislation)thanALLoftheotherstatescombined!ThisiswhatIsodesperatelywantforpharmacy.
Now,I’mnotsayingthatweeliminatesomeofthenationalorcompetingstatepharmacyorganizations.WhatIamsayingis:weallneedtogetonthesamepageandrealizeitisOneProfession,OneLicenseandmakeitOneVoiceforPharmacy.Ineachstate,youshouldestablishanAllPharmacyConferencethatmeetsthreetofourtimesayearaswedidhereinSouthCarolinaandwhatwasdoneinNewYork.Wemetwithallrepresentativesfromthevariouspharmacypracticeareas,including,Medicaid,BoardofPharma-cy,PhRMA,CMSRegional,DepartmentofHealth(PharmacyPolicy,NarcoticEnforcement),DEA,major
by:CraigM.Burridge,MS,CAECEO,SCPhA
Pharmacists
One Profession.
One License.
One Voice.
Palmetto Pharmacist • Volume 54, Number 2 7
managedcareorganizations,independents,chains,LTC,compounding,clinical,hospitalandacademia.Alltoldmorethan60individualsateachofourmeet-ingssofarandgrowing.Theirpurpose:Toworktogetherasateamtoresolveissuesforsectorsofpharmacy,thestate,Medicaid,BoardofPharmacy,etc.Wealsorunlegislationandrulemakingchangesbythesegroupstomakesurewehaveconsensusforchangeandwedonotharmaparticularsectorofpharmacythroughregulatoryorlegislativeinitiatives.Weworkforthepurposeoftheprofession.Whybother?
Whatpharmacists,studentpharmacistsandpharmacytechniciansneedtounderstandisthatifonesectorofpharmacysneezes,everyoneinpharmacyissuscep-tibletoacold.Youcannotseparatethe‘business’ofpharmacyfromthe‘practice’ofpharmacy.Itisimperativethatpharmacyleadershipandacademiamakeitunderstoodhowallofpharmacyisinextrica-blylinkedtothenecessityofafinanciallysoundandvibrantbusinessofcommunitypharmacies,aswellas,thescopeofpractice.Weallknowthat90%ofpharmacistpositionsaretiedtoourcommunity-basedbrickandmortarpharmacies.Iftheyarefinanciallyfrailforwhateverreason,jobgrowthslowsorisnon-existent.Whenunemploymentincreasesamongourpharmacists,competitionforjobsdrivesalariesandbenefitsdownnomatterwhatsectorofpharmacyyouworkin.Forthosepharmacistsluckyenoughtobeemployed,badthingshappenwhenreimburse-mentscontinuetofreefall.WhatIseefirst,asanassociationCEO,arecutbacksintechnicianhours.Then,rollbacksinpharmacisthours.Longerdaysforpharmacistsasoverlappharmacisthoursareelimi-nated.Hasthishappenedtoyou?I’veseenhospitalpharmacistsstartingsalariesdropby15%becauseofcommunitypharmacyclosuresofmergers.Stilldon’tthinkthebusinessofpharmacyaffectsyou?Thinkagain.IamremindedofthisalmostweeklyasIfieldcallsandemailsfromangrypharmacistswhohadtheprescriptionfillbarraisedyetagaininordertogetmoretechnicianhoursortobringonanotherphar-macist.Or,whojustlostmoretechnicianhoursandnowhavetogettoworkearlierandstaylater(offthebooks)justtokeepupwiththedemand.I’veheardofseniorpharmacistshavingtheirweeklyhoursrolledbackfrom45to32.What’sthat,$1,300lessinyourpaycheckeverytwoweeks?Wouldthataffectyou?Howdoespharmacyexpectto‘use’theirexpandedscopeofpracticeauthorityiftherearenodollarsto
supportthesenewinitiatives?Everythingislinked.Nothingstandsalone.Everyoneinpharmacyisvul-nerable.Whattodo?Everystatepharmacyorgani-zationinthenationneedstostartanAllPharmacyConferenceandmakesureitmeetsonaregularbasis.Nationals–youneedtoencourageyourchaptersorstateassociationstoparticipateandsupporttheseefforts.Trustme,itwillimpressthemanagedcareentitieswhentheyseeyourpassionfortheprofes-sionandyourpatients.Itwillopendoorstopayerstoexpandpaymentsforpharmacyservicesasthesemeetingsareusedtoconductpresentationsofsomeofthegreatthingspharmacistsaredoingtosavethehealthcaresystemmoneywhileincreasingthequalityoflifeforyourpatients.SCPhAisusingthisforumatourMay22meetingtolaunchourseverementalhealthpatientstudyinitiativeinconcertwiththeSCDepartmentofMentalHealthandMedicaid.WhenthisstudywasmentionedbyMedicaidatourlastSCAllPharmacyConference,amanagedcareplanaskedtheDirectorofMedicaidPharmacyPolicyiftheycouldincludeprivatepaypatientsinthisstudy.Theyagreedtodiscussafterthemeeting.ThereasonhesaidwewereusingMedicaidonlypatientswasbecauseMedicaidhadaccesstoalltheDMHpa-tient’shealthcarecosts.
Doyouseehowthisworks?Whenallofpharmacysitsatthetable,anyregulatoryorstatutoryissuescanbediscussedand/oransweredduringthemeeting.Anyconcernsaboutaregulationorbillcanbemadeandadjustmentsmadeaccordingly.It’sameetingwhereyoucanrallyALLofpharmacy(eventhoughitmayonlybenefitoneortwosectors)tosupportthelegislationorregulatorychangesneeded.Itprovidesandavenueforstateandfederalregulatoryagenciestorunsomethingbytheprofessionbeforeintroduc-inganychanges.Whatitdoesisuniteallofphar-macyandstopthepublicairingofanydirtylaundry.Whenunited,legislatorsarehardpressedtouseonepharmacyorganizationagainstanothertodonoth-ing.Wehavealreadyhadsuccesswiththisapproachinthelegislaturewhereallpharmacyorganizationsstoodtalltodefeattwoverydamagingamendmentstoabillweallsupported.Thiscooperationiswhatisneededtomovepositivepharmacylegislationfor-warded.Remember,it’snotindependentpharmacy’sproblemorLTCpharmacy’sproblemorhealth-sys-tempharmacist’sissue;it’sPharmacy’sissue.
Pharmacy
8 Palmetto Pharmacist • Volume 54 Number 2
FACT CHECK:Pharmacyisaprofessionthatisrelativelysmallinnumberscomparedtomostotherhealthrelatedprofessions.Thereare3.5millionnursesand1millionphysiciansnationallycomparedtosome290,000pharmacists.So,ifwejustusethe10%ruleofthose‘activists’withinanyprofession,thenonly10%ofnursescanoutnumber100%ofpharmacists.Thisis‘WHY’allpharmacists,techni-cians,owners,etc.needtofighthardforregulations(suchasCMS’2015AnyWillingPharmacyandMACPricingStandards),aswellas,FederalProviderstatus.Itaffectsyouall.Maybenottoday,ortomor-row,butsoonenough.
Iencourageallpharmacists,pharmaciststudentsandpharmacytechnicians,toworktogetheronallissuesimpactingthebusinessandpracticeofpharmacy,notjustthosethatbenefityoursector.Iencourageallofthenationalstocontinuetheirgreateffortstoworktogetherandtoencourageandsupportthestatesinbringingtheprofessiontogetherasonevoice.Helpeachotherforthebenefitofthewholeprofession.Ifyouarenotamemberofyournationalandstateas-
sociation,thenjointoday.Don’tthinkbecauseyou’reemployedtodaythatyouwillbetomorrow.Ihavesatdownwithtoomanypharmacistsintheirlate40’s,early50’swhoarewithoutapaycheckforthefirsttimeintheirlives.Therewasnotasectorofphar-macynotaffectedbylayoffsorcutbacksinstaffinghours.Ifyouarealreadyamemberofyourstateandnationalpharmacyassociations,thankyou!Now,getactive.Givebacktoyourprofessionwhichhasprovidedyouwithagoodlifewithnosmalleffortbyyourprofessionalassociations.
Free Vacation Voucher
Free Vacation Voucher
Palmetto Pharmacist • Volume 54, Number 2 9
Time: 5-7pm Date: 05/12/2014
Location SCPhA Office
1350 Browning Road Columbia, SC 29210
Student Board Review
Trivia Night
What: Pharmacy history, general knowledge and OTC medications questions for a chance to win gift cards! (1st and 2nd place prizes)
Cost: FREE!!!
Who: Students (Guests are invited to watch)
Sign up today! Email Kit ([email protected]) or Stacie ([email protected]) for questions or
to submit your 3 person team!
10 Palmetto Pharmacist • Volume 54 Number 2
Palmetto Pharmacist • Volume 54, Number 2 11
Registration Type:
□ Full Registration without CE ($199) □ MPJE Only without CE ($89) □ NAPLEX Only without CE ($169) □ Full Registra�on with CE ($259) □ MPJE Only with CE ($109) □ NAPLEX Only with CE ($199)
Name_________________________________________ School____________________ Phone________________________ Email___________________________________________ NABP e‐ID________________ Birthdate_____________________ Address_______________________________________________________________________________________________ Payment Type: □ Check _________ 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.
MPJE/NAPLEX REVIEWMay 12‐14, 2014 USC Law School Auditorium Corner of Greens St. & Main St. Columbia, SC
Don’t Forget! • Parking is included with your registration. • There will be a short mid‐day break for lunch on your own each day. • Handouts will be available for printing prior to the course.
Schedule: Mon., May 12: MPJE Review, Dr. Jennifer Baker (7.5 hours) Tues.‐Wed., May 13‐14: NAPLEX review, Dr. Scott Sutton (7 hours per day)
Details will be sent out regarding parking and handouts closer to the date.
Register at www.scrx.orgor complete this form
and return, with payment, to: SC Pharmacy Association 1350 Browning Road Columbia, SC 29210 or 803.354.9207 (fax) or
New for 2014! If you don’t pass the NAPLEX after
taking this review, we will refund you $100!
Please refer to www.scrx.org for more information.
12 Palmetto Pharmacist • Volume 54 Number 2
SCCP
MymostrecentcolumninthePalmettoPharma-cistannouncedthelaunchoftheWalkerPharmacyLeadershipScholarsEndowment,aninitiativemadepossiblebya$525,000giftfromUniversityofSouthCarolina(USC)pharmacyalumnaDonnaWalker’79.TheSouthCarolinaCollegeofPharmacy(SCCP)iscommittedtorecruitingandeducatingstudentswhohavetheattributesofleadership.
Pharmacistsoftenfillleadershiprolesintheircom-munities.Manypeoplewhogointocommunitypharmacy,pharmacyownersaswellasthoseinchainstores,refinetheirskillsasleadersandbecomeknownandtrustedbythepeopleoftheircommunity.Health-systempharmacistshavesimilarexperiencesworkingwithcolleaguesinmulti-disciplinaryenvi-ronments.
Ascommunityleaders,manypharmacistshavebeenelectedtopoliticaloffice,wheretheyhaveanoppor-tunitytoleadandhelptheircommunities.Whileinoffice,theyalsohavetheopportunitytoimprovethewell-beingofSouthCarolinacitizensthroughhealth-careadvocacy,educationandpolicycreation.Whenissuesarisethatrelatetothepharmacyprofessionoreducatingpharmacists,thesepolicymakersareinpositiontoprovideinsightandguidanceabouttheprofessiontolegislatorsandotherelectedofficials.Therewere46pharmacistsservinginstatelegisla-turesacrossthecountryenteringthe2012elections,accordingtotheAmericanPharmacistsAssociation(APhA).Aspharmacydeterminesitsplaceinanevolvinghealthcaresystem,havingexperiencedpro-fessionalsparticipateinpolicydiscussionsiscrucial.Inthelasttwoyears,twohighprofileexamplesofthosekindsofdiscussionsincluderesponsetothemeningitisscareand,inSouthCarolina,theadoptionofanewimmunizationprotocolforpharmacists.IntheSouthCarolinaLegislature,therearethreepharmacistscurrentlyserving,twoofwhomarealumniofSCCP’sfoundinginstitutionUSC:Sena-tor Ronnie Cromer USC ’73 (District 18), Senator Kevin Bryant (District 3), and Representative Kit Spires USC ’76 (District 96).
Sen.Cromer,whoownsLorexDrugsinNewberry,S.C.andisapartnerintheUnionFamilyPharmacyinUnion,S.C.,hasservedintheS.C.Senatesince2003.Heisco-orprimarysponsorof15bills,in-cludingthePharmacyPracticeAct(S.0183)toregu-
Updates at SCCP by Joseph DiPiro, Dean SCCP lateprescriptionbenefitsmanagersandacharitablefundsact(S.0250)toaddpublicschoolsasorganiza-tionsexemptfromfiling.HealsoservesontheSouthCarolinaCollegeofPharmacy(SCCP)LeadershipAdvisoryCouncil.
Rep.Spires,whoownsBigSDiscountDrugsinPelion,S.C.,hasservedintheS.C.HouseofRepre-sentativessince2007.Heisco-orprimarysponsorof10bills,includingthePharmacyPracticeAct(H.3161)tohelpestablishnewregulationsforcom-poundingpharmaciesandthePharmacyPatientPro-tectionAct(H.3151)toregulateprescriptionbenefitsmanagers.
Sen.Bryant,presidentofBryantPharmacyandSup-plyinAnderson,S.C.,isco-orprimarysponsorof13bills,includingthePrescriptionMonitoringProgramAct(S.0840)toamendlawsrelatedtosubmissionofinformationbydispensers.
AnumberofotherUSCandMedicalUniversityofSouthCarolina(MUSC)pharmacyalumnihavebeenelectedtolocaloffices.Asmallsamplingincludes:
•Frank Brunson MUSC ’76 isthemayorofForestAcres,S.C.Hebecamseinvolvedinpoliticsinjuniorhighschoolandwaselectedtohisfirstmayoraltermwith81percentofthevote.AftergraduationfromMUSC,hedidaresidencyatRichlandMemorialHospitalandstayedonasahospitalemployeeforthreeyearsbeforerunningaretailpharmacyfrom1979to1997.In1997,helaunchedInfusionCareofSouthCarolina.
•Mike Ross USC ’76waselectedmayorofBly-thewood,S.C.in2012.HestartedBlythewoodPhar-macyinSeptemberof1981andopeneditscurrentlocationin1986.Alongtimecommunityleader,hewaselectedpresidentoftheS.C.PharmacyAssocia-tion(SCPhA)forthe2000-01termandvotedPhar-macistoftheYearin2001.In2009,hereceivedtheBowlofHygeiaAward.HealsoservedaspresidentoftheUSCPharmacyAlumniSocietyLeadershipCouncil.
•Don Wall USC ’67,ownerofseveralpharmaciesinGreer,S.C.,MountainView,S.C.,Greenville,S.C.
continued on next page...
Palmetto Pharmacist • Volume 54, Number 2 13
andTravelersRest,S.C.,servedasmayorofGreer,S.C.from1992-2000.Apracticingpharmacistfor45years,WallwashonoredwiththeBowlofHygeiain1993andthe2012OutstandingAlumnusoftheYearbytheUSCcampusoftheSCCP.
•Tom Rivers USC ’65 servedasmayorofWillis-ton,S.C.for20yearsbeforefinallysteppingdownin2013,sayingitwastimetopassthereinstoayoungergeneration.Firstelectedtotowncouncilin
OnMay10,2014,PresbyterianCollegeSchoolofPharmacywillholditsfirstgraduationofpharmacystudents.SeventysixstudentswillreceivetheirdiplomasforcompletingtheDoctorofPharmacydegreeatPresbyterianCollege.Morethanthreehun-dredundergraduateandgraduatestudentdegreeswillbeconferredthatSaturdaymorning.
Precedingthegraduation,theinauguralgraduat-ingclassofpharmacystudentswilltakepartintheSchool’sfirstDoctoralHoodingCeremony.Over400peopleareexpectedtobeinattendancewillbewelcomedbyPresidentClaudeC.LillyandDeanCliffFuhrman.ThekeynotespeakerwillbeDr.Lu-cindaMaine,ExecutiveVicePresidentandCEOoftheAmericanAssociationofCollegesofPharmacy.Graduatingstudentswillbepresentedwiththeirdoc-toralhoodbyDr.LauraFox,AssistantDeanofPro-fessionalandStudentAffairsandDr.Fuhrman,andwillreceiveanalumnipinfromDr.LewisMcKelvey,AssistantDeanofExperientialEducation.Severalstudents,facultyandpreceptorawardswillalsobepresentedattheceremony.
Asurveyofourgraduatesindicatedthat80%haveal-readyacceptedjoboffersorresidencyappointments.Wehada50%successrateforstudentsapplyingforresidencyprograms(8of16successfullymatchedinASHPprograms).Inaddition,onestudentwillattendtheUniversityofTexastopursueaPhDinPharmaceuticalOutcomes.
PCSP
1988,hehasbeeninthepharmacybusinesssince1970andistheownerofRiversPharmacyinWilliston.Thesearejustanillustrativefewofthemanyphar-macistsinleadershippositionsinSouthCarolina.TheCollegeisproudtohavecontributedtotheshapingoftheseleadersduringtheirpharmacyeducationsandweintendtocontinueemphasizingtheimportanceofleadershipaspartoftheCollegecurriculum.
ItseemssuchashorttimeagothattheClassof2014begantheiracademicjourneyatPCSP.Now,fouryearslater,theyeagerlyanticipatetheircareerpathsinthepharmacyprofession.Graduationdayhasandalwayswillbethebestdayoftheyear.Seeingtheproudandsmilingfacesonourgraduates’andtheirfamilies’isextremelygratifyingtoourfacultyandstaff.Weeagerlylookforwardtowatchingouralumniprovidequalityhealthcareandpublicservicetothecommunitiesinwhichtheyreside.
OnceaBlueHose…AlwaysaBlueHose!
An Inaugural Event at Presbyterian College by Cliff Fuhrman, Dean PCSP
continued from previous page...
ThePalmettoPharmacistNetwork(PPN)hasworkedwithSouthCarolinaemployerstoprovidediabetesself-managementservicessince2006.Ourdiabetesself-managementprogramwasorigi-nallyprovidedthroughtheDiabe-tesTenCityChallenge(DTCC)inpartnershipwiththeAmericanPharmacistsAssociationFounda-tion.TheprogramhascontinuedastheHealthMapRxProgramforDiabetes,ahealthcareinitiativethatfocusesonindividualswhohavebeendiagnosedwithdiabe-tes.
HealthMapRxworkswithemploy-erstoofferconsumerincentiveprogramsthatfocusonpatientself-managementeducationandtechniquestohelppatientswithchronicconditionsimprovehealthoutcomes.Theprogrammatcheshealthplanbeneficiarieswithcommunitypharmacist“coaches”whoprovidehands-oneducation,whilemonitoringandevaluatingtheemployees’healthimprove-ments.Throughone-on-onecoun-selingsessionswithpharmacists,employeescanlearnhowtobettermanagetheirchronicconditions
(diabetes,highbloodpressure,cholesterol)andreduceassociatedrisks.1
Thisinnovativeprograminvolvesthecollaborativeeffortsofem-ployers,localhealthcareprovid-ers--includingpharmacistsandphysicians,andhealthinsurerstoenableemployeestobetterman-agetheirdiabetes.Financialincen-tives,suchasreducedorwaivedmedicationco-pays,areofferedtoemployeesforparticipating.
Theprimaryelementsofthepro-graminclude:• Identifyingandenrollingemployeesandbeneficiarieswhohavediabetes,andarecoveredbytheemployer’shealthplan• ContractingwiththePal-mettoPharmacistNetworktopro-videtheappropriatepharmaceuti-calcare,coaching,andcounselingtohelppatientseffectivelymanagetheirdiabetes• Assessingeachpatient’sunderstandingofhis/herdiabetes• Conductinganeducationalandskillstrainingprogramtai-loredfortheneedsofeachpatient• Preliminarilyassessing
eachpatient’shealthandreinforc-ingthephysician’streatmentplan• Periodicevaluationofeachpatient’sknowledge,skills,andperformance• Establishingasecuredatacollectionmechanismandmain-tainingaconfidentialdatasourcethatcantrackandanalyzeaggre-gateoutcomedataforpurposesofdevelopingstatisticalcomparisonsofimprovedpatienthealthandtotalhealthcaresavingsfortheemployer• Evaluatingandreportingresultsofprogram.
Ourprogramispatient-focusedandsuccessoftheprogram,inlargepart,dependsonthepa-tient’sactiveparticipationinhis/herowncare.Theprogramisdesignedtohelppatientsmaintaingoodcontrolovertheirdiabetesbyhelpinghim/herlearnhowtobetterself-managetheircondition.Patientsmeetregularlywiththehealthcareteam–thephysician,pharmacist,andwhenneeded,otherspecialists.Thepharmacistworkswiththepatienttoidentifyknowledgedeficienciesandtodevelopaneducationsupportplan
The Palmetto Pharmacist Network by Cecily V. DiPiro, PharmD
Coordinator, Palmetto Pharmacist Network
14 Palmetto Pharmacist • Volume 54 Number 2
that(a)meetshis/herindividualhealthcareneedsand(b)providestheeducationandskilltrainingthathe/sheneedstooptimallyself-managetheirdiabetes.OurprocessofcareismodeledaftertheAmericanDiabetesAssocia-tionGuidelines.
EachemployeeenrolledintheHealthMapRxprogramsignsareleaseofinformationformautho-rizingthepharmaciststoobtainlaboratorytestresults.Evaluationofclinicaloutcomeshasshownconsistentvaluesforkeyclinicalindicatorsindiabetesmanage-ment.AveragehemoglobinA1cresultsforemployeesofonePPNemployerhaverangedfrom7.1to7.39over3years(2009-2012;targetA1c≤7.0)andaverageLDLhasrangedfrom82to91duringthesametimeperiod(targetLDL≤100).
TheeconomicoutcomesfortheDTCCshowedareductionof$1,079inaveragetotalhealthcarecostsperpatientperyearascomparedwithprojectedcosts.2AnalysisofhealthcarecostsbyoneemployercontractedwithPPNhasshownconsistentlylowercostsperenrolleeperyear(2009–2013;nodataavail-ablefor2010)ascomparedtoanationalbenchmarkforaveragecostsforapatientwithdiabetes.
Weworkcloselywithourem-ployersandhaveworkedwiththeCityofCharlestonsinceimplementationoftheDTCC.JanPark,BSRN,EmployeeWellnessManagerfortheCityofCharlestonrecentlysum-marizedthebenefitstoCityemployeesasfollows:
“Theparticipantsinthisprogramaretaughttoself-managetheirdiabetes.Theylearnagreatdealaboutallaspectsofdiabetescareincludingglucosemonitoring,medicationmanagement,andtheimportanceofhealthynutri-tionandexercise.Thepharmacistcoachbecomesanimportantpartoftheircareteam.Ourparticipantsunderstandandcomplywiththeirmedicationregimensbetterwiththecounselingandtheyappreci-atebeingabletocalltheircoachiftheyareconfusedonanything.Ac-cordingtoourlastclinicalreport,theaverageA1cofparticipantsis7.2.Weareexcitedthatwecanofferthissupporttoourstaff.”
TherelationshipbetweentheenrolleeandthePPNcoachiskeytothecontinuedsuccessofthismodelofcare.WeareproudoftheworkdonebythepharmacistsworkingwithPPNandarework-
ingtoexpandtheHealthMapRxmodeltootheremployersintheStateofSouthCarolina.
References:1. http://www.healthmaprx.com/. Accessed March 6, 2014.2. Fera T, Bluml BM, Ellis WM. Diabetes Ten City Chal-lenge: Final economic and clini-cal results. J Am Pharm Assoc 2009;49:e52-e60.
Palmetto Pharmacist • Volume 54, Number 2 15
PPN
16 Palmetto Pharmacist • Volume 54 Number 2
SCPHA’S ANNUAL CONVENTION
IS RIGHT AROUND THE CORNER!
JUNE 19-22, 2014 MARRIOTT RESORT AND SPA
HILTON HEAD ISLAND, SC THEME: ROARING 20S
Journal Special! $10 off Full or VIP Registration
Promo Code: journal Offer good through May 28, 2014.
REGISTER AT WWW.SCRX.ORG
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.
Palmetto Pharmacist • Volume 54, Number 2 17
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.
18 Palmetto Pharmacist • Volume 54 Number 2
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.
Palmetto Pharmacist • Volume 54, Number 2 19
Where would you prefer to have your HIPAA training?
Option A Option B
Yep. That’s what we thought. Get your HIPAA training online, 24 hours a day, 7 days a week with SCPhA’s on-line HIPAA training program.
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!
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.
American Pharmacists Association Foundation
News Release FOR IMMEDIATE RELEASE CONTACT: Megan Lewis
March 25, 2014 202.558.2724; [email protected]
APhA Foundation and IQware Solutions announce partnership for new data integration and analytics
Expanded research capabilities will leverage the value of pharmacists’ patient care services
WASHINGTON, DC – The American Pharmacists Association (APhA) Foundation and software company IQware
Solutions announce a new partnership to create core components of an IMPACT Healthcare Innovation Hub, a new data
aggregation and reporting tool that will integrate clinical and economic data. The secure web-based platform will include
data collection, importing, analytics and reporting capabilities currently used in the Foundation’s successful research
projects. Using the hub, healthcare organizations will be able to produce a set of self-service reports using uploaded data
that demonstrate the value of pharmacists’ patient care services as an efficient, cost-effective healthcare solution.
The hub will enable the Foundation to build upon its rich history of research outcomes showing the value of pharmacists’
patient care services through a rapid, comprehensive analysis of data to collaborating stakeholders. “We are pleased to
have the opportunity to develop new tools to streamline data collection and reporting in a way that produces evidence of
the impact pharmacists’ patient care services have on healthcare delivery and ultimately, patient health outcomes,” said
Mindy Smith, APhA Foundation Executive Director.
“Privacy, confidentiality, reliability and security are of paramount importance to our research at the APhA Foundation and
to our collaborators,” said Benjamin Bluml, APhA Foundation Senior Vice President, Research and Innovation. “One of
the key reasons we selected IQware as our development partner is for the flexibility its secure, patented technology offers
in developing an infrastructure that allows us to adapt to a continuously evolving marketplace as we work to expand our
research and innovation enterprise to help invent a preferred future.”
Healthcare organizations who use the IMPACT Healthcare Information Hub will be able to collect, analyze, report and
aggregate data depending on their needs. The software will allow the option to enter data directly into the system if an
electronic medical record system (EMR) is not in place, convert non-standardized formats into standardized data, or
accommodate market standards for health information exchange if a standard EMR system is used.
“We are confident that the unique attributes of the IQware architecture will provide the APhA Foundation with the
information technology platform needed to lead the pharmacy profession into a new future and are proud to be a partner,”
said Donald L. Seddon, President of IQware Solutions, LLC.
About the American Pharmacists Association Foundation
The APhA Foundation, a nonprofit organization based in Washington, D.C., is a trusted source of research demonstrating
how pharmacists can improve health care. The APhA Foundation’s mission is to improve people’s health through
pharmacists’ patient care services. The APhA Foundation is affiliated with the American Pharmacists Association, the
national professional society of pharmacists in the U.S. For more information, please visit the APhA Foundation website
www.aphafoundation.org. Follow the APhA Foundation on Twitter and Facebook for the latest updates.
About IQware Solutions
Answering the call for an all-new method for software development, IQware created a patented (US #7,322,028, others
pending), revolutionary process that removed coding and scripting from the equation. Since its initial release in 2007, the
IQware Development Platform has evolved to include the necessary intelligence to deploy new applications in response to
events. Innovation continues to ensure IQware delivers solutions that enable healthcare organizations to capitalize on big
data by securing all data in motion against external and internal threats with 24x7 availability, and the ability to change
applications on the fly, adding/changing functionality even when systems are in use. For more information, please visit the
IQware website www.iqwaresolutions.com.
###
American Pharmacists Association Foundation ● 2215 Constitution Avenue, NW ● Washington, DC 20037-2985
P: 202.429.7565 ● F: 202-783-2351 ● www.aphafoundation.org
20 Palmetto Pharmacist • Volume 54 Number 2
APhA
2014’s Convention Exhibitors & Sponsors Merck
Mutual Wholesale Drug Co. Mylan
Nephron Pharmaceuticals Novo Nordisk, Inc.
PACE Alliance Pharmacists Mutual
PPSCPresbyterian CollegeQS/1 Data Systems
Return Solutions Rite Aid
Rx Systems Sanofi
SC Board of Pharmacy SCCP
SC Medicaid/DHHS SCRIPTS
Smith Drug Company South University
Takeda Pharmaceuticals Vital Care Walgreens
There are still a few booths available!For more information, please call 803.354.9977.
*This list was current at time of publishing and is subject to change.
AbbVieAbsolute Total Care
ACHCAmerican Associated Pharmacies
AmerisourceBergen APCIBDC
Cardinal Health Computer Rx
CPFI CVS
Designer Greetings Display Options
Eli Lilly EPIC Pharmacies, Inc.
Fred’s, Inc. iMedicare
Janssen Pharmaceuticals LMK Wealth Management
Magellan Medicaid Administration McKesson
MedaMedicine On Time
Palmetto Pharmacist • Volume 54, Number 2 21
Bowl of Hygeia State Association Challenge 2.0 –
Help South Carolina Take the Lead!
Goal: $600,000 Endowment Yet to raise: $150,000
How You Can Help:
• Save time: Make $10
quick donations by text - RxBowl to 52000
• We are encouraging all
former recipients to contribute!
Contact: Lynette Sappe-Watkins:
[email protected] or 202-429-7534
Prizes Funds for a Bowl of Hygeia Reception at
your next Annual Meeting
1st Place is $2,500: Awarded to the state raising the most over
$5,000 before APhA2014*.
2nd Place is $1,000: Awarded to the state raising the 2nd highest
amount over $5,000 before APhA2014*.
3rd Place is $500: Awarded to the state raising the 3rd highest
amount over $5,000 before APhA2014*.
NEW! 1st, 2nd and 3rd place winners may have the Bowl of Hygeia sent to
their meeting for your reception! * Funds must be received by the APhA Foundation by March 15, 2014
22 Palmetto Pharmacist • Volume 54 Number 2
In Association with the South Carolina Chamber of Commerce,The 29th Annual Ranking of the State’s Largest Privately Owned Companies.
J M Smith Corporation Ranked 3rd
J M Smith Companies
1. Milliken & Company - Spartanburg 2. The Intertech Group, Inc. - North Charleston 3. J M Smith Corporation - Spartanburg4. United Sporting Companies, Inc. - Chapin5. Southeastern Freight Lines, Inc. - Lexington
R
We are proud to announce that
Palmetto Pharmacist • Volume 54, Number 2 23
Student Article
WhenIregisteredforaclinicalpracticerotationinantimicrobialstewardship,itwasachallengetoascertainexactlywhatmyresponsibilitieswouldbe.Ittookseveraldaysofrotationformetotrulyrealizewhatantimicrobialstewardshipreallymeans.TheCentersforDiseaseControl&Prevention(CDC)definesantimicrobialstewardshipasusingtherightantibiotic,attherightdose,attherighttime,fortherightduration.1Thefirstrealizationisthatthe“right”answerisrarelytheobvious,simple,orstraight-forwardone.Thepracticeofstewardshiprequiresanintrinsiccuriosityandapropensityfortheartofproblemsolving.Onemustconsidereveryaspectofaparticularcasetoselecttheoptimalantimicrobialagent,includingsiteofinfection,drug-specificfac-torsincludingdosing,cost,potentialadverseevents,andahostofpatient-specificfactors.
Theimplementationofantimicrobialstewardshipprogramshasbeenshowntoreduceratesofresis-tance,infectionssecondarytomulti-drugresistantorganisms,riskofC.difficileinfection(CDI),andfinancialburdenonthehealthcaresystem.Antimi-crobialresistanceisescalatingatanalarmingrate.In2013,theCDCestimatedthatmorethan23,000Americansdieeveryyearfromantibiotic-resistantinfections,andantimicrobialresistanceleadsto$20billioninexcesshealthcarecosts.2Theleadingcontributortothisresistanceisprimarilyantibioticexposure.Often,theseexposuresaresecondarytoantibioticsprescribedinappropriately,inefficiently,orexcessively.Similarly,theprimarycauseofCDIisantibioticuse.Eachyear,C.difficileinfectionhasbeenassociatedwithover14,000Americandeathsandatleast$1billioninexcessmedicalcosts.2,3
Basicapplicationofantimicrobialprescribingprin-ciples,resultinginjudicioususeofantimicrobialagents,hasbeenshowntoreducebothclinicaland
A Call to Action: The What, Why, and How of Antimicrobial StewardshipMaggie K. Brilhart, PharmD Candidate, 2014 & P. Brandon Bookstaver, PharmD, BCPS (AQ-ID), AAHIVP
financialsequelaeassociatedwithCDIanddrug-resistantinfections.
Asfuturepharmacists,Iwouldencouragestudentstoapplyantimicrobialstewardshipprinciplesinallpracticesettings.Intheacutecaresetting,thisisfairlystraightforward.Determineifyourpatient’schoiceofantimicrobialtherapyisthemoststream-linedagent,coveringtheappropriateconfirmedorsuspectedbacteriawiththeleastamountofpatientriskandmakerecommendationstoprescribers.Fol-lowculturesandsensitivitiestoensurethattherapyisbeingappropriatelyadjusted.Confirmthatanti-microbialordersincludeappropriatedose,duration,androute.Addresstheavailabilityandrestrictionsofhigh-riskantibioticstotheprescribingteams.Thesepracticerecommendationshavebeenpre-sentedbytheInfectiousDiseasesSocietyofAmericawithafocusonbenefitsandmethodsofstewardshipimplementation.3Communitypracticemaypresentachallengeofinvolvement,buthasahighlevelofpotentialimpactwiththemajorityofantimicrobial
Student Articles
24 Palmetto Pharmacist • Volume 54 Number 2
useintheoutpatientsetting.Thereareseveralwaystoensurequalitypatientcarebyminimizingriskandimprovingoutcomes.Spendingafewminuteswithapatientcanclarifyasituationandprovideopportunitytointerveneappropriately.Whatinfectionisbeingtreated?Whatarethemostlikelybacterialsources?Monitorpastantibioticexposures–isthepatientreceivingtheirthirdantibioticthismonth?IdentifyriskfactorsforCDI,andrecognizebarrierstoap-propriatetreatmentandclinicalsuccess.Similarly,providebriefpatientcounselingontheimportanceofcompletingtherapyandusingtheantimicrobialforonlytheintendedpurpose.Youshouldstresstheimportanceofnotsharingantibioticsandtodiscardunusedantibioticsforsafetyissues.Additionalcounselingpointsincludepotentialadverseeffectsandreconcilingmedicationallergies,whichcouldsavethepatientandhealthcaresystemconsiderabletimeandunduecost.Thesesmallstepsareacru-cialcomponentofpatientsafety,asallergiesareofparticularconcerninantimicrobialuse.Anticipationofcertaincommonadverseeventsmayputpatientsatease,whileawarenessofserioussideeffects,suchasprolongeddiarrhea,canfacilitateearlierdiscontinua-tionortreatment.
Whilepharmacistsplayacriticalroleineffectivelymanagingantimicrobialtreatmentregimens,otheravenuesofconcernincludecontinuedoveruseofantibioticsinlivestockandtherelativelackofanti-bioticsinthepipeline.Iencourageyoutoadvocateforlegislationthatwillhelptosupportbothantibioticdevelopmentandtargetedinterventionstoreducetheburdenofresistantorganisms.5,6Iurgeeachofyou,regardlessofpracticesetting,toadoptthehabitofactingasapatientadvocateinthecontextofanti-microbialuse.Itisaninvestmentinthesafetyandwell-beingofourglobalhealthcaresystemformanyyearstocome.
Maggie Brilhart is a fourth year pharmacy student at the SC College of Pharmacy at the University of South Carolina. Brandon Bookstaver is a faculty member at the SC College of Pharmacy at the Uni-versity of South Carolina and maintains a clinical practice site in infectious disease at Palmetto Health Richland.
References:
[1] Antibiotic resistance threats in the United States, 2013. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf. Published April 23, 2013. Accessed December 22, 2013.
[2] Get smart for healthcare: why inpatient steward-ship? Centers for Disease Control and Prevention Web site. http://www.cdc.gov/getsmart/healthcare/inpatient-stewardship.html. Published November 15, 2010. Accessed December 22, 2013.
[3] Dellit TH, Owens RC, McGowan JE, et al. Infec-tious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007; 44:159-77.
[4] Spellberg B, Blaser M, Guidos RJ, et al. Com-bating antimicrobial resistance: policy recommenda-tions to save lives. Clin Infect Dis. 2011; 52 (suppl 5): S397-S428. doi: 10.1093/cid/cir153.
[5] United States. Committee on Energy and Com-merce. Cong. Senate. Strategies to Address Antimi-crobial Resistance Act. 2013. Washington: GPO, 2013. Print.
[6] Spellberg B, Guidos R, Gilbert D, et al. The epi-demic of antibiotic-resistant infections: a call to ac-tion from the Infectious Diseases Society of America. Clin Infect Dis. 2008; 46:155-64.
Student Articles
Palmetto Pharmacist • Volume 54, Number 2 25
Past:Theprofessionofpharmacyhasevolvedsubstantiallyoverthousandsofyears.Thefirst“pharmacies”,ordrugstores,wereestablishedinBaghdad,Iraqin754.TheMiddleEastmademanyadvancesinbotanyandchemistry,leadingtothemedicinaluseofchemicalcompoundsandthefirstpharmacopoediathatlistedvariousdrugsandremediesforailmentsin869.1 For centuries,theonlywayonecouldentertheprofes-sionwasthroughapprenticeship,orworkingside-by-sidewithan“apothecary”.Apothecarieswereknowntocompoundanddispensemedications,muchliketo-day’spharmacists,butalsoprovidedmedicaladviceandserviceswhichareperformedbyothermedicalspecialiststoday.
EdwardParrishoftheAmericanPharmaceuticalAs-sociationcoinedtheterm“pharmacist”nearly150yearsagoafterhesuccessfullyproposedthatallofthevariedpharmaceuticalprofessionalmembersbeconsidered“pharmacists.”2Oncethefieldofphar-macywasformalized,pharmacistsmade,prescribed,andcounseledpatientsuntiltheirrolechangedin1951.
The1951Durham-HumphreyamendmenttotheFederalFood,Drug,andCosmeticActof1938definedtwoseparatecategoriesformedications,overthecounter(OTC)andlegendproducts;andrequiredpharmaciststoobtainaprescriptionfromaphysi-ciantodispensemedications.3Thisrestrictionpushedpharmaciststofocustheirtimeondispensingandproductsafety.
Thepharmacist’srolechangedonceagaininthe1980’sasaprofessionalmovementurgingpharma-ciststoperformmoreclinicaldutiesgainedmo-mentum.However,legislationdidnotcatchupwiththemovementuntiltheMedicarePrescriptionDrugImprovementandModernizationActwaspassedin2003,whichmandatespatientstobecounseledbypharmacists.3ThislegislationalsoopeneddoorsforpharmacistsinregardstoMedicationTherapyManagement(MTM)whichisperformedbymanypharmaciststoday.
Present:TheWorldHealthOrganization(WHO)estimatesthereareatotalof2.5millionpharmacistsand
Transitioning Role of the Pharmacist:Past, Present,
and Future
Jessica T. Langdon, PharmD/MBA candidate 2014, SUSOPJenny Pope, PharmD Candidate 2014, SCCP, USC Campus
Student Articles
26 Palmetto Pharmacist • Volume 54 Number 2
pharmacypersonnelworldwide.Manypeopleoutsidetheprofessiontypicallyviewapharmacistassome-onewhocountspillsandlabelsvials,butweknowtoday’spharmacistisresponsibleformuchmore.With129pharmacyschoolsintheUnitedStatesgraduatingthousandsofstudentseveryyearwithaDoctorateofPharmacy,PharmDdegree,pharmacistsaretransitioningtobecomeamoreclinicalhealthcareprofessional.2 Pharmacistspracticeinavarietyofsettingsincludingcommunity,hospital,industry,longtermcare,homeinfusion,academics,amongothers.Theirdutiesconsistofverifyingprescriptionorders,counselingpatients,administeringvaccines,interpretinglabval-ues,androundingwithhealthcareteamsinthehos-pital.Intheretailsetting,pharmacistsareprovidingMedicationTherapyManagement(MTM)servicesthatoptimizepatientspecificmedicationregimensandreducehealthcarecosts.Advancesintechnologylikeautomateddispensingmachines,refillsviasmartphoneapplications,drive-thrupharmacies,andtheelectronicpatientrecordallowpharmaciststospendmoreoftheirtimeonclinicaldutiesandworktothefullextentoftheirdegree.Thisleadsustowonderwhatthefutureholdsforpharmacistsasaprofession.
Future:Pharmacistshavebeenthemostaccessiblehealthcareprofessionalavailabletotheirpatientsovertime,whetheritisoverthephoneorinperson,atalmostanytimeofday,andarelationshipisformedfromthebeginningandmanycontinuetoremain!Throughtime,theserelationshipsallstartedwithapatientcomingtoapharmacyandgettinganewprescriptionthatthepharmacistcounseledthemon.Whenpa-tientsunderstoodtheknowledgebaseofthepharma-cist,theybegantotrustthemandaskmorequestionswitheveryvisittothepharmacy.Itisbecauseofthisrelationshipwiththepatientthattheroleofthephar-macistismovingtowardabroaderscopeofpracticetoallowformorefacetimewiththeirpatientsinthefuture.
Whatisbeingproposedforthefutureofpharmacyistobeabletodomoreofwhatistermedas“postdiagnosticcare.”“Onceadiagnosisismadebytheprimarycareprovider,pharmacistsmanagediseaseandprovidepatientcare.Pharmaciststhatperformintheserolesfunctionashealthcareproviders.”5Pharmacistsinsomestatesandfacilities-theIndian
HealthService,theVeteranAffairs,andtheDepart-mentofDefense–havealreadybeenmovinginthisdirectionbutuntilpharmacistsarerecognizedashealthcareprovidersthistransitiontoabroaderscopeofpracticewillbedifficulttoaccomplishnationwide.
Havingamedicalinformationdatabasewillalloweveryoneonthehealthcareteam-thephysician,thepharmacist,andanyotherspecialist-forapatient’scaretoeasilysharehealthinformationwitheachother.Thiswillhelppreventduplicationsincare,improveapatient’squalityoflife,assureeveryoneisintheknow,andreducehealthcarecostforboththepatientandtheinsuranceprovider.Pharmacieshaveanaddedbenefitsinceitisaeasyaccesspointtothepublicthatisfrequentlyuseddailywithextendedhoursofoperation;itmakesitmoreconvenientforpatientstogoaftertheygetoffwork.6 Pharmacists candeterminewhothehighriskpatientsarebasedontheirmedicationlistandcanofferneededvac-cinations,basedonusingthisdatabasetoensurethepatientisofferedtheopportunityiftheyhadnotreceivedthevaccinationyet.6
Currently,pharmacistserviceshavebeenincreasingincomplexitypertainingtospecificallyclinicalser-vicesbutthereisareductionintherevenuegenera-tionpotential.5Bypharmacistsbeingrecognizedashealthcareprovidersthisreimbursementofservicesisabletochange.
Thenextquestioniswhatclinicalserviceswillpharmacistbeabletoofferwiththisbroaderscopeofpractice?
References:1. Hadzovic, S (1997). “Pharmacy and the great contri-bution of Arab-Islamic science to its development”. Medicinski Arhiv (in Croatian) 51 (1-2): 47–502. Urdang G. Edward Parrish, a forgotten pharmaceuti-cal reformer. Am J Pharm Educ. 1950;14:223–32.3. Food and Drug Administration, Legislation,http://www.fda.gov/RegulatoryInformation/Legislation/default.htm4. AACP. Academic Pharmacy’s Vital Statistics. Available at: http://www.aacp.org/about/pages/vitalstats.aspx. 5. Gilberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S.Surgeon General. Office of the Chief Phar-macist. U.S. Public Health Service. Dec 2011.6. DHHS/CDC. Advisory Committee on Immunization Practices (ACIP).Summary Report, Atlanta, Georgia. June 19-20, 2013.
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Palmetto Pharmacist • Volume 54, Number 2 29
30 Palmetto Pharmacist • Volume 54 Number 2
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Asyouretire,therearevariablesyoucan’tcontrol;investmentperformanceandfatearecertainlyto-wardthetopofthelist.Yourapproachtowithdraw-ingandpreservingyourretirementsavings,however,maygiveyoumorecontroloveryourfinanciallife. Drawingretirementincomewithoutdrainingyoursavingsisachallenge,andtheresponsetoitvariesperindividual.Today’sretireeswilllikelyneedtobemoreflexibleandlookatdifferentwithdrawalmethodsandtaxandlifestylefactors. Shouldyougobythe4%rule?Fordecades,retireeswerecautionedtowithdrawnomorethan4%oftheirretirementbalancesannually(adjustednorthforinflationastheyearswentby).This“rule”stillhasmerit(althoughsometimesthepercentagemustbeincreasedoutofnecessity).T.RowePricehasesti-matedthatsomeoneretiringwithatypical60%/40%stock/bondratiointheirportfoliohasjusta13%chanceofdepletingretirementassetsacross30yearsifheorsheabidesbythe4%rule.A7%initialwith-drawalrateinvitesan81%chanceofoutlivingyourretirementassetsin30years.1
Thatsoundslikeaprettygoodargumentforthe4%ruleinitself.However,whilethe4%ruleregulatesyourwithdrawals,itdoesn’tregulateportfolioper-formance.Ifthemarketsdon’tdowell,yourportfo-liomayearnlessthan4%,andifyourinvestmentsrepeatedlycan’tmakebacktheequivalentofwhatyouwithdraw,youwillriskdepletingyournesteggovertime. Orperhapstheportfoliopercentagemethod?SomeretireeselecttowithdrawX%oftheirportfolioinayear,adjustingthepercentagebasedonhowwellorpoorlytheirinvestmentsperform.Asthiscanproducegreatlyvaryingannualincomeevenwithresponsiveadjustments,someretireestakeasecondstepandsetupperandlowerlimitsonthedollaramounttheywithdrawannually.Thisapproachismoreflexiblethanthe4%rule,andintheoryyouwillneveroutliveyourmoney. Ormaybethespendingfloorapproach?That’sanotherapproachthathasitsfans.Youestimatetheamountofmoneyyouwillneedtospendinayearandthenarrangeyourportfoliotogenerateit.Thisimpliesaladderedincomestrategy,withtheportfo-
Palmetto Pharmacist • Volume 54, Number 2 31
lioheavilyweightedtowardsbondsandawayfromstocks.Thisisamoreconservativeapproachthanthetwomethodsabove:withalowequityallocationinyourportfolio,onlyaminorityofthoseassetsareexposedtostockmarketvolatility,andyettheycanstillcapturesomeupsidewithafootinthemarket.
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Citations.1 individual.troweprice.com/staticFiles/Retail/Shared/PDFs/retPlanGuide.pdf [5/10]2 online.wsj.com/article/SB10001424052748703529004576160693310435366.html [3/7/11]3 www.dailyfinance.com/2012/09/03/postpon-ing-retirement-70-not-the-new-65/ [9/3/12]4 www.marketwatch.com/story/good-health-means-more-retirement-money-2012-12-06 [12/6/12]
Pat Reding and Bo Schnurr may be reached at 800-288-6669 or [email protected] Representative of and securities and investment advisory services offered through Berthel Fisher & Company Financial Services, Inc. Mem-ber FINRA/SIPC. PRISM Wealth Advisors LLC is independent of Berthel Fisher & Company Financial Services Inc.
This material was prepared by MarketingLibrary.Net Inc., and does not necessarily represent the views of the presenting party, nor their affiliates. All informa-tion is believed to be from reliable sources; however we make no representation as to its completeness or accuracy. Please note - investing involves risk, and past performance is no guarantee of future results. The publisher is not engaged in rendering legal, ac-counting or other professional services. If assistance is needed, the reader is advised to engage the ser-vices of a competent professional. This information should not be construed as investment, tax or legal advice and may not be relied on for the purpose of avoiding any Federal tax penalty. This is neither a solicitation nor recommendation to purchase or sell any investment or insurance product or service, and should not be relied upon as such. All indices are unmanaged and are not illustrative of any particular investment
32 Palmetto Pharmacist • Volume 54 Number 2
Palmetto Pharmacist • Volume 54, Number 2 33
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 Dr. Patricia H. Fabel, PharmD, BCPS, Clinical Assistant Professor in the Department of Clinical Pharmacy and Outcomes Sciences at the South Carolina College of Pharmacy (SCCP)
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-
34 Palmetto Pharmacist • Volume 54 Number 2
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
Palmetto Pharmacist • Volume 54, Number 2 35
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-
24
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– 20mg every2weeks 60
Sertraline (Zoloft) 25 Increase by 50mg within1week, thenby 25– 50mg every 1 – 2weeks
200
Paroxetine (Paxil) 10 10mg 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– 200mg (in2divideddoses) everyweek
600
Amitriptyline(Elavil) 25– 100 25– 50mgeveryweek 300
Desipramine(Norpramin) 100– 200 100mg 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: 10mg *After week4,thedose canbeincreasedby 5mg incrementsuntilsymptoms are resolved *Iftherapyisinterruptedfor3ormoredays,thenreinitiateatthelowestdoseandre-titrateaccordingtoschedule
20 (or higherif
needed/tolerated)
*IR=immediaterelease;XR=extendedrelease
36 Palmetto Pharmacist • Volume 54 Number 2
JOURNAL CEfunction,and/orwhatisknownas“jitterinesssyn-drome.”JitterinesssyndromemayoccurwheninitiatingaSSRI/SNRIandincludesshakinessortremor,increasedanxiety,andinsomnia.17Somecommontreatmentstrate-giesforjitterinesssyndromeincludeusingalowerinitialdoseorslowertitration.
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
38 Palmetto Pharmacist • Volume 54 Number 2
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.Therehavebeentenpublishedrandomizedcontrolledtrialsexaminingolanzapineandrisperidoneandtwotrialsexaminingquetiapineasadjuncttherapy
inPTSD.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)andadverseeffects(35%versus18%,p=0.008)comparedtoprazosin.
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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.36Un-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,BZDscancauseparadoxicalagitation/aggression.37IntheVA/DoD
treatmentguidelines,BZDsarelistedas“nobenefit/harm.”Unfortunately,ifapatientisalreadyonaBZD,itcanbedifficulttowithdrawtheagent.Thediscon-tinuationofaBZDcanresultinanxiety,sleepdistur-bances,rage,hyperalertness,increasednightmares,andintrusivethoughts.Thesewithdrawalsymptomshavebeenreportedafteraslittleasfiveweeksoftherapy.16ABZDshouldneverbediscontinuedabruptly.WhendiscontinuingaBZD,thetaperscheduledependsonthelengthoftimethepatientwasontheBZD.Forex-ample,ifapatientwaspreviouslyonaBZDforgreaterthanoneyear,thetapercanoccurovertwotofourmonths.Ageneralruleofthumbfordiscontinuationtoavoidwithdrawalistoreducethedoseby50percentthefirsttwotofourweeksandmaintainthatdoseforonetotwomonths.Then,reducethedoseby25percenteverytwoweeks.38
Prazosin for the Treatment of NightmaresPatientswhoexperiencetheintrusionsymptomofnightmareswithPTSDshouldbetriedonprazosinther-apy.Thisagentisconsideredtobethefirst-lineoptionforPTSD-relatednightmaresandhasbeenshowntobemoreeffectiveversusquetiapineasnotedabove.33Incombat,arushofadrenalineornorepinephrinecanoc-curandhelpsoldiersstayalert.Unfortunately,thismaybecomepersistentandmaladaptiveinnormalsituationsinwhichthisrushofadrenalineisnotneeded.Prazosincannormalizethearousalresponsetonorepinephrineinlowthreatenvironments.39Itisacentrallyactivealpha-1adrenergicantagonistthatisFDAapprovedforthetreatmentofhypertension.16Prazosinisthoughttobethemosteffectivealphaantagonistduetoitshighli-pophilicity.Ithastheabilitytopenetratethebloodbrainbarriertoagreaterextentthandoxazosinandterazosinwhichcrossthebloodbrainbarrierpoorly.40However,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 NightmareseveritywasmeasuredusingthenightmareitemfromtheCAPSandClinicalGlobalImpressionofchange(CGI)scale.Twopatientsachievedadailydose
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40 Palmetto Pharmacist • Volume 54 Number 2
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.
References1. Kessler, RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Post-traumatic stress disorder in the National Comorbidity Survey. Arch Gen
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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 disor-ders 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 Find-ings 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: Psychologi-cal 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, Pandurangi AK. Posttraumatic stress disorder: clinical features, pathophysiol-ogy, 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. Wash-ington (CD): Veterans Health Administration, Department of Defense; 2010 Oct. Available 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: Thom-son 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 antide-pressant-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 sexu-al 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 discontinuation syndrome. Am Fam Physician. 2006 Aug 1;74(3):449-56.21. Butterfield MI, Becker ME, Connor KM, Sutherland S, Churchill LE, Davidson 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 Psychiatry. 2002;159(10):1777-9.24. Hamner MB, Deitsch SE, Brodrick PS, Ulmer HG, Lorberbaum JP. Quetiapine 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 disor-der. 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 Psychopharm. 2003a;18:1-8.
29. Monnelly EP, Ciraulo DA, Knapp C, Keane T. Low-dose risperidone as adjunctive 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 Psychopharm. 2006;21:275-80.31. Reich DB, Winternitz S, Hennen J, Watts T, Stanculescu C. A prelimi-nary 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 Psychiatry. 2008;69:520-5.33. Byers MG, Allison KM, Wendel CS, Lee JK. Prazosin versus quetiap-ine for nighttime posttraumatic stress disorder symptoms in veterans: an assess-ment 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. Divalproex in the treatment of posttraumatic stress disorder: a randomized, double-blind, placebo- controlled trial in a veteran population. J Clin Psycho-pharmacol. 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 treatment 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 trau-matic brain injury: a neuropsychiatric approach to diagnosis, evaluation, and treatment. 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 noradren-ergic 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 antag-onizes neuronal responses mediated by alpha1-adrenoceptors in brain. Naunyn Schmiedebergs 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/viewarti-cle/760070. 42. Raskind MA, Dobie DJ, Kanter ED, Petrie EC, Thompson CE, Pes-kind ER. The alpha1-adrenergic antagonist prazosin ameliorates combat trauma nightmares 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 Psychiatry. 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 Psychiatry. 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 cypro-heptadine 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. Cypo-heptadine treatment of nightmares associated with posttraumatic stress disorder. J Clin Psychopharmacol. 1999;19:486-7.55. Boehnlein JK, Kinzie JD. Pharmacologic reduction of CNS norad-renergic activity in PTSD: the case of clonidine and prazosin. J Psychiatr Pract. 2007;13(2):72-8.
JOURNAL CE
42 Palmetto Pharmacist • Volume 54 Number 2
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.Thepublicdependsonpharmacistsfortheproductionofsafemedications,andsometimessuffertheconsequencesofunaccept-
ableworkplaceconditions,inadequateattentiontostandardprocedureandpoorqualitycontroloverproducts.TheharmcausedbythecontaminatedmedicationsproducedbytheNewEnglandCompoundingCenter(NECC)wasadramaticexampleofhowtheseissuescanhavetragicconsequences.Theprofession’sresponsehasbeenswiftandappropriate.UnsafesterilecompoundingtechniquewasattheheartoftheNECCout-break,inwhichtaintedsteroidinjectionsledtomorethan750fungalinfections,includingafewcasesinSouthCarolina,and64deathsnationwide.Intheaftermath,theInstituteforSafeMedicationPracticesissuedaclarioncallforadditionalmonitoringandregulationsofsterilecompounding--currentlybeingimplementedfollowingapprovaloftheDrugQualityandSecurityAct--andagreaterempha-sisonhands-ontraining.Aspharmacyeducators,wehavetheresponsibilityofprovidingthattraining.Safesterilemedicationcompoundingrequireshighlyspe-cifictraininginanenvironmentnotreadilyavailabletomanypharmacists.Drugshortagesandspecializedmedicationshaveincreasedtheneedforcompoundedproducts,whichincreasestheneedforproperly-trainedpharmacistswhocansafelymakethemforpatients.Lastmonth,theSouthCarolinaCollegeofPharmacy(SCCP)attheUniversityofSouthCarolinaopenedastate-of-the-artsterilemedi-cationcompoundingfacilitythatisoneofthefewofitskindinthecountry.Createdtohelpassurethatpharmacistslearnthehigheststandardsforcompoundingofmedications,theAsepticCompoundingEx-perience(ACE)LaboratoryenablestheCollegetoofferoneofthenation’sfewUniversity-affiliatedsterilemedicationcompoundingLEARNING 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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Palmetto Pharmacist • Volume 54, Number 2 43
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44 Palmetto Pharmacist • Volume 54 Number 2
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