AJP Fall 2011

ARIZONA JOURNAL A JP OF PHARMACY THE OFFICIAL PUBLICATION OF THE ARIZONA PHARMACY ALLIANCE

FALL 2011

Kevin Boesen, Pharm.D. AzPA President 2011-2012

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ARIZONA JOURNAL A JP OF PHARMACY Vol. 3, No. 3

FALL 2011

IN THIS ISSUE BOARD OF DIRECTORS PRESIDENT Kevin Boesen PRESIDENT-ELECT Michael Dietrich TREASURER Ken Mahan PAST PRESIDENT Kelly Ridgway SECRETARY Ray Clark COMMUNITY PHARMACY ACADEMY CHAIR Teresa Stickler COMMUNITY PHARMACY ACADEMY CHAIR-ELECT Kristin Calabro HEALTH-SYSTEM PHARMACY ACADEMY CHAIR Jonathan Merchen HEALTH-SYSTEM PHARMACY ACADEMY CHAIR-ELECT Lindsay Davis MANAGED CARE PHARMACY ACADEMY CHAIR Julie Hernandez MANAGED CARE PHARMACY ACADEMY CHAIR-ELECT Ann Sears SENIOR CARE PHARMACY ACADEMY CHAIR Dawn Knudsen-Gerber SENIOR CARE PHARMACY ACADEMY CHAIR-ELECT Tara Storjohann STUDENT PHARMACIST ACADEMY CHAIRS Valerie Bostel, Midwestern University College of Pharmacy Glendale Jessica DiLeo, The University of Arizona College of Pharmacy STUDENT PHARMACIST ACADEMY CHAIRS-ELECT Sophia Galloway, Midwestern University College of Pharmacy Glendale Eric Wong, The University of Arizona College of Pharmacy TECHNICIAN ACADEMY CHAIR Mike Severn TECHNICIAN ACADEMY CHAIR-ELECT Joy Davis NORTHWEST DISTRICT DIRECTOR Norbert Laskowski NORTHEAST DISTRICT DIRECTOR Mary Lou Brubaker SOUTHWEST DISTRICT DIRECTOR Lisa Keller SOUTHEAST DISTRICT DIRECTOR Ken Fletcher INDUSTRY REPRESENTATIVE Chris Ellis DEANS OF COLLEGES J. Lyle Bootman The University of Arizona College of Pharmacy Dennis McCallian Midwestern University College of Pharmacy Glendale LEGAL COUNSEL Roger Morris, Quarles & Brady EDITOR’S NOTE: Any personal opinions expressed in this magazine are not necessarily those held by the Arizona Pharmacy Alliance. “Arizona Journal of Pharmacy” (ISSN 1949-0941) is published quarterly by the Arizona Pharmacy Alliance at 1845 E. Southern Avenue, Tempe, AZ 85282-5831. PHONE (480) 838-3385, FAX (480) 8383557, email info@azpharmacy.org. It is distributed to members as a regular member service paid for through an allocation of dues of $20.00 in advance.

COLUMNS President’s Message CEO’s Message Academy News • Community Pharmacy Academy • Health-System Academy

• Managed Care Academy

• Senior Care Academy • Student Pharmacist Academy • Technician Academy

28 29 30 31 32 33

FEATURES AND ARTICLES Calcium Intake for the Treatment and Prevention of Osteoporosis and Fracture

Negative Consequences of Prescribing Medications: How to Improve Patient Medication Outcomes Behind the Counter A Look Back - Homeopathic Medicine Kit Time Capsule DEPARTMENTS New Members Alliance News Legislative Update PAPA Drug Information Questions Feature Pharmacist • A Leader in Innovation Rx and the Law Continuing Education Obituaries Financial Forum

2 3

38 41 43 45 59 4 5 25 26 34 36 46 47 56 60

EDITOR-IN-CHIEF Janet Weigel Marketing and Communications Director EDITORIAL BOARD Leslie Rodriguez, Pharm.D. Tina Smith, Pharm.D., BCPS Whitney Rice, Pharm.D. Nicholas Muscolino, Pharm.D. Rinku Patel, Pharm.D.

Arizona Journal of Pharmacy 1

President’s Message Be Passionate brother, I bought him Cubs gear: shirts, hats, socks, and bibs. I also loaded both my kids up with all the accessories: bats, balls, posters, pennants, signs, pictures, and Cubby blue paint on their bedroom walls. I have tried my best to inspire my kids to be passionate about the Cubs. After all, what’s better than a father and son enjoying a summer afternoon ball game together?

Kevin Boesen, Pharm.D. AzPA President I love being a pharmacist. If you’re reading this, then chances are you love being a pharmacist, too.

I also love the Chicago Cubs. I have for as long as I can remember. If you’re not a baseball fan, let me explain why many baseball fans don’t understand my passion for the Cubs. The Cubs are one of baseball’s most storied franchises. They were founded in 1871 making them one of the oldest teams in American sports. The Cubs have a rich history filled with great players, unique stories, and have played their games in historic Wrigley Field since 1914. For baseball fans that are drawn to the history of the game, the Chicago Cubs seem to have it all. The Cubs have even been dominant at times. They once won the World Series (the sport’s championship) in two consecutive years.

Here is the problem. Those back-toback titles are the only World Series that the team has ever won and it happened over 100 years ago in 1907 and 1908. Why root for a team that hasn’t won in over 100 years? It’s not like they haven’t tried. They spend money and often sign the biggest names in the game. One year, arguably one of the league’s greatest players, Andre Dawson, signed a blank contract just so he could be a Cub. It’s also not like they haven’t been close. In my lifetime, the Cubs have been to the playoffs six times.

In 2003, they were five outs away from the World Series.

That year, 2003, is the same year my youngest son was born. Like his older 2 Arizona Journal of Pharmacy

Here’s the thing. My kids aren’t buying it. My oldest son stopped cheering for the Cubs a long time ago. He’ll tell you he’s an Arizona Diamondbacks fan. But my youngest, that’s a different story. I can tell he wants to be a Cubs fan. He sees how passionate I am and wants to share that passion. The problem is the Cubs won’t give him a reason. He’s competitive and can’t fathom being my age and never having the chance to celebrate a World Series title for his favorite team.

I have reasons to love the Cubs. I was born just outside of Chicago. My dad’s a Cubs fan. Going to a Cubs’ game with my dad is one of the highlights of my childhood. But, my son doesn’t have those same reasons. He was born in Arizona. He loves going to the Arizona Diamondbacks games with me. He also likes winning.

That is why he’ll tell you he is a Boston Red Sox fan.

So, what’s my point? If you have passion, there is a reason for that passion.

My reason for loving being a pharmacist is the patients I serve. As a pharmacist, I have a unique opportunity to improve patient care. When I started my career, I worked in community pharmacy.

Community pharmacy was one of the most rewarding positions I’ve had. I developed close relationships with my patients and improved their health.

Now, I use my passion to find innovative ways for more pharmacists to improve health outcomes. Five years ago, I started the Medication Management Center at The University of Arizona.

The center now has over 70 employees and serves hundreds of thousands of

patients across the country. Every day, pharmacists, student pharmacists, and pharmacy technicians help thousands of patients improve their health through education and collaboration with their providers.

Earlier this year, the Arizona Pharmacy Alliance helped pass legislation that creates new opportunities for passionate pharmacists like you. There are two key pieces to the legislation. The first allows pharmacists to administer vaccines to children ages 6 to 17 without a prescription and student pharmacists to administer vaccines under the supervision of a pharmacist. To date, thousands of pharmacists and hundreds of student pharmacists have taken advantage of this opportunity and are certified to administer vaccinations.

The second part of the legislation allows for expansion of collaborative practice. Collaborative practice offers a unique opportunity for pharmacists to be involved in monitoring and modifying a patient’s drug regimen. For those pharmacists with collaborative practice agreements, the patient health outcomes are impressive. However, very few pharmacists - less than 10 - currently practice under this model. The legislative changes were designed to eliminate some of the barriers that have prevented widespread implementation of this practice model.

It is clear that patients benefit from passionate pharmacists. My hope is that like the legislation that allows for pharmacists to provide vaccinations, the collaborative practice legislation will drive thousands of pharmacists to expand their practice. I know it won’t be easy, but the Arizona Pharmacy Alliance will be here to help.

This year, let your passion for pharmacy challenge you to do great things for your patients. And I’ll keep rooting for the Cubs.

CEO’s Message Kelly Ridgway, R.Ph., Named New Chief Executive Officer of the Arizona Pharmacy Alliance The Arizona Pharmacy Alliance announces that Kelly Ridgway, R.Ph., is its new Chief Executive Officer. As CEO, Ridgway will serve as the executive director of the association and provide leadership for all association activities, including administrative oversight of the Arizona Pharmacy Foundation, a 501(c) 3 organization; an AzPA for-profit subsidiary, the Pharmacy Network of Arizona; and the Pharmacists Political Action Committee of Arizona.

“The Arizona Pharmacy Alliance is excited to welcome Kelly as CEO,” stated Kevin Boesen, President of the Arizona Pharmacy Alliance Board of Directors. “Her commitment to the advancement of the pharmacy profession is evident in her dedicated service and enthusiasm for her work. With her experience, talent, expertise, and passion for the profession, Kelly is the ideal person to lead AzPA as the association begins a new chapter in its more than 100 year history of representing pharmacy in Arizona.”

A graduate of the University of Toledo College of Pharmacy, Ridgway came to Arizona in 2001. She comes to AzPA from her position as Pharmacy Care Manager for Safeway Inc., where she was responsible for patient care programs including immunizations, medication therapy management, community health fairs, and in-

store screening services. Ridgway also developed Safeway’s Community Pharmacy Practice Residency Program, which was accredited in 2004 by both the Association of Health-System Pharmacists and the American Pharmacists Association.

In addition to her responsibilities with Safeway Inc., Ridgway is the Immediate Past President of the Arizona Pharmacy Alliance and has served on its Board of Directors in various capacities since 2006. She is also a preceptor and adjunct faculty member at Midwestern University College of Pharmacy Glendale.

Ridgway was a member of the Arizona State Board of Pharmacy Immunizations and Vaccines Advisory Committee and currently serves on The Arizona Partnership for Immunizations (TAPI) Steering Committee. She was an active leader and advocate for the passage of HB2164 in 2009 and SB1298

Kelly Ridgway, R.Ph. AzPA CEO

in 2011, expanding pharmacists’ immunization authority and redefining collaborative practice agreements.

“I am humbled and honored to accept the position of CEO of the Arizona Pharmacy Alliance,” said Ridgway. “This is an exciting time for the profession of pharmacy and I am committed to ensuring that AzPA continues to lead the way in optimizing the role of pharmacists and improving patient care and medication outcomes.”

Ridgway begins her tenure with the Arizona Pharmacy Alliance in early October.

MISSION STATEMENT The Arizona Pharmacy Alliance is committed to serving and representing all practice settings.

AzPA will foster safe and effective medication therapy, promote innovative practice, and empower its members to serve the health care needs of the public.

VISION Empowering pharmacy professionals to provide optimal patient care

Arizona Journal of Pharmacy 3

New Members WELCOME NEW MEMBERS Sarah Allen Daniel Doetsch Tilitha Doughty Kali Finn Susana Henri Lien Ho Ibrahim Lala Anne Nelso Burrell Richards Nicole Vacek Kate Van Hassel Hillary Volsteadt Ahmed Altyar Kelsey Bohling Jake Bradshaw Adam Brunelle Kathie Colgan Honeylit Cueco Matthew Duff Danielle Frost Mark Lattimore

Elisabeth Palmer Rod Shafer Sarah Simmers Antonella Sola Amanda Szopinski Richard Yang Eizel Yap MaryJo Zunic Jody Agena Jagdeep Bains Joyce Buchanan Matthew Carsten Melissa DiCamillo Megan Dill Sophia Galloway Lori Gindlesperger Tiffany Gordon Isabelle Griffith Jasmine Henley Jerrelee Hollings Aimee Keller

Jennifer Knutson Sarah Minor Julia Pheifer Jinna Ramsey Daniel Saldivar Kristin Sechena Benjamin Thompson Stewart Wilson Jessica Winstead Joshua Wyche Cassandra Anderson Asal Azizoddin Brian Bainter Rebecca Bainter Mark Bank Karen Chemodurow Crissa Clark Nisa Cooper Matthew Dean Jacqueline Ducksworth Jacob Frick

Lara Frick Catherine Graeff Lisa Hiller Jacinta Hines Joe Kliegl Andrew Lester Jeff Lieber John Nord Teresa Nord Lara Petrossian William Radovanovich Shiva Salek Pratichee Shukla

Do you know someone who is not a member of the Arizona Pharmacy Alliance . . . and should be?!

Invite them to join the only statewide organization that represents the pharmacy profession in Arizona.

Annual dues for a pharmacist are just $225 per year. This equates to: • Approximately 2/10 of 1% of the annual wage for a new practitioner pharmacist • Less than 5 hours of work per year, after taxes • Less than 62 cents per day Visit the AzPA website at www.azpharmacy.org to join online or click here to download a printable Membership Investment Statement.

AzPA values its members and recognizes that your time is valuable. Monthly payment plans are available for pharmacist membership categories, as well as an automatic annual renewal option, when you provide your credit card information.

4 Arizona Journal of Pharmacy

Alliance News Cheers for Volunteers!

The Arizona Pharmacy Alliance staff is here to support YOU - our members.

We acknowledge the contributions of the volunteers who have made a difference for our organization and their fellow pharmacy professionals. Thank you for all you do!

Laura Hanson Joe Rowan Althea Alderson Cheryl Shafer Mindy Throm Burnworth

Lindsay Huxtable Butch David Ken Mahan Terry Daane Julie Hernandez Peggy Khan Ray Clark Jessica DiLeo Bonnie DiLorenzo Mark Boesen Kelly Ridgway Kevin Boesen Lindsay Davis Martie Fankhauser Dawn Gerber Paul Smith Mike Severn Norbert Laskowski Chuck Dutcher John Nicolais Lisa Keller

Chris Lesaca Jon Merchen Teresa Stickler Mike Dietrich Crane Davis Leslie Rodriguez Tina Smith Whitney Rice Bob Lipsy Jon Glover Valerie Bostel Steve LeMahieu Larry Ganann Kim Cauthon Mary Gurney Kip Raney Kristin Calabro Joy Davis Ann Sears Ken Fletcher Tara Storjohann

Mary Lou Brubaker Kristen Allison Rick Herrier Eric Wong Jim Kloster Keith Boesen Erin Raney Shareen El-Ibiary Dyan Cherry Christi Jen Bill Jones Sandra Leal Elizabeth Pogge Lisa Sims Andrew Varker Lisa Whittington Grace Akoh-Arrey Jamie Joy Marjorie Ford Nick Muscolino Rinku Patel

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Rx relief’s Standards of Excellence screening Continuous assessment and client communication • Handling all types of staffing situations and emergencies • Over 60 years of pharmacy management experience • •

Rx relief ® Your Trusted Pharmacy Staffing Partner Arizona Journal of Pharmacy 5

Alliance News AzPA Annual Meeting ROCKED! The Arizona Pharmacy Alliance 7th Annual Meeting kicked off at the Westin La Paloma Resort and Spa in Tucson, Arizona on July 7th with a pre-conference activity, Pharmaceutical Management for Patients with Diabetes. Presented by Grace Akoh-Arrey, 50 participants from all over the United States attended this sold-out session.

On Thursday evening at the VIP Reception, Speaker of the House Andy Tobin gave insight about the current status of state government and his vision for the future.

Special guest Diane Ginsburg, former ASHP President, enthusiastically spoke about the profession.

With over 300 pharmacists, interns, and technicians in attendance throughout the meeting, the Arizona pharmacy profession embraced the theme of the convention and proved that pharmacy does rock and exemplifies a lifetime commitment to patient care.

Attendees were given the opportunity to earn up to 16.0 hours (1.6 CEUs) of continuing pharmacy education credit, reconnect with friends, and expand their Arizona pharmacy networks.

Many thanks to the speakers and presenters at this year’s meeting. A special thanks to Jon Glover, Chair, and the members of the Annual Meeting Steering Committee for an outstanding slate of continuing pharmacy education activities.

In addition to the continuing education activities, attendees were able to take advantage of the rock-androll themed Exhibit Hall. There they had the opportunity to network and socialize with colleagues and learn about the latest pharmaceutical products, technology, and services.

Early Friday morning, players gathered at the La Paloma Country Club Golf Course for a round of golf and support the Llyn Lloyd Scholarship Fund. There were 60 pharmacists and friends who joined in the morning festivities. Following the tournament, awards were given for closest to the pin and longest drive, for both men and women.

There were more than 100 attendees at the Pharmacists Political Action Committee of Arizona (PharmPAC) Breakfast Saturday morning. Featured guest Secretary of State Ken Bennett spoke about the current budget in Arizona and how the state funding got to where it is now.

The AzPA Town Hall meeting followed, beginning with a presentation of proposed resolutions by Legislative Affairs Committee Chair Mark Boesen.

Concerns discussed included the number of pharmacists 6 Arizona Journal of Pharmacy

versus the number of available positions in the state, the increase in fraudulent controlled prescriptions, and issues with PBMs. These and other resolutions will be addressed at upcoming legislative committee meetings.

A legislative panel with Senator Frank Antenori and Representative Matt Heinz discussing the value of the pharmacist on the health care team followed the resolution presentation. The panel was asked to support our endeavors in receiving compensation for the services pharmacists provide, such as medication therapy management. A positive response was received from the panel and additional data and information to support the value of a pharmacist will be provided to the legislators.

After the panel discussion, a PharmPAC and legislative affairs update were presented to members to recap the past fiscal year and highlight what to expect this year.

Wrapping up the AzPA Town Hall meeting, pharmacist brothers Mark, Kevin, and Keith Boesen offered a good-natured debate on medical marijuana, presenting the controversy and potential future issues in the wake of the recent legalization by the Arizona voters of the illegal drug.

The Annual AzPA Awards Banquet took place on Saturday evening. Mindy Smith said her farewells and was acknowledged for her contributions as the Chief Executive Officer of AzPA. Peers and colleagues were recognized for their achievements and the Alliance leadership transition was celebrated, including the installation of the 2011-2012 Board of Directors.

Rock star “Bon Jovi” and his crew, Renegade Suite, surprised newly installed AzPA President Kevin Boesen as Immediate Past President Kelly Ridgway passed the gavel with best wishes for his term. Kevin expressed his excitement and got the members revved up about the upcoming year.

Good luck to the new Board and we look forward to seeing everyone at the AzPA 8th Annual Meeting at The Wigwam in Litchfield Park, Arizona, from June 28 to July 1, 2012.

Alliance News

VIP Reception Photos 1.

2.

3.

4.

Amy Woodbeck, Bonnie DiLorenzo, and Ron Woodbeck.

5.

Diane Smith, Martie Fankhauser, and Gary Smith.

6.

Mike Noel and Hal Wand.

Dave Pogge, Elizabeth Pogge, Nathan Storjohann, Ryan Williams, Maria Rodriguez, and Lindsay Davis.

Joel Butler, Brian Willis, Genevieve Johnson, and Teresa Stickler.

Eileen Telles, Randle House, Greg Arnold, John Musil, Mike Quick, Julie Miramont, and Gary Quraishi.

Arizona Journal of Pharmacy 7

Alliance News

VIP Reception Photos 1.

2.

3.

4.

Ken Mahan, Janice Ganann, and Larry Ganann.

Leslie and Manny Rodriguez.

Keith Boesen, Kelly Green-Boesen, Kevin Boesen, Lisa Whittington, and Jon Merchen.

Mike Dietrich and Diane Ginsburg.

5.

6.

Laurita Lipsy, Diane Smith, Gary Smith, and Bob Lipsy.

Laura Adams, Kevin Boesen, Jim Kloster, and Robert Squire.

Alliance News

Thank you to our VIP Reception Sponsors AmerisourceBergen Cardinal Health Johnson & Johnson McKesson PhRMA Sunovion

VIP Reception Photos 1.

2.

3.

Sheri Calderon, Christy Lemons, and April Grant.

Larry Anderson, Devi Anderson, and Ty Gospodarec.

Mindy Smith, Rep. Matt Heinz, Speaker

4.

5.

of the House Andy Tobin, and Kelly Ridgway.

Mike Gibbons, Jeff Marshall, Eric Ensman, and Ty Gospodarec.

Barbara and Lou Goldstein.

Alliance News

Midwestern University College of Pharmacy-Glendale Dessert Reception 4. Elizabeth and Dave Pogge.

1. Reid and Mindy Burnworth.

5. Valerie Bostel, Whitney Rice, and 2. John Discerni, Marsha Nicole Romney.

Trathen, Steve LeMahieu, 6. Eric Wong, Natalee Tanner, Jessica Marie Discerni, and Emily DiLeo, and Kate Murphy.

Discerni.

3. Yayun Lee, Tina Tran, Dawn Knudsen-Gerber, Thao Tran, and John Lin. 10 Arizona Journal of Pharmacy

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Arizona Journal of Pharmacy 9

Alliance News AzPA 7th Annual Meeting Annual Awards Presentations Outstanding Leadership Award In recognition of exceptional leadership qualities and vision displayed during the past year.

Presented to Kelly Ridgway, R.Ph. Outgoing President Award Sponsored by McKesson Presented to Kelly Ridgway, R.Ph. Pharmacy Leadership Award Sponsored by NCPA In recognition of accomplished leadership in the advancement of pharmacy.

Presented to Kevin Boesen, Pharm.D. Incoming President Award Sponsored by AmerisourceBergen Presented to Kevin Boesen, Pharm.D. Pharmacy Appreciation Awards Individuals who have demonstrated very special or unique interest and concern for the advancement of Arizona pharmacy as reflected by dedicating significant personal time and effort in completion of one or more special activities or services for AzPA and/or the profession of pharmacy.

Presented to: Keith Boesen, Pharm.D. Kevin Boesen, Pharm.D. Christine Cassetta, J.D. Paul Draugalis, R.Ph. Lindsay Davis, Pharm.D. Bonnie DiLorenzo, Pharm.D. Candidate Martha Fankhauser, MS Pharm Kerry Redman, Pharm.D. Candidate Corporate Appreciation Award A corporation or business who serves Arizona pharmacy, routinely demonstrates a very high level of professionalism, and is committed to improving medication use by supporting AzPA in a significant way.

Presented to Express Scripts, Inc. Distinguished Young Pharmacist of the Year Sponsored by Pharmacist Mutual Insurance Companies An Arizona pharmacist who has demonstrated significant leadership in Arizona pharmacy in the previous year. Contributions can relate to AzPA participation, activities within his/her professional practice, or community service.

Presented to Kelly Kistler, Pharm.D. Excellence in Innovation Award Sponsored by Upsher-Smith Laboratories A practicing pharmacist in Arizona who has demonstrated significant innovations in their respective pharmacy practice.

Presented to Kurt Weibel, Pharm.D.

12 Arizona Journal of Pharmacy

Pharmacy Academy Service Awards Arizona pharmacists or pharmacy technicians who have demonstrated outstanding leadership and service for an AzPA Academy during the previous year.

Presented to: Community Pharmacy: Chad Schuster, Pharm.D. Health-System: Jean Patel, Pharm.D. Managed Care: Ken Bykowski, R.Ph. Senior Care: Sandra Brownstein, Pharm.D. Student Pharmacist Academy - U of A: Scott Hall, Pharm.D. Student Pharmacist Academy - MWU: Andrew Gifford, Pharm. D. Candidate Technician: Mike Severn, C.Ph.T. Preceptor of the Year Award University of Arizona College of Pharmacy Presented to Kelly Green-Boesen, Pharm.D., BCPS Rookie Preceptor of the Year Award University of Arizona College of Pharmacy Presented to Erin Ballard, Pharm.D. Preceptor of the Year Award Midwestern University College of Pharmacy Glendale Presented to Harvey Hill, B.S., R.Ph. Rookie Preceptor of the Year Award Midwestern University College of Pharmacy Glendale Presented to Christopher Dinoffria, Pharm.D. Outstanding Pharmaceutical Representative Award A pharmaceutical industry representative who serves Arizona pharmacy, routinely demonstrates a high level of professionalism, and is committed to improving medication use by supporting their customer’s patient care goals.

Presented to Ken Frisard, Pharm.D., sanofi-aventis Exemplary Patient Care Award An Arizona pharmacist who provides or enables exemplary patient care, regardless of practice setting, by consistently providing exemplary patient care services, serving as a role model for contemporary pharmacy practice, or developing or fostering the development of an innovative pharmacy practice resulting in improved patient care.

Presented to Nicole Scovis, Pharm.D. Bowl of Hygeia Sponsored by APhA and NASPA The highest level of recognition provided to an Arizona pharmacist who has compiled an outstanding record of community service.

Presented to Roger Morris, R.Ph., J.D.

Elias Schlossberg Award The highest level of recognition for an Arizona pharmacist who has made significant contributions to health-system pharmacy in the form of sustained exemplary lifetime service that reflects positively on the profession of pharmacy.

Presented to Butch David, R.Ph. Hall of Fame Award In honor of a pharmacist member of AzPA with at least 10 years of practice experience in Arizona who has demonstrated innovation or excellence in practice, education, or research.

This person is an Arizona pharmacy pioneer who has been instrumental in advancing the profession of pharmacy by promoting the importance of innovation and integrity in the field.

Presented to Robert C. Johnson, MS, R.Ph. Technician of the Year Award An Arizona pharmacy technician who has excelled in the field of pharmacy technology and has demonstrated a high level of service and professionalism in pharmacy during the previous year.

Presented to Chris Lesaca, C.Ph.T. Pharmacist of the Year Sponsored by Pfizer An Arizona pharmacist who has actively demonstrated outstanding leadership and service for AzPA or for the profession of pharmacy in Arizona during the previous year.

Accomplishments include providing significant AzPA organizational leadership and reflect ongoing personal time and effort to mentor and/or serve the needs of AzPA members and Arizona pharmacy.

Presented to Ken Mahan, BS, R.Ph. Llyn A. Lloyd Service to Pharmacy Scholarship A $500 scholarship is awarded to a pharmacy student at each of the colleges of pharmacy in Arizona in honor of Llyn A. Lloyd.

Presented to Bernadette Aragon, Class of 2012, University of Arizona Bonnie DiLorenzo, Class of 2012, Midwestern University Poster Award Winners First Place: Brenda Burke, Pharm.D., BCPS; Andrew Barrett, Pharm.D.; Todd Rowland, Pharm.D., BCPS; Michelle Wilhardt, Pharm.D. Second Place: Scott Hall, Pharm.D.; Ferena Salek, Pharm.D.; Edina Hall, MS, Pharm.D.; and John Glover, Pharm.D.

Alliance News

Award Recipient Photos 1. Retiring AzPA Board of Directors members: Mark Boesen, Butch David, Kim Cauthon, Bonnie DiLorenzo, and Chris Lesaca.

2. Kelly Ridgway with Pharmacist of the Year Award recipient Ken Mahan.

3. Chris Meilinger (center) accepts the AzPA Corporate Appreciation Award on behalf of Express Scripts, Inc. from Mindy Smith and Kelly Ridgway.

4. Mark Boesen presents the Outstanding Leadership Award to Kelly Ridgway, 2010-2011 AzPA President.

5. Chris Lesaca receives the AzPA Pharmacy Technician of the Year Award from Kelly Ridgway.

Arizona Journal of Pharmacy 13

Alliance News

Award Recipient Photos 1. AzPA Pharmacy Appreciation Award winners: Paul Draugalis, Bonnie DiLorenzo, Christine Cassetta, Martha Fankhauser, Lindsay Davis, Keith Boesen, and Kevin Boesen.

2. Roger Morris receives the Bowl of Hygeia Award from Mark Boesen.

3. Kurt Weibel receives the Excellence in Innovation Award from Diane Ginsburg, Past President of ASHP. 4. Jim Kloster honors Nicole Scovis with the Exemplary Patient Care Award.

5. Diane Ginsburg presents the Elias Schlossberg Award to Butch David.

14 Arizona Journal of Pharmacy

Alliance News

Award Recipient Photos 1. Ryan Goodrich presents the Pharmacists Mutual Distinguished Young Pharmacist of the Year Award to Kelly Kistler.

2. Ken Frisard accepts the Outstanding Pharmaceutical Representative of the Year Award from Mindy Smith.

3. Ray Clark honors Robert C. Johnson with the 2011 AzPA Hall of Fame Award.

4. Kevin Boesen accepts the Incoming President Award from Greg Arnold of AmerisourceBergen.

5. Jeff Marshall of McKesson presents the Outgoing President Award to Kelly Ridgway.

Arizona Journal of Pharmacy 15

Alliance News

The University of Arizona College of Pharmacy Reception 1.

2.

3.

4.

Tony Morkunas, Ray Clark, Kim Kelley, Roger Morris, and Mark Boesen.

Deborah Van Sant and Greg Rogan.

Annie and Tom Batik.

Roger Morris and Crane Davis.

5.

6.

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Carla Rowe and Jenny Whitney.

Chenery Kinemond and Jamie Joy. Kathryn Kalsman, Dean Wright, and Ann Sears

Alliance News Thank you to our 2011 Annual Meeting Exhibitors Abbott Diabetes Care AIMSCO/Delta Hi-Tech, Inc. American Regent, Inc Ameridose AmerisourceBergen Corporation Amylin Pharmaceuticals Arizona Health-e Connection Arizona Smokers Helpline Astra Zeneca Banner Health BD Diabetes Boehringer Ingelheim Pharmaceuticals BTG Cardinal Health Complete Rx CSL Behring Cubist Pharmaceuticals CVS Caremark

Daiichi Sankyo Nephron Pharmaceuticals Environmental Pharmaceuticals NIPRODiagnostics, Inc. Express Scripts Northern Arizona Healthcare Forest Pharmaceuticals Novo Nordisk Fry’s Pharmacy Otsuka Pharmaceutical Genentech Pharmacists Mutual Companies GSK Community Pharmacy Team PharMEDIUM Services Grifols PharmPAC H & H Wholesale Roche Diabetes Care Humana RightSource Rx Rx Relief IntelliQuick Delivery Safeway, Inc. LifeScan, Inc. sanofi-aventis Lilly USA Sunovion Pharmaceuticals McKesson U. S. Army Medical Recruiting Meda Pharmaceuticals University of Arizona COP Merck Wal-mart

Merck Vaccines Midwestern University - CPG

Exhibitors 1. Cardinal Health: Amber Graham, Riley 3. McKesson: Mike Gibbons, Julie Gibbons, Amy McLaughlin, Genevieve Johnson, Brian Willis, Marshall, and Jeff Marshall. and Joel Butler.

4. AmerisourceBergen: Greg Arnold, Eileen 2. Humana RightSource Rx: Kathleen Berrier, Mike Telles, Julie Miramont, Oscar Acosta, and Scott Taday, Jarrod Gonzales, Bob Keiser, and Jace Dahlstrom.

Larkin.

Alliance News Thank you to our Annual Meeting Sponsors AmerisourceBergen Cardinal Health Fry’s Food & Drug H & H Wholesale Johnson & Johnson Lilly Diabetes McKesson MWU-CPG U of A COP

Fun in the Exhibit Hall 1. Christy Lemons and Katy the Kangaroo.

2. Lou and Barbara Goldstein.

3. Marjorie Ford watches her children Billy and Michelle Nenadich play Guitar Hero.

4. Ann Klever, Ingrid Vandenberg, and Christine Bakken.

5. Elvis shakes it up with David and Judy Lee. 6. Chris Lesaca and Mayela Fox.

18 Arizona Journal of Pharmacy

Alliance News

More fun photos 1. Jim “Bon Jovi” Kloster and Kevin Boesen.

2. Medical Marijuana debaters: Kevin Boesen, Keith Boesen, and Mark Boesen.

3. Chris Lesaca rocks out!

4. HYPNOTIZED! 5. Past Presidents’ Reception Attendees Back Row: Mike Dietrich, Alan Barreuther, Mark Boesen, Terry Daane, Crane Davis, Paul Smith and Kelly Ridgway.

Front Row: Bob Lipsy, Mike Kalsman, Kathryn Kalsman, Steve LeMahieu, Ruth Demar, Kevin Boesen, and Tom Batik.

Arizona Journal of Pharmacy 19

Alliance News Rockin’ Banquet with “Bon Jovi” 1. Lindsay Davis rocks!

2. Tara Storjohan, Nathan Storjohann, and Crane Davis are cool!

3. Boesen Clan and “Bon Jovi”: Mark, Kellie, Kevin, Keith, and Cindy.

4. “Bon Jovi” and Mayela Fox. 5. Ken Mahan, “Bon Jovi”, and Christy Lemons.

6. Jim and Virginia Kloster with “Bon Jovi”.

Alliance News

AzPA Annual Banquet photos 1. Maria and James Chase.

2. Tina and Bob Johnson.

3. Dan and Judy Boesen.

4. Betty and Jim Louton.

5. Laura Adams and Jim Kloster.

6. Mindy Smith toasts her final AzPA Annual Meeting as CEO. Arizona Journal of Pharmacy 21

Alliance News APF News

United Ways of Arizona

APF Golf Tournament The Arizona Pharmacy Foundation (APF) Annual Golf Tournament was held July 8, 2011, on the beautiful La Paloma County Club Golf Course. More than 60 golfers participated in the four-person scramble format. The team of Ken Fey, Jon Reilly, Chris Richards, and Kelvin Richards took first place. Jim Bowman claimed honors for the men’s longest drive and closest to the pin. Amy Cotton won women’s closest to the pin and Erica Mascarenas had the longest drive for the women.

River Cities United Way PO Box 966, Lake Havasu City, AZ 86405-0966 Phone: (928) 855-6333; Fax: (928) 855-5275

Many thanks to our tournament sponsors: Above & Beyond Delivery, Inc., Amerisource Bergen, Berry/Kerr Prescription Packaging, Cardinal Health, Fry’s Food & Drug, Johnson & Johnson, and McKesson. A portion of the proceeds from the annual golf tournament benefit the Llyn Lloyd Service to Pharmacy Scholarship Fund.

Silent Auction Benefits APF At the Arizona Pharmacy Alliance 7th Annual Meeting, the APF conducted a silent auction of pharmacy collectibles.

For the second year in a row, Dr. Robert Kravetz, Phoenix gastroenterologist and pharmacy memorabilia connoisseur, graciously donated items from his personal collection to the Foundation for the auction, including medicated toilet paper, apothecary almanacs, shelfware, and tonic bottles. The auction raised $900 for APF. Many thanks to Dr. Kravetz for his generous donation which spurred interest in pharmacy antiques. It was particularly fun to see pharmacy professionals of all ages compete for the top bid on their favorite items.

United Way Donations Do you know that you can support the Arizona Pharmacy Foundation through your workplace United Way campaign?

Many of you are employed at companies and organizations that conduct annual United Way campaigns. As this year’s fundraising drives kick off all across Arizona, please consider making a gift to APF. Most United Way pledge forms allow you to designate your contribution to a specific agency. This is commonly called a “Restricted Contribution” or a “Designated Donation”. When you identify the Arizona Pharmacy Foundation as the specific agency on your pledge form, be sure to include the APF address: 1845 East Southern, Tempe, Arizona, 85282. APF has not yet been assigned an agency code. A list of United Ways in the state of Arizona accompanies this article. Contributing to your local United Way and designating APF is a simple and convenient way to support APF and your community.

APF is a non-profit 501(c)3 charitable organization. Its mission is to educate the public concerning the delivery of pharmaceutical care.

22 Arizona Journal of Pharmacy

United Way of Graham County, Inc. 924 West 16th Street, Safford, AZ 85546 Phone: (928) 348-9347; Fax: (928) 428-0061 United Way of Greater Sierra Vista & Cochise County 4564 Queens Way, Sierra Vista, AZ 85635 Phone: (520) 458-3288; Fax: (520) 458-3288 Mesa United Way 137 East University Drive, Mesa, AZ 85201 Phone: (480) 969-8601; Fax: (480) 834-8184 United Way of the Navajo Nation P.O. Box 309, Window Rock, AZ 86515 Phone: (520) 871-6661; Fax: (520) 871-6663 United Way of Northern Arizona 1515 East Cedar Ave # D-1, Flagstaff, AZ 86004.3121 Phone: 928.773.9813; Fax: 928.773.9814 United Way of Pinal County PO Box 10541,Casa Grande, AZ 85130-0541 Phone: (520) 836-0736; Fax: (520) 836-0737 United Way of Santa Cruz 855 West Bell Road, Suite 700, Nogales, AZ 85621 Phone: (520) 761-1840; Fax: (520) 761-1845 United Way of Tucson and Southern Arizona 330 North Commerce Park Loop, Suite 200, Tucson, AZ 85745 Phone: (520) 903-9000; Fax: (520) 903-9002 United Way of Yavapai County, Inc. 3343 North Windsong Drive, Suite 7, Prescott Valley, AZ 86314 Phone: (928) 778-6605; Fax: (928) 771-8858 United Way of Yuma County 477 South Orange Avenue, Yuma, AZ 85364 Phone: (928) 783-5155; Fax: (928) 782-5463 Valley of the Sun United Way 1515 East Osborn Road, Phoenix, AZ 85014.5386 Phone: (602) 631-4800; Fax: (602) 631-4809

Alliance News

Arizona Pharmacy Foundation Golf Tournament 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Eileen Telles practices her putting.

Crane Davis and Lindsay Huxtable.

Tom Van Hassel and Mike Gibbons.

Butch David and Jeff Marshall.

Amy Cotton, Women’s Closest to the Pin. Chad Schuster and Jim Schleiger.

Dean Wright and Ed Hunter.

Jim Bowman, Men’s Closest to the Pin and Longest Drive.

Joyce Kossick and Zeke Misner.

First Place Foursome: Ken Fey, Chris Richards, Jon Reilly, and Kelvin Richards.

Alliance News ARE You AWARxE? Get informed.

AWARxE Volunteer Opportunities: • Speak at neighborhood events and community organization meetings • Assist with medication take-back program • Attend and staff the AWARxE booth at events AWARxE Sponsorship Opportunities: • American Pharmacists Month activities – October 2011 • Billboard sponsorship • PSA sponsorship • TV and radio spots • Print advertising • Ongoing campaign support • Collateral materials: i.e., brochures, posters, bookmarks • PSA’s • TV and radio spots • Print advertising • Partnerships with school districts, municipalities (local,

county, state) and community organizations • Outreach programs

What is AWARxE? AWARxE is an information source providing authoritative resources about medication safety, prescription drug abuse, medication disposal, and safely buying medications on the internet.

Mission: To provide information and resources needed to make the right decisions about prescription and over-the-counter (OTC) medications.

In response to tragic events involving prescription drug abuse and misuse in our community, AWARxE is an ideal vehicle for the pharmacy profession to address this alarming trend. Pharmacists can communicate to the public: • Medicine is more than a commodity • Value of pharmacists and other health care professionals • Individual’s responsibility for personal health care The Arizona Pharmacy Foundation and AWARxE The Arizona Pharmacy Foundation, a 501(c)3 non-profit corporation, is a licensee of the AWARxE program, in collaboration with the National Association of Boards of Pharmacy (NABP).

For more information about AWARxE, including sponsorship and volunteer opportunities, contact Janet Weigel, Marketing and Communications, janet@azpharmacy.org or 480.838.3385.

.

The Arizona Pharmacy Foundation has embarked on an AWARxE public awareness campaign focusing on: • Illicit Online Pharmacies • Counterfeit Drugs • Prescription Drug Abuse and Recovery • OTC Abuse by Kids and Teens • Medication Disposal • Medication Misuse/Patient Safety and Adherence October is American Pharmacists Month and APF will spotlight the AWARxE program through billboards, print advertising, public service announcements, community outreach events, and internet-based outlets. Volunteers from the Arizona Pharmacy Alliance are conducting presentations on AWARxE with parent teacher associations, student groups, and other community organizations.

Does a Drug Dealer Lurk in your Medicine Cabinet?

Proper drug disposal protects your loved ones from misuse.

FACT: Prescription drugs are the most commonly abused drugs among 12 to 13 year olds.

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In partnership with the Arizona Affiliate of the Partnership for a Drug Free America, the Phoenix office of the Drug Enforcement Agency (DEA), the Arizona Department of Public Safety, and other community organizations, AWARxE will participate in the October 29, 2011, DEA Take-Back Day.

CMYK Red: 0.100.96.28 Black: Process 100K

24 Arizona Journal of Pharmacy

Find out more about the DEA Take-Back Day on October 29, 2011 and safe disposal methods at AWARErx.org

Legislative Update American Pharmacists Month 2011

2011 Hot Summer Nights PharmPAC winners: Kneeling (left to right): Jim Schleiger, Kevin Boesen, Keith Boesen. Standing (left to right): Lucy Fund, Jennifer Knutson, Mike Dietrich, James Chase, Maria Chase, Lindsay Huxtable, Jeremy Gerber, Lindsay Davis, Dawn Gerber, Laura Adams, Larry Anderson, Kenneth Berry.

PharmPAC The Pharmacists Political Action Committee of Arizona (PharmPAC) plays an important role in advancing the legislative action mission of the pharmacy profession.

At the AzPA 7th Annual Meeting Annual Awards Banquet, the PharmPAC held a drawdown ticket drawing to raise funds to support pharmacy political action. A total of 110 tickets were sold at $100 each. Ten cash prizes were awarded totalling $5,500.

Dawn Gerber } Jeremy Gerber } Lindsay Huxtable } Keith Boesen } Mark Boesen } Kevin Boesen }One Group Ticket: $137.50/$13.75 each Ray Clark } Lindsay Davis } Mike Dietrich } John Murphy } Larry Anderson $ 137.50 Kenneth Berry $ 137.50 Nic Hiner $ 137.50 Laura Adams $ 275.00 (two tickets @ $137.50 ea.)

Jennifer Knutson $ 275.00 James and Maria Chase $ 275.00 James Schleiger $1,375.00 Lucy Fund $2,750.00

Celebrate American Pharmacist Month in October.

This month-long observance is a time to recognize the significant contributions to health care and the commitment to patient care by pharmacists in ALL practice settings from around the country. “Know Your MEDICINE, Know Your PHARMACIST” is the theme and core message of the month.

The American Pharmacists Association (APhA) has some great tips for celebrating American Pharmacists Month in your practice setting. Here are just a few.

Community: Decorate your pharmacy and invite the public to a party! Pick one or more days during the month to offer a treat to your patients. Invite a local elementary school class to visit the pharmacy and “meet the pharmacist.”

Managed Care: Hold a “medication check-up” or “brown bag” event for your patients. Schedule a special event like a flu shot clinic or a health-screening day.

Health-System: Create a lobby display promoting the pharmacy department. Schedule an “Open House” and invite hospital employees to visit the pharmacy.

Senior Care/Long Term Care: Visit individual patients in their rooms and answer questions. Hold an informational program for patient families and caregivers, offering information on the pharmacist’s role in medication management.

Technicians: Use a special message promoting American Pharmacists Month when you answer the phone: “Hello, this is XYZ Pharmacy. We are celebrating American Pharmacists Month. How may I assist you?”

Students: Celebrate American Pharmacists Month on campus by holding a lunch for all student pharmacists.

Plan a fundraiser to sell American Pharmacists Month t-shirts or other items to student pharmacists and faculty.

For downloadable planning guides visit www.aphanet.org.

PHARMACY’S FUTURE IS UP TO ALL OF US! GET INVOLVED! STAY INVOLVED! MAKE YOUR FUTURE! BECOME A PharmPAC MEMBER TODAY! Visit the AzPA website at www.azpharmacy.org.

Arizona Journal of Pharmacy 25

PAPA

Fighting Demons

by Kyle Malhotra Edited with help from: Emily Jean Catron, Natalie Rose Apar, and Kellen Vann Renshaw Author’s note: places, identities, and details have been changed to protect those involved.

Sarah had called me over at 2 a.m. She introduced me to her new friend, Keith. They had just met an hour before. He was doing lines of cocaine while she was high on Ambien.

“Hey, you want some?” Keith gestured to a mirror with several lines of cocaine. It looked exactly like it did in the movies.

“That’s very kind of you, but I’ll pass.”

“Wh-wh-why are you here?” Sarah asked. The Ambien was clearly having an effect on her.

“You said you really wanted to talk and that you were going to come over. I convinced you to stay put and I’d drop by instead.

Do you remember any of this?”

Keith mumbled something about running out of coke and left.

“Oh my God. You’re such a good friend!” Sarah slurred.

“Yeah, I’m a fantastic friend. I’m gonna head out.”

She made it halfway to her bedroom before she decided that her hallway was a good place to pass out. I picked up her keys, and then left her apartment, locking it on the way out.

The plane shook me awake. I straightened my neck out, feeling a series of pops travel down from the base of my skull into my back. The pilot announced that we would be landing in Salt Lake City within 15 minutes.

The sky was gray in Utah that morning. It had been raining for days and everyone’s luggage was soaked. My pants were soaked, too, as soon as I stepped off the airport curb. I had arrived for the University of Utah’s School on Alcoholism and Other Drug Dependencies.

The conference was set up so that there were lectures during the first half of the day, and the second half of each day generally consisted of Alcoholic Anonymous (AA), Narcotics Anonymous (NA), and Al-Anon Family Group meetings (which were dedicated to the experiences of friends and families, rather than that of recovering addicts). During the introductory session, all of the students were divided into different groups depending upon where their schools were located. Some schools sent ten students, but I was the only one representing my school.

During an introduction that evening, one of the pharmacy section leaders asked everyone who was at the conference alone to please stand up. A handful of students, myself included, stood up, glancing around anxiously. The speaker paused, then said, “Please make these students feel welcome. This will be a great week, but some of these sessions may bring up some tough memories for you.” I already knew how right he was.

Sarah, began having trouble sleeping. Her psychiatrist prescribed Ambien. Like many sleeping aids, Ambien is addictive when used improperly. It was only a matter of time before she started taking the medications not to sleep, but to get high. It quickly spiraled out of control, as Sarah increased her dosage independently and began to combine the medication with alcohol.

26 Arizona Journal of Pharmacy

I remember one day in particular, just after she’d seen her doctor. Sarah’s speech was so slurred, I could barely understand her. “They s-s-said I’m ab-ab-abusing the pills. I want to s-s-stop using…them.” Her eyes were drooping.

“Okay, where are they?” I asked.

“Desk.”

I opened the desk drawer, grabbed her supply, and threw the pills into her apartment complex’s dumpster. I was half surprised she even let me do it. When I returned, she was passed out on the living room floor with her cat curled up on her head. I took it upon myself to refill the cat’s food and water, and then slept on the couch.

Addiction doesn’t happen to everyone who misuses a drug, prescribed or otherwise. Some will become addicts while others will not. It is unclear how thin the line is between abuser and addict. How does it take over the brain at such a deep level that the brain starts to believe, at an unconscious level, that the drug is required for survival?

One of the lecturers at the conference began with a story from his medical training. “During my residency, we were walking through the hospital with a physician, going from patient to patient. We arrived at a room occupied by an elderly man. He was sleeping when we came in, but the doctor leading rounds woke him up. As the patient’s eyes opened, I was shocked to see they were fluorescent yellow. The doctor said, ‘All right old man, you keep coming in here, we fix you, then you leave and start drinking again. What do you want to do? Do you want to die? Well, do you?’ The old man quietly responded, ‘If I could, I would.’ It amazed me that with all these modern treatments, addiction could still be so difficult to overcome.”

As is commonly misunderstood, addiction is not a moral failing, but a very real disease. Drugs act in the midbrain; specifically, in the ventral tegmentum and nucleus accumbens.

The midbrain is responsible for deep instincts like survival, reproduction, and eating. Drugs overtake the survival hierarchy within the brain. For example, if the hierarchy before drugs was “eat, kill, sex,” the new hierarchy would be “drug, eat, kill, sex.”

Not only do drugs become a requirement for survival, but they also hijack the brain’s pleasure system. Our brain has a hedonic set point. Drugs will raise the hedonic set point, so someone can only experience pleasure through the use of the drug. This increase in the hedonic set point changes the brain in such a way that everyday pleasures will no longer bring the addict happiness.

Continued use of the drug will further raise the hedonic set point, driving the user to continually increase their dose.

With this in mind, it’s easy to see why many addicts relapse when they attempt to stop using the drug. Even individuals with astounding willpower struggle, due to the change in their fundamental response to the stresses of everyday life. To make matters worse, it is often the case that these individuals feel the drugs are filling a hole in their heart or soul, and the user begins to view the drug in an emotional light. For real recovery to take place, the addict has to relearn how to respond to life’s stresses and develop healthy coping mechanisms. That is, the hole has to be filled with something other than the drug. One of the reasons AA and NA work so well is because they fill that hole with friends and family, giving the addict a desperately needed support system.

The next morning I woke up early. Sarah’s kitchen was completely empty, so I decided to purchase some groceries for her. I was busily making scrambled eggs and toast when I heard Sarah weeping.

In between tears she choked out, “Jake’s not returning my calls.”

“He broke up with you five months ago—he’s not coming back.” I replied.

She wandered into her bedroom and slammed the door.

It was day four of no pills. Sarah was in bed, though she hadn’t slept or eaten since she passed out on her living room floor that first night after the doctor. I had called her sister over so I could take some time to go home and recharge myself, but she hadn’t arrived yet.

“God, this headache is killing me,” Sarah grumbled.

“Don’t complain!” I snapped, “It was your choice to start lying to the doctors to get more of the medication. You were supposed to go to sleep after you take the medication, but instead you choose to stay awake to get completely drugged off your ass. And it was your choice to start doing shots with your meds, too. Because of you, I’ve missed a week of work. You’re a self-absorbed junkie with no integrity wallowing in self-pity, destroying the lives of everyone around you. Quit your whining.

You deserve worse.”

She looked stunned. Her sister arrived about an hour later.

After she learned of my outburst, she asked me to leave. That was the last time I saw Sarah, nearly five years ago.

I was sitting in the NA meeting at the conference. The room started to spin around me. Just as I’d been warned that first day, all the painful memories were flooding back to me. I couldn’t stop thinking about the things I said to my closest friend, who had been like a sister to me, and the regret tied my stomach into knots. The way she had acted wasn’t because she was selfish, or because she didn’t have integrity; it was her drug abuse. I wished I’d realized it at the time.

On the fifth night of the conference, I decided to call my estranged friend after the closing 12-step meeting. Many people who had chosen to remain quiet during the past several days decided to speak. This session was different than the previous meetings in its focus on relationships. Addiction does not only affect the person afflicted with the disease, but touches the lives of everyone around the addict. The Big Book by AA Services states, “The [addict] is like a tornado roaring his way through the lives of others. Hearts are broken. Sweet relationships are dead.

Affections have been uprooted. Selfish and inconsiderate habits have kept the home in turmoil.” Pharmacists and physicians spoke of putting their licensure on the line after being caught using medications illegally. Others had taken advantage of their friends and family to support their addiction: stealing money from their parents, abandoning spouses and children, and abusing power in their workplace by stealing inventory.

Finally, I had to step out of the meeting. Thankfully, the rain had stopped and it was calm, cool, and balmy. As I scrolled through my contact list to find Sarah’s number, I rehearsed what I was going to say to her. I was nervous. Was she still abusing Ambien? Had the addiction taken her life? Or had she cleaned up and become sober? I had no idea what to expect. I swallowed hard, took a deep breath, and dialed her number.

PAPA “Hello?” I recognized her voice immediately.

“Hi.” I’d suddenly forgotten what I had planned to say. There was a moment of awkward silence, during which my mouth dried out. It felt like I was chewing on sand.

“Who is this?”

“This is Kyle. I…” A lump formed in my throat and it was becoming difficult to speak.

“Hey, Kyle. Is everything okay?” I couldn’t help but notice that she sounded well.

My voice had turned into a rasp at this point and I was choking back tears. “I know it’s been a while since we last spoke. I wanted to say…I wanted to say that I’m sorry for storming out all those years ago. I’m sorry for the things I said.

Our friendship meant too much to throw away. I’m just…I’m so sorry.”

“It’s okay. Kyle, it’s been so long. Are you sure everything’s okay?”

“Yeah, I’m fine. I’m at this conference in Utah and we went to these meetings…” I trailed off for a moment. “Do you want to get together or something?”

Over the next two weeks, I learned that Sarah had never used Ambien again, but did continue abusing alcohol. After she got pulled over for a DUI, she stopped drinking. She threw herself back into her research and completed her degree successfully.

Despite Sarah's best efforts, her ex-boyfriend and several of her closest friends never spoke with her again. The heavy toll it took on her relationships is something that still hurts her nearly five years later. This was echoed in many of the recovering addicts I spoke to at the conference. The pain their drug dependence had caused friends and family is something that continued to haunt them.

As I dozed off on the plane ride back to Tucson, AZ, the meetings of the past week were what stayed with me the most.

The information was undoubtedly important, but it was the stories that had the deepest impact on me. The content of the meetings that was important, but the atmosphere that was created out of the experiences: an atmosphere completely devoid of all judgment. I was able to come to terms with what happened with Sarah.

“I can’t tell you how much I appreciate your staying with me.”

“Don’t worry about it. That’s what friends are for, right?”

Sarah rested her head on my lap. She had been without Ambien for close to 48-hours and her headaches were getting progressively worse.

“Come on, look up.” I gently put my hands on either side of her head. “When I was little, I used to get the worst headaches.

My mom would massage my temples to help me sleep.”

I put two fingers on each temple and rubbed them in little circles. I looked down at her and she had fallen asleep.

Arizona Journal of Pharmacy 27

Academy News Community Pharmacy Academy News Greetings, Community Pharmacy Academy Members, Thank you to the following AzPA Community Pharmacy Academy (CPA) members who have volunteered to serve on the CPA Executive Committee: Dorian Bella and Chris Ferrier, Membership Committee; Nick Muscolino, Communications Committee; Ken Fletcher and Kris Kaniski, Legislative Affairs Committee; Kristin Calabro, AWARxE and Medication Waste Disposal Committees.

Pharm.D., and I were the competition judges.

Congratulations to Matthew Bauer on winning the challenge and $500!

The final program of the conference was a law CE on the Secure and Responsible Drug Disposal Act of 2010 conducted by Paul Moran, VP Sales/Marketing with Environmental Pharmaceuticals.

The CPA continues to monitor the status of medical marijuana in Arizona, as well as proposed federal legislation HR 1971- Pharmacy Competition and Consumer Choice Act and HR 1946 - Preserving Our Hometown Independent Pharmacies Act.

At the AzPA 7th Annual Meeting, the CPA presented its Academy Service Award to Chad Schuster, Pharm.D., for his outstanding leadership to the academy and the patients he serves. Congratulations, Chad, and thank you for all you do.

Community pharmacies across the state will be involved with the DEA Drug Take-Back Day on October 29, 2011 and AWARxE activities. Please contact me if you wish to get involved or have any questions about the CPA activities.

On August 23, 2011, the Independent Pharmacy Owners Forum met. The topic was Marketing and Social Media. Thank you to Cardinal Health for sponsoring the dinner for the meeting. The next Independent Pharmacy Owners Forum will be held later this fall.

Sincerely,

The 2011 Community Pharmacy Academy Conference was held Saturday, September 17, 2011, at the Crowne Plaza Phoenix Airport Hotel. More than 60 people attended the meeting which offered 6.0 hours (.60 CEUs) of continuing pharmacy education. Thank you to the speakers, judges, panelists, and participants.

The all-day conference began with a presentation led by yours truly on Opportunities in Independent Pharmacy, followed by a discussion about Compounding in Community Pharmacies: What’s Hot and What’s NOT conducted by Dana Reed-Kane, Pharm.D., Linda Cappellini, Pharm.D., and Kevin Borg, Pharm.D. Dawn Knudsen-Gerber, Pharm.D., CGP, FASCP presented L-Carnitine, Tumeric, and HCG, Oh, My!: An Herbal Update.

Healthy competition and fun was served up in the Pharmacy Professional Pain Counseling Competition.

Ken Fletcher, Pharm.D., served as moderator and Kristin Calabro, Pharm.D., Robert Kronenberg, 28 Arizona Journal of Pharmacy

Teresa Stickler, R.Ph. Community Pharmacy Academy Chair melrosepharmacy@yahoo.com

Pharmacy Professional Pain Counseling Competition finalists (left to right) Matthew Bauer, Deborah Van Sant, and Crane Davis.

Health-System Academy News Greetings, Health-System Academy Members, The Health System Academy (HSA) had a great year in 2010-2011 with the re-establishment of the Health System Leadership Forum, led by Butch David, and the Academy receiving full reaffiliation status with American Society of Health-System Pharmacists. There are several important issues ongoing in the world of health systems on a national and local level including drug shortage issues and reimbursement for pharmacists providing patient care services. Additionally, ASHP’s 2015 Initiative, aimed at improving the practice of pharmacy in the health systems, has also been a topic of interest for the HSA here in Arizona. One area of focus for the Leadership Forum, using a survey-based gap analysis performed last fall, has been to discuss ways in which health systems in the state of Arizona can meet the goals of the ASHP 2015 Initiative.

Affiliation with ASHP has also been an important relationship for the HSA since first receiving full affiliation in 2006. ASHP’s goal in establishing affiliate relationships is to extend ASHP’s ability to achieve its purposes as defined in its charter. In return, ASHP supports the growth of its affiliates through programs aimed at assisting their development and improvement, as well as providing information and tools regarding professional practice, practice standards, government affairs, public relations, grant funding for continuing education, and events.

Affiliates are invited to participate in shaping ASHP’s national agenda for health-system pharmacy. There are many services and assistance provided by ASHP, which makes affiliation one key to our success as an Academy.

Other ongoing initiatives on the national level are the ASHP’s Pharmacy Practice Model Initiative (PPMI) and the Pharmacy Technician Initiative. For more information, please follow the links to the ASHP website. http://www.ashp.org/menu/PracticePolicy/ Initiatives/2015Initiative.aspx http://www.ashp.org/ppmi http://www.ashp.org/menu/PracticePolicy/Initiatives/ PharmacyTechnicianInitiative.aspx

Academy News Other Academy news that is very noteworthy includes recognition of two individuals at the AzPA Annual Meeting this past July for their contributions to pharmacy in Arizona and health systems. Jean Patel was recognized with the Health-System Pharmacy Academy Service Award for her outstanding leadership to the academy and patient care and Butch David was honored with the Elias Schlossberg Award which is the highest level of recognition for an Arizona pharmacist who has made significant contributions to health system pharmacy. Thank you so much to both Jean and Butch for their hard work and contributions.

The Academy is always looking to foster leadership by providing opportunities to get involved including volunteers from the Academy to author articles for the HSA publication the eHeartbeat and for the Arizona Journal of Pharmacy. The HSA held its first conference call meeting in August and is gearing up for another great year in 2011-2012.

Sincerely, Jon Merchen, Pharm.D. Health-System Academy Chair jonathan.merchen@va.gov

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For more information please call or email: Terry Cater, R.Ph. 925.895.1506 terry@terrycater.com Arizona Journal of Pharmacy 29

Academy News Managed Care Academy News Dear Managed Care Academy Colleagues, I bring my greetings to you as your newly-installed Managed Care Academy (MCA) Chair, and introduce you to Ann Sears, who is our Chair-Elect.

If you missed our Annual Meeting, you missed a rockin’ good time. The Annual Meeting Steering Committee always does a fabulous job, and the AzPA staff works so hard to put it all together, including special little touches like decorations and centerpieces and fun and surprises, as well as the CE we all go for.

Plan to join us next year in June at The Wigwam in Litchfield Park.

Congratulations to Ken Bykowski as this year’s recipient of the Managed Care Academy Service Award for his outstanding leadership to the Academy and the patients he serves.

We have already been busy with quite a year planned!

You should have received a short survey regarding your opinions on potential academy activities. I hope you were able to take a moment to complete it, as we value your input. Part of what we want to do is have fun together as well as participate in a local charity event of some sort, with a focus on health care.

As managed care pharmacy professionals we are often invisible--we generally don’t work directly with patients. We would like to create more visibility by participating in a event that will support the charity’s goals. We are hoping to support an organization that has a statewide presence to engage as many AzPA members as possible. If you don’t know who your district director is, they are listed on the AzPA website under the Board of Directors. We want to get out there, have fun, support the cause, and let the public know we’re here as their managed care pharmacists and technicians, and that we care.

Our Second Annual MCA Chill & Chat is coming up on Friday, October 7, 2011 from 5:30 pm to 7:30 pm at Majerle’s at Chandler Fashion Center. I hope you can join us. A Tucson event is also in the works.

30 Arizona Journal of Pharmacy

We are very excited about our MCA conference, coming next March. I also want to thank our planning committee for volunteering their time to work with Kathy Harty in the AzPA office to plan the event.

We really appreciate those of you who have stepped forward to commit your time and ideas.

We have had several people join us on the MCA Executive Committee--these are the people who have volunteered to represent our academy on one of AzPA’s committees. Thank you and welcome to those of you who have committed to another year on their respective committee or who have stepped up to join us for the first time. The names of the MCA Committee Representatives are listed in our section on the website.

Are you new to AzPA and/or our group? Have you considered getting involved but don’t know what you can do? Please contact me and we can see where you might best fit and plug you in to try it. Check the Managed Care Academy page on the AzPA website at www.azpharmacy.org for the open committee representative positions. We can’t do it without our volunteers. The time commitment is minimal, depending on the committee, usually an hour or two per quarter. Don’t be shy! Step right up!

I wish you all the best.

Julie Hernandez, Pharm.D. Managed Care Academy Chair rxchica@cox.net

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Senior Care Academy News Greetings, Senior Care Academy Members, Thank you to everyone who participated in the Senior Care Academy (SCA) name change survey.

We received more than 95 responses and at the SCA Meeting held on July 8, 2011 at the AzPA 7th Annual Meeting, the new name was unanimously voted to be “Geriatric Care Academy.� The proposed name change will be brought to the full AzPA Board of Directors at the October 12, 2011 meeting.

Also during the July SCA meeting, Sandra Brownstein, Pharm.D., was honored with the Senior Care Academy Service Award in recognition of her service to the academy and the patients she serves.

Congratulations, Sandra.

The American Society of Consultant Pharmacists (ASCP) will hold its annual meeting here in Phoenix, November 16-18, 2011, at the Phoenix Convention Center. This is an excellent opportunity to network with your pharmacy peers from all over the country. A special one-day registration on Friday, November 18, 2011 for Arizona pharmacists is available for just $50.

Go to www.ascpannual.com for complete information about the conference. Be sure to enter promo code AZDAY to receive the special $50 one-day rate.

Plans are underway for the 2012 SCA conference scheduled for May. If you wish to get involved as a coordinator or speaker for this conference, please contact me at dknuds@midwestern.edu. Watch future issues of the Arizona Journal of Pharmacy and the AzPA website for more information as details are confirmed.

Academy News October is American Pharmacists Month and we invite you to get involved with the DEA Take Back Day Event on October 29, 2011. Contact your local law enforcement agencies for locations and times in your community.

Thank you to the following AzPA members who have volunteered to serve on the SCA Executive Committee: Laura Hanson, CE Committee; Justin Brock, Membership Committee; Sandra Brownstein, Annual Meeting Steering Committee; Jim Kloster and Kim Cauthon, Legislative Affairs Committee; Kim Cauthon, Academy Conference Planning Committee; Melissa Rudinsky, Technician Representative; Chris Ferrier, New Practitioners Forum; and Lindsey Ong and Angie Rosselli, Public Affairs Committee and Student Representatives. We are still looking for volunteers to serve on the Professional Affairs Committee.

Also, if you have a passion for writing and are interested in being published, AzPA is always looking for members to contribute continuing pharmacy education articles on varied subjects that will be considered for publication in the Arizona Journal of Pharmacy and possibly other state association journals. Contact Kathy Harty at kathy@azpharmacy. org or Janet Weigel at janet@azpharmacy.org for more information.

As always, contact me with your ideas and questions.

Sincerely, Dawn Knudsen-Gerber, Pharm.D., CGP, FASCP Senior Care Academy Chair dknuds@midwestern.edu

Arizona Journal of Pharmacy 31

Academy News Student Pharmacist Academy News Greetings, Student Pharmacists, Congratulations to the Class of 2011! The University of Arizona College of Pharmacy and Midwestern University College of Pharmacy Glendale graduated 86 and 122 new pharmacists, respectively! We wish all the graduates great success as you embark on your pharmacy career and hope you will remain active members of the Arizona Pharmacy Alliance as new practitioners.

Welcome to the first year pharmacy students at both colleges of pharmacy. Midwestern University CPG counts 149 new first year students and The University of Arizona COP first year enrollment numbers 101.

You are beginning an exciting journey as you prepare for your future as a pharmacist.

Congratulations to Eric Wong, Pharm.D. candidate, The University of Arizona COP, Class of 2014, and Sophia Galloway, Pharm. D. candidate, Midwestern University CPG, Class of 2014, as the Co-ChairsElect of the AzPA SPA. We are very excited to have you represent your schools on the AzPA Board of Directors.

identified by the colleges of pharmacy. The next AzPA SPA Leadership Conference is planned for April 2012.

Invitations will be extended in early 2012. If you are interested in participating, be sure to get involved with your student organizations and demonstrate your leadership.

As the Co-Chairs of the AzPA Student Pharmacist Academy (SPA), we invite you to enhance your pharmacy school experience by getting involved!

Please contact us to find out how. Let’s have another great year!

Sincerely, Valerie Bostel and Jessica DiLeo AzPA Student Pharmacy Academy Co-Chairs valerie.bostel@gmail.com dileo@pharmacy.arizona.edu

If you or someone you care about is suffering from an alcohol and/or chemical dependency problem…

As the Student Pharmacist Academy enters its second year of existence, we have much to celebrate from the inaugural year and many plans for this coming year. The AzPA SPA will be active with other student organizations on the colleges of pharmacy campuses and busy coordinating events throughout the year.

Pharmacy Day at the State Capitol is tentatively scheduled for Wednesday, January 25, 2012. This annual event presents an opportunity for student pharmacists to meet with Arizona legislators and communicate the important role that pharmacists play as health care providers. Watch for more information about this annual event.

In April 2011, the Inaugural AzPA Student Pharmacist Academy Leadership Conference offered leadership training to 50 student pharmacist leaders from both MWU-CPG and UofA COP. This prestigious program is reserved for a select group of student leaders as 32 Arizona Journal of Pharmacy

“A Partnership in Caring”

Pharmacists Assisting Pharmacists of Arizona (PAPA)

is Available For Help and Information CALL LISA YATES AT 928-532-2293 ALL CALLS CONFIDENTIAL • CALLER REMAINS ANONYMOUS

Technician Academy News

Academy News

Greetings, Pharmacy Technician Academy Members, Welcome to the beginning of the 2011-2012 year for the Technician Academy. It was great to see many of you at the 7th Annual Meeting at the Westin La Paloma in Tucson, and I applaud your support of AzPA. On behalf of the Technician Academy, I wish Mindy Smith the greatest success in her future endeavors at APhA. She will be greatly missed by the members of AzPA. Many thanks to Chris Lesaca for his excellent service to the Technician Academy. During his tenure, Chris helped grow the Academy’s membership by almost 15%, was instrumental in putting together one of the most successful Technician Academy Conferences to date, sponsored technicians to attend conferences, as well as devoted a lot of his personal time to lead this Academy over the last year. Chris has left very large shoes for me to fill and I hope I am up to the task!

Thank you, Chris!

As we move forward this year, I will be working with our new Chair-Elect, Joy Davis. Joy comes to the Technician Academy from retail pharmacy and has a lot of unique ideas. Joy and I think very much alike and have a lot of goals for the Academy this year.

Welcome, Joy! One of these goals is to increase communication in the Academy. We will be having monthly conference calls starting in October. Please look for the email notification. There are also several positions available on various committees and we encourage any technicians who are interested in serving to contact me or a staff member in the AzPA office.

I look forward to leading the Technician Academy this year. I hope to be able interact with all of you and welcome any ideas that would further the practice of pharmacy for the technicians. It is my goal to continue the great work and growth from last year!

Mike Severn(center) accepts the Technician Academy Service Award from Chris Lesaca and Joy Davis presented at the AzPA 7th Annual Meeting.

AzPA Calendar of Events October 2011 American Pharmacists Month October 5, 2011 PTCB Exam Prep Course Begins October 7, 2011 Health-System Directors of Pharmacy LeadershipForum October 12, 2011 AzPA Board of Directors Meeting October 29, 2011 DEA Take-Back Day November 4 & 5, 2011 Anticoagulation Certificate Program Crowne Plaza Phoenix Airport Hotel November 12, 2011 APhA Immunization Certificate Program Doubletree Suites Phoenix Visit www.azpharmacy.org for all upcoming events.

Sincerely, Mike Severn, C.Ph.T. Technician Academy Chair amsevern@gmail.com

Empowering pharmacy professionals to provide optimal patient care

Arizona Journal of Pharmacy 33

Drug Information Questions Question: Is grapefruit safe for ingestion while on warfarin therapy?

by Jamie K. Joy, Pharm.D., Clinical Coordinator, Cancer Treatment Centers of America® at Western Regional Medical Center, Goodyear, Arizona; Kristen Mah, Pharm.D.

Answer:

Grapefruit, or Citrus paradisi, and warfarin have well documented drug interactions associated with their use. Grapefruit interacts with various medications, such as 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors and calcium channel blockers.1 The mechanism of the grapefruit-drug interaction is attributed to inhibition of the the cytochrome P450 (CYP450) system.1 Generally, patients are advised to avoid grapefruit or grapefruit juice while on certain high-risk medications. Warfarin is well known to interact with several medications as well as natural products. Fruit and fruit juices, such as cranberry and pomegranate, have been implicated as possibly interacting with warfarin as well. Although data are limited on a possible cranberry-warfarin interaction, cranberry is listed as an agent that may increase the effects of warfarin.2-4 Warfarin and grapefruit can potentially interact with many agents warranting the question of whether grapefruit consumption is safe for patients on warfarin therapy.

A literature search of Medline (1950-May 2011) and International Pharmaceutical Abstracts (1970-May 2011) using the terms Citrus paradisi, Coumadin, grapefruit, grapefruit juice, and warfarin identified one primary study5 and one case report.6 The pharmacokinetics of warfarin and grapefruit are also reviewed in this article.

One prospective study investigated the effect of grapefruit juice on prothrombin time (PT) in patients on stable warfarin therapy with targeted international normalized ratio (INR) measurements of 2 to 3.5 Ten male patients ages 55 to 75 years old who had two consecutive baseline PT levels within 10% of each other were included in the study. Patients were excluded if they ingested alcohol or grapefruit juice prior to the study. Study patients were given pre-measured 8 oz grapefruit juice doses (Smith’s Grapefruit Juice, Salt Lake City, UT) prepared from frozen concentrate three times daily for one week.

PT/INR levels were monitored the day before grapefruit juice consumption and on days 2, 6, and 8. Regimen compliance was assessed and ranged from 85.7 to 100%.

There was no significant difference among PT/INR levels during the course of therapy (p = 0.8). Limitations to this study were: small sample size, short duration (8 days), no female participants, and non-randomized. The conclusion of this study was that there appears to be no significant drug-food interaction with warfarin and grapefruit juice.

In a case report by Bartle et al. the INR was significantly elevated (6.29) in one patient following ingestion 34 Arizona Journal of Pharmacy

of approximately 50 oz of grapefruit juice daily for approximately 10 days.6 The patient’s INR goal was 2 to 3 and the INR had been within therapeutic range approximately 50% of the time prior to the elevated level.

The only variable identified was the ingestion of grapefruit juice. The management of this patient was to withhold two doses of warfarin and then resume the weekly warfarin dosage of 55 mg/week while withholding grapefruit juice.

His INR level one week later was 1.82. The authors concluded that although grapefruit juice is not known to interact with warfarin, grapefruit juice consumption in this patient was the only variable identified in relation to the elevated INR. One interesting note about this case report is that the main author reported that he attempted to reproduce this drug-food interaction on himself. He took warfarin until his INR was 2 to 3 and then ingested the same quantity of grapefruit juice for the same time period—this failed to reproduce the drug-food interaction.

Warfarin elimination occurs via hepatic metabolism

by CYP450 enzymes.2 The primary CYP450 enzyme responsible for S-warfarin metabolism is 2C9 with minimal involvement of 3A4 (Table 1)2,7. R-warfarin is metabolized primarily by CYP450 1A2, 3A4, and 2C19.

Grapefruit is a potent inhibitor of the intestinal CYP450 system, specifically 2C9 and 3A4 (Table 1)1,4. However, the pharmacokinetics of grapefruit is not well understood and various articles report different CYP450 enzymes as the primary cause of the enzyme inhibition. Based on the pharmacokinetics, it is theoretically possible that a drugfood interaction could occur with grapefruit and warfarin resulting in increased warfarin concentrations.

Overall, there are limited data available to support either a drug-food interaction or lack of a drug-food interaction with warfarin and grapefruit. In theory, there may be the potential of a drug-food interaction based on limited published pharmacokinetic data. Since warfarin has a narrow therapeutic range and abnormal levels increase the risk of bleeding or a thromboembolic event, it is prudent to regularly monitor PT/INR levels when a questionable food is introduced to the diet. Patients should be questioned at each visit about specific dietary changes such as ingestion of grapefruit juice or other types of fruit juices (cranberry, pomegranate, others). More studies are needed to determine the clinical significance of a grapefruit-warfarin interaction.

Drug Information Questions (continued from page 34) References 1. Jellin JM, Gregory PJ, Batz F et al. Grapefruit. Therapeutic research faculty. Natural Medicine Comprehensive Database. www.naturaldatabase.com (accessed 2011 April 28).

Warfarin elimination occurs via hepatic metabolism by CYP450 enzymes.2 The primary 2. Full prescribing information. Coumadin. Bristol-Myers Squibb. Available at http://packageinserts.bms.com/pi/pi_ coumadin.pdf.

CYP450 enzyme responsible for S-warfarin metabolism is 2C9 with minimal involvement of 3A4 3. Jellin JM, Gregory PJ, Batz F et al. Cranberry. Therapeutic research faculty. Natural Medicine Comprehensive Database. is 2011 metabolized (Table 1)2,7. R-warfarin www.naturaldatabase.com (accessed May 27). primarily by CYP450 1A2, 3A4, and 2C19. Grapefruit is a 4. Ulbricht C, Chao W, Costa D, et al. Clinical evidence of herbdrug interactions: a systematic review by the natural standard potent inhibitorCurrent of theDrug intestinal CYP450 system, specifically 2C9 and 3A4 (Table 1)1,4. However, research collaboration.

Metabolism.

2008;9:10631120.

5. Sullivan DM, Ford MA, Boyden Grapefruit is juice the understood and various articles report different the pharmacokinetics ofTW. grapefruit notandwell response to warfarin. Am J Health-Syst Pharm.1998;55:1581-3.

6. Bartle WR. Grapefruit juice might still be a factor in warfarin response.

Amenzymes J Health-Syst CYP450 asPharm.1999;56(7):676. the primary cause of the enzyme inhibition. Based on the 7. Pangilinan JM, Pangilinan PH, Worden FP. Use of warfarin in the patient with cancer. J Support Oncol. 2007;5:131-6.

pharmacokinetics, it is theoretically possible that a drug-food interaction could occur with grapefruit and warfarin resulting in increased warfarin concentrations.

Table 1: Cytochrome P450 enzymes involved in inhibition and metabolism of grapefruit, cranberry and warfarin1-4,7 CYP450 enzyme

Grapefruit

Cranberry

Warfarin

2C9

Inhibitor

Inhibitor *

Substrate***

2C8

Inhibitor

Substrate

2C18

Inhibitor

Substrate

2C19

Inhibitor

Substrate**

1A2

Inhibitor

Substrate**

3A4

Inhibitor

Substrate***

2A6

Inhibitor

2D6

Inhibitor

2E1

Inhibitor

*conflicting data on evidence of enzyme inhibition by this agent, **metabolism of R-warfarin, ***metabolism of S-warfarin Arizona Journal of Pharmacy 35

Feature Pharmacist A Leader in Innovation

As pharmacy moves to a technology driven profession with the electronic medical record and Computerized Physician Order Entry (CPOE), Dr. An innovative and progressive pharmacist, Kurt Weibel sees major changes for the future. The Weibel, Pharm.D., MS, is the Assistant Director of “transcription piece” is being taken away, which will Pharmacy Services at The University of Arizona open up a lot of clinical roles and move away from Medical Center (UAMC) in Tucson, Arizona. Dr. the dispensing role. Dr. Weibel is one step ahead Weibel received his Doctorate of Pharmacy from of the game by implementing the tech-check-tech the University of Wisconsin, pursued a two year program at UAMC after a waiver was granted by the Pharmacy Practice Management Residency at Arizona State Board of Pharmacy (ASBP) to deviate the Methodist University Hospital in Memphis, from a state requirement for experimentation and Tennessee, and then obtained his Masters in Health technological advances, according to A.R.S. 32-1904 Science Administration from the University of Powers and Duties of the Board, Section (B)6. The Tennessee. After extensive training, Dr. Weibel and change was well-received as the ASBP is interested in his family moved to Arizona. He started his career as ensuring patient and public safety. a staff pharmacist and then moved up to Director of Since the bar coding service is already in place, Pharmacy at Healthsouth Rehabilitation Institute in the goal is to automate as much as possible. The Tucson, Arizona. Eventually, he moved on to become driving force behind the proposal was to diminish the the current Assistant Director of Pharmacy Services at distributive or dispensing role of the pharmacist and to UAMC in Tucson, Arizona. increase the number of pharmacist hours per week in At the Arizona Pharmacy Alliance 2011 Annual the emergency department.

Meeting, Dr. Weibel received the 2011 UpsherUAMC will replace the pharmacist scan check of Smith Laboratories Excellence in Innovation Award, the Pyxis refill process with a pharmacy technician recognizing a practicing Arizona pharmacist who scan check using Parx, which is a bar code scanning has demonstrated significant innovations in their technology developed by Cardinal. The proposed respective pharmacy practice. use of the pharmacist time freed will be dedicated to When asked what motivated him to become a extending the hours of clinical pharmacy services in pharmacist, Dr. Weibel replied, “I did not always know the Emergency Department. The proposed process I was going to be a pharmacist. I enjoyed science, is as follows: an automated dispensing cabinet will economics, and business.” With passions at two ends notify the pharmacy technician of a needed refill via a of the spectrum, Dr. Weibel pursued pharmacy because handheld device. Next, the technician will scan the bar it offered him a combination of both hospital and code on the medication to be refilled and its identity is management. “As a manager, you never accomplish confirmed by the scanner, which will produce a label. anything by yourself. The best aspect of working at The medication will then be placed in the labeled bag.

UAMC is working with a great team where the role of A second technician will visually confirm that the the pharmacist is well established as a necessary part correct product is being refilled and scan the bag at the of the patient care team.” check station to confirm that it is the correct product.

Dr. Weibel is a preceptor for the institution, Finally, the technician will deliver the medication medication safety, and administration rotations. He to the automated dispensing cabinet, scan the label has assigned different goals for each of the different affixed to the bag, and refill the appropriate pocket. rotations. In the institution rotation, he tries to expose The tech-check-tech program is easier to his students to as many different situations as possible implement within the larger institutions that already within the acute care setting. In his medication safety have the bar coding process in place. This type of and administration rotation, he focuses his students on technology will increase the efficiency and safety of real projects and real problems during their time with patient care. him. He encourages them to see the imperfections of Since implementing the program the role of the the institution in order to develop the thought process pharmacist has not changed drastically. Thus far, the needed to solve problems as future pharmacists in program does allow technicians to take on their respective practice settings. more responsibility. “This is the beginning of a lot

by Winnie Thi, Pharm.D.

36 Arizona Journal of Pharmacy

Feature Pharmacist A Leader in Innovation (continued from page 36) of changes to come. ASBP licenses technicians, so pharmacists and managers can be a bit more comfortable in allowing technicians to take on expanded roles.

A member of the Arizona Pharmacy Alliance (AzPA) and the American Society of Health-System Pharmacists (ASHP), Dr. Weibel says, “Being involved allows pharmacists to exchange ideas and piggyback on others’ good ideas in an effort to solve your own problems within your own practice setting.

Investing in local organizations such as the Arizona Pharmacy Alliance allows you to have a representative serving as the voice of pharmacy.”

Dr. Weibel has some advice for graduating pharmacy students. “Have goals, but be realistic.”

Most people will not achieve their career goals within the first three years of their career. But with that being said, the way to achieve that goal is to be willing to chip in even when it may not be clearly outlined in your job duties.

“As pharmacists, we are always looked at to lead,” a statement that could not be truer. Leadership continues after graduation and may not always come with an impressive title. However, in order to move our profession forward, leadership and passion for pharmacy must permeate every aspect of our professional lives. Dr. Weibel is an inspiration to pharmacists and student pharmacists as he continues to be a leader in our profession.

Expand Your Practice.

Become Certified in Anticoagulation Management.

The Arizona Pharmacy Alliance presents Anticoagulation Certificate Program Friday, November 4, 2011 4:30 pm to 8:45 pm and Saturday, November 5, 2011 8:00 am to 12:30 pm Crowne Plaza Phoenix Airport Hotel 4300 East Washington Street Phoenix, Arizona 85034 This program will train pharmacists and pharmacy students to participate in anticoagulation management programs.

18 HOURS OF CPE (1.8 CE) • 10 hours didactic home-study knowledge-based activity #0100-9999-11-045-H01-P • 8 hours live, hands-on training practice-based activity #0100-9999-09-077-L01-P Course Overview: • Patient assessment • Understanding anticoagulant drugs • Pathophysiology of thrombosis • Focus on factors which influence therapy • Clotting and cascading mechanisms • Current ACCP Guidelines • And more!

Early Registration Fees Until 10/05/2011 AzPA Member Pharmacist Non-Member Pharmacist AzPA Member Allied Pharmacy* Non-Member Allied Pharmacy*

$300 $400 $200 $250

*Allied Pharmacy category includes pharmacy resident, federal commissioned pharmacist, student, or nurse.

Kurt Weibel, Pharm.D., Assistant Director of Pharmacy Services, The University of Arizona Medical Center

Arizona Journal of Pharmacy 37

Features and Articles Calcium Intake for the Treatment and Prevention of Osteoporosis and Fracture

by Satoru Ito, Pharm.D. Candidate, The University of Arizona College of Pharmacy, and Janet Cooley, Pharm.D. University Physicians Healthcare

Introduction Osteoporosis is characterized by reduced bone mass and deteriorated bone tissue structure1. According to National Osteoporosis Foundation, it is estimated that 10 million Americans already have osteoporosis and additional 34 million Americans have low bone density based on the census in the year 20002. It is estimated that 12 million American women aged more than 50 years will have osteoporosis by year 20123.

Calcium and vitamin D are widely used supplementations for the treatment and prevention of osteoporosis. A new study published in British Medical Journal on May 24, 2011 reported daily calcium consumption of more than 750 mg has no added benefit in prevention of hip fractures and osteoporosis in women4.

From this study, doctors and media5 are questioning the current calcium intake recommendation in the United States, which is much higher than the recommended intake level in this study.

The Women’s Health Initiative (WHI) recommends at least 1000-1500 mg of calcium and 400-800 international units of vitamin D per day6. The Food and Nutrition Board at the Institute of Medicine of the National Academies recommends 200 mg of calcium daily for females aged 0-6 months, 260 mg for ages between 7 and 12 months, 700 mg for ages between 1 and 3 years, 1000 mg for ages between 4 and 8 years, 1300 mg for ages between 9 and 18, 1000 mg for ages between 19 and 50 years, and 1200 mg of calcium daily for women of ages greater than 50 years old7. These recommendations are based on numerous other studies including WHI trials. In this review, the new extensive study was compared with other available studies to evaluate the current daily calcium intake recommendations.

Literature Review Warensjo et al. conducted a longitudinal prospective cohort study in Sweden, evaluating the relationship 38 Arizona Journal of Pharmacy

between dietary calcium intake and the risk of fracture and osteoporosis4. A total of 61,433 women (age range of 39-76 years) were included in this study, and they were followed up for average of 19 years. Of these participants, 5,022 participants were randomly selected as a subcohort to be assessed for osteoporosis using dual energy x ray absorptiometry (DXA). The daily calcium intake levels were categorized in quintiles of <751 mg, 751-882 mg, 882-996 mg (reference level, Hazard Ratio (HR) set as 1.0), 996-1137 mg, and >1137 mg. Dietary calcium intake below 751 mg a day was found to be associated with increased risk of any fracture, hip fracture, and osteoporosis (adjusted HR (aHR) 1.18, 1.29, and 1.47, respectively). Except for hip fractures, dietary calcium intake levels in other quintiles (above 750 mg a day) were found to have no significant differences in the risks of fractures or osteoporosis and any fracture. Additionally, daily dietary calcium intake of >1137 mg per day was found to have significantly increased risk of hip fractures (aHR 1.19, 95% CI 1.061.32). Therefore, daily dietary calcium intake of 750 mg is suggested from this study. Although this study utilized a great number of participants, there were some limitations. First, the calcium intake values were calculated using reported dietary contents via questionnaires, which would result in significant variations among participants especially with such a long follow-up period of 19 years. Additionally, the calcium intake was not controlled because no standard calcium dose was given. Also, the participants included both pre- and post-menopausal women (ages 39-76 years), and the menopausal status was not considered.

Jackson et al. conducted a randomized, double-blind, prospective WHI trial on the effect of calcium and vitamin D supplementation on fracture risks8.

A total of 36,282 participants aged between 50 and 79 years were included in this study. Of these participants, 18,176 participants were assigned to receive 1000 mg of calcium and 400 units of vitamin D, and the other 18,106 participants were assigned to receive placebo. Because personal calcium and vitamin D supplements were allowed in both groups, the average calcium intake in the supplementation group was found to be 1150 mg calcium. The total-hip bone mineral densities at 3 year, 6 year, and 9

year-visits were found to be significantly higher in supplementation group than that in placebo group (mean difference = 0.59%, p<0.001; 0.86%, p<0.001; 1.06%, p=0.01, respectively). Bone mineral densities in total-spine and whole body were found to have no significant differences between supplementation group and placebo group. When intentionto-treat analysis was performed, no significant difference was found in the rates of fractures in hip, clinical vertebral, and lower arm or wrist bones. When an analysis was conducted only on those who were adherent to the regimen (at least 80% adhrerence), supplementation group was found to have less rate of hip fractures than in placebo group (HR 0.71; 95% CI 0.52-0.97). However, in women aged between 50 and 59 years, the supplementation group was found to have increased risk of hip fracture (HR 2.17; 95% CI 1.13-4.18). Also, the risk of hip fracture was found to be lower in those who were not taking any additional personal calcium supplements (HR 0.70; 95% CI 0.51-0.98). Lastly, the rate of kidney stone formation, or renal calculi, was higher in supplementation group than in placebo group (HR 1.17; 95% CI 1.02-1.34). Limitations of this study include lack of control of additional supplementation and lack of comparisons of other doses. This study compared only 1000 mg calcium group versus placebo group.

Bolland et al. conducted a metaanalysis evaluating the risk of cardiovascular events associated with calcium and vitamin D supplementation9.

The cardiovascular events in this study included myocardial infarction (MI), coronary revascularization (coronary artery bypass graft (CABG) or percutaneous coronary intervention), death from coronary heart disease, and stroke.

The main study the investigators evaluated was the WHI trial by Jackson et al.8 described above. The WHI trial patients included in this re-analysis were divided into a group with additional personal calcium supplementation and another group with no additional personal calcium supplementation and each of these groups was further divided into the treatment subgroup (calcium and vitamin D) and the placebo subgroup. Within the group of no personal supplementation, the hazard ratios of clinical MI, clinical MI or

Features and Articles Calcium Intake for the Treatment and Prevention of Osteoporosis and Fracture (continued from page 38) revascularization, and clinical MI or stroke were found to be significantly greater in the treatment subgroup than in the placebo subgroup (HR 1.22, p=0.05; HR 1.16, p=0.04; HR 1.16, p=0.05, respectively).

No statistical significance between the treatment subgroup and the placebo subgroup was observed in the group of patients with personal supplementation.

The investigators also analyzed the association of daily supplement intake on the risk of cardiovascular events using the WHI trial and other studies.

The group of patients with personal supplementation was divided into three levels of daily calcium intake: 1-499, 500-999, and ≥ 1000 mg. No statistical difference was found between the three intake levels for the risk of cardiovascular events. The investigators also conducted a meta-analysis of trials comparing cardiovascular events between calcium and vitamin D group and placebo group.

The trials included the WHI trial and five other trials. In this analysis, MI, stoke, and composite of MI or stroke were found to be significantly greater in the calcium and vitamin D supplementation group than in placebo group (relative risk (RR) 1.21, p=0.04; RR 1.20, p=0.05; RR 1.16, p=0.02, respectively). Also, calcium with or without vitamin D was found to increase the cardiovascular risk significantly compared to placebo. A limitation of this study includes the limited dataset from WHI trial.

Tang et al. conducted a meta-analysis in 2007 evaluating the effect of calcium and vitamin D on bone loss and fracture risks in people aged 50 years and above10.

Twenty-nine studies were included in this meta-analysis with a total of 63,897 patients, of which 58,785 patients (92%) were women. The studied outcomes were the risks of fractures and bone-mineral density. For fractures, calcium and calcium plus vitamin D groups were found to have the risk ratio of 0.88 (p=0.0004). Calcium and calcium plus vitamin D groups were also found to reduce the bone loss of the hip and the spine by 0.54% (p<0.0001) and 1.19% (p<0.0001), respectively. No statistical difference in the risk ratios was found between calcium alone and the combination of calcium and vitamin D. When different doses of calcium were

analyzed, the risk ratio for fracture was significantly lower in patients taking ≥ 1200 mg than those taking < 1200 mg (0.80 vs. 0.94, p=0.006). The investigators concluded that daily intake of at least 1200 mg of calcium and 800 units of vitamin D is recommended in people aged 50 years and above. However, there were 47,359 patients taking < 1200 mg while only 5,266 patients were taking ≥ 1200 mg of calcium.

Conclusion Currently, the Women’s Health Initiative recommends 1000-1500 mg of calcium a day for postmenopausal women.

No recommendation for premenopausal women was found in the WHI source.

The Institute of Medicine recommends 1200 mg of calcium for women above the age of 50. In women ages between 14 and 50, 1300 mg is recommended.

On the contrary, the most recent study conducted by Warensjo et al. concluded that 750 mg of daily dietary calcium intake is optimal for the prevention of fractures and osteoporosis4. Additionally, daily dietary calcium intake of less than 700 mg was found to significantly increase the risk of fractures and osteoporosis. A greater amount of calcium intake (> 1137 mg) was also found to increase the risk of hip fracture. This study seems to have accounted for possible variabilities very well by including a very large number of patients (n=61,433). However, due to lack of control of personal supplementation, use of estimated calculations of dietary calcium intake based on questionnaires, and the wide range of ages (39-76 years old), the conclusion of this study remains uncertain. Other studies concluded that 1000-1200 mg of calcium supplement was found to lower the risk of fractures and osteoporosis8-10. However, most of these studies compared only single dosage against placebo. There are very limited number of available studies that compared different doses. The meta-analysis by Tang et al. found that calcium intake of ≥ 1200 mg was more effective than < 1200 mg in reducing the risk of fracture. However, the number of patients in the two groups differed significantly10.

In terms of safety, increased level of daily calcium intake does not seem to increase the occurrence of adverse effects significantly. Bolland et al. found significant increase in risk of

cardiovascular events in calcium group compared to placebo, but no difference was found between different levels of daily calcium intake9. Jackson et al. found that 1000 mg calcium was associated with increased incidence of renal calculi compared against placebo in their WHI trial. This study, however, did not compare different levels of daily calcium intake8.

It is difficult to recommend that the new daily calcium intake should be 750 mg based on one study. Until more controlled studies become available, post-menopausal women should take 1200 mg of daily calcium as recommended by the Institute of Medicine, especially those women at risk of osteoporosis or not getting enough dietary calcium.

References 1. Rizer MK. Osteoporosis. Prim Care Clin Office Pract. 2006;33:943-51.

2. National Osteoporosis Foundation [homepage on the Internet]. Prevalence report. Washington, DC. National Osteoporosis Foundation; c2011.

Available at http://www.nof.org/advocacy/resources/ prevalencereport. Accessed 2011 Jun 16.

3. U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2011;154:356-64.

4. Warensjo E, Byberg L, Melhus H et al. Dietary calcium intake and risk of fracture and osteoporosis: prospective longitudinal cohort study. Brit Med J. 2011;342:d1473 doi:10.1136/bmj.d1473. Available at http://www.bmj.com/content/342/bmj.d1473.

Accessed 2011 May 26.

5. Shute N. Extra calcium may not do older women much good. The National Public Radio. 2011 May 25. Available at http://www.npr.org/blogs/ health/2011/05/28/136657122/extra-calcium-maynot-do-older-women-much-good. Accessed 2011 May 26.

6. Women’s Health Initiative. Health recommendations for postmenopausal women.

Updated 2006 Feb. Available at http://www.nhlbi.nih. gov/whi/recommend.htm. Accessed 2011 May 26.

7. Office of Dietary Supplements National Institutes of Health. Dietary supplement fact sheet: calcium.

Updated 2011 Jan 2011. Available at http://ods. od.nih.gov/factsheets/calcium/. Accessed 2011 May 26.

8. Jackson RD, LaCroix AZ, Grass M et al. Calcium plus vitamin D supplementation and the risk of fractures. New Engl J Med. 2006;354:669-83.

9. Bolland MJ, Grey A, Avenell A et al. Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Women’s Health Initiative limited access dataset and metaanalysis. Brit Med J. 2011;342:d2040 doi:10.1136/ bmj.d2040. Available at 10. Tang B, Eslick GD, Nowson C et al. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis.

Lancet. 2007;370:657-66.

Arizona Journal of Pharmacy 39

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Negative Consequences of Prescribing Medications: How to Improve Patient Medication Outcomes

by Martha P. Fankhauser, MS Pharm, FASHP, BCPP

The goal of appropriate and safe use of medications includes an accurate diagnosis of a disease or disorder as well as its assessment and the monitoring of medications for adequate doses, adverse effects, drug interactions, and adherence to therapy.

Prescription documentation in the medical records requires a systematic approach since omission of pertinent information may increase the risk of negative health outcomes. Continuum of care or coordination of care is often lacking when patients are admitted into hospitals or treatment facilities and upon discharge to other settings. Medication errors (e.g., omission of a medication or reporting a medication that is not used) are common when patients are seeing more than one prescriber. Often documentation is lacking in the patientâ&#x20AC;&#x2122;s medical record, in reports from laboratories, procedures and from specialists, and from hospitals to track decision making with medication therapy.

Electronic medical records (EMR) using health care information technology and exchange between providers (e.g., medical practices, hospitals), laboratories, radiology centers, pharmacies, and payers has been recommended as the most comprehensive way to improve communication between providers.

Comprehensive and affordable health care that includes electronic health records, preventative treatment approaches, and patient-centered care with medication management has been recommended as the best approach to improve health care in the United States.

A patient-centered medical home (PCMH) is described as an organized family medicine practice that includes: 1) health information technology (e.g., medication interaction checking, electronic health records and e-prescribing), 2) quality measurements that track patientspecific data, clinical information, and evidence-based practices, and 3) clear and appropriate communication with patients about their health care with active

Features and Articles involvement in self-management and decision-making processes. Insurance reimbursements and organized health care are increasingly focusing on PCMH. The American Academy of Family Physicians (AAFP) has developed a Patient-Centered Medical Home Checklist.

This includes reminders for how to assess components of quality measures, patient experience, health information technology, and practice organization and includes the documentation of medication-related issues that need to be collected and analyzed for optimum patient outcomes.

Patients are increasingly being seen by multiple providers in a variety of organizations and at different locations that raises the risk of fragmentation of care and negative outcomes. Coordination of care between practitioners is essential for tracking referrals to specialists, sharing of laboratory results, checking for drug interactions and duplication of therapy, and in keeping track of all prescribed medications including OTC and nutrient products. Communication and coordination between medical and behavioral healthcare requires that providers provide accurate, complete, and timely information for persons receiving services from both systems.

Often behavioral health patients have more cognitive problems that may impact on their ability to share treatment plans, remember medications, and adhere to treatments. Many psychoactive drugs cause central nervous depression and may impair both cognitive and motor abilities.

Patients with cognitive impairments and with lower literacy levels often have a poorer understanding and participation in their health care decisions and are at risk for negative health outcomes.

Polypharmacy occurs when a medication regimen includes at least one unnecessary medication. Reasons for polypharmacy include multiple medical problems, combining therapies for augmentation, and self-treatment with drugs. Prescriber factors include excessive prescribing practices, multiple providers, and lack of a coordinating provider who tracks medication use. Complications of polypharmacy include increased adverse reactions, nonadherence, increased hospitalizations, and higher healthcare costs.

Medications are an important aspect of the health care but can cause negative

outcomes if not properly prescribed or monitored. Elderly patients are the most vulnerable to polypharmacy and adverse side effects because they have more acute and chronic diseases. The aging process also changes the pharmacokinetics of medications due to reductions in renal and hepatic function that decreases drug clearance, increases in body fat that increases the volume of distribution of lipid-soluble drugs and lengthens the halflife of the drug, and changes in receptor sensitivity due to aging. Side effects of medications can be mistaken for a new illness and medications are added without an assessment of the underlying cause of side effects. Inappropriate medication use and underuse are common in elderly patients taking five or more medications.

Polypharmacy can be reduced by utilizing one pharmacy for dispensing, providing medication education, sharing the decisions for drug treatment goals and plan, simplifying drug regimens by decreasing dosing frequency, eliminating pharmacologic duplication, and regularly reviewing all prescribed medications, OTC and nutrients products, and substance use.

The goal of polypharmacy should be to prescribe the least number of medications, reduce complex drug regimens if possible, reduce cost of therapy, and regularly monitor medical problems, symptoms, drug interactions, and adverse effects.

Medication errors are one of the leading causes of injury and death and the most common errors are giving/ taking the wrong drug or the wrong dose.

The Institute of Medicine estimates that approximately 98,000 individuals die each year as a result of medical errors.

Strategies for preventing medication errors include having the patient as an active participant of the health care team and helping to make decisions about health care. Documentation of how medications are started and discontinued with tapering schedules (e.g. start and stop dates with dosing instructions) should be provided to the patient as well as appropriate medication education written at the correct literacy level that includes information about potential adverse side effects and drug interactions.

Comprehensive medication management services enhances the continuity of care between providers for assessing and monitoring patient outcomes Arizona Journal of Pharmacy 41

Features and Articles Negative Consequences of Prescribing Medications (continued from page 41) and should be conducted at each medical visit and at admission and discharge from a facility along with updating an electronic medication records to reduce discrepancies and errors.

A comprehensive medication list with dosing and refill information that is linked with a disease disorder, prescriber, and dispensing pharmacies is essential so that all inpatient and outpatient providers can make accurate and rational decisions about medication therapy management. Sample medications that are dispensed directly to the patient instead of through a pharmacy should be included in the medication list as well as OTC and nutrient products.

Use of alcohol, nicotine, caffeine, and substances of abuse should be documented since these agents may impact on health care and cause drug interactions.

Patients should be assessed at each provider visit for current medications and doses being taken and to have updated lists that indicate medications to be started and stopped. Regularly updating the problem list, purpose of the medications, allergies, medication interactions, and treatment goals and expectations helps to engage the patient into providing accurate clinical information.

The integration of medication management to optimize patient outcomes in PCMH has been described as “the standard of care than ensures each patient’s medications (whether they are prescription, nonprescription, alternative, traditional, vitamins or nutritional supplements) are individually assessed to determine that each medication is: appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended.”

Comprehensive medication management services can be delivered by a clinical pharmacist as a pharmacotherapy manager in a PCMH because of their expertise and training (e.g., complex cases with multiple disease states or providers, drug therapy problems such as multiple medications, adverse reactions and interactions, poor outcomes, and treatment resistant disorders). The specific procedures recommended to optimize outcomes include: 42 Arizona Journal of Pharmacy

1) an assessment of the patient’s medication-related needs, 2) identification of the patient’s medication-related problems, 3) development of a care plan with individualized therapy goals and personalized interventions, and 4) follow-up evaluation to determine actual patient outcomes.

Integrating the concepts of PCMH into medical practice, engaging patients in their health care decisions, and utilizing comprehensive medication management will decrease the negative consequences of prescribing medications and help to improve patient medication outcomes.

Resources: American Academy of Family Physicians (AAFP) has a checklist for a Patient-Centered Medical Home: http://www.aafp.org/online/en/home/ membership/initiatives/pcmh.html, and health information for consumers: http://familydoctor.org/ online/famdocen/home.html MedlinePlus provides information on health topics, drugs, supplements, and herbals products from the U.S. National Library of Medicine and the National Institutes of Health: http://www.nlm.nih.gov/ medlineplus/druginformation.html Food and Drug Administration Adverse Events Reporting System: http://www.fda.gov/Safety/ MedWatch/default.htm and MedWatch Safety Alerts provides safety alerts about medical products: http:// www.fda.gov/Safety/MedWatch/ucm228488.htm

within 24 hours. Providers register with PCSS-P and receive the contact information of a mentor who is a specialist in screening, brief intervention, treatment and referral for patients with substance abuse problems. Mentors can then be contacted, via phone or email, with specific questions about clinical situations involving alcohol, drugs, and tobacco. To take advantage of the service, physicians can call PCSS-P at 877-630-8812, or register online at www.

PCSSmentor.org.

The service is an extension of NIDAMED, NIDA’s initiative to give health care professionals the tools and resources to screen their adult patients for tobacco, alcohol, and drug use. The initiative stresses the importance of the patient-doctor relationship in identifying unhealthy behaviors before they evolve into life threatening conditions. NIDAMED resources include a companion quick reference guide and a comprehensive resource guide for clinicians. The NIDAMED resources, including the Quick Screen, can be found at http://www.drugabuse.gov/nidamed/.

White House Prescription Drug Abuse Prevention Plan The Obama Administration has produced a plan that includes action to reduce prescription drug abuse through education, monitoring, proper disposal, and enforcement. The plan blueprint, “Epidemic: Responding To America’s Prescription Drug Abuse Crisis,” is available at http://www. whitehousedrugpolicy.gov/publications/pdf/rx_ abuse_plan.pdf.

This article first appeared in the Vol. 22, No. 2 edition of AzMedicine and is reprinted with permission.

Institute for Safe Medication Practices lists error-prone abbreviations, symbols, and dosage designations, confused drug names (look-alike and sound-alike names), products with drug name suffixes that contribute to confusion and medication errors, high high-alert medications that cause a significant harm when an error occurs, and guidelines for standard order sets for both electronic and paper formats: http://www.ismp.org Patient-Centered Primary Care Collaborative has a resource guide for “Integrating Comprehensive Medication Management to Optimize Patient Outcomes”: http://www.pcpcc.net/files/ medmanagepub.pdf and information on medication management: http://www.pcpcc.net/medicationmanagement Health, United States, 2010 provides reports of the health issues facing the American population: http:// www.cdc.gov/nchs/data/hus/hus10_InBrief.pdf Physician Clinical Support System for Primary Care (PCSS-P) & NIDAMED A project of the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health, and the American Society of Addiction Medicine (ASAM), PCSS-P is a free, nationwide service to help primary care providers seeking to identify and advise substance-abusing patients. PCSS-P features a “warm” line service, with a response

Martha P. Fankhauser, MS Pharm, FASHP, BCPP, specializes in Neuropsychiatric Pharmacy Practice and has her own Consulting Practice, available at www.martiefankhauser.com.

Ms. Fankhauser is a Clinical Professor in the College of Pharmacy at The University of Arizona, Tucson. She is a Pharmacy Consultant for HealthCare Partnership – UA Department of Psychology and a Pharmacotherapy Specialist for ASHLine at the UA College of Public Health.

Features and Articles Behind the Counter

by Joe Rowan, R.Ph.

In 1945 I began my senior year of high school and the Rowan family still didn’t have a car. At my mother’s insistence, I had been purchasing U.S. Postal Savings Certificates from the post office with part of my weekly wages. As I remember, you could buy these certificates in denominations from $1 to $200.

Banks still had a bad reputation from the depression days of the 1930’s, so quite a few folks invested in these postal certificates. They drew a small amount of interest and could be cashed any time at the post office. I usually bought a one-dollar certificate each payday and by the fall of 1945 I had accumulated about $350. For $250, I purchased the first automobile ever owned by the Rowan clan. T’was a 1933 Ford V8 sedan that the previous owner had painted a nifty light blue with silver streaks. Owning the car soon took the balance of my Postal Savings Certificates! In about 1965 I realized I had about $5 of those babies, so I cashed them in just before the post office closed that facet of its operations. If I had saved them until now, some collector would probably be offering big dough for such a rare item!

U.S. Postal Certificates were issued from 1911 to 1966.

Individuals were allowed a single account with a maximum balance of $2,500. Interest was paid at the rate of 2% per annum.

Since I had already decided I would be going off to pharmacy school after graduation, Mr. Casteel of the Gunning Casteel Drug Store chain in El Paso, Texas, assigned me to the Alta Vista store under the tutelage of Mr. Targett, my old boss from my soda jerk days. My new position of drug clerk gave me the opportunity to learn the pharmacy aspect of the drug store. Non-pharmacists were not allowed to fill prescriptions – we didn’t have pharmacy technicians in those days – but Mr. Targett knew how to accomplish education in the prescription department on the edge of the law. El Paso was 600

miles from Austin, the state capital, which meant the state pharmacy inspector did not show up very often in El Paso in those days. He would call from Fabens, Texas, a town about 30 miles from El Paso, and warn one or two of the pharmacists in the area that he was likely to drop in on them at any time. The word spread like wild fire and those of us in the “learning process” quickly retreated to the front end of the store and remained there for three days until the inspector wended his way back toward Austin.

As a drug clerk, I not only learned the ins-andouts of the prescription department, I was expected to stock shelves, check in and mark new merchandise, and assist customers with their patent and proprietary needs. Wrapping sanitary napkins in plain wrapping paper and marking the contents on the outside of the wrapped package occupied quite some time as the ladies, and even the men shopping for their wives, did not desire to pick up and carry such items around in the original box. Prophylactics were kept in a drawer in the prescription room and the pharmacist handled these transactions. Behind-the-counter items included cough and cold, laxatives, aspirin, first aid items, ointments, creams, mouth washes, suppositories, razors, blades, and almost anything other than gifts and notions. “Self-service” was a term that did not exist in those days; however it was a concept that I became very much involved with later in my career.

Time permitting, drug clerks would often sneak behind the prescription counter to observe the activities of the pharmacist. Quite a few prescriptions were compounded back in those days. One pharmacist, a retired physician, would allow me to assist in the process of mixing ointment ingredients or crushing tablets to create a liquid prescription or powder paper. He would also allow me to punch capsules with the ingredients he compounded.

Tablets and capsules were dispensed in hinged boxes bearing the name of the pharmacy on the top flap with the direction label affixed inside of the top flap. Some pharmacies used white slide boxes with the label affixed to the top of the box. Of course, all the labels bore the name, address, and phone number of the pharmacy and were customized for the patient’s name, physician’s name, and directions as well as date of filling. The name of the medication never appeared on the label – this was a private matter between patient and physician.

Arizona Journal of Pharmacy 43

Features and Articles Behind the Counter (continued from page 43) The prescription labels were individually created on a typewriter – a now almost forgotten machine.

Those pesky little labels would slide around in the typewriter causing an untidy appearance, a problem resolved with brains rather than brawn. No white out in those days! We learned to wrap a prescription blank around the roller of the typewriter, reducing the tendency to float and shift and resulting in a tidy label. Some drug stores provided local physicians with prescription blanks imprinted with the physician’s information across the top and the drug store information across the bottom. Many pharmacy associations considered this unethical since it could be interpreted that the prescription should be taken to that particular drug store for filling.

Vintage 1930’s typewriter. Photo by © Nerd Nest.

The average price of a prescription in the 1930’s and 1940’s was 90 cents to $1.25. Very few exceeded the $2.00 mark. This was total price, not co-pay.

What would a word like “co-pay” mean to us anyway?

Each patient paid for the own prescriptions in cold cash, charge, or by check. A prescription was more or less for the life of the patient as there were no stringent laws on refills or expiration dates. Many pharmacies used an arbitrary one-year rule, however this was not regulated in most states.

Narcotics such as Empirin with codeine, straight codeine, and cocaine did require written prescription by the physician and were non-refillable. Exempt narcotics such as elixir of terpin hydrate, codeine cough syrup, cheracol syrup, and paregoric (camphorated tincture of opium) required only the signature of the purchaser, date of purchase, and size of container dispensed. Federal Law provided that four ounces of cough syrups and two ounces of 44 Arizona Journal of Pharmacy

paregoric constituted the limit to be sold at any one time. Some of the purchases were legitimate, but the majority provided a “high” for the purchasers.

You might say these items were the popular “pot” of the time and, while certainly not intended, the laws allowed such abuse. Many times we would recover the empty bottles right outside the door of the drug store.

Penicillin and sulfa drugs hit the market as a result of medical advancement during World War II. Sulfa remained a relatively inexpensive treatment for infections, but penicillin tablets and injections were more effective. There were no tranquilizers during this era and those with nervous disorders loaded up on phenobarbital, a medication that today is tightly regulated and restricted by the Drug Enforcement Administration. We had one customer who would come in once a week and, and if the pharmacist was busy, would refill his own two-pint bottles from our five gallon jug of phenobarbital! Our pharmacy laws are much more restrictive today and for good reason.

By the time I graduated from high school in June 1946, I had decided to apply to the University of Texas to begin my quest to enter the profession of pharmacy.

Dr. Gidley, the dean of the pharmacy school, convinced my mother on the reason I should attend pharmacy school by telling her that by the time I finished my sophomore year, I would be able to make a fine cold cream for her. This projection remained true and my mother held me to it.

This is the third in a series of reflections from Joe Rowan, R.Ph., longtime Arizona pharmacist and AzPA member.

Follow Joe’s memoirs in future issues of the Arizona Journal of Pharmacy.

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Features and Articles

A Look Back - Homeopathic Medicine Kit

by Robert E. Kravetz, MD, FACP, MACG American College of Gastroenterology

“Therapeutic skepticism” was common in the first half of the nineteenth century because of a lack of scientific knowledge for treatments that were effective.

After the discovery of the germ theory in 1880, traditional medicine became more widely accepted.

Alternative theories and treatments were popular and none more so than that of homeopathy.

of the individual as well as their illness. Homeopathic doses were of no value since by diluting medications to their smallest effective dose resulted in drugs with no therapeutic value at all. One good thing about homeopathy was that while the doses prescribed were inadequate, there was no danger of overdose and side effects were rare.

Samuel Hahnemann, a German-born and educated physician with a keen interest in therapeutics, formulated the germ theory based on experiments performed upon himself. The principles of Hahnemann’s system are (1) diseases or symptoms of diseases are curable by those particular drugs which produce a similar effect upon the body – “like cures like”: similibus similibus churner; and (2) the effect of the drugs is heightened by giving them in infinitesimally small doses.

This Smith’s homeopathic medicine kit for families dates from 1871 when it sold for $1.00. It contained 12 homeopathic medicines including nux vomica, phosphorus, pulsatilla, ipecac, chamomile, rhus tox, and bryonia. These could be self-prescribed for sick family members, with indications for each remedy.

The famous “law of similar” was published in Hahnemann’s 1796 essay, New Principle for Ascertaining the Curative Power of Drugs. Homeopathy was popular because it emphasized treating the lifestyle

Dr. Robert Kravetz, Phoenix gastroenterologist and pharmacy memorabilia connoisseur, generously donated items from his personal pharmacy memorabilia collection for the Arizona Pharmacy Foundation Silent Auction. The auction raised $900 for APF. Many thanks to Dr. Kravetz for his Arizona Journal of Pharmacy contributions and his generous donation, which are spurring interest in pharmacy antiques.

Anyone interested in pharmacy collectibles and memorabilia may contact Dr. Kravetz at bob@brownies.com .

Arizona Journal of Pharmacy 45

Rx and the Law

AND THE LAW

by Don R. McGuire, R.Ph., J.D. This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

YOU’VE BEEN SERVED! The day that you had hoped would never come has come. The sheriff makes his way through the store, with papers in his hand, heading towards the prescription counter. The sheriff says, “Chris, I’ve got something for you.” The sheriff hands you the summons and complaint and walks out of the store. A summons is the notice that a suit has been filed against you. A complaint is the actual lawsuit. Now what do you do?

The most important thing is to not ignore it. This event, service of process, is the start of a procedure that is very time-sensitive. Unfortunately, some defendants read through the complaint and conclude that it is either a bogus case or just a ploy to extract money from them. The worst thing you can do is to toss it aside or throw it in a drawer and forget about it. This is not something that is going to go away. Ignoring it is only going to cause you more problems. In fact, the clock started when the sheriff handed Chris the summons.

Court rules prescribe the time frame within which some sort of response to the summons must be made. Depending on the jurisdiction, this is typically 20 or 30 days, although there are some other limitations out there. If nothing is filed with the court before this time expires, the plaintiff may be able to file for a default judgment. A default judgment essentially says, “You failed to respond, you lose.” If the plaintiff gains a default judgment, they can then begin to try to collect the money from you. The worst thing about a default judgment is that there is no deliberation on the facts or the issues of the case. You might end up paying on that bogus case that you tossed into the desk drawer.

The most typical response to a summons and complaint is to file an answer. The answer addresses all of the allegations made by the plaintiff. The responses are usually one of three possibilities; admission, denial, or not enough information. With an admission, you admit that the allegation is true. With a denial, you deny that the allegation is true. The third response is used when you don’t know enough about the allegation to admit or deny it. For litigation purposes, this is treated as a denial. A 46 Arizona Journal of Pharmacy

response needs to be made for each and every allegation in the complaint. The answer is also the place where affirmative defenses are raised. These are legal defenses that counteract the allegations against you. For example, raising truth as a defense to slander or libel.

However, there are circumstances when other filings are made instead of an answer. These are generally motions that raise a particular issue to the court. The purpose of these motions is to contest certain issues prior to actually working on the substance of the case via the answer. If you are successful on these issues, many times the case is thrown out and there is no need to work on the substance of the case. The issues contested here can include the lack of jurisdiction by the court, the case is filed in the incorrect venue, the summons and complaint was improperly served, the case failed to name the proper parties, or the case is a duplicate of a previously filed case in another court.

It takes time to evaluate the allegations, decide whether to file an answer and/or a motion and to decide what allegations need to be admitted or denied. Timeliness is your most valuable asset. Don’t be an ostrich when you are served. Sticking your head in the sand won’t make it go away and ignoring it could result in some serious negative ramifications for you. Call your attorney and/or insurance company as soon as possible. The more time they have to work on your response, the better it will be. © Don R. McGuire Jr., R.Ph., J.D., is General Counsel at Pharmacists Mutual Insurance Company.

This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly.

Kenneth R. Baker, RPh, JD Legal and Consulting Practice

Pharmacy Law Pharmacy Regulation Risk Management Insurance Pharmacy Quality Programs (CQI) Medication Error Reduction

Phelps Dodge Tower One North Central, Suite 900 Phoenix, AZ 85004 602-307-9900 Main 602-256-3086 Direct 602-307-5853 Fax kbaker@rcdmlaw.com

Hypertension Therapy Update

Continuing Education

by: Condit F. Steil, Pharm.D., CDE Professor and Chair, Pharmacy Practice Department School of Pharmacy, Gordon E. Inman College of Health Sciences and Nursing, Belmont University Goal: This home-study CPE activity has been developed to discuss hypertension and its medical management.

Objectives: At the conclusion of this lesson, successful participants should be able to: 1. list goals for hypertension control 2. chart categories of drug therapy available for hypertension treatment 3. describe the use of each agent, dosing, and monitoring guideline 4. forecast potential direction for future hypertension therapy plans The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7 Report) identifies evidence-based treatment steps for the management of hypertension.

Blood pressure has been classified into 4 stages; normal (<120/80 mm Hg), prehypertension (120-139/80-89 mm Hg), stage 1 hypertension (140-159/9099 mm Hg), and stage 2 hypertension (>160/>100 mm Hg). Diagnosis and classification of hypertension are determined from the average of 2 blood pressure readings obtained from 2 separate clinic visits; it is measured with the patient in a seated position, after at least a 5 minute rest. According to JNC-7 guidelines, the blood pressure goal in hypertensive patients without diabetes or any additional compelling conditions is less than 140 mm Hg systolic and less than 90 mm Hg diastolic, or less than 130 mm Hg systolic and less than 80 mm Hg diastolic in patients with diabetes or chronic kidney disease. Depending on the presence of other comorbid conditions, the individualized goal may be lower.

Treatment plans for hypertension have evolved to include combination therapy that targets different mechanisms to obtain optimal levels in blood pressure and possibly limit side effects.

Although the JNC-7 is the most recent report of recommendations, it was released in 2003, and new products and clinical evidence indicate some change will occur with the next review, the JNC-8. The indication from the Joint National Committee website (www.nhlbi.

nih.gov/guidelines/hypertension/) is that the JNC-8 will not be released until 2011. One possible direction for the next review may be to recommend combination antihypertensive therapies very early in the treatment plan for a patient with high blood pressure, rather than maximizing the dose of one drug at a time. The role of diuresis, and thiazide diuretics specifically, continues to be a topic of debate with each set of new guidelines. Diuretics improve the efficacy of the other agents for hypertension by limiting fluid retention.

Some evidence suggests long term diuretic use may not result in optimal outcomes when compared to other combinations.

Another potential shift may be a change in the goal blood pressure levels. The recent ACCORD blood pressure study demonstrated that tight management of blood pressure did not result in improved outcomes in patients with type 2 diabetes.

The study design called for the intensively treated group to achieve a systolic blood pressure of <120 mm Hg, and the control group to achieve a systolic blood pressure of <140 mm Hg. A review of the data shows that the average systolic blood pressure achieved in the intensive treatment group was 119 mm Hg and 133 mm Hg in the control group. These results translate into positive outcomes in diabetic patients, due to their systolic blood pressure goal of less than 130 mm Hg. Blood pressure is the product of cardiac output and total peripheral resistance (TPR). Cardiac output is the product of the stroke volume and heart rate.

Pathophysiologic changes that result in hypertension are usually not limited to one abnormality; rather, several changes in the normal function of body systems contribute to the hypertensive condition.

Two important systems that work to maintain normal blood pressure are the autonomic nervous system and the renin-angiotensin-aldosterone system.

The autonomic nervous system maintains regulatory action for the vascular system.

Abnormal sympathetic/adrenergic tone contributes to increased peripheral resistance. As a patient challenges his or her vascular system with increased fluid and sodium, renin activity in the kidney, a primary component of compensation,

adjusts to the increased volume.

Inhibition of renin reduces blood pressure and can reverse albuminuria.

The renin-angiotensin-aldosterone system regulates the balance of fluid volume, electrolytes, and blood volume in the body. Altered/decreased levels of fluid or sodium in the distal tubule of the nephron in the kidney stimulate the release of renin, which activates angiotensinogen to form angiotensin-I (AT-I). Angiotensinconverting enzyme (ACE), in the pulmonary and vascular endothelium, then converts AT-I to angiotensin-II (AT-II).

Aldosterone is released from the adrenal gland to induce retention of sodium and water with the goal of maintaining proper fluid and electrolyte balance.

However, this renin activity also produces vasoconstriction, sodium retention, smooth muscle proliferation, and increased antidiuretic hormone in the vasculature.

The real concern is that abnormally high renin activity is required to maintain balance. While some diseases can cause high renin activity, no specific cause other than poor health habits (high caloric and sodium intake, stressful lifestyle, tobacco use) can be identified in the majority of patients. Abnormally high release of renin over time can result in intraglomerular hypertension, with resulting proteinuria.

These changes are chronic in nature and result in endothelial dysfunction and microalbuminuria. Insulin resistance is also a by-product of this long term assault on the kidney.

Therapy of Hypertension Lifestyle modification should be the initial step of hypertension therapy for all patients. This treatment includes a meal plan such as the DASH (Dietary Approaches to Stop Hypertension) diet that limits sodium intake and facilitates healthy eating. Regular physical activity, according to each individual patientâ&#x20AC;&#x2122;s tolerance level and comorbid conditions, should be included, as should possible weight reduction and stress relief.

Smoking cessation, if needed, is also a valuable addition to the treatment plan. All healthcare providers should be prepared to assist and reinforce the message about Arizona Journal of Pharmacy 47

Continuing Education (continued from page 47) these health habits.

Several different categories of antihypertensive medications with varying mechanisms are marketed.

Today, the clinician can choose from a variety of products that may provide enhanced effects for the specific patient while limiting the side effect of the treatment. Table 1 provides a listing of the medication categories, products, and their dosing.

Types of Anti-hypertensive Medications The diuretics clinically used for hypertension include thiazide-type, loop, and potassium-sparing agents, and the decision of which to use is based on their mechanism and/or site of action. Baseline renal function and serum potassium are important factors in determining the initial choice of diuretic. Thiazide diuretics are usually the initial or second agent used for hypertension. Combination therapy with other preferred antihypertensive agents work synergistically to minimize the fluid retention of other therapies.

The JNC-7 report recommends thiazidetype diuretics as first-line therapy for uncomplicated hypertensive patients.

Hydrochlorothiazide (HCTZ) is the most frequently prescribed diuretic for the treatment of hypertension alone, though not effective in patients with significant decline in renal function. Loop diuretics are the choice diuretic when the patientâ&#x20AC;&#x2122;s glomerular filtration rate (GFR) falls below 30 mL/min, or in a situation where greater diuresis is needed, specifically in a volume overloaded patient with symptomatic heart failure. Potassiumsparing diuretics are the only diuretics that may increase serum potassium; loop and thiazide diuretics typically lower serum potassium based on their site of action.

Clinically, potassium-sparing diuretics are combined with a thiazide-type diuretic to balance serum potassium. Alone, these medications have minimal effect on reducing blood pressure.

The various types of diuretics work in different areas of the kidney. Thiazidetype diuretics inhibit the Na+/Cl- channel in the distal convoluted tubule of the nephron, whereas loop diuretics inhibit the Na+/K+/2Cl- action in the ascending limb of the loop of Henle. Potassium sparing agents, amiloride and triamterene inhibit the luminal Na+ channels, while spironolactone and eplerenone are 48 Arizona Journal of Pharmacy

aldosterone antagonists. Initially, the drop in blood pressure from diuretics is due to a decreased cardiac output as a result of decreased blood volume. Chronically, the blood pressure reduction is not a result of diuresis.

Diuretics are generally taken once daily in the morning to limit sleep disruption from frequent urination, which can be caused by dosing diuretics in the evening.

Low doses are used for the initial therapy and can be titrated up if necessary. For example, when treating hypertension alone, doses >25mg of HCTZ show no additional decrease in blood pressure.

Patients with preexisting gout or uric acid stone disease, severe renal impairment, hepatic dysfunction, and/ or electrolyte imbalances require close monitoring, as diuretics can induce flare-ups/worsening of these disorders.

Thiazide-type diuretics (except metolazone) are contraindicated in patients with a known hypersensitivity to sulfonamides, though the risk of crosssensitivity is not well defined. Adverse effects associated with diuretics can include changes in serum electrolytes, such as hypokalemia, hypomagnesemia, hyperuricemia, hyperglycemia, hyperlipidemia, hypercalcemia (thiazides), and hypocalcemia (loop). Photosensitivity has been reported. Some drug interactions of significance include nonsteroidal antiinflammatory drugs (NSAIDs), which can decrease the antihypertensive effect of diuretics. Diuretics can substantially increase lithium levels by inhibiting lithiumâ&#x20AC;&#x2122;s elimination; therefore, lithium levels should be monitored 5 to 7 days after starting or discontinuing a diuretic.

Thiazide diuretics are known to inhibit the release of insulin from the beta cells of the pancreas, resulting in hyperglycemia.

Baseline blood pressure, serum electrolytes, uric acid, glucose, and lipids should be measured prior to initiating therapy, after 1-2 months, and every 6-12 months thereafter.

An angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) is recognized as a step one or a step two drug following a diuretic treatment. This staging is dependent on the patientâ&#x20AC;&#x2122;s other compelling indications for therapy, such as chronic kidney disease, diabetes mellitus, heart failure, post-MI, or recurrent stroke prevention. ACE inhibitors can delay the progression of microalbuminuria to macroalbuminuria.

ACE inhibitors inhibit the formation of angiotensin-II by blocking the conversion of angiotensin-I to angiotensin-II. These agents increase bradykinin, which stimulates release of nitric oxide, a vasodilator. ACE inhibitors cause dilation of the efferent arteriole in the renal circulation, which aids in the lowering of blood pressure and long term renoprotective action but can also reduce GFR and induce acute renal failure.

ARBs are traditionally prescribed when ACE inhibitor therapies are not tolerated due to side effects such as cough. ARBs inhibit angiotensin-II release by blocking the Angiotensin-I receptor. This leads to a reduction in aldosterone secretion, vasoconstriction, and sympathetic activity.

ACE inhibitors are often less effective at lowering blood pressure and may increase the risk of angioedema in AfricanAmericans.

ACE inhibitors and ARBs are generally administered 1 to 3 times daily with or without food. Once-daily dosing can be in the morning or evening, based on patient preference and adverse effects, such as drowsiness. Taking the medication at the same time every day is important.

Concurrent food intake may affect the absorption of captopril and moexipril, so dosing prior to a meal is warranted. The effects of blood pressure lowering can be seen within 1 hour of administration, with maximum effects after 6 to 8 hours. ACE inhibitors and ARBs are contraindicated during pregnancy. Use in the second or third trimesters can lead to fetal injury or death.

Overall, ACE inhibitors are well tolerated with few side effects, especially if monitored appropriately. The most notorious adverse effect, often the reason for discontinuation of ACE inhibitors, is cough. This adverse effect is primarily due to the increase in bradykinin activity. Other adverse effects commonly associated with ACE inhibitors include fatigue, headache, dizziness, hyperkalemia, acute hypotension, and gastrointestinal problems. Hematologic effects, such as neutropenia and agranulocytosis, have also been reported.

Concurrent use of NSAIDs, potassiumsparing diuretics, and potassium supplements may increase potassium levels. ACE inhibitors can increase lithium levels, due to decreased fluid volume and loss of sodium ions; therefore, close monitoring of lithium levels is

Continuing Education (continued from page 48) recommended. Blood pressure, serum electrolytes, and renal function should be measured at baseline, in the first month, and every 6 months throughout treatment.

ARBs are listed as category C for the first trimester of pregnancy and category D for the second and third trimesters, so ARBs should be avoided in pregnancy.

ARBs are contraindicated in patients with significant disease of a single, functional kidney.

ARBs are generally well tolerated, with more common adverse effects including dizziness, diarrhea, dyspepsia, hyperkalemia, headache, and upper respiratory complaints. The frequency of cough associated with ARBs is less than with ACE inhibitors. Concurrent use of potassium-sparing diuretics, potassium supplements, or salt substitutes may increase serum potassium levels significantly. Use of ACE inhibitors and/ or beta-blockers with ARBs should be avoided in patients with heart failure.

ARBs can increase lithium levels due to decreased fluid volume and loss of sodium ions; therefore, close monitoring of lithium levels is recommended. Blood pressure, serum electrolytes, and renal function should be measured at baseline and periodically throughout treatment.

Potassium levels should be monitored within the first month of initial therapy and every 4-6 months, due to the potential onset of hyperkalemia.

Direct renin inhibitors (DRIs) are a relatively new category of agents for hypertension. They work within the reninangiotensin-aldosterone system. This category is not included in the JNC-7, as it was introduced after the release of JNC-7.

DRIs directly inhibit renin, which means that little or no contribution will result from the renin-angiotensin-aldosteronesystem. Aliskiren is taken once daily and can be taken with or without food.

Starting therapy begins with a low dose and is adjusted to goal. Adding an ARB or diuretic to aliskiren can be helpful in lowering blood pressure. DRIs are contraindicated in pregnancy. They have a low adverse effect profile that includes a cough, though the incidence is less than with ACE inhibitors. Diarrhea, dizziness, headache, rash, edema, increased uric acid, and low blood pressure can occur.

Aliskiren is metabolized in the liver by the cytochrome P-450 3A4 system, and patientsâ&#x20AC;&#x2122; blood pressure, electrolytes, and renal function should be monitored while

on aliskiren.

Beta-blockers are commonly prescribed as an addition to an existing hypertension treatment plan. Beta-blockers are beneficial for patients with concurrent cardiac problems and are indicated for patients with high risk for coronary disease, as well as secondary prevention of MI and heart failure. There are 2 main types of beta-adrenergic receptors in human physiology, beta1 and beta2. Beta1 receptors are located on the heart, where activation causes an increase in heart rate, contractility, and conduction velocity.

Blockade of these receptors reduces cardiac output. The agents with combined alpha and beta blockade will be considered here with their improved lipid profile.

Beta-receptors have a wide range of functions in the body. Activation of beta1receptors located in the juxtoglomerular cells of the kidney stimulate the release of renin. Beta2-receptors in the liver increase hepatic-mediated glucose output when stimulated. Beta2-receptors in the lungs induce bronchodilation. Some beta blockers are selective for beta1 effect while others are nonselective and inhibit both the beta1 and beta2 receptors equally. When higher doses of a beta1selective blocker are given, selectivity diminishes. Highly lipid-soluble beta1receptor blockers cross the blood brain barrier readily and increase the risk of central nervous system adverse effects.

Some beta-blockers also have intrinsic sympathomimetic activity (ISA). Betablockers are administered once to twice daily and should be taken at a consistent time.

Atenolol is classified as pregnancy category D and crosses the placental barrier, producing a reduced weight of infants. Beta-blockers are contraindicated in patients with sinus bradycardia.

Nonselective beta-blockers are contraindicated in patients with asthma.

Beta-blockers can inhibit the release of insulin from the pancreas, resulting in increased blood glucose levels in patients with type 2 diabetes. Conversely, they can also mask hypoglycemic-induced tachycardia, as it can decrease the individualâ&#x20AC;&#x2122;s awareness of hypoglycemia, which typically presents as dizziness and sweating but may not be visible when a patient is on beta-blocker therapy.

Common adverse effects with beta-blockers are CNS-related, such as sedation, dizziness, drowsiness,

lightheadedness, fatigue, and headache.

Other notable adverse effects include bradycardia, hypotension, depression, and sexual dysfunction, especially in older adults. Gastrointestinal effects of constipation, diarrhea, and nausea have been reported but occur less frequently.

Beta-blockers have additive effects on heart muscle contractility with nondihydropyridine calcium channel blockers (Diltiazem and Verapamil), amiodarone, and digoxin. Typically, patients taking beta-blockers should be tapered down when they are discontinued and not stopped suddenly. Baseline blood pressure, heart rate, lipid profile, and blood glucose levels should be conducted. Betablockers can increase total cholesterol, LDL-cholesterol, and triglycerides and decrease HDL-cholesterol.

Calcium channel blockers (CCBs) are an additional group of agents for hypertension control. Typically, they are a second or third option, and have less of an impact on cardiovascular disease when compared to other antihypertensive agents. Nondihydropyridine CCBs can be considered for patients who have not tolerated ACE inhibitor or ARB therapy.

Nondihydropyridine CCBs may reduce proteinuria. CCBs are structurally classified as nondihydropyridine and dihydropyridine. CCBs block the L-type calcium channel, which results in vasodilation. Nondihydropyridine CCBs primarily cause vasodilation within coronary vessels and have a more depressive effect on cardiac conduction, while dihydropyridine CCBs primarily cause vasodilation in the vascular smooth muscle. CCBs are dosed 1 to 3 times daily and can be taken with food to minimize adverse effects. Low initial dosage is adjusted every 2 weeks to patient tolerance, blood pressure, and heart rate. An immediate-release dosage form is rarely used for the treatment of hypertension. Typically, once-daily calcium channel blocker formulations are dosed in the morning, except for verapamil extended-release products, which are given at bedtime.

CCBs are also contraindicated in patients with sick sinus syndrome or a heart block without a pacemaker.

Verapamil is contraindicated in patients with congestive heart failure. CCBs can induce headache, dizziness, nausea, dyspepsia, flushing, and constipation.

Arizona Journal of Pharmacy 49

Continuing Education (continued from page 49) Nondihydropyridine CCBs are associated with cardiac adverse effects including cardiac conduction abnormalities and bradycardia. Dihydropyridine CCBs have adverse effects related to their relaxing of vascular tone. Dihydropyridine CCBs cause peripheral edema more significantly than the other CCBs. Most CCB drug interactions stem from the cytochrome P-450 enzyme system. Concurrent medications and foods (such as grapefruit juice) that are also metabolized through this system should be used cautiously.

Diltiazem and verapamil can inhibit other CYP3A4 substrates, such as statins and theophylline. CCBs inhibit platelet function, resulting in an increased risk for bleeding if used concurrently with anticoagulants, such as warfarin or aspirin.

Although indicated for the treatment of hypertension, alpha1-receptor blockers are rarely prescribed for this indication. They are most beneficial in patients with benign prostatic hyperplasia (BPH). Alpha1receptor blockers can be a treatment option for patients with both diabetes and BPH. The alpha1-receptor blockers inhibit the effect of norepinephrine on vascular alpha1-receptors. Activation of the alpha1receptor by norepinephrine leads to vasoconstriction, resulting in an increase in TPR. The alpha1-receptor blockers are preferably dosed at bedtime to minimize the risk of postural hypertension often observed within hours after administration.

Initial therapy often starts with a lower dose and can be adjusted to goal.

The alpha1-receptor blockers also cause a mild decrease in neutrophils and white blood cell counts, which is generally not significant. Adverse effects commonly associated with alpha1-receptor blockers include fatigue, malaise, dizziness, shortness of breath, hypotension, edema, and weight gain; palpitations, blurred vision and sexual dysfunction have also been noted. Blood pressure and heart rate should be monitored at baseline and at each visit after initiating treatment.

If antihypertensive agents are added, the patient should be assessed for firstdose syncope and postural hypotension.

Interruptions in therapy increase the risk; thus, nonadherent patients are not good candidates for this drug. Syncope is managed by having the patient lie down, rest, and receive supportive care as necessary.

Vasodilators induce their action by 50 Arizona Journal of Pharmacy

direct vasodilation of the vascular smooth muscle, producing a significant reduction in peripheral resistance. A reflex action from the baroreceptors to this action is an increase in heart rate, cardiac output and renin release. Candidates for vasodilators should receive diuretics and an agent that reduces adrenergic tone, perhaps a beta-blocker. Side effects include an increased heart rate, water retention, and dermatitis, and some cases report a peripheral neuropathy. Hydralazine may induce a dose-related, reversible lupuslike syndrome. Minoxidil can cause a hypertrichosis reaction.

While indicated for the treatment of hypertension, central-acting alphaadrenergic agonists are rarely prescribed for this indication. Central-acting alpha-adrenergic agonists stimulate alpha2-receptors in the brain to inhibit the production of serotonin, dopamine, norepinephrine, and epinephrine. This inhibition produces decreased heart rate and TPR. Central-acting alpha-adrenergic agonists are available in tablets and a transdermal patch (Catapres速). Tablets are taken in daily divided doses, preferably at consistent times. Transdermal patches are applied once weekly. Clonidine is classified as pregnancy category C and should be avoided. Methyldopa is pregnancy category B and can be used in pregnancy. It is converted to alphamethylnorepinephrine, a natural byproduct of catecholamine breakdown, which may also limit its use in gestation.

The use of a monoamine oxidase inhibitor (MAOI) is contraindicated in patients taking methyldopa as hypertensive crisis reactions have been reported. Centralacting alpha-adrenergic agonists are contraindicated in patients with severe coronary insufficiency, recent MI, cerebrovascular disease, and renal or hepatic dysfunction. Side effects can include nausea, vomiting, constipation, dry mouth, and CNS-related effects, such as sedation, weakness, nervousness, dizziness, and drowsiness. Hypotension, sexual dysfunction, and hair thinning/loss have been reported.

Iron can decrease the absorption of methyldopa up to 66%. Therefore, iron should be separated by at least 2 hours from methyldopa administration.

Methyldopa also increases the risk of lithium toxicity, even in the presence of normal lithium levels. Signs and

symptoms of lithium toxicity, such as lethargy and muscle weakness, should be monitored. Over-the-counter drug products containing pseudoephedrine and ma huang (ephedra, ephedrine) can increase blood pressure. This is greatly enhanced for patients taking-methyldopa and clonidine. Tricyclic antidepressants, e.g., amitriptyline and imipramine, may antagonize central alpha2-receptors.

Clonidine and methyldopa should also be used cautiously with beta-blockers, since withdrawal of these agents in patients concurrently on beta-blockers has led to life-threatening increases in blood pressure. Patients should be monitored for signs of depression at clinician visits.

When stopping the drug, gradual tapering of the drug should occur over several days to prevent withdrawal.

Summary Several agents are now marketed to control blood pressure to the desired range. However, little improvement in overall control has been noted, and further efforts are needed to encourage patients to continue to follow proper meal plans, engage in regular physical activity, and take their medications. Continual patient instruction about emerging techniques is vital. The future changes and updated recommendations brought forth by the JNC-8 will be interesting to observe.

ACPE UAN # 0100-9999-051-H01-P This continuing education activity originally appeared in the September 2010 issue of Tennessee Pharmacist and is reprinted with permission from the Tennessee Pharmacists Association and the authors. No financial support was received for this activity. This activity may appear in other state pharmacy association journals.

Continuing Education (continued from page 50) Table 1 Oral Hypertensive Drugs Usual Usual Dose Daily Range in Frequency Mg/Day

Class

Drug (Trade Name)

Thiazide diuretics

chlorothiazide (Diuril) chlorthalidone (generic) hydrochlorothiazide (Microzide, HydroDIURIL) polythiazide (Renese) indapamide (Lozol) metolazone (Mykrox) metolazone (Zaroxolyn)

125-500 12.5-25

1-2 1

12.5-50 2-4 1.25-2.5 0.5-1.0 2.5-5

1 1 1 1 1

bumetanide (Bumex) furosemide (Lasix) torsemide (Demadex)

0.5-2 20-80 2.5-10

2 2 1

Potassium-sparing amiloride (Midamor) diuretics triameterene (Dyrenium)

5-10 50-100

1-2 1-2

Aldosterone receptor blockers

eplerenone (Inspra) spironolactone (Aldactone)

50-100 25-50

1-2 1-2

Beta Blockers

atenolol (Tenormin) betaxolol (Kerlone) bisoprolol (Zebeta) metoprolol (Lopressor) metoprolol extended release (Toprol XL) nadolol (Corgard) propranolol (Inderal) propranolol long-acting (Inderal LA) timolol (Blocadren)

25-100 5-20 2.5-10 50-100 50-100 40-120 40-160 60-180 20-40

1 1 1 1-2 1 1 2 1 2

BBs with intrinsic sympathomimetic activity

acebutolol (Sectral) penbutolol (Levatol) pindolol (generic)

200-800 10-40 10-40

2 1 2

Combined alphaand BBs

carvedilol (Coreg) labetalol (Normodyne, Trandate)

12.5-50 200-800

2 2

Direct Renin Inhibitors

aliskiren (Tekturna)

150-300

1

ACEIs

benazepril (Lotensin) captopril (Capoten) enalapril (Vasotec) fosinopril (Monopril) lisinopril (Prinivil, Zestril) moexipril (Univasc) perindopril (Aceon) quinapril (Accupril) ramipril (Altace) trandolapril (Mavik)

10-40 25-100 5-40 10-40 10-40 7.5-30 4-8 10-80 2.5-20 1-4

1 2 1-2 1 1 1 1 1 1 1

Angiotensin II antagonists

candesartan (Atacand) eprosartan (Teveten) irbesartan (Avapro) losartan (Cozaar) olmesartan (Benicar) telmisartan (Micardis) valsartan (Diovan)

8-32 400-800 150-300 25-100 20-40 20-80 80-320

1 1-2 1 1-2 1 1 1-2

Loop diuretics

Class

Drug (Trade Name)

CCBsâ&#x20AC;&#x201D;nonDihydropyridines

diltiazem extended release (Cardizem CD, Dilacor XR, Tiazac) diltiazem extended release (Cardizem LA) verapamil immediate release (Calan, Isoptin) verapamil long acting (Calan SR, Isoptin SR) verapamil (Coer, Covera HS, Verelan PM)

Usual Usual Dose Daily Range in Frequency Mg/Day 180-420 120-540

1 1

80-320

2

120-480 120-360

1-2 1

amlodipine (Norvasc) felodipine (Plendil) isradipine (Dynacirc CR) nicardipine sustained release (Cardene SR) nifedipine long-acting (Adalat CC, Procardia XL) nisoldipine (Sular)

2.5-10 2.5-20 2.5-10 60-120

1 1 2 2

30-60 10-40

1 1

Alpha-1 blockers

doxazosin (Cardura) prazosin (Minipress) terazosin (Hytrin)

1-16 2-20 1-20

1 2-3 1-2

Central alpha-2 agonists and other centrally acting drugs

clonidine (Catapres) clonidine patch (Catapres-TTS) methyldopa (Aldomet) reserpine (generic) guanfacine (Tenex)

0.1-0.8 0.1-0.3 250-1,000 0.1-0.25 0.5-2

2 1 wkly 2 1 1

25-100 2.5-80

2 1-2

CCBsâ&#x20AC;&#x201D; Dihydropyridines

Direct vasodilators hydralazine (Apresoline) minoxidil (Loniten)

Arizona Journal of Pharmacy 51

Continuing Education

Natural Products: Goldenseal, Gotu Kola, Grapeseed Extract, Green Tea

by J. Richard Wuest, R.Ph., Pharm.D., Professor Emeritus, University of Cincinnati, Cincinnati, Ohio and Thomas A. Gossel, R.Ph., Ph.D., Professor Emeritus, Ohio Northern University, Ada, Ohio Goals The goals of this lesson are to present information on the claims, mechanisms of action, typical dosages used and other items of interest on natural products and nutraceuticals alphabetically from goldenseal to green tea, and to provide background information for assisting others on their proper selection and use.

Objectives At the conclusion of this lesson, successful participants should be able to: 1. exhibit knowledge of the claims, mechanisms of action and typical dosages for natural products and nutraceuticals presented; 2. select from a list, the synonyms for these products; and 3. demonstrate an understanding of information that can be used when discussing these products with consumers.

GOLDENSEAL Goldenseal (Hydrastis canadensis), also known as eye balm, eye root, goldenroot, goldsiegel, ground raspberry, hydrastis, Indian dye, Indian plant, Indian tumeric, jaundice root, orange root, turmeric root, warnera, wild curcuma, yellow Indian paint, yellow paint, yellow puccoon, and yellow root, is an herb found in the midwestern areas of the United States along the Ohio river valley running up into the northeastern parts of the country.

While it is indigenous to the U.S., it is now cultivated in many other areas of the world.

Goldenseal is a horizontal bright yellow plant with knotty and twisted rhizomes (creeping underground stems) out of which root fibers grow. These are the medicinal parts of the herb. They are harvested in the autumn, air dried and ground for use. The taste is very bitter and its odor is strong and disagreeable. The plant received its name from the goldenyellow scars on the rhizomes. When they are broken, the scars resemble the gold wax letter seals used in Colonial days. The coloration comes from the large amounts of the yellow alkaloid berberine, which is one of the constituents of goldenseal.

Other bioactive components of goldenseal 52 Arizona Journal of Pharmacy

include canadine, canadaline and hydrastine.

American Indians used goldenseal root as a diuretic, tonic, insect repellent, and for irritated and inflamed eyes. They also used it to treat arrow wounds and to make a yellow dye.

Today, goldenseal is used to treat the symptoms of the common cold, flu, whooping cough and other upper respiratory infections, chronic fatigue syndrome, colitis, constipation, diarrhea, dysmenorrhea and excessive menstrual flow, flatulence, gastritis, gonorrhea, hay fever, hemorrhoids, jaundice, liver disease, loss of appetite, malaria, peptic ulcer disease, postpartum bleeding, urinary tract infections and vaginitis.

Topically, goldenseal is used as a mouthwash for sore gums and irritation of mucosal tissue. It is used on the skin for acne, eczema, infections, itching, rashes, seborrhea, ulcers and infections, including ringworm and herpes. In the eye, it is used for inflammation, conjunctivitis and redness. Goldenseal is used in the ears for earache and tinnitus.

In homeopathic medicine, goldenseal is used for treatment of bronchitis, digestive problems and irregular menstruation.

There is a traditional belief that goldenseal can be used to affect the outcome of urinalysis for illicit drugs by being ingested prior to testing or adding it to the urine sample after collection. It is reported to be commonly detected in urinalysis in drug screening programs.

This concept dates back to a novel, Stringtown on the Pike, written in the mid 1800s in which goldenseal bitters are mistaken for strychnine in a simple alkaloid test by an expert witness in a murder trial.

It is of some interest that the novel was one of several authored by a prominent pharmacist of his day, John Uri Lloyd.

He was also a founder of the Cincinnati College of Pharmacy, cofounder of the American Pharmaceutical Association, the “Father of eclectic pharmacy” and developer of the extensive line of “Lloyd’s Specifics.” For historical perspective, eclectic pharmacy was the systematic collection and testing of substances

(mostly herbs and plants) of potential medicinal value and selecting the best and most desirable for treating complaints and diseases. Eclectic pharmacy bridged the gap between leeches, strong laxatives and unproven remedies and today’s scientific and chemical-based therapeutic practice.

Proponents of the use of goldenseal claim that its components inhibit the growth of several microorganisms, including Chlamydia trachomatis, Shigella dysenteriae, Salmonella paratyphi, Klebsiella, Mycobacterium tuberculosis and Helicobacter pylori.

Berberine is reported to have choleretic (bile-stimulatory), hypotensive, antisecretory and sedative effects.

Detractors of its use report that the alkaloids of goldenseal are poorly absorbed when given orally and might not reach adequate concentrations in the body to produce significant pharmacologic activity. Conversely, proponents of the use of goldenseal state that the fact they are detectable in urine attests to their absorption and systemic activity.

When taken orally in appropriate doses for short-term use in adults, goldenseal appears to be safe. However, very high doses may rarely cause nausea, anxiety, depression, seizures and paralysis.

Goldenseal is contraindicated for use during pregnancy and lactation. Berberine reportedly crosses the placenta and may harm the fetus. Kernicterus has developed in newborn infants exposed to goldenseal.

It also can be excreted in breast milk.

The traditional dose of goldenseal is 250 to 500 mg of extract (standardized to 5 percent hydrastine) three times a day.

Also, 500 mg to 1 gram of dried rhizome three times a day has been used.

GOTU KOLA Gotu kola (Centella asiatica, C. coriacea), also known as brahma-buti, brahma-manduki, centella, centellase, divya, hydrocotyle, idrocotyle, Indian Pennywort, Indian water navelwort, khulakhudi, madecassol, mandukaparni, manduk parani, mandukig, marsh penny, talepetrako, thick-leaved pennywort, tsubo-kusa, tungchian and white rot, is a slender creeping plant that grows in

Continuing Education (continued from page 52) swampy areas of India and Sri Lanka, southern China, Madagascar, South Africa, the southern U.S., Mexico, Columbia, Venezuela, eastern South America and the South Sea Islands.

The medicinal portions of gotu kola are the dried above ground parts, the fresh and dried leaves, and its stem. Highly used in Indian and Chinese medicine, the plant is harvested throughout the year and dried in the sun.

People take gotu kola to reduce anxiety, depression and fatigue; to improve intelligence and memory; to enhance circulation, decrease edema and treat varicose veins; as an aphrodisiac as well as a contraceptive; and to increase longevity. It has been used to treat symptoms of the common cold and the flu, abdominal pain, anemia, asthma, cholera, diabetes, dysentery, diarrhea, epilepsy, gastric and peptic ulcers, gastritis, hepatitis, indigestion, jaundice, leprosy, pleurisy, peripheral artery disease, sunstroke, tonsillitis, shingles and urinary tract infections. Topically, gotu kola is used for wound healing and to reduce scarring.

In homeopathic medicine, gotu kola is used for skin diseases associated with itching and swelling, and to reduce inflammation of the uterus.

Gotu kola has several constituents that are thought to have pharmacologic activity. These include asiatic acid, madecassic acid, asiaticosides A and B, various essential oils, flavonoids and flavone derivatives. There is evidence, but not conclusive proof, that gotu kola might bind with cholecystokinin in the intestine and GABA receptors in the central nervous system. Cholecystokinin is a hormone liberated by the intestinal mucosa on contact with entering gastric contents. It stimulates the gallbladder and the secretion of pancreatic juices.

This would provide gastrointestinal and digestive effects.

GABA (gamma aminobutyric acid) is the principle inhibitory neurotransmitter in the central nervous system. If gotu kola does significantly bind with GABA receptors, this could provide anti anxiety, sedative, analgesic and anticonvulsant activity. There are proponents of its use who believe that gotu kola might protect neurons in the brain from beta-amyloid (the substance thought to destroy neurons in the hippocampus, which leads to

memory loss) toxicity and thus have a role in treating patients with Alzheimerâ&#x20AC;&#x2122;s dementia.

There are reports suggesting that constituents of gotu kola seem to speed up wound healing, have anti-inflammatory effect, improve connective tissue remodeling by increasing fibroblast (cells in connective tissue that form collagen) activity, increasing epithelial cell turnover and decreasing capillary permeability.

It has been proposed that gotu kola might increase the collagen content within arterial plaque. Since plaque with low collagen content are structurally weak and linked to an increased risk of rupture and embolism, gotu kola might help stabilize arterial plaque. Proponents further state that there is preliminary evidence that it may have a strengthening effect on the gastric mucosal lining and suppress free radical damage, thus providing useful preventative and therapeutic effects on gastrointestinal ulcers.

Taken in recommended doses, gotu kola is usually well-tolerated. However, there are reports of gastrointestinal upset and nausea. Rarely, hepatotoxicity has been associated with its use. When used topically, gotu kola can rarely cause allergic contact dermatitis.

The typical oral dose of gotu kola is 60 mg of its extract two to three times a day. One percent creams have been used topically for wound healing.

GRAPESEED EXTRACT Grapeseed (Vitis vinifera), also known as activin, calzin, enocianina, European wine grape, flame grape, leucoanthocyanin, muskat, oligomeric proanthocyanidins, oligomeric procyanidins, OPC, PCOs, petite sirah, proanthodyn, procyanidolic oligomers and sultanas, is indigenous to southern Europe and western Asia. However, it is cultivated in most temperate regions of the world.

The medicinal portions of grape plants are considered to be the leaves, fruit and flowers. Grapeseed extract, the most used and studied portion, is generally obtained as a byproduct of wine production.

Although wine has been a beverage ingested by humans for millennia, the use of grapeseed extract for medicinal purposes is a relatively recent event.

Its popularity increased in the Western World with the French using it to treat venous and capillary disorders such as

retinopathies, venous insufficiency and vascular fragility. This has been reported to be the result of what has been called the French Paradox. The observation has been made that even though the French have a high dietary intake of fatty foods, this is not associated with a higher occurrence of atherosclerosis and other cardiovascular diseases seen elsewhere in Europe and North America. Allegedly, this is due to their high intake of wine and wine byproducts.

Grapeseed extract is used in folk medicine for preventing cardiovascular diseases, atherosclerosis, cerebral and myocardial infarction, hemorrhoids, hypertension, peripheral vascular disease and varicose veins. It is also used for the complications of diabetes, such as neuropathy; allergic rhinitis; age-related macular degeneration, poor night vision; to improve wound healing; and to prevent dental cavities, cirrhosis of the liver, cancer and the breakdown of collagen.

The therapeutic activity of grapeseed extract is attributed to its component proanthocyanidins, which are members of a group of compounds called flavonoids. These substances are claimed to have a wide variety of effects, including antioxidant, vasodilatory, antilipoperoxidant activity and antiplatelet aggregation properties, all of which would be helpful in treating heart disease.

Proanthocyanidins are responsible for producing the red color of grapes. The red varieties of grapes reportedly provide greater antioxidant activity than the white or blush categories, with red wines containing approximately 10 times more proanthocyanidins than white wines.

Other flavonoid constituents of grapeseed extract include catechin, kaemferol (aka kaempferol), myricetin and quercetin. Catechin reportedly can inhibit low-density lipoprotein oxidation, and the others have antioxidant activity as well.

Catechins might inhibit allergen-induced histamine release from mast cells.

Flavonoids also appear to decrease superoxide production, increase nitric acid release from platelets and increase the levels of antioxidants, such as alphatocopherol (vitamin E) from storage in the body. Claims are made that grapeseed proanthocyanidins may produce greater protection against reactive oxygen species, free-radical induced lipid peroxidation and DNA damage than Arizona Journal of Pharmacy 53

Continuing Education (continued from page 53) combinations of vitamin C and vitamin E, with or without beta-carotene (vitamin A).

Grapeseed extract is well tolerated, with no adverse events reported at a higher level of occurrence than those seen with placebo.

The typical dose of grapeseed extract for treating chronic venous insufficiency using commercially available products is 75 to 300 mg daily for three weeks followed by maintenance doses of 40 to 80 mg daily. For cardiovascular protective effects, 150 to 300 mg of proanthocyanidins from grapeseed extract is suggested.

GREEN TEA Green tea (Camellia sinensis, C. thea, C. theifera, Thea bohea, T. sinensis, T. viridis), also known as Chinese tea, epigallo catechin gallate, and Japanese tea, is a large evergreen shrub native to eastern Asia. Although originally cultivated in China, the tea plant is now grown in extensive amounts for commercial purposes in Argentina, India, Indonesia, Japan, Kenya, Malawi, Pakistan, Sri Lanka and Turkey.

The tea plant has leathery, dark green leaves and fragrant, white flowers. The dried, cured leaves of green tea have reportedly been used medicinally for more than 5,000 years to promote digestion, improve mental faculties, decrease flatulence and regulate body temperature.

It is no news bulletin to state that other than water, tea is the most widely ingested beverage around the world, with the exception of the United States, where coffee has become the most popular beverage. Elsewhere, tea is used at meals, ceremonies, celebrations and relaxation time. What is not generally known is that the three major types of tea, black, green and oolong, do not differ in the species of plant on which the leaves grow. Rather, the difference is in the way the leaves are processed after they are harvested.

Black and oolong tea are produced by fermenting and oxidizing the young tea leaves. Black tea is fully fermented and oolong tea is partially fermented. Green tea is produced by steaming fresh leaves at high temperatures. This inactivates the oxidizing enzyme components, leaving the polyphenol flavonoid content intact (i.e., catechin, epicatechin, epigallocatechin, and gallocatechin). Green tea has approximately six times the antioxidant 54 Arizona Journal of Pharmacy

activity as the other two types. All three types of tea contain similar amounts of caffeine, theobromine, theophylline and tannins until they are commercially processed.

Green tea is taken to improve mental alertness and cognitive performance. The CNS stimulant effect of green tea is due to its caffeine content, which averages 2 to 4 percent, or 10 to 80 mg per cup, depending on how much tea is used and how long it is brewed.

It is also used as a diuretic; in combination with other herbs for appetite suppression; and to treat diarrhea, stomach disorders, vomiting and headache. It has also been used to reduce the risk of breast, colon, gastric, lung, prostate and skin cancer, and to treat solid tumor cancers.

Other uses include treating cardiovascular disease, chronic fatigue syndrome and Crohn’s disease, diabetes, hypertension, kidney stones, migraine, and Parkinson’s disease.

Topically, green tea has been used as a wash to soothe sunburn, as a poultice for “bags” under the eyes, as a compress for tired eyes and headaches, and to stop bleeding from the socket after tooth extraction.

In homeopathic medicine, green tea is used to treat agitation, cardiac and circulatory conditions, depression, headache and stomach complaints. In Indian medicine, green tea preparations are used for cardiac pain, diarrhea, loss of appetite and migraine. In Chinese medicine, green tea is used to treat diarrhea resulting from digestive problems, malaria, migraine and nausea.

It has also been used in China as a cancer preventative.

There is little doubt that in most people, consumption of green tea (and any other caffeinated beverage) will increase mental alertness and improve cognitive performance. There is evidence that combining caffeine-containing beverages with glucose as “energy” drinks may improve mental performance better than placebo or either caffeine or glucose alone.

There is some, but inconclusive, evidence that drinking green tea may reduce the risk of bladder, esophageal, gastric and pancreatic cancer, as well as breast and ovarian cancer recurrence.

Drinking green tea on a daily basis seems to lower cholesterol and triglyceride levels, as well as the risk of hypertension,

and to help prevent or delay the onset of Parkinson’s disease. But, none of the studies reporting these effects meet the rigorous standards needed for FDA approval of such claims.

There is insufficient reliable evidence that consuming green tea lowers the risk of developing diabetes, lung cancer, ischemic heart disease and death after myocardial infarction, or that it is useful for weight reduction in obese individuals.

Other pharmacologic activities attributed to caffeine include increased release of dopamine; decreased airway resistance along with stimulation of respiration; decreased gamma aminobutyric acid (GABA) and serotonin signaling; positive inotropic and chronotropic effects on the heart; elevation of both diastolic and systolic blood pressure (but not in chronic users); and a diuretic effect.

The proposed mechanism of action of the polyphenol flavonoids contained in green tea include an antimutagenic effect that may protect DNA, inhibit tumor cell proliferation, cause cell cycle arrest and cancer cell death. Animal research suggests these components may do this via reactive oxygen species formation and mitochondrial depolarization.

Polyphenol flavonoids are claimed to reduce cellular adhesiveness of bacteria associated with dental disease. Further claims are made that they prevent skin damage and cancer caused by ultraviolet radiation by means of their antioxidant effect.

Although some individuals cannot tolerate green tea and those with conditions adversely affected by caffeine should avoid it, there is a lack of reports of clinical toxicity from daily consumption of moderate amounts of green tea. However, there are reports of excessive CNS stimulation (such as dizziness, insomnia, agitation, restlessness, tremors, fatigue, confusion), nausea, vomiting, abdominal bloating and pain, upset stomach, flatulence and diarrhea resulting from ingestion of large amounts of green tea or high doses of green tea extract, equivalent to five or more liters of tea per day.

Large doses of caffeine can also cause massive catecholaminerelease leading to irregular heartbeat, metabolic acidosis, hyperglycemia and ketosis, headache, anxiety, ringing in the ears, hypokalemia, respiratory distress and chest pain. Having

Continuing Education (continued from page 54) reported all this, it should be pointed out that the daily consumption of moderate amounts of green tea seems to cause no health problems.

The typical doses of green tea vary significantly, ranging up to 10 cups per day. The commonly used dose consumed for medicinal purposes in tea-drinking nations is around three cups per day using one teaspoonful of powdered tea in eight ounces of boiling water. This would provide 240 to 320 mg of polyphenol flavonoids.

ACPE UAN #0100-9999-050-H01-P The content of this lesson was developed by the Ohio Pharmacists Foundation and reprinted with permission. No financial support was

received for this activity. This activity may appear in other state pharmacy association journals. Participants should not seek credit for duplicate content.

CPE Monitor: Information for Pharmacists and Pharmacy Technicians What is CPE Monitor?

CPE Monitor is a national, collaborative effort by ACPE and the National Association of Boards of Pharmacy (NABP) to provide an electronic system for pharmacists and pharmacy technicians to track their completed continuing pharmacy education (CPE) credits.

It will also offer boards of pharmacy the opportunity to electronically authenticate the CPE units completed by their licensees, rather than requiring pharmacists and pharmacy technicians to submit their proof of completion statements (i.e. statements of credit) upon request or for random audits.

How CPE Monitor Works Pharmacists and pharmacy technicians will receive a unique identification number (ID) after setting up their e-Profile with NABP (see How to Register for CPE Monitor). Beginning in the latter part of 2011, pharmacist and pharmacy technician participants will provide their NABP e-Profile ID and date of birth (in MMDD format) to the ACPE-accredited provider when

they register for a CPE activity or submit a request for credit. It will be the responsibility of the pharmacist or pharmacy technician to provide the correct information [i.e. ID and DOB (in MMDD format)] in order to receive credit for participating in a CPE activity.

The CPE Monitor system will direct electronic data from ACPEaccredited providers to ACPE and then to NABP, ensuring that CPE credit is officially verified by the providers.

Once information is received by NABP, pharmacists and pharmacy technicians will be able to log in to access information about their completed CPE activities.

How to Register for CPE Monitor Pharmacists and pharmacy technicians are asked obtain their NABP e-Profile ID now at www.MyCPEmonitor.net to ensure their e-Profile is properly setup prior to implementation of CPE Monitor.

In the latter part of 2011, the e-Profile ID will be required to receive credit for any ACPE-accredited CPE activities.

Set up your NABP e-Profile to obtain your ID here Benefiting Pharmacists and Pharmacy Technicians CPE Monitor will provide a secure, central system that maintains and tracks all ACPE-accredited CPE credits. This streamlined process will eliminate the

need to file and maintain hard copy statements of credit for CPE activities taken from ACPE-accredited providers.

Instead, online access to their inventory of completed credits will allow pharmacists and pharmacy technicians to easily monitor their compliance with the CPE requirements of the state or states where they hold a license or registration. Licensees of participating boards will no longer have to mail hard copy proof of CPE statements of credit to those boards.

For added convenience, the NABP e-Profile is available 24/7 for pharmacists and pharmacy technicians to view a comprehensive list of the ACPE-accredited CPE activities they have taken. All information will be maintained in a highly secure environment. ACPE and NABP do not distribute any personal information for commercial purposes without consent.

Pharmacists or pharmacy technicians with questions regarding their NABP e-Profile or CPE Monitor should refer to the FAQ section on the NABP website or contact NABP Customer Service.

NABP Customer Service custserv@nabp.net Tel: 847-391-4406 Fax: 847-391-4502 Hours: Monday - Friday, 9:00 a.m. to 5:00 p.m. central time Arizona Journal of Pharmacy 55

Obituaries

Wayne William Willer, 87, and long time Cave Creek resident died on Sunday, June 12. Wayne was born Jan. 7, 1924 in Sioux City, Iowa to Henry and Sylvia Willer.

He attended East High in Sioux City, graduating in 1942. He served in the Army Air Corps from 1943 to 1946, where he served as a radio/weatherman and gunner on P-38s, B-17s, B-24s and B-29s. He also played in the drum and bugle corps and continued his musical talent in his later years playing the gut bucket at several of his favorite Cave Creek hideouts.

In 1943 he married Dorothy Louise Hakes of Lavinia, Iowa.

They started their family in Sioux City. He received his pharmacy degree from the University of Iowa and remained an avid Hawkeye fan throughout his life. He moved with his family to Phoenix, Ariz. in 1950 and worked at pharmacies in both Phoenix and Carefree.

In 1970 he purchased the Carefree Pharmacy and moved to Cave Creek. In 1975 Wayne married Susan VanNimwegan of Phoenix. He worked for the Arizona Board of Pharmacy for 10 years retiring, as Chief Drug Inspector in 1989. Wayne’s contributions to his profession include serving on the sheriff’s posse, he was a volunteer ambulance driver, served as a board member of the Cave Creek Museum, chairman of the Cave Creek Fiesta Days parade several times, and was a member of the American Legion Post 34 for 40

years.

Wayne was President of the Arizona Pharmacy Association in 1977-1978.

His son Randy preceded him in death in 2003. He was a loving husband, father, and brother and is survived by his wife, Sue; Dorothy, the mother of his children; sons Jeff (Ellen) of Phoenix; Rick (Jeanette) of Tempe and Maui, Hawaii; and Rob (Stephanie) of Bedford, N.H., and his daughter Lori (Gary) Hay of Cave Creek; brothers David and Vern, and sister Marilyn, and five step-children. He has eleven grandchildren and four great grandchildren.

In lieu of flowers, donations can be made to Cave Creek Museum, P.O. Box 1, Cave Creek, AZ 85327.

Are you a recent pharmacy school graduate?

Have you relocated to Arizona and wish to apply for reciprocity?

The Arizona Pharmacy Alliance’s Online Pharmacy Law & Quality Assurance Course is ideal preparation for the MPJE! 15 Hours of continuing pharmacy education completely online!

This two-week course is designed to provide home study law credit to any pharmacist wanting to learn about quality assurance strategies and Arizona’s pharmacy laws, and ideal for pharmacists applying for reciprocity into Arizona, recent pharmacy school graduates preparing to take the MPJE, or pharmacists who want an update on Pharmacy Law and Quality Assurance.

Online discussion boards, instructor monitoring, and interaction keep you on track throughout the course.

Assignments, tests and quizzes track your progress. You must receive a score of 70% or higher on the final exam to pass this course and receive credit. This course is accredited by ACPE for 15 hours (1.5 CEUs) of home study pharmacy law continuing education.

Course Fee including textbook: AzPA Member $215 AzPA Student Member $145 Non-Member $315 56 Arizona Journal of Pharmacy

Visit www.azpharmacy.org to register.

Continuing Education Quiz Hypertension Therapy Update 1. A 54 year-old male has a blood pressure reading in your pharmacy of 152/94 mg Hg. How would you classify this blood pressure reading?

A. Prehypertension.

B. Stage 1 hypertension.

C. Stage 2 hypertension.

D. Normal blood pressure.

2. New data indicates: A. Diuretics are not effective in blood pressure control.

B. Single drug therapy to the maximum effective level is preferred.

C. Use of more than one medication with gradually increasing from small doses is effective.

D. All antihypertensives result in lowered potassium serum levels.

3. Renin is released secondary to: A. Decreased sodium and/or fluid in the distal convoluted tubule.

B. Increased potassium levels in the loop of Henle.

C. Increased sodium and/or fluid in the distal convoluted tubule.

D. Decreased sodium and/or fluid in the proximal convoluted tubule.

4. Thiazide diuretics lower blood pressure in patients with hypertension. The mechanism(s) for this action are: A. Reduce alpha adrenergic tone and decrease heart rate.

B. Reduce fluid levels through diuresis and additional activity on blood vessels.

C. Reduce fluid levels through diuresis and a central nervous system action to decrease alpha adrenergic action.

D. Reduce fluid levels through diuresis and reduce cardiac output by decreasing heart rate.

5. Beta blockers actions: A. Can reduce hepatic glucose output.

B. Can directly cause bronchodilation.

C. Can increase LDL-cholesterol levels.

D. Can reduce renin release in the kidney.

6. Angiotensin converting enzyme inhibitors: A. Routinely increase heart rate by direct stimulation.

B. Exert selective action on Beta-2 nerves in the vascular smooth muscle.

C. Cannot be given concurrently with thiazide diuretics.

D. Can produce a chronic cough.

7. Calcium channel blocking agents can cause all but which of the following?

A. Peripheral edema.

B. Altered INR results in patients taking warfarin.

C. Stimulation of renin release.

D. Worsening of heart failure.

8.Alpha-1 blockers: A. Can induce a syncopal episode with the first dose of the medication.

B. Are effective for benign prostatic hypertrophy.

C. Cause lowered blood pressure through their effects of limiting norepinephrine action.

D. A and B. E. All of the above.

9. Which of the following is/are good patient teaching tips for methyldopa?

A. Take the medication at the same time each day if possible.

B. Report any new medications added to your regimen to your primary physician.

C. Take your methyldopa in the morning with your other medications, including iron if prescribed.

D. A and B. E. All of the above.

10. Which of the following is considered a cardiovascular risk factor?

A. Routine aerobic physical activity of 45 minutes per session five times a week.

B. Women aged 56 years old with no other cardiovascular event history.

C. Presence of microalbuminuria.

D. Body mass index of 26 Kg/m2.

This activity was developed by the Arizona Pharmacy Alliance as a knowledge-based learning activity. The Arizona Pharmacy Alliance is accredited by the Accreditation Council for Pharmacy Education as providers of continuing pharmacy education.

Arizona Pharmacy Foundation Hypertension Therapy Update

ACPE UAN#0100-9999-051-H01-P This activity is accredited for 1.5 hours of CPE credit (CEUs 0.15) This activity is a benefit to AzPA members. Non-members of AzPA must enclose a $25.00 check payable to the Arizona Pharmacy Foundation.

In order to qualify for ACPE credit, participants must achieve a grade of 70% or above on the quiz and submit a completed activity evaluation.

ACTIVITY EVALUATION – Please indicate if the activity met the stated learning objectives: 1. List goals for hypertension control 2. Chart categories of drug therapy available for hypertension treatment 3. Describe the use of each agent, dosing, and monitoring guideline 4. Forecast potential direction for future hypertension therapy plans

AGREE AGREE AGREE AGREE

Will the information presented cause you to make any changes to your style or method?

Yes If you answered “yes” please list one or two things you will do differently: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Overall evaluation of the article content: (please circle one)

Name __________________________________________________________ Address ________________________________________________________

Poor

1

DISAGREE DISAGREE DISAGREE DISAGREE

No

2

3

4

5

Excellent

Activity accredited date: 10-01-2011 Expiration date: 10-01-2012.

Send this page to: APF, 1845 E. Southern Ave., Tempe, AZ 85282

Email ________________________________________________________

City, State, Zip ___________________________________________________

Certificates will be mailed within 60 days.

Continuing Education Quiz

Natural Products: Goldenseal, Gotu Kola, Grapeseed Extract, Green Tea 1. All of the following are synonyms for goldenseal EXCEPT: a. centella. b. ground raspberry. c. hydrastis. d. Indian tumeric.

2. The coloration of goldenseal comes from its large content of the alkaloid: a. atropine. b. berberine. c. hydrastis. d. Indian tumeric.

3. The systematic collection and testing of plants of potential medicinal value and selecting the best for treating complaints is called: a. organic pharmacy. b. naturopathic pharmacy. c. homeopathic pharmacy. d. eclectic pharmacy.

4. The medicinal portions of gotu kola include all of the following EXCEPT the: a. fresh leaves. b. stems. c. roots. d. dried leaves.

This activity was developed by the Ohio Pharmacists Foundation for pharmacists as a knowledge-based learning activity.

The Arizona Pharmacy Alliance and OPF are accredited by the Accreditation Council for pharmacy Education as providers of continuing pharmacy education.

5. There is evidence, but not conclusive proof, that gotu kola might bind with which of the following substances in the body? a. Pepsinogen b. Intrinsic factor c. Hydrochloric acid d. Cholecystokinin 6. The popularity of using grapeseed extract increased in the Western World with the French using it to treat all of the following ailments EXCEPT: a. retinopathies. b. sleep disorders. c. vascular fragility. d. venous insufficiency.

7. Proanthocyanidins are members of a group of compounds called: a. alkaloids. b. cyanides. c. flavonoids. d. prostaglandins.

8. The three major types of tea (black, green, oolong) come from: a. the same species of tea plant. b. two different species of tea plant. c. three different species of tea plant. d. more than a dozen different species of tea plant.

9. Which type of tea has the greatest antioxidant activity compared to the other two types? a. Black b. Green c. Oolong 10. One of the pharmacologic activities attributed to caffeine includes increased release of: a. serotonin. b. gamma aminobutyric acid. c. dopamine. d. acetylcholine.

Arizona Pharmacy Foundation Natural Products: Goldenseal, Gotu Kola, Grapeseed Extract, Green Tea

ACPE UAN #0100-9999-050-H01-P. This activity is accredited for 1.0 hours of CPE credit (CEUs 0.10) This activity is a benefit to AzPA members. Non-members of AzPA must enclose a $25.00 check payable to the Arizona Pharmacy Foundation.

In order to qualify for ACPE credit, participants must achieve a grade of 70% or above on the quiz and submit a completed activity evaluation.

ACTIVITY EVALUATION – Please indicate if the activity met the stated learning objectives:

1. exhibit knowledge of the claims, mechanisms of action, and typical dosages for natural products and nutraceuticals presented.

2. select from a list, the synonyms for these products 3. demonstrate an understanding of information that can be used when discussing these products with consumers.

AGREE AGREE

AGREE

Will the information presented cause you to make any changes to your style or method?

Yes No If you answered “yes” please list one or two things you will do differently: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

DISAGREE DISAGREE DISAGREE

Overall evaluation of the article content: (please circle one) Poor 1 2 3 4 5 Excellent

Activity accredited date: 10-1-2011 Expiration date: 10-1-2012.

Name __________________________________________________________ Send this page to: APF, 1845 E. Southern Ave., Tempe, AZ 85282 Address ________________________________________________________

Email_________________________________________________________

City, State, Zip ___________________________________________________

Certificates will be mailed within 60 days.

Time Capsule Pharmacy Time Capsules Third Quarter 2011 •

1986—Twenty-five Years Ago: •

72 accredited US colleges of pharmacy graduated 10,685 students with entry level professional degrees (9,501 BS and 1184 PharmD).

•

75 accredited US colleges of pharmacy graduated 3,497 students with entry level professional degrees (3,395 BS and 102 PharmD).

1936—Seventy-five Years Ago: •

1911—One Hundred Years Ago: •

1961—Fifty Years Ago:

Pentothal (thiopental sodium) is introduced by Abbott Laboratories. Ernest Volwiler, one of the inventors, went on to become president of Abbott. The American Association of Colleges of Pharmacy’s premier research award is given annually in his name.

Hospital Pharmacists of Minnesota (HPM) formed with the objective of extending and promoting hospital pharmacy.

Pharmacy education resumed its operation as The University of Tennessee School of Pharmacy, upon the transfer of the UT medical and dental schools to Memphis.

1886—One Hundred Twenty-five Years ago: •

John Pemberton, an Atlanta pharmacist, concocted a flavorful syrup which was added to carbonated water at Jacobs Pharmacy and Coca Cola was born.

One of a series contributed by the American Institute of the History of Pharmacy, a unique non-profit society dedicated to assuring that the contributions of your profession endure as a part of America’s history.

Membership offers the satisfaction of helping continue this work on behalf of pharmacy, and brings five or more historical publications to your door each year. To learn more, check out: www.aihp.org.

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Arizona Journal of Pharmacy 59

Financial Forum

FINANCIAL FORUM This series, Financial Forum, is presented by Pro Advantage Services, Inc., a subsidiary of Pharmacists Mutual Insurance Company, and your State Pharmacy Association through Pharmacy Marketing Group, Inc.,a company dedicated to providing quality products and services to the pharmacy community.

COMMON FINANCIAL MISTAKES A few things you can’t afford to do Are you making mistakes with your money?

Many people do, because of inattention, a lack of knowledge or confidence, or relying of the advice of friends rather than professionals. Here are some alltoo-common money errors to avoid …

Putting off financial planning.

This may be the biggest mistake of all. Procrastination does not help you save for retirement, and it will not help you reduce your taxes or transfer money to your heirs. Delaying necessary financial planning can be perilous. Some avoid planning out of fear – they simply don’t know where to begin. Don’t let this stop you. Decide today to do something about your financial future.

Putting all your eggs in one basket.

Too many people invest everything in just one place.

Try spreading your assets across multiple investments, and you’ll help to insulate them against the effects of economic ups and downs.

Buying more home than you can afford.

Interest-only loans, option adjustable-rate mortgages (option ARMs) and lease purchases still tantalize couples and families with small nest eggs, modest salaries and credit blemishes into taking on much more liability than they can bear. The result is often foreclosure. Speak to a professional to make sure the amount of home you purchase makes sense for you.

Making impulsive or emotional money decisions.

A decision that feels good (or exciting) may not be appropriate for you financially. Avoid spur-of-themoment financial choices, and the influences that may trigger them. The next time you’re about to make a snap decision, stop and think. Will you lose the opportunity if you take a while to consider your next move? Consider and compare whenever possible.

60 Arizona Journal of Pharmacy

Living above your means.

In the acclaimed book The Millionaire Next Door, authors Thomas Stanley and William Danko found that most millionaires drive used American cars and shun a champagne-and-caviar lifestyle. It is the middle class that is generally seduced by big-debt, big-ticket luxury items … sometimes all the way into bankruptcy. Make wise decisions about money, take the time to consider big purchases, and be mindful of what effect they’ll have on finances down the road.

Avoiding all risk.

Caution is good, but being extremely risk-averse (for example, refraining from investment and just putting your money in an FDIC-insured bank account) may cost you in terms of the growth of your retirement savings and assets. If you’re holding back because you’re unsure, speak with a financial advisor.

Provided by courtesy of Pat Reding, CFPTM of Pro Advantage Services Inc., in Algona, Iowa. For more information, please call Pat Reding at 1-800-288-6669.

Registered representative of and securities offered through Berthel Fisher & Company Financial Services, Inc. Member NASD & SIPC. Pro Advantage Services, Inc./Pharmacists Mutual is independent of Berthel Fisher & Company Financial Services Inc. Berthel Fisher & Company Financial Services, Inc. does not provide legal or tax advice.

Before taking any action that would have tax consequences, consult with your tax and legal professionals. This article is for informational purposes only. It is not meant to be a recommendation or solicitation of any securities or market strategy.

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Pharmacy Quality Commitment® (PQC) is a continuous quality improvement (CQI) program that supports you in responding to issues with provider network contracts, Medicare Part D requirements under federal law, and mandates for CQI programs under state law. When PQC is implemented in your pharmacy, you will immediately improve your ability to assure quality and increase patient safety.

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Call toll free (866) 365-7472 or go to www.pqc.net for more information.

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