AJP Summer 2011

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

SUMMER 2011

Arizona Pharmacy Alliance 7th Annual Meeting July 7-10, 2011

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A Lifetime Commitment to Patient Care

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ARIZONA JOURNAL A JP OF PHARMACY Vol. 3, No. 2

SUMMER 2011

IN THIS ISSUE BOARD OF DIRECTORS PRESIDENT

Kelly Ridgway PRESIDENT-ELECT

Kevin Boesen TREASURER

Ken Mahan PAST PRESIDENT

Mark Boesen SECRETARY

Michael Dietrich COMMUNITY PHARMACY ACADEMY CHAIR Teresa Stickler COMMUNITY PHARMACY ACADEMY CHAIR-ELECT Chad Schuster HEALTH-SYSTEM PHARMACY ACADEMY CHAIR Butch David HEALTH-SYSTEM PHARMACY ACADEMY CHAIR-ELECT Jonathan Merchen MANAGED CARE PHARMACY ACADEMY CHAIR Ray Clark MANAGED CARE PHARMACY ACADEMY CHAIR-ELECT Julie Hernandez SENIOR CARE PHARMACY ACADEMY CHAIR Kimberly Cauthon SENIOR CARE PHARMACY ACADEMY CHAIR-ELECT Dawn Gerber STUDENT PHARMACIST ACADEMY CHAIRS Bonnie DiLorenzo, Midwestern University College of Pharmacy Glendale Kerry Redman, University of Arizona College of Pharmacy STUDENT PHARMACIST ACADEMY CHAIRS-ELECT Valerie Bostel, Midwestern University College of Pharmacy Glendale Jessica DiLeo, University of Arizona College of Pharmacy TECHNICIAN ACADEMY CHAIR Chris Lesaca TECHNICIAN ACADEMY CHAIR-ELECT Mike Severn NORTHWEST DISTRICT DIRECTOR Norbert Laskowski NORTHEAST DISTRICT DIRECTOR Chuck Dutcher SOUTHWEST DISTRICT DIRECTOR Lisa Keller SOUTHEAST DISTRICT DIRECTOR John Nicolais INDUSTRY REPRESENTATIVE Greg Morrill DEANS OF COLLEGES

J. Lyle Bootman 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

2 CEO’s Message

3 Academy News • Community Pharmacy Academy 18 • Health-System Academy

19 • Managed Care Academy

20 • Senior Care Academy

20 • Student Pharmacist Academy 22 • Technician Academy

23 FEATURES AND ARTICLES Launch of CPE Monitor to Streamline Reporting of CPE Activity, Saving Boards Time & Resources 33 AzPA Member Satisfaction Survey Results 34 We’re in the “Army” Now

35 A Look Back - Pill Silverer

37 Time Capsule

55 DEPARTMENTS New Members

4 Alliance News

5 Legislative Update

14 PAPA

17 Drug Information Questions

24 Feature Pharmacist

• Innovation, Integrity, and Inspiration 26 • An Inspirational Leader and Mentor 28 • Compounding & Politics: A Leader in the Midst 29 Student Perspective

• SPA Leadership Conference

31 Rx and the Law 38 Continuing Education

39 Financial Forum

56 EDITOR-IN-CHIEF Mindy D. Smith, R.Ph., Executive Director MARKETING AND COMMUNICATIONS Janet Weigel EDITORIAL BOARD Leslie Rodriguez, Pharm.D. Julie Hernandez, Pharm.D. Tina Smith, Pharm.D., BCPS Whitney Rice, Pharm.D.

Arizona Journal of Pharmacy 1

President’s Message Pharmacy Rocks!

A Lifetime Commitment to Patient Care

Kelly Ridgway, R.Ph. AzPA President

Pharmacy does rock! We belong to one of the few health care professions that has a significant opportunity to reinvent ourselves. Unfortunately, we are also one of the most underutilized professionals on the health care team. Although we know what we are capable of and the benefit we can provide to our patient’s overall health care, the question we need to ask ourselves is: are we practicing this way, and if not, why not? Does the law allow us to practice this way? Are we getting paid to practice this way? Does the health care community expect us to practice this way?

This is an exciting and critical time for our profession and we need to continue to forge ahead to establish our footprint on the evolving health care reform debate or we will be left behind continuing to get paid pennies to dispense a product that a machine can do more efficiently and accurately. As automation improves and technicians are given more responsibilities, this frees up a pharmacist’s time and we need to be able to justify that having a pharmacist available for this “extra time” is valuable to both our patients and to our bottom line.

Recently, state boards of pharmacy have started granting waivers allowing 2 Arizona Journal of Pharmacy

facilities with proper automation to remove the pharmacist requirement for final verification. Some states are also passing tech-check-tech laws giving the technicians more autonomy. Both are being done to allow pharmacists “more time” with their patients. Or is it a financial strategy by the employers to save money? The bottom line is that the remuneration we receive reflects the perceived value of our services.

In order to secure our profession for the future we need to lobby on both a state and national level and insist that pharmacists be recognized as health care providers. We all have talked about this within our lecture halls, in our practice settings, and at professional meetings. While we all realize its potential, little progress has been made over the last decade toward this goal. Why? Can we blame the legislature? Can we blame the state and national agencies and organizations? Are the other health care disciplines holding us back? Or, alternatively, is it our own inaction and complacency?

We have had some exciting scope of practice expansions in recent years, specifically in the area of pharmacistadministered immunization services, collaborative practice opportunities, and MTM services. These services are the open door we have been waiting for and just may be the gateway we need to finally get paid for our services, but this will only happen if we are all engaged and only if we are all participating. These services need to become a standard of practice and something our patients, physicians, and third-party payers see as a benefit expected from all pharmacies and pharmacists.

In addition, we have the ability to get involved in other preventive screening and disease management programs to keep our patients healthy and out of the hospital. Again, the key is provider status. Anytime health care is discussed it should seem odd not to have pharmacy at the table.

Unfortunately, we are too often left out of these discussions and have to play catch up while trying to insert ourselves into the conversation.

I feel somewhat guilty ending my term as President on such a somber note. However, I do not want to sugar coat the state of our profession and the issues we need to address together as we look to the future. We have been on a “sugar high” for too long. I feel very privileged and honored to have had the opportunity to serve you and this organization over the last year. We have had a great year both legislatively and financially at AzPA and our organization is growing and reaching more pharmacists, technicians, and student pharmacists, which is very exciting. I challenge all of you to get more involved with AzPA and encourage your fellow colleagues to get involved as well.

All of this success is credited to your continued support of our organization, our Board of Directors, committee members and chairs, and last but not least the wonderful staff at AzPA. I will continue to do all I can to advocate for our profession as the Immediate Past President and welcome the leadership of Kevin Boesen, our new President.

See you all at the AzPA 7th Annual Meeting!

CEO’s Message New Opportunities I know you have heard me say

this before, but as I leave the Arizona Pharmacy Alliance and embark on the next chapter of my career, the last message I leave for you in the Arizona Journal of Pharmacy is that pharmacy needs passionate people… and deserves passion like never before. Each and every pharmacist has the ability to change the perception of pharmacy by adding value to the services you provide on a daily basis.

If your practice setting is not allowing you to practice or if your workplace is not allowing you to see patients in the capacity you should be seeing them…if you are not allowed time with your patients to provide the highest quality of care they deserve, then I would encourage you to find a different practice setting. Don’t be afraid to take a risk or to be innovative. Invent or find a pharmacy practice that will allow you to serve your patients and provide optimal patient care.

Aside from the fact that I have had the privilege to work with the most passionate and talented pharmacists in the country, my most rewarding professional experience is the passage of HB2164 and SB1298, which allow pharmacists in the state of Arizona to administer most adult vaccines, the influenza vaccine to children age 6-17 without a prescription, and all other childhood vaccines with a prescription.

Since November 2009, when HB2164 went into effect, over 350,000 adult vaccines have been given to patients in Arizona by pharmacists and the number of pharmacists certified to give vaccines has nearly quadrupled.

The significant impact of patient care that the passage of HB2164 demonstrated led to the passage of SB1298 which becomes law July 20,

2011 and expands pharmacists’ ability to immunize children, empowers student pharmacists to play an active role in affecting public health, as well as amends our collaborative practice/ drug therapy management agreement statute so now pharmacists in all practice settings can enter into such agreements.

On page 4 is the text of the new collaborative drug therapy management (CDTM) law which goes into effect July 2011, pending rules and regulations from the Arizona State Board of Pharmacy.

CDTM is a comprehensive approach to health care, encouraging the collaboration of health care providers, improving the quality, efficiency, and cost-effectiveness of medical care. Research and outcome studies focused on collaborative practice illustrate the significant impact and benefit of including pharmacists in patient-centered care.

When physicians and pharmacists work together to monitor a patient’s response to a particular drug therapy, they are able to detect adverse reactions more quickly, which ultimately saves lives and unnecessary costs.

Empowering pharmacists with tools they need to positively impact the health of so many individuals is the mission of AzPA and I am proud to have had an opportunity to be a part of these efforts. Efforts such as these demonstrate the value of the pharmacist on a local, state, and national level, as well as show how valuable the role of the pharmacist is to improve access to health care. With the changes in health care, pharmacy must work hard to reinvent itself, to capitalize on a social need to provide

Mindy D. Smith, R.Ph. Chief Executive Officer

greater expertise in the medication use process, and to position itself as a more significant player in the health care delivery system.

Each and every one of you has the ability to make that change and challenge yourself everyday. You are capable of changing the perception of pharmacy by adding value to the services you provide on a daily basis. Now it is up to you to create opportunities to utilize CDTM and make a difference as an integral part of the health care system. I truly believe that if each and every pharmacist will commit themselves to the profession and dedicate themselves to each and every patient, not only would more lives be saved, but the perception of our profession would begin to change, health care consumers would become patients again, and the value of our profession would be recognized as priceless and irreplaceable.

Thank you for giving me the opportunity to serve you and the profession of pharmacy in Arizona.

Arizona Journal of Pharmacy 3

New Members WELCOME NEW MEMBERS Neil Coronado Amanda Dawes Kathryn Elofson Michelle Taylor Ford Ashlee Dawn Gerfen Jason Gerstner Francis Daniel Gray Michael J Hanson Mercedes Ann Hendrix Kevin Hinton John Howell Dan Anthony Khamis Christy Lemons Danielle McKenna Ryun McKenzie Anne Marie Meerfeld Peter Phuoc Nguyen William O’Neill Lindsey Ong Andrew Park Yolanda Q Petri

Gary Ray Shurtz Stephanie Stanley Heather Crump Thoreson Tu Tran Ephu Yip Michael Guo Zhang Guy Baker Gina Besteman Andrea Bisso Jacqueline Campbell Christopher Chapman Vickie Lee Crouch Ami Desai Jonathan Ross Dietrich Hieu Do Michael Jeffrey Franklin Ed Hunter Garrett Husted Brittany Ann Kaufman Phillip Hoang Le Deanna Lind

Paul B Lorton Katrina Ann Ramsey Rebecca Marie Ramsey Cassandra Lynn Rexroad Tanya m Ribald Angela L Rosselli Nicole Marie Runge Alison Sutton Linda Trinh Heather Walker Melanie J. Yerondopoulos Kevin Lawrence Aholt Matthew Crunden Gerald L Denny Kim Thien Dinh Jarrod Richard Gonzales Christine Mary Hanna Shelley Kauffman Jayun Lee Debra Lynn Legner Marie E Maloney

Marilyn L. Morano Naimil Patel Linda Pelger Melissa Petrick Joanette Pivonka Jeanine Ruby Kevin Charles Schmidt Benjamin Paul Sechena Sabrina Manjarres Sykes Thao Hieu Tran Lisa Whittington Jessica Dao Nadine Kazem Heather Ann Pritchard Erin Epley Kyle Linhardt

Be it enacted by the Legislature of the State of Arizona, Section 1.

Section 32-1970, Arizona Revised Statutes, is amended to read: 32-1970. Implementing, monitoring and modifying drug therapy and use; conditions; definitions A. A pharmacist licensed pursuant to this chapter may implement, monitor and modify drug therapy and use only under the following circumstances: 1. The patient’s drug therapy and use are pursuant to a provider.

2. The pharmacist complies with rules adopted by the state board of pharmacy.

3. The pharmacist follows the written drug therapy management protocols prescribed by the provider who made the diagnosis and implements, monitors or modifies a person’s drug therapy and use only pursuant to those protocols. Each protocol developed pursuant to the drug therapy agreement shall contain detailed directions concerning the actions that the pharmacist may perform for that patient. The protocol shall specify, at a minimum, the specific drug or drugs to be managed by the pharmacist, the conditions and events for which the pharmacist must notify the provider and the laboratory tests that may be ordered. A provider who enters into a protocol-based drug therapy agreement must have a legitimate provider-patient relationship.

B. A licensee who violates this section commits an act of unprofessional conduct.

C. A pharmacist is responsible for the pharmacist’s negligent acts that are the result of the pharmacist’s change of medication or that relate to patient drug usage pursuant to drug therapy management protocols. This subsection does not limit a provider’s liability for negligent acts that are not related to a pharmacist’s change of medication pursuant to the protocols.

D. For the purposes of this section: 1. “Implement, monitor and modify” means that a pharmacist may perform specific acts as authorized by a provider pursuant to written guidelines and protocols. This does not include the selection of drug products not prescribed by the provider unless selection of the specific drug product is authorized by the written guidelines and protocols.

2. “Protocol” means a provider’s written order, written standing medical order or other written order of protocol as defined by rules adopted by the Arizona medical board and the board of osteopathic examiners in medicine and surgery and that are patient, provider and pharmacist specific for prescriptions or orders given by the provider authorizing the written protocol who acts as a primary care practitioner.

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!

Butch David Ken Mahan Terry Daane Julie Hernandez Kerry Redman

Peggy Khan Ray Clark Jessica DiLeo Bonnie DiLorenzo Mark Boesen Kelly Ridgway Kevin Boesen Keith Boesen Jayne Knott 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 Mike Blaire Bob Lipsy Jon Glover Valerie Bostel Steve LeMahieu Larry Ganann Kim Cauthon Stacy Haber Mary Gurney Kip Raney Kristin Calabro Laura Hitchingham Brian O’Halloran Joy Davis Joshua Kramer Ann Sears

Ken Fletcher Tara Storjohann Mary Lou Brubaker Kristen Allison Melanie Yerondopoulos Mitchell Buckley Mitch Librodo Robin Staib Tom Jaeger Kellie Miller Rick Herrier Tricia Marie Rader Debbie Brown Laura Hanson Joe Rowan Shannon Li Ushma Kanzaria Winnie Thi Alexandria Smith Jacqueline Campbell JoAnn Froshaug

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Alliance News

Arizona Pharmacy Alliance Announces 2011-2012 Board of Directors The Arizona Pharmacy Alliance (AzPA) announces the election of the 2010-2011 Board of Directors.

Beginning their one-year terms in July 2011 are: Kevin Boesen, President Michael Dietrich, President-Elect Kelly Ridgway, Past President Ken Mahan, Treasurer Butch David, Secretary Teresa Stickler, Community Pharmacy Academy Chair Kristin Calabro, Community Pharmacy Academy Chair-Elect Jonathan Merchen, Health-System Academy Chair Lindsay Davis, Health-System Academy Chair-Elect Julie Hernandez, Managed Care Academy Chair Ann Sears, Managed Care Academy Chair-Elect Dawn Gerber, Senior Care Academy Chair Tara Storjohann, Senior Care Academy Chair-Elect Mike Severn, Technician Academy Chair Joy Davis, Technician Academy Chair-Elect Jessica DiLeo, Student Pharmacist Academy Chair University of Arizona COP Valerie Bostel, Student Pharmacist Academy Chair, Midwestern University CPG Eric Wong, Student Pharmacist Academy Chair-Elect,University of Arizona COP Norbert Laskowski, Northwest District Director Mary Lou Brubaker, Northeast District Director Lisa Keller, Southwest District Director Ken Fletcher, Southeast District Director Chris Ellis, Industry Representative J. Lyle Bootman, Dean, University of Arizona COP Dennis McCallian, Dean, Midwestern University CPG Roger Morris, Legal Counsel Election of the Student Pharmacist Academy ChairElect for Midwestern University College of Pharmacy Glendale will take place in Fall 2011. The 2011-2012 AzPA Board of Directors will be installed during the AzPA 7th Annual Meeting at the Westin La Paloma Resort & Spa in Tucson, Arizona, July 7-10, 2011.

PHARMACISTS POLITICAL ACTION COMMITTEE OF ARIZONA The Pharmacists Political Action Committee of Arizona (PharmPAC) plays an important role in advancing the legislative action mission of the profession of pharmacy here in Arizona and in Washington, D.C. You can make your voice heard.

Become a PharmPAC member!

SPECIAL INVITATION-ONLY EVENT FOR PharmPAC MEMBERS! Saturday, July 9, 2011 7:00 am Breakfast with Ken Bennett Arizona Secretary of State Come meet Secretary Bennett - and possibly our next Governor - for breakfast and a political overview and discussion of Arizona’s role in health care reform.

Reserve your exclusive seat now by joining the PharmPAC for as little as $10!

All current PharmPAC members will gain admission to attend this exclusive event.

SUPPORT PHARMACY POLITICAL ACTION & RECEIVE A CHANCE TO WIN UP TO $5000*!

Ten cash prizes awarded = Ten chances to win!

You do NOT need to be present to win.

PAC Drawdown Tickets are available for $100 each.** Winners will be announced Saturday, July 9, 2011 during the AzPA Annual Awards Banquet *Assuming the receipt of 200 entries. In the event 200 entries are not received, prizes may be reduced proportionally. **Tickets may be purchased by AzPA members only.

Tickets are available online at www.azpharmacy.org PharmPAC contributions are not tax deductible.

6 Arizona Journal of Pharmacy

Alliance News Mindy Smith Named Executive Director of APhA Foundaton Mindy D. Smith, BPharm, has been named as the American Pharmacists Association (APhA) Foundation new Executive Director. In her new role, Smith will lead the Foundation’s operations, research objectives and strategic direction, providing support and guidance to the Board of Directors and monitoring pharmacy trends to maintain the Foundation’s forward-facing mission.

Smith will join the APhA Foundation from her position as Chief Executive Officer of the Arizona Pharmacy Alliance (AzPA) where she served as the executive head of the association providing leadership for all association activities, including administrative oversight of the Arizona Pharmacy Foundation, a 501(c) 3 organization whose services include delivery of the Pharmacist Assisting Pharmacist Program, a drug and alcohol addiction recovery program. She also oversees an AzPA for-profit subsidiary, the Pharmacy Network of Arizona, and the Pharmacists Political Action Committee of Arizona.

“The APhA Foundation is excited to welcome Mindy and have her join us,” stated Dennis K. Helling, President, APhA Foundation Board of Directors. “Her commitment to the advancement of the pharmacy profession is evident in her dedicated service and enthusiasm for her work. She has served as the leader of two pharmacy associations and is a passionate political advocate. Mindy is a wonderful addition to the APhA Foundation team, due to her experience, talent, expertise and belief that all pharmacists should be empowered with the tools they need to positively impact health.”

“It has been an honor and a professionally satisfying journey for me to serve as Chief Executive Officer of the Arizona Pharmacy Alliance, so it is with great sadness that I am leaving AzPA, but with great excitement that I am joining the team at the APhA Foundation to continue the journey of optimizing the role of pharmacists in improving people’s health,” Smith said. “I have enjoyed working with all AzPA members and stakeholders. I appreciate all of the support and opportunities I have been afforded working for AzPA.” Smith will start her tenure with the Foundation later in the summer. The AzPA Executive Committee has established a search committee and will be seeking applicants to find a new chief executive officer for AzPA by July 2011 to ensure a smooth transition of duties.

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.

“Every man owes a part of his time and money to the business or industry in which he is engaged.

No man has a moral right to withhold his support from an organization that is striving to improve conditions within his sphere.”

Theodore Roosevelt, 1908 26th President of the United States

Arizona Journal of Pharmacy 7

Alliance News Are You Ready to Rock? The AzPA 7th Annual Meeting is Almost Here!

The 7th Annual Meeting of the Arizona Pharmacy Alliance is less than a month away! Join us July 7-10, 2011, at the beautiful Westin La Paloma Resort & Spa in Tucson, Arizona. This year’s conference, PHARMACY ROCKS: A Lifetime Commitment to Patient Care, offers an impressive selection of continuing education programs, networking sessions, opportunities for personal and professional growth, entertainment, and fun!

This year’s pre-conference continuing education activity is the Pharmaceutical Care for Patients with Diabetes Certificate Program. This knowledge-based and practice-based learning activity provides 24 hours (2.4 CEUs) of continuing pharmacy education and equips pharmacists to expand their scope of practice to include diabetes management services.

The conference tees off with the annual Arizona Pharmacy Foundation (APF) Golf Tournament on Friday, July 8, 2011. A portion of the proceeds from the APF tournament benefit the Llyn Lloyd Service to Pharmacy Scholarship Fund.

The conference begins on Friday, July 8, 2011, wth Health Behavior Change: Motivational Interviewing presented by Mary Gurney, R.Ph., Ph.D., and Jon Glover, Pharm.D. This three-hour continuing education offering is included with full-conference registration, however seating is limited to 100 and pre-registration is suggested.

The Opening Session on Friday, July 8, 2011, is 2011 Health Care Reform Update presented by Diane Ginsburg, M.S., R.Ph., FASHP. Other general sessions include MTM Update presented by Robert Lipsy, Pharm.D., BCPS; Pharmacy Electronic Health Information Technology offered by Shelly Spiro, Director, Pharmacy e-HIT Collaborative; An AzPA Town Hall Law Debate featuring Mark Boesen, Pharm.D., Kevin Boesen, Pharm.D., and Keith Boesen, Pharm.D.; Suicide Prevention: Identifying Patients at Risk, presented by Erin Adams Goldman, LCSW; and Helping People with Mental Issues Live Longer without Tobacco coordinated by the Arizona Smokers’ Helpline.

This meeting marks the transition of our organization’s leadership. A highlight of the event is the AzPA Awards Banquet on Saturday, July 9, 2011, when we recognize the contributions and accomplishments of our members.

Rumor has it that we may have a special appearance by a rock and roll legend.

Don’t miss this year’s rock-and-roll-themed Exhibit Hall. More than 50 exhibitors will be showcasing their companies and organizations in the Canyon Ballroom.

Come try your hand at Guitar Hero and pose for a photo in your favorite rock and roll era. As always, we will have great food, fun, and prizes.

8 Arizona Journal of Pharmacy

The list of exhibitors already registered for this year’s meeting includes: • Abbott Diabetes Care • AIMSCO/Delta Hi-Tech • American Regent • Ameridose Medical Sales Management • Amerisource Bergen • Amylin Pharmaceuticals • Arizona Smokers Helpline • Astra Zeneca • AWARxE Program • Arizona Pharmacy Alliance • Banner Health • BD Diabetes • Boehringer Ingelheim • BTG • Cardinal Health • Complete Rx • CSL Behring • Cubist Pharmaceuticals • CVS/Caremark • Daichi Sankyo • Environmental Pharmaceuticals • Express-Scripts, Inc • Forest Pharmaceuticals • Fry’s Pharmacy • Genentech • Grifols • GlaxoSmithKline Community Pharmacy Team • Humana RightSource Rx • Intelliquick Delivery • LifeScan, Inc • Lilly USA • McKesson Corporation • Meda Pharmaceuticals • Merck Pharmaceuticals • Merck Vaccines • Midwestern University CPG • Nephron Pharmaceuticals • NIPRO Diagnostics Inc • Northern Arizona Healthcare • Novo Nordisk • Otsuka US • Pharmacists Mutual • PharMEDium Services • Roche Diabetes • Rx Relief • Safeway, Inc • sanofi-aventis • Sunovion Pharmaceuticals • University of Arizona COP • US Army Medical Recruiting • Wal-mart Pharmacy • Williams Medical

at oday org t r e t Regis harmacy. .azp www

Arizona Pharmacy Alliance 7th Annual Meeting July 7-10, 2011 Tentative Agenda At-A-Glance All times and programs are subject to change.

8:00am am- -5:00 5:00pm pm 8:00 5:00 pm 9:00 am 4:00 pm 9:00 am - 4:00 pm

8:00 am 9:00 am - 4:00 pm

4:00pm pm- -6:00 6:00pm pm 4:00 6:00 pm - 8:00 pm 6:00pm pm - 8:00 pm 6:00

4:00 pm 7:00 am - 12:00 pm 6:00 pm - 8:00 7:00pm am - 12:00 pm 7:00 am - 8:00 am

7:00 am am 7:00 am - 12:00 pm 8:00 am- -8:00 11:00 am 8:00 am - 11:00 am

l:00 pm - 1:30 pm 7:00 am - 8:00 am l:00 1:30pm pm- -1:30 2:30pm pm 1:30 pm 8:00 am - 11:00 am- 2:30 pm

2:30 2:30pm pm––3:30 3:30pm pm 3:30 pm – 3:45 pm l:00 pm - 1:30 pm 3:45 3:30pm pm-–4:45 3:45pm pm 1:30 pm - 2:30 pm 3:45 pm 3:45 pm- -4:45 4:45pm pm 3:45 pm- -4:45 4:45pm pm 3:45 pm 2:30 pm – 3:30 pm 3:45pm pm- -6:00 4:45pm pm 5:00 3:30 pm – 3:45 pm 5:00pm pm- -8:30 6:00pm pm 5:00 3:45 pm - 4:45 pm 5:00 pm- -9:30 8:30pm pm 8:30 pm 8:30 pm - 9:30 pm 3:45 pm - 4:45 pm 9:30 pm 3:45 pm - 4:45 pm - 11:00 pm 9:30 pm - 11:00 pm

5:00 pm - 6:00 pm 7:00 am to 7:45 am 5:00 pm - 8:00 pm– 10:00 am 8:00 am 7:00 am to 7:45 am 9:00pm am - 2:00 pm 8:00 pm - 9:00 8:00 am – 10:00 am

10:00 am – 10:15 am 9:00 am - 2:00 pm 10:15 am – 10:45 am 10:00 pm am – 10:15 am 9:30 pm - 11:00 10:45 am – 11:45 am 10:15 am – 10:45 am 11:45 am - 2:00 pm 10:45 am – 11:45 am 2:10 pm 8:00 am – 9:30 am 11:45 am- 3:10 - 2:00pm pm 2:10 pm 3:10 pm - 3:10pm pm 9:00 am - 2:002:10 pm 2:10 2:10pm pm- -3:10 3:10pm pm 9:30 am – 9:45 am 2:10 pm 3:10 2:10 pm - 3:10pm pm 3:10 pm 9:45 am – 10:15 2:10am pm- -3:30 3:10pm pm 3:30 3:10pm pm- -5:00 3:30pm pm 10:15 am – 11:45 am 3:30 3:30pm pm- -5:00 5:00pm pm 11:45 am - 2:00 pm - 5:00 pm 3:30 3:30pm pm - 5:00 pm 2:10 pm - 3:10 pm 3:30 pm 3:30 pm- -5:00 5:00pm pm 5:00 pm 6:00 pm 3:30 pm 5:00 pm 2:10 pm - 3:10 pm 5:00 5:00pm pm- -6:00 6:00pm pm 2:10 pm - 3:10 pm 5:00 pm - 6:00 pm 2:10 pm - 3:10 6:00pm pm - 6:45 pm 6:00 pm- -7:00 6:45pm pm 6:30 pm 3:10 pm - 3:30 pm 6:30 pm 7:00 7:00pm pm - 10:30 pm 3:30 pm - 5:00 7:00 pm - 10:30 pm

3:30 pm - 5:00 pm 3:30 pm - 5:00 pm 7:00 am 6:00am am 7:00 3:30 pm - 5:007:30 pm am 8:30am am 7:30 am - 8:30 5:00 pm - 6:00 pm 7:45 am 8:00 am 7:45 am - 8:00 am 8:00 am 9:00 am 5:00 pm - 6:00 pm 8:00 am - 9:00 am

9:00 am - 10:00 am 9:00 am - 10:00 am 10:00 am - 10:30 am 6:00 pm - 6:45 pm 10:30 am - 11:30 am 10:00 am - 10:30 am 10:30 am - 11:30 am 6:30 pm - 7:00 pm 10:30 am - 11:30 am 10:30 am - 11:30 am 7:00 pm - 10:30 10:30pm am - 11:30 am 11:45 am - 1:15 pm 10:30 am - 11:30 am 11:45 am - 1:15 pm

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THURSDAY, JULY 2011 THURSDAY,JULY JULY7,7,7, 2011 THURSDAY, 2011 Arizona State Board Arizona State BoardofofPharmacy PharmacyMeeting Meeting Arizona State Board of Pharmacy Meeting Pharmaceutical Care for Patients with Diabetes Certificate Program Pharmaceutical Care for Patients with Diabetes- A -A Certificate Program separate registration is required.

Pharmaceutical CareSeparate for Patients withis Diabetes registration required. - A Certificate Program AzPA ofofDirectors AzPABoard Board DirectorsMeeting Meeting Separate registration is required.

VIP Reception – invitation Only VIP Reception – Invitation Only Board FRIDAY,AzPA JULY 8, 2011 of Directors Meeting FRIDAY, JULY 8, 2011 Arizona Pharmacy Foundation Annual Golf Tournament and Luncheon Reception Invitation Only Arizona Pharmacy VIP Foundation Annual–Golf Tournament and Luncheon separate registration is required.

FRIDAY, JULY 8, 2011 Separate registration is required.

Continental Breakfast Continental Breakfast Arizona Pharmacy Foundation Annual Golf Tournament and Luncheon Pre-Symposium: Motivational Interviewing Pre-Symposium: Motivational Interviewing Pre-registration is suggested.

Walk-ins subject space availability.

Separate registration istorequired.

Pre-registration is suggested.

Walk-ins subject to space availability.

Opening Remarks & Award Presentations Continental Breakfast Opening Remarks Award Opening SessionTaking& Practice toPresentations the Next Level: Opening Session Keynote Address: Health Interviewing Care Reform Pre-Symposium: Motivational Pharmacy Practice Model Initiative General Session: Medication Therapy Management General Session Collaborative Medication Therapy Management Programs: Pre-registration is suggested. Walk-ins subject to space availability.

Break Successful Outcomes Opening Women’s Remarks & Award Presentations Health Update Break Opening Session Address: Health Care Reform Clinical Pearls Hot Keynote Topics in Contraception Clinical Pearls Preceptor’s Workshop General Session: Medication Therapy Management Preceptor’s Workshop Academy Meetings: ManagedBreak Care, Senior Care, Technician Academy Meetings:Exhibit Managed Care, Senior Care, Technician Hall Reception Women’s Health Update Exhibit Hall Reception Midwestern University College of Pharmacy - Glendale Midwestern University College of Pearls Pharmacy - Glendale Clinical Dessert Reception Dessert Reception New Practitioners’ Forum Social Event Preceptor’s Workshop New Practitioners’ SATURDAY, JULY 9, 2011Forum Social Event Committee/Academy Meetings Featuring Hypnotist Lepine PharmPAC Breakfast Kevin – Invitation only SATURDAY, 9,Hall 2011Continental Exhibit Hall Reception General Session: AzPAJULY Town Breakfast and Law Update PharmPAC Breakfast – invitation only PosterCollege Exhibits of Pharmacy - Glendale Midwestern University General Session: AzPA Town Hall Continental Breakfast and Law Update BreakReception Dessert Poster Exhibits Opening Remarks & Award Presentations Break New Practitioners’ Social Keynote General Session:Forum Pharmacy e-HITEvent Opening Remarks & Award Presentations SATURDAY, JULY 9, Hall 2011Luncheon Exhibit Keynote General Session - Electronic Health Records: The Pharmacist’s Role DM Update: Access, Intervention Cost Intervention General Session: AzPA Town Hall&Breakfast with Law Update Exhibit Hall Luncheon Update on Acute Management of Atrial Fibrillation DM Update: Access, Intervention & Cost Intervention Poster Exhibits COPD and of 3DAtrial Interactive Update on AcutePathology Management Fibrillation Break Before It’s Too Late: Post Prophylaxis Exposure COPD Pathology and 3D Interactive Break Opening Remarks & Award Presentations Before It’s Too Late: Post Prophylaxis Exposure DMGeneral Treatment: AnBreak ActiveKeynote Learning Exercise Session: Speaker Update Chronic Management of Atrial Fibrillation DM on Treatment: An Active Learning Exercise Exhibit Hall Luncheon Respiratory Pharmacology & Collaborating with Patients Update on Chronic Management of Atrial Fibrillation DM Update:Pharmacology Access, Intervention &with Cost Intervention 2011 Immunization Update Respiratory & Collaborating Patients Academy Meetings: Community Pharmacy, Health-System, Student Pharmacist 2011 Immunization Update Update on Acute Management of Atrial Fibrillation of Arizona College of Pharmacy Academy Meetings:University Community Pharmacy, Health-System, Student Pharmacist COPD Pathology and 3D Interactive Alumni & Friends Reception University of Arizona College of Pharmacy Immunization I Only Alumni & Friends Reception Past Presidents’ Reception – Invitation Past Presidents’ Reception – invitation Awards Banquet Reception Only Break Awards Banquet Reception Awards Banquet & Entertainment DM Treatment: An Active Learning Exercise Awards Banquet &registration.

Entertainment Included with full conference Ticket required.

Update on Chronic Atrial Fibrillation included with full conference ticket required.

SUNDAY, JULY 10, Management 2011 registration. of SUNDAY, JULY 10, 2011 Respiratory Pharmacology with Arizona Pharmacy Foundation&RxCollaborating Riders Motorcycle RunPatients Arizona Pharmacy Foundation Rx Riders Motorcycle Run Arizona Pharmacy Foundation 5K Fun Run/Walk Immunization II Continental ContinentalBreakfast Breakfast Committee/Academy Meetings Opening OpeningRemarks Remarks General University Session: Identifying Patients at Risk ofPrevention: Arizona College of Pharmacy General Session: Suicide Suicide Prevention - Identifying Patients at Risk General Session: Helping People with Mental Issues Live Longer without Tobacco Alumni & Friends Reception General Session: The Arizona Initiative for Tobacco-Free Living in Individuals Break with Behavioral Health Disorders Past Presidents’ – Invitation Mental Health Crises: How toReception Assess and Refer Patients for Only Help Break MTM Pharmacy Services for Tobacco Cessation Awards Banquet Reception Mental Health First Aid & How to Assess and Refer People in Crisis for Help Behavioral Disturbances in Patients with Dementia &Tobacco Entertainment MTMAwards PharmacyBanquet Services for Cessation Closing Session: Rx Patrol - Pharmacy Safety & Security Disorders registration. in the Elderly Ticket required.

Included withBehavioral full conference

Closing Session: Rx Patrol - Pharmacy Safety & Security

y

Alliance News REGISTER TODAY FOR THE ARIZONA PHARMACY ALLIANCE 7TH ANNUAL MEETING!

AzPA offers three easy ways to register for this year’s conference offering 15 hours of continuing pharmacy education over the three-day meeting, the largest pharmacy meeting in Arizona!

• ONLINE REGISTRATION! Visit www.azpharmacy.org and logon today!

• DOWNLOAD A REGISTRATION FORM AND MAIL OR FAX IT TO AzPA. http://www.azpharmacy.org/associations/10285/ files/AZPA_REGISTRATION_ BROCHURE_2011.pdf • CALL THE AzPA OFFICE AT 480 838-3385 AND WE WILL PROCESS YOUR REGISTRATION OVER THE PHONE.

SUPPORTING PHARMACISTS ADVANCING CAREERS Find the best jobs and highly qualified pharmacists Arizona has to offer.

ONLINE CAREER CENTER www.azpharmacy.org/jobs

Pharmacy: A Lifetime Commitment to Patient Care If you or someone you care about is suffering from an alcohol and/or chemical dependency problem…

Pharmacy ROCKS

“A Partnership in Caring”

Pharmacists Assisting Pharmacists of Arizona (PAPA)

is Available For Help and Information Register online at www.azpharmacy.org/2011_Annual_ Meeting_Registration 10 Arizona Journal of Pharmacy

CALL LISA YATES AT 928-532-2293 ALL CALLS CONFIDENTIAL • CALLER REMAINS ANONYMOUS

Alliance News C H W C A R E E R S . O R G / A R I Z O N A

Experience a truly fulfilling career.

At CHW, our commitment to employee satisfaction is unwavering.

We work hard to ensure our employees have the support they need to live their lives to the fullest — both professionally and personally. And by creating an environment that inspires them to perform at their best every day, we’re able to continuously deliver the extraordinary care our patients have come to expect.

We’re CHW Arizona, comprised of Chandler Regional Medical Center, Mercy Gilbert Medical Center, and St. Joseph’s Hospital and Medical Center. Our focus on employee satisfaction has helped us earn recognition as: • A “Best Place to Work in the Valley” by the Business Journal, Phoenix • One of “Arizona’s Most Admired Companies” by the Best Companies AZ • One of the “Top 100 Best Places to Work in Healthcare 2010”

by Modern Healthcare magazine (second year in a row) • One of the “Top 25 Best Places to Work for Women 2011”

by AZ Magazine • One of the Valley’s Healthiest Employers 2011 by the Business Journal, Phoenix Find us on Facebook and follow us on Twitter: CHWAzCareers.

Come and experience the many opportunities we give you to learn, grow and achieve. Whatever it is you’re looking for in a career, you can find it at CHW Arizona. For more information, visit chwcareers.org/Arizona.

EOE. © 2011 Catholic Healthcare West Arizona

Arizona Journal of Pharmacy 9

Alliance News The Arizona Pharmacy Foundation In conjunction with the Arizona Pharmacy Alliance 7th Annual Meeting presents The Annual APF Golf Tournament

Friday, July 8, 2011 La Paloma Country Club 3660 E Sunrise Drive Tucson, Arizona 85718 6:30 a.m. Shotgun Start Individual Golfer Registration $150.00 Includes: 18-holes of golf, with greens fees, cart and range balls Sleeve of balls Post-tournament lunch 2 beverage tickets Contests and Prizes

Proceeds from the APF Golf Tournament benefit the Llyn Lloyd Service to Pharmacy Scholarship Fund.

The Arizona Pharmacy Foundation, a non-profit charitable organization, is a 501 (c) 3 corporation. All donations are 100% tax-deductible.

Visit www.azpharmacy.org for Registration Form and Sponsorship Packages.

If you would like to play golf, please provide the following information: [Individuals and two-somes will be paired randomly to create four-somes. Four-somes will play as listed.]

PLAYER NAME

COMPANY

1. _________________________________________

_____________________________

2. _________________________________________

_____________________________

3. _________________________________________

_____________________________

4. _________________________________________

_____________________________

On-line registration is available on the Arizona Pharmacy Alliance website at www.azpharmacy.org/APF_Golf_Tourney Make checks payable to: APF Annual Golf Tournament. Mail this form to: APF Annual Golf Tournament, 1845 E. Southern Ave., Tempe, AZ 85282 APF Tax ID #86-0679270 – proceeds to benefit Llyn Lloyd Pharmacy service scholarship Award fund

Or fax CC info to: 480/838-3557 Credit Cards accepted: m/C visA AmeX

Credit Card # ___________________________________________________ exp. date____________ security Code ___________ FAX 480/838-3557 or email: azpa@azpharmacy.org or call 480/838-3385 for more information.

12 Arizona Journal of Pharmacy

APF News In 2009 the Arizona Pharmacy Foundation (APF) established the Llyn Lloyd Service to Pharmacy Scholarship Fund. Llyn Lloyd served as executive director of the Arizona State Board of Pharmacy for more than 20 years. He dedicated his life to protecting and advancing the pharmacy profession. The scholarship award honors his personal and professional commitment.

Each year this scholarship recognizes a pharmacy student at each of the colleges of pharmacy in Arizona - Midwestern University Glendale and The University of Arizona - for their service to the profession of pharmacy. The students each receive a $500 award from APF. At the Inaugural Student Pharmacist Academy Conference on April 16, 2011 (see story on page 31), two pharmacy students were awarded this year’s Llyn Lloyd Scholarship: Bernadette Aragon, The University of Arizona College of Pharmacy Class of 2012, and Bonnie DiLorenzo, Midwestern University College of Pharmacy Glendale Class of 2012. Congratulations Bernadette and Bonnie!

Annual APF Golf Tournament You can support the Arizona Pharmacy Foundation and the Llyn Lloyd Service to Pharmacy Scholarship Fund by playing in or becoming a sponsor of the APF annual golf tournament. Mark your calendars for Friday, July 8, 2011. This year’s event will be held at the La Paloma Golf and Country Club in Tucson, Arizona. Shotgun start is at 6:30 am for the the best-ball format competition. Prizes will be awarded for longest drive, closest to the pin, hole-in-one, and winning team. Proceeds from the tournament benefit the Llyn Lloyd Service to Pharmacy Scholarship. To register go to www.azpharmacy.org/APF_Golf_Tourney

Alliance News The Arizona Pharmacy Foundation is a 501(c)3 non-profit, charitable foundation. In addition to playing in or becoming a sponsor of the APF Annual Golf Tournament, you can support APF by participating in the APF Legacy Endowment program, designating APF in your workplace United Way or other charitable fundraising campaign, or making a donation in cash or kind. All donations are 100% tax-deductible.

Bernadette Aragon, Pharm.D. Candidate, The University of Arizona College of Pharmacy, Class of 2012.

Bonnie DiLorenzo, Pharm.D. Candidate, Midwestern University College of Pharmacy Glendale, Class of 2012.

Is there a drug dealer lurking in your medicine cabinet?

Arizona Journal of Pharmacy 13

Legislative Update State Legislative Update – Final Report

50th Legislature, 1st Regular Session (2011) Days of Session: 100 Adjourned, Sine Die: Thursday, April 20, 2011 at 5:25 AM General Effective Date: July 20, 2011 Bills Posted: 1,350 Bills Passed: 386 Bills Signed: 357 Bills Vetoed: 29 Bills Filed Without Signature 0 Special Sessions Called: 2 • 1st Special: Medicaid eligibility and funding • 2nd Special: Economy and jobs Link to final Bill Tracking List: http://www.azpharmacy.org/associations/10285/files/2011_ AzPA_Year_End_Report.pdf 2011 Session at a Glance The 50th Arizona State Legislature, First Regular Session convened on January 10, 2011, just three days following the tragic shootings in southern Arizona which claimed the lives of six and injured 14, including former Arizona state legislator and current US Congresswoman Gabrielle Giffords. In a somber setting, Arizona Governor, Jan Brewer delivered an abbreviated state of the state address honoring both the victims and heroes from the tragic incident. Despite the somber atmosphere, Arizona lawmakers wasted no time, quickly turning their focus to the state’s budget deficit, job creation, and Medicaid reform.

Republicans touted this legislative session as perhaps one of the most successful in Arizona history.

Controlling supermajorities in both legislative chambers, GOP members were able to quickly and easily pass out legislation regardless of any Democrat opposition. Many of the 386 bills that reached the Governor’s desk were passed with over two-thirds support.

Despite having to make some difficult decisions, the Republican led legislature passed the first balanced budget in over five years that did not contain any new rollover, debt, loan, or other budgeting gimmick used in the past. The legislature also successfully approved sweeping changes to the state’s pension and Medicaid systems and perhaps most importantly, passed a historic jobs bill aimed at stimulating job growth.

On Wednesday, March 20, 2011 at 5:25am, after 100 days, the Arizona State Legislature adjourned sine die. This was the fastest legislative session in Arizona in over a decade (April 18, 2000 100 days).

Budget Going into the 2011 legislative session lawmakers were once again faced with the daunting task of having to close a significant budget gap of well over $1 billion. Both legislative chambers clashed with one another in addition to the Governor’s Office over how exactly to resolve the budget shortfall. Suggestions on how to close the gap ranged from wide sweeping cuts to state agencies, debt financing, department consolidations, and even the possible elimination of the state’s Medicaid system, AHCCCS. The Senate even went as far as to draft and pass their own version of a budget package, modeled largely after the 14 Arizona Journal of Pharmacy

Governor’s budget, despite not having an agreement in place with either the House or the Governor.

After months of debate and contentious negotiations, on Friday, April 1st, the Legislature approved a comprehensive final budget package that was signed by the Governor. The votes on the budget were strictly along party lines, with no Democrats supporting any of the budget bills. The compromise $8.4 billion spending plan is anticipated to close the state’s $1.5 billion budget gap for fiscal years 2011 and 2012. The plan included $1.1 billion in spending cuts, mostly from education and healthcare, along with $190 million in various fund sweeps. The remaining balance comes from adjustments made to the state’s Medicaid system, AHCCCS. Republicans have touted the budget plan as the state’s first balance budget in over 5 years, containing no new rollovers, debts, loans or other budgeting gimmicks.

Medical Marijuana The passage of the medical marijuana initiative left employers with many questions, including how to define “impairment” and how to determine if an employee has a state approved ID card authorizing the use of marijuana given that access to the data base is limited to law enforcement. The latter question can be a significant problem for employers with drug testing policies.

Both of these concerns were addressed in HB2541, which was introduced by Rep. Kim Yee. HB2585, introduced by Rep. Matt Heinz, requires the controlled substances prescription monitoring program, administered by the Arizona State Board of Pharmacy, to include data from the Department of Health Services that identifies residents who possess a valid registry identification card (see section below for additional detail on both bills).

2012 Legislative Outlook 50th Legislature, 2nd Regular Session Arizona House of Representatives Going into next year’s legislative session, Republicans will continue to comfortably control the House of Representatives, maintaining 40 out of the 60 seats in the legislative chamber; however their leadership team will have a new look.

In late April, Representative Kirk Adams announced his resignation as Speaker of the House. Adams has announced his candidacy for Congress in Arizona’s CD6. He will face off in a GOP primary against former US Congressman, Matt Salmon and former state legislator Chuck Gray, to fill the congressional seat currently held by Congressman Jeff Flake. Flake is running for the US Senate to replace retiring US Senator Jon Kyl. The Maricopa County Board of Supervisors will be selecting Adams’ replacement shortly.

Replacing Adams as Speaker is Representative Andy Tobin (R-Paulden). Previously the House Majority Leader, Tobin ran unopposed for the top leadership spot and was approved with unanimous consent by the entire Arizona House of Representatives. Tobin was first elected to the House in 2006.

In somewhat of a surprise move, Representative Steve Court (R-Mesa) will take over as Majority Leader. Court was first elected to the Arizona House of Representatives in 2008. This session he served as Chairman of the House Higher Education Committee. House Majority Whip, Debbie Lesko (R-Glendale) will remain in her current leadership position. Lesko was rumored to have been considering a run at majority leader; however she decided to not run.

Legislative Update (continued from page 14) Speaker Tobin is expected to carry on many of the similar policies as Kirk Adams. Tobin has expressed a strong interest in addressing the state’s energy policies; however overall, the politics of the House are expected to remain the similar to the past session.

Arizona State Senate Controlling 21 out of the 30 Senate seats, Senator Russell Pearce will return as Senate President next legislative session.

This past year, the Senate was the more conservative of the legislative chambers. We can expect to see another attempt to pass additional immigration reforms along with another series of bills aimed at challenging the federal government for authority.

Executive Serving in her first elected term as Arizona’s governor, Jan Brewer was quite active this legislative session, especially with her veto stamp. Brewer, a Republican, approved over 350 bills and vetoed 29, all Republican sponsored. Brewer did not shy away from preventing several measures from going into law regardless if the bill received two-thirds vote. Going into next year’s legislative session, it will be interesting to see how the Legislature responds to the Governor and whether or not they try to challenge her vetoes. Because many of Governor’s Brewer’s vetoes were after the legislature adjourned, they could not vote to override.

Special Session This Fall Governor Brewer anticipates that she will call a special legislative session sometime early this fall. The special session will likely deal with several issues including the Tax Correction Act of 2011 which the governor vetoed shortly after session ended. The Governor vetoed the measure because the bill included other provisions such as an STO tax credit for corporations, rather than the usual technical tax correction language typically contained in the bill.

Additionally, Brewer has indicated that she would like to see the issue of personnel reform addressed in a special session later this year. The Governor had pushed for the Legislature to consider her proposal toward the end of the session; however, lawmakers were focused more at completing the budget. Under Brewer’s proposal, many state employees would be given “uncovered status,” meaning they would lose or never receive merit-system protection and therefore be easier to terminate.

Reaction from Republican members has been mixed to the Governor’s plan.

Specific Issues/Actions Budget The budget included two bills of importance to AzPA, SB 1612; 2011-2012 general appropriations, and SB 1619; budget reconciliation; health; 2011-2012.

SB 1612; 2011-2012 general appropriations SB 1612 is the main piece of the budget that contains appropriations for the various agencies. It also contained the general fund reduction to AHCCCS ($540M), which encompasses Governor Brewer’s waiver to the U.S. Department of Health and Human Services to reduce the Prop 204 AHCCCS

population and reduce various benefits. The modified plan for AHCCCS would prevent such a large number of people from losing coverage as was initially proposed by the Governor. If adopted and approved by federal officials, the plan is expected to achieve roughly $500 million in state savings in the partial first year. Provisions include: • Eliminates new enrollment of childless adults. Only six other states provide Medicaid coverage for this population. With attrition, Arizona’s enrollment of childless adults would shrink by roughly 100,000 over 12 months.

• Eliminates the “spend down” program (Medical Expense Deduction or MED population) • Eliminate enrollment of parents earning 75-100% of the FPL • Eliminate Federal Emergency Services for non-qualified aliens • Reduces reimbursement rates for health providers, on top of rates cuts that have been implemented to date.

• Implement or increase co-payments for AHCCCS members, including for children, institute a “no-show” fee for missed appointments, elimination of non-emergency transportation, and limit certain benefits such as inpatient hospital stays (limit to 25 days).

• Proposed sweeps to the Board of Pharmacy by the Executive totaling $1.8M were not implemented by the Legislature • Lastly, SB1612 reduces funding to ADHS by ($53M), mostly from reductions to behavioral health and the transfer of CRS to AHCCCS. There was no overall lump sum reduction to the agency as there has been in years past. Funding for the two Poison Control Centers remains the same as last year.

SB 1619; budget; reconciliation; health; 2011-2011 SB1619 contains the policy provisions necessary to implement budget appropriations, and in the case of AHCCCS budget reductions, includes the following provisions: • Directs AHCCCS to reduce provider payments and makes other changes to provider reimbursement methodology.

Implements and increases various co-payments for AHCCCS members.

• Eliminates non-emergency transportation in Maricopa and Pima counties with some exceptions.

• Directs AHCCCS to adopt rules to implement the reduction of the Prop 204 population. This is the language necessary to implement Governor Brewer’s wavier application to HHS if accepted.

• Creates the Prescription Drug Rebate Program within AHCCCS, retroactive to March 1, 2011.

Health Care Provider Assessment The Arizona Hospital and Healthcare Association, along with others in the healthcare community, floated the concept of a health provider assessment late in the session to offer another proposal in order to try to put off the rollback of the Prop 204 population contained in the budget and Governor Brewer’s wavier to HHS. Under the plan, hospitals would pay a $275-perday assessment for inpatient stays, which would generate about $360 million per year for AHCCCS. A 4 percent assessment on AHCCCS health plan providers would generate another $100 million for the Medicaid program, while a nursing home assessment would bring in another $5 million. The taxes would Arizona Journal of Pharmacy 15

Legislative Update (continued from page 15) have generated about $549 million in the fiscal year 2012 and $732 million in fiscal year 2013, with the majority of the money going to AHCCCS. The public health care system would receive $348 million in 2012, $465 million in 2013 and $232.5 million in the first half of the fiscal year 2014.The rest of the money would go to a funding pool for hospitals and would be eligible for a twoto-one match from the federal government, which would offset the cost of the assessment to hospitals. The taxes would expire on Jan. 1, 2014, when the Patient Protection and Affordable Care Act require state Medicaid programs to cover anyone earning up to 133 percent of the federal poverty level. At that time, states will receive additional federal money to help cover those costs. The plan also called for the state to not reduce payments to AHCCCS health care providers while the assessments are in place. It would freeze AHCCCS enrollment on July 1 and implement a membership cap beginning Jan. 1, 2012. It includes a number of other cost-sharing and personal accountability provisions; similar to what is in the Governor’s plan, such as increasing the co-payment for non-emergency use of emergency rooms by $10 to $15; implementing co-payments for urgent care visits; and higher co-payments for office visits. It also proposed eliminating coverage of some “durable medical equipment,” gastric bypass surgery and transportation for non-emergency medical care. This proposal could come back should the lawsuit against the rollback of the Prop 204 population be successful. Then the Governor and the legislature would need to figure out how to cut almost $500 million in savings gained by cutting the Prop 204 population.

HB2585 Medical Marijuana and Prescription Monitoring Several bills were introduced in response to the passage of the medical marijuana initiative. One, HB2595, followed one of the suggestions that AzPA provided to the Dept of Health Services as it relates to the controlled substances monitoring program. The bill requires the controlled substances prescription monitoring program, administered by the Arizona State Board of Pharmacy, to include data from the Department of Health Services that identifies residents who possess a valid registry identification card. AzPA worked with the Board of Pharmacy, the Dept of Health Services and the sponsor, Rep. Matt Heinz, to ensure that the Board would have adequate resources to administer the legislation. ADHS committed to provide the Board with funding to modify the database.

SB1298 pharmacists; drug therapy protocols After many long stakeholder meetings and a successful sunrise application/hearing, agreement was reached on bill language by all parties and a proposal to expand pharmacists’ scope of practice successfully passed the Legislature almost unanimously and was signed by the Governor. The Legislation removes the location restrictions for pharmacists to enter into drug therapy agreement with physicians and also allows such agreements to be entered into with nurse practitioners that are primary care practitioners. Pharmacists are also allowed to immunize children ages 6-17, under certain conditions and student pharmacists can immunize under supervision. The expanded immunization authority will require additional conversations with AHCCCS, as they want to fully understand how children covered by Medicaid in Arizona will be impacted by the bill and whether pharmacists can be Vaccine for Children eligible providers. This law will go into effect on July 20, 2011 but there will be a rules making process by the Arizona State Board of Pharmacy as well.

Arizona Vaccine News A summary of local, national, and international vaccine information that affects Arizona can be accessed by clicking on this link: http://www.azpharmacy.org/associations/10285/files/ AZ_VaccineNews_May_11_2011.pdf

Link to signed bill – click here HBs 2167 and HB2510-Dangerous substances Participated as a stakeholder on legislation to make illegal several synthetic substances youth are using as a substitute to marijuana and cocaine. AzPA participation ensured that legitimate substances would not get pulled into the list of dangerous substances, similar to what happened with legislation that was introduced last year. HB2167 (synthetic cannabis) passed and was signed by the Governor and HB2510 (bath salts) did not pass.

16 Arizona Journal of Pharmacy

SB1593 health insurance interstate purchase The bill as introduced allowed foreign insurers to issue policies relating to health or sickness coverage in Arizona. The bill was amended on the House floor to state that if a foreign insurer issues a policy relating to health or sickness coverage in Arizona that does not include a state mandated health coverage, an insurer holding a Certificate from Arizona may issue a policy that does not include that state mandated health coverage. This would have eliminated a host of insurance mandates and caused many that benefit from these mandates to ask for a veto of the bill. The Governor ultimately agreed with the opposition and vetoed the bill.

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

A Pharmacist’s Story As a professional I never wanted to be counted as one of “Them”, an addict, an alcoholic, in other words a loser. This is what I was raised with, what I new to be my truth. I refused to buy into those labels; I was different, special, and terminally unique. I justified, rationalized, and minimized my situation; I was in pain, I had a prescription, I would never use at work, I was functional. The lies I told myself never covered up the disquiet inside that something was wrong. What it really came down to, no matter what I told myself, I was an addict, the worst kind, or so I thought, one who dealt with pills that became my demons: a pharmacist.

I could never put my finger on what it was. From the time I was small I had always felt a sense of disquiet within, a lack of peace, serenity and comfort within my own skin. I tended towards being a perfectionist, incredibly smart and capable, but never satisfied with the work I did. I could always do better, or at least that is what I thought and felt. This sense of striving, combined with my intelligence paid off quiet well, I received two bachelor’s degrees in four years, went straight for my doctor in pharmacy and never took time to look back. I never paused and dealt with stress or negative emotions. I didn’t have the time. I was frazzled, overwhelmed and depressed. I was like a snowball rolling down a mountain, gaining momentum and destroying the beauty in my path.

I then went through a series of severe physical setbacks that necessitated the use of opiates. I never thought twice that they would be my undoing; again I was too smart, too good, too in control to ever have an issue. As I graduated and my professional life blossomed so did my stress and in turn the use of prescription opiates, and eventually alcohol. It was an insidious downward spiral. An extra pill here, a glass of wine (or four) in the evening there, to deal with the “stress”. I didn’t notice when the physical pain of my injuries had minimized to the point where I didn’t need the pills anymore, but by this point I had taught myself that they could do what I had never been able to master, the art of alleviating emotional pain. I had found the panacea, or so I thought at the time.

The legitimate use quickly turned for the worse. All of the things I promised myself would never happen were long in the rearview mirror - doctor shopping, emergency room abuse, diverting from work, using at work - to the point where I was caught at work. At some point before I was caught I realized this was not normal, but I was so far down the road I didn’t know where to turn. I remembered PAPA coming to speak to my graduating class, but was afraid of losing my job, my reputation, and any other ego based reason my mind could come up with to prevent me from seeking help. Most of all I was just plain afraid.

The person who had conquered all was now unrecognizable. I was an addict, an alcoholic and I certainly felt like a loser. I had been busted at work not only stealing medication but using, too.

I was at a crossroads. I contemplated killing myself. I felt so ashamed, so lost, and knew that losing my license was inevitable.

I could not even ask for help, as that would somehow admit my

PAPA guilt. I still thought I could somehow talk my way out of the mess I had created of my life. I couldn’t fathom where my addiction had taken me, and so quickly.

I was blessed to be given the opportunity to redeem myself through the PAPA program. Initially I thought that I’d just go along for the ride, get my license back, and I could go back to my life as it were (minus the drugs and maybe the alcohol, I could still drink couldn’t I?) Little did I know that I would never trade the life I have now for even a moment of the misery and stress I had before entering recovery. The whole concept of “rehab” has become one of the biggest societal jokes, with the Lindsay Lohans of the world claiming “sobriety” every other day, whilst being caught out with a drink in the hand or a white line under their noses. Initially my life was far from perfect in recovery.

I had a disaster of a life to try and clean up and mend as best I could. In retrospect it was like a tornado had come through my life and just because the winds of immediate drug and alcohol use weren’t tearing a tract through it anymore didn’t mean there wasn’t a whole lot of mending and work to do.

The Arizona State Board of Pharmacy and PAPA didn’t trust me, which was a self imposed situation. I had lost my job, my license, my reputation, my integrity, my relationship, pretty much everything I had ever considered my identity. I however did not give up hope. For once in my life I started taking the direction of others, people who had figured their lives out and whom I respected. I entered treatment and eventually found 12 step recovery as a means of maintaining my sanity. Through this process I began to grow as a person and learned to deal with life on life’s terms. I began to accept and face the destruction I had caused and began taking life one day at a time, living well, and not using or drinking alcohol. Then one day it dawned on me: it doesn’t really matter what I use to artificially give myself a sense of ease and comfort - drugs, alcohol, shopping, relationships - I found out that all of them can be used and abused to create a false sense of serenity.

Today, on most days, I have a sense of peace and calm.

Through the ever-winding twists and turns of recovery I have gained back so much more than my license and career as a pharmacist. I have a life, one with breadth and depth, friends and family, love and companionship, and most of all a sense of knowing. Yes, I am both an addict and an alcoholic. Would I trade that in for what I have now? No. Would I have done anything differently? Yes, many things, but the biggest is I would have gotten help much sooner.

PAPA is not meant as a punitive measure. I later found out that if I had voluntarily entered treatment, I would have remained anonymous to the Board and maintained my license, but could have received the structured help that was desperately needed.

Hindsight is 20/20. If you suffer from this similar fate, I advocate you reach out in whatever form you need and get help.

Arizona Journal of Pharmacy 17

Academy News Community Pharmacy Academy News

Greetings, Community Pharmacy Academy Members,

Congratulations to Kristin Calabro for becoming the new Community Pharmacy Academy Chair-Elect.

Welcome!

Please join us at the AzPA Annual Meeting for the Community Pharmacy Academy meeting on Saturday, July 9, 2011 at 5 pm. We will have much to discuss, including some of the following topics: Several new bills were introduced recently in Congress.

HR1971 - Pharmacy Competition and Consumer Choice Act and S1058 • Increase PBM transparency • Provide protections from certain burdensome practices • Allow any willing pharmacy to participate in a network, so long as it is eligible to participate in a federal or state health plan HR1839 - Community Pharmacy Fairness Act of 2011 and HR1946 - Preserving Our Hometown Independent Pharmacies Act of 2011 • Provides narrow anti-trust exemption to allow independent community pharmacies to collectively negotiate terms and conditions of insurance contracts for fairer plan designs and greater patient choice • Provide leverage to small pharmacies to negotiate on a more level playing field

drug sites. We are looking for volunteers to reach out to communities across the state. Please contact the AzPA office if you would like to get involved.

A pharmacy ownership conference is in the planning stages. This event is intended to provide information and resources on becoming an independent pharmacy owner. Also, the next Independent Pharmacy Owners Forum will be held during the 3rd quarter of this year.

Stay tuned for more information.

With the legalization of medical marijuana in Arizona, the AzPA CPA introduced a resolution to the American Pharmacists Association to recommend that marijuana be reclassified from C-I to C-II status, allowing pharmacists to be involved in the dispensing of the drug. Without this reclassification, any pharmacist involved in dispensing medical marijuana faces possibe federal prosecution and loss of their license.

If you wish to become involved with any of our CPA activities, please contact me.

Sincerely,

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

PAAS Membership Benefits

• Expert Third-Party Audit Assistance • Monthly Third-Party Newsline • PAAS Member Manual & Third-Party Guide • PBM Resource/Advice & Contract Information • Valuable Forms & Reference Tools

Please call or email your Senators and US Congressmen today and tell them to support these bills to protect patients, and reduce costs. Go to www. congress.org to obtain contact information for your congressional representatives. If you would like more information on this issue, please contact me at melrosepharmacy@yahoo.com.

The Community Pharmacy Academy is working on several projects, including the AWARxE campaign to increase public awareness about prescription drug abuse, safe disposal of medications, and rogue internet 18 Arizona Journal of Pharmacy

Be Proactive. Be Protected. Be Prepared.

JOIN PAAS TODAY! 888.870.7227 | PAASnational.com

Health-System Academy News Greetings, Health-System Academy Members, The 2011 AzPA Health-System Academy Conference was held April 2, 2011 at Banner Desert Medical Center. More than 70 participants were in attendance.

Many thanks to our speakers: Lindsay Davis, Michelle Baker, Robin Staib, Mitch Librodo, Butch David, Mitchell Buckley, Melanie Yerondopolous, Thomas Jaeger, Mindy Smith, Christine Cassetta, and Susan Brichler Trujillo. Also, thank you to our luncheon sponsor, Boehringer Ingelheim. A huge thank you to Jean Patel and her committee for presenting another outstanding academy conference!

The recent problems with drug shortages frustrate many of us. Up until the last few years, few of us ever worried about PhRMA being able to supply drugs to our pharmacies. The biggest question was how much were they going to charge. Today, however, the lack of reliability forces us to reexamine how we do business.

There are few simple answers to what causes a drug shortage. The most common reason (from ASHP) is ‘Manufacturing Problems’ at 28% of the reported causes. At the same time, 27% of the shortages had no explanation. ASHP has a drug shortage reporting site: http://www.ashp.org/shortages as does the FDA: http://www.fda.gov/Drugs/DrugSafety/DrugShortages/ default.htm.

Academy News At my hospital, we have had to stratify therapy, delay some treatments, cancel some procedures, and pay a lot more than usual for a lot of short supply drugs. The ASHP specifically recommends against stockpiling, as it can cause a more severe problem, but it is difficult to avoid the temptation to load up on a medication as soon as you hear of a potential shortage.

Please share some of your own experiences with this issue: email dop@azpharmacy.org and share your ideas!

This is my last message as Health-System Academy Chair. Jonathan Merchen will begin his term in July, and Lindsay Davis has been elected HSA Chair-Elect.

I leave you all in very capable hands.

Plan to attend the Health-System Academy meeting at 5 pm on Saturday, July 9, 2011 at the AzPA 7th Annual Meeting. See you all there!

Sincerely, Butch David, R.Ph. Health-System Academy Chair butch.david@bannerhealth.com

The best single source for an overview of this problem is at this link: http://www.ashp.org/DocLibrary/Policy/ DrugShortages/ASHP_shortage_guide09.pdf .

This same link provides an excellent flow chart suggesting how to manage a drug shortage at your own facility. In short, validate the shortage, assess its impact on your own patients and facility, determine a plan, and then communicate that plan.

What will resolve this? Senators Klobuchar and Casey submitted the bill “Preserving Access to Life Saving Medications Act” this spring in an attempt to empower the FDA to regulate drug supplies in our country. Only time will tell if this Act will help.

l to r: Linda McCoy, Butch David, and Jean Patel at the 2011 AzPA Health-System Academy Conference.

Arizona Journal of Pharmacy 19

Academy News Managed Care Academy News

Senior Care Academy News

Greetings, Managed Care Academy Members!

Greetings, Senior Care Academy Members,

Be sure join us for our academy meeting at the AzPA annual meeting in July. There will be many items on the agenda that we will need your input on. Our academy is currently slated to meet at 5 pm on Friday, July 8, 2011, so please check your meeting program for details.

Please join me in congratulating Brian O’Halloran on his appointment to the Managed Care Academy’s Executive Board as our representative on the AzPA Legislative Committee. Please check out our page on the AzPA website if you would like to become more involved and/or volunteer for one of our open committee assignments.

The AMCP Western Regional Student Conference will be hosted by UCSF on June 25-26, 2011, in San Francisco. According to UCSF’s outstanding AMCP Chapter President Maher Abdel-Sattar, “The annual meeting is entirely organized by students and attracts an audience of about 80 future pharmacists from universities all over the West Coast. Attendees will learn about the wealth of opportunities in the realm of managed care pharmacy through a variety of student-oriented lectures and educational programs.”

Additional details can be found can at http://amcpwesternconference.weebly.com.

As my term as Managed Care Academy Chair is drawing to a close I am very proud to be passing the torch to Julie Hernandez. Julie is an awesome leader and a very talented managed care pharmacist. I have a feeling that the upcoming year is going to be our academy’s best year ever. Also, Ann Sears has been elected Managed Care Academy Chair-Elect.

Congratulations, Ann! I look forward to seeing everyone at the AzPA Annual Meeting!

Best regards,

Ray Nelson Clark, Jr., PharmD Managed Care Academy Chair ray.nelson.clark@gmail.com 20 Arizona Journal of Pharmacy

Over the last quarter, the Senior Care Academy has been very active. The academy annual conference was held, the academy is considering a name change, monthly conference calls are being scheduled, plans for the annual meeting are being finalized, and a new Chair-Elect has been selected. The Academy has worked to achieve its goals of strengthening our affiliation with the American Society of Consultant Pharmacists and promoting and increasing academy membership.

The Senior Care Academy conference was held May 6, 2011 at the Grace Inn of Ahwatukee in Phoenix.

There was great attendance with 47 participants.

Excellent round table discussions were led by Rick Herrier, Kelly Ridgway, Jane Abrams, and Kip Raney.

They presented the following infectious disease topics: topical fungal infection treatments, immunizations for the elderly, urinary tract infection therapies, and MRSA medications. A federal pharmacy law update with a long-term care focus was provided by Lynne Batshon, the Director of Policy and Advocacy for the American Society of Consultant Pharmacists. She provided great insight into short cycle dispensing, controlled medication access, and pharmaceutical waste issues. Thank you to our fantastic speakers!

The Senior Care Academy is proposing to change the academy name to better represent the purpose of the academy. The reason for this name change is because there has been confusion from AzPA members, nonmembers from the pharmacy community, and other community partners about who the Senior Care Academy represents. We have received questions that range from whether the academy represents retired pharmacists, to senior citizens from the community.

We would like to change the name to better represent our academy and the name change proposal was discussed at the 2010 AzPA annual meeting with the Senior Care Academy and with the AzPA Board of Directors. We have asked the AzPA membership for feedback regarding their support for a name change and suggestions for an academy name. We currently propose the name to be changed to the Geriatric Care

Academy News Pharmacy Academy but are open to other ideas. Please email me with your feedback. The final decision will be voted on by the AzPA Board of Directors.

Conference call meetings have been scheduled for the academy to meet via phone and increase communications and networking with our members.

The conference calls are tentatively scheduled for noon on the second Wednesdays of the month.

You are encouraged to attend the AzPA Annual Meeting, July 7-10, 2011, at Westin La Paloma Resort & Spa inTucson, Arizona. There will be many programs applicable to the care of geriatric patients and it will be a fun conference. The Senior Care Academy will meet on Friday, July 8, 2011, at 5 pm at during the annual meeting to discuss plans for the next year.

Congratulations to Tara Storjohann, who was elected as Senior Care Academy Chair Elect. My term is ending and Dawn Knudsen Gerber will transition to the Chair for 2011-2012 starting in July. It has been a great pleasure to serve as the Senior Care Academy Chair and I hope to see you at the Annual Meeting!

Sincerely, Kim Cauthon, Pharm.D. Senior Care Academy Chair kbyrdx@midwestern.edu Photos top to bottom: Clinical Pearls-Infectious Diseases and the Geriatric Patient Round Table Discussions at the Senior Care Academy Conference.

Topics included: UTI Treatment with a Focus on the Geriatric Patient presented by Jane Abrams; Immunizations for the Elderly facilitated by Kelly Ridgway; Update on MRSA Treatment with a Focus on the Geriatric Patient coordinated by Kip Raney; and A Primer on Dermatology and the Geriatric Patient offered by Richard N. Herrier

Arizona Journal of Pharmacy 21

Academy News Student Pharmacist Academy News Greetings, Student Pharmacists, Student Pharmacists have found a home within AzPA! This past academic school year was the inaugural year of the AzPA Student Pharmacist Academy (or as we sometimes like to call it, the “SPA.�) In years past, student pharmacists from the University of Arizona and Midwestern Colleges of Pharmacy would become members of AzPA without truly understanding the AzPA mission or recognizing AzPA membership benefits. With the creation and implementation of AzPA-SPA, student pharmacists have been able to learn more about what AzPA does for Arizona Pharmacy and have become more involved in AzPA sponsored events. The organization of AzPA-SPA is such that each school elects one Co-Chair and one Co-Chair elect who serve as the primary liaisons with AzPA. These people oversee activities at their given school. In addition, each school has eight committee members that work with the different AzPA standing committees. This ensures more involvement by students.

At the University of Arizona, AzPA-SPA launched a membership drive at the beginning of the semester.

During this drive, we offered students a speaker luncheon where they learned about AzPA from the ever-entertaining and superb speaker, Dr. Crane Davis. This drive resulted in over 160 U of A student pharmacists signing up or renewing their memberships, not including those students who registered online. Since 2010 was an election year, we hosted a voter registration and awareness drive that provided students with the resources to learn more about candidates who ran in their districts and who their current elected officials were. In January, the SPA hosted an AzPA booth at Pharmacy Day at the Capitol.

On that day, we discussed with legislators and staffers the then un-assigned Senate Bill 1298, and practiced grassroots lobbying for pharmacy causes. We wanted to inform student pharmacists of the recent passage of the medical marijuana bill in Arizona and how this would affect pharmacists. Therefore, we organized a medical marijuana lunch debate with Drs. Mark, Kevin, and Keith Boesen. We wrapped up the year by 22 Arizona Journal of Pharmacy

helping organize the certified AzPA-SPA Leadership Conference.

At Midwestern University, AzPA-SPA started off the fall quarter hosting a luncheon with Dr. Mark Boesen speaking. It was the beginning of our campus awareness and membership drive. We were happy to receive many paper forms and comments about people signing up on-line during this time. We hosted informational meetings during lunch hours and were very instrumental in getting students involved in Pharmacy Day at the Capital in various aspects. AzPA CEO, Mindy Smith was instrumental having joined us on campus to discuss some big pieces of legislation that we could then discuss with the legislators.

In capping off our inaugural year, Midwestern University and the University of Arizona worked closely to develop a student leadership conference (see story on page 31). This was the culmination of all the possibilities the SPA could be for students, highlighting the dramatice impact that AzPA could have on students and the profession of pharmacy.

This has been an exciting and busy year for us as Co-Chairs! It has given us the opportunity to really engage student pharmacists in the efforts of AzPA and offer them more value from their AzPA membership, while establishing a more formal AzPA presence on each campus. In addition, we were fortunate to expand our leadership skills and work with some of the most passionate leaders in Arizona Pharmacy, including student pharmacists. It has been an inspiring experience and we are very grateful to have served!

We look forward to the future developments of this Academy.

Your new SPA Co-Chairs, Valerie Bostel and Jessica DiLeo, begin their terms in July. The new Co-Chair Elect from the U of A is Eric Wong. Elections for MWU Co-Chair Elect will be held in September.

Sincerely, Kerry Redman and Bonnie DiLorenzo AzPA Student Pharmacy Academy Co-Chairs bblorenzo@hotmail.com kredman@email.arizona.edu

Academy News Technician Academy News Greetings, Pharmacy Technician Academy Members,

Kerry Redman and Bonnie DiLorenzo, Student Pharmacist Academy Chairs, 2010-2011 at the SPA Inaugural Leadership Conference.

AzPA Calendar of Events July 7, 2011 Diabetes Certificate Program Westin La Paloma Resort & Spa July 7-10, 2011 AzPA 7th Annual Meting Westin La Paloma Resort & Spa September 2011 Community Pharmacy Academy Conference TBD September 2011 Diabetes Certificate Program TBD

October 2011 Anticoagulation Certificate Program TBD October 2011 American Pharmacists Month November 2011 Managed Care Academy Conference TBD November 2011 APhA Immunization Certificate Program TBD

Visit www.azpharmacy.org for all upcoming events.

The AzPA 7th Annual Meeting is just one month away. Are you planning to attend? It will be held at the Westin La Paloma in Tucson, Arizona, July 7-10, 2011. This year’s theme is Pharmacy Rocks: A Lifetime Commitment to Patient Care. Registration for technicians is just $200 for the three-day conference, offering more than 15 hours of continuing education, including 2 hours of Law. Suggested breakout sessions for technicians include Hot Topics in Contraception, COPD Pathology, and Respiratory Pharmacology. All general sessions are accredited for both pharmacists and pharmacy technicians.

The Techician Academy will meet on Friday, July 8 2011, at 5 pm to discuss plans for the coming year. If you will be in Tucson, please plan to attend.

This is my last message as your Technician Academy Chair. I am very proud and happy to have worked for you, and to represent Pharmacy Technicians on the AzPA Board of Directors for the past two years.

Remember, technicians, we are often the first contact with a patient at the pharmacy and we should be proud to represent our profession. We can help our patients understand the different programs and services that pharmacy can offer. By doing this, in the future we will be rewarded and appreciated by our fellow technicians and co-workers.

Mike Severn is your Technician Academy Chair for the 2011-2012 year. Congratulations to Joy Davis as your new Technician Academy Chair-Elect! I know they will serve the AzPA and our profession very well. Thank you to everyone who supported the AzPA Technician Academy over the past years.

Sincerely, Chris Lesaca, C.Ph.T. Technician Academy Chair azclml@yahoo.com

Empowering pharmacy professionals to provide optimal patient care

Arizona Journal of Pharmacy 23

Drug Information Questions

Question: What evidence exists for the use of roflumilast (Daliresp®) in COPD?

by Jennifer A. Larson, Pharm.D. Candidate, and Stacy L. Haber, Pharm.D., Associate Professor, Midwestern University College of Pharmacy-Glendale

Answer:

Introduction According to the most recent National Vital Statistics Report performed by the Centers for Disease Control and Prevention, the fourth leading cause of death in the United States is chronic lower respiratory diseases.1 Chronic obstructive pulmonary disease (COPD) is characterized by decreased airflow that is not fully reversible.2 Chronic inflammation of airways leads to structural changes and damage, which cause shortness of breath, cough, and sputum production. The most common risk factor for development of COPD is cigarette smoking; however, exposure to tobacco smoke and environmental pollutants are also risk factors.2,3 Goals of treatment are to relieve symptoms and to prevent and treat exacerbations.2,4 In addition to smoking cessation, these goals are achieved through pharmacotherapy, with appropriate agents selected based on a patient’s disease severity.

Disease severity is determined primarily by spirometry, which includes postbronchodilator forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), to classify patients as mild (Stage I), moderate (Stage II), severe (Stage III), or very severe (Stage IV).2,4 Short-acting bronchodilators are the firstline agents for patients with any stage of COPD for symptomatic relief. Long-acting bronchodilators are recommended for patients with poorer lung function (Stages II to IV), who experience symptoms more frequently.2 For patients with Stages III and IV, additional agents are controversial. Inhaled corticosteroids may decrease exacerbations, but they fail to improve lung function, and theophylline is limited by side effects, drug interactions, and therapeutic monitoring.2,4,5 Because of a lack of treatment options for patients with severe disease, researchers have been investigating new agents. In March of 2011, roflumilast (Daliresp®) became the first FDAapproved phosphodiesterase 4 inhibitor to reduce the risk of COPD exacerbations. Phosphodiesterase 4 inhibitors prevent the breakdown of cyclic AMP, which results in smooth muscle relaxation in airways and decreased pulmonary inflammation.6,7 Five reports of 7 randomized controlled trials evaluating the efficacy of roflumilast in COPD have been published and will be summarized below.8-12 Clinical Trials In a trial by Rabe et al.,8 the safety and efficacy of 2 roflumilast regimens were tested compared to placebo over 24 weeks. A total of 1411 patients with Stage II or III COPD were randomized to receive roflumilast 500 mcg daily, roflumilast 250 mcg daily, or placebo. The primary endpoints were postbronchodilator FEV1 and St. George’s respiratory questionnaire (SGRQ) total score, a measure of health impairment and perceived well-being. Secondary endpoints included prebronchodilator FEV1, postbronchodilator FVC, and number of COPD exacerbations. Postbronchodilator FEV1 24 Arizona Journal of Pharmacy

increased by 51 mL with roflumilast 500 mcg (p=0.012) and by 29 mL with roflumilast 250 mcg (p=0.012) and decreased by 45 mL with placebo (p=0.016). SGRQ scores decreased (improved) by 3.5 units with roflumilast 500 mcg (p<0.0001), by 3.4 units with roflumilast 250 mcg (p<0.0001), and by 1.7 units with placebo (p<0.05). Significant improvement in prebronchodilator FEV1 and postbronchodilator FVC was seen in both roflumilast groups compared to placebo. The percentage of patients with exacerbations was 28% with roflumilast 500 mcg, 36% with roflumilast 250 mcg, and 35% with placebo (p=0.0114). The authors concluded that roflumilast improves lung function and reduces exacerbations in patients with moderate-to-severe COPD. The trial was limited by its short duration and exclusion of patients with very severe disease.

Calverley et al.9 performed a 1-year, double-blind trial of roflumilast 500 mcg daily compared to placebo in patients with Stages III and IV COPD. Compared to Rabe et al., this trial included patients with more severe disease; however, patients were not required to have a history of exacerbations or chronic bronchitis. Patients were allowed to continue inhaled corticosteroids (2000 mcg of beclomethasone daily or equivalent) and short-acting bronchodilators, but all other COPD medications were discontinued. A total of 1513 patients were randomized to receive roflumilast or placebo. Postbronchodilator FEV1 improved by 39 mL with roflumilast compared to placebo (p=0.001). The rate of moderate or severe exacerbations and change in total SGRQ score did not differ significantly between the groups. In subgroup analyses, roflumilast caused 18.4% fewer exacerbations in patients requiring systemic corticosteroids (p=0.029) and 36.1% fewer exacerbations in patients with Stage IV disease (p=0.024). The authors concluded that roflumilast provides modest but important benefits in lung function and may decrease the number of exacerbations in COPD patients. The concomitant use of inhaled corticosteroids and lack of history of exacerbations were limitations of the study.

In 2007, Grootendorst et al.10 published the first randomized, double-blind, crossover study to evaluate the effect of roflumilast on sputum neutrophil and eosinophil numbers. Thirty-eight patients received roflumilast 500 mcg or placebo for 4 weeks, followed by a 4-to-6-week washout period, and then they received the other treatment for 4 weeks. Patients were allowed to continue short-acting bronchodilators, but all other COPD medications were discontinued. The primary endpoint was percentage of sputum neutrophils. Secondary endpoints included pre- and postbronchodilator FEV1, markers of activation of inflammatory cells, markers of microvascular leakage, and inflammatory cell numbers and percentages in sputum.

Researchers found no statistically significant difference in the percentage of neutrophils in sputum, with a mean difference between roflumilast and placebo of -1.6 (95% CI, -4.8 to 1.6, p=0.31). Prebronchodilator FEV1 improved by 79.5 mL (p<0.0001) and postbronchodilator FEV1 improved by 68.7 mL (p=0.018) with roflumilast compared to placebo. All markers of

Drug Information Questions (continued from page 24) inflammation, except lactoferrin, and markers of microvascular leakage improved significantly with roflumilast. No significant change was seen with roflumilast in inflammatory cell numbers and percentages in sputum, with the exceptions of absolute number of eosinophils (-50.0%, p=0.0005), neutrophils (-35.5%, p=0.0017), and lymphocytes (-34.8%, p=0.022). Despite not finding statistical significance in the primary endpoint, the authors concluded that roflumilast has anti-inflammatory properties and improves lung function in COPD patients.

Two randomized controlled trials were published by Calverley et al.11 in 2009. Both trials were 52 weeks and compared roflumilast 500 mcg once daily to placebo in patients with Stage III or IV COPD. Study participants were allowed to continue short-acting bronchodilators and long-acting β2 agonists at stable doses, but were not allowed to use inhaled corticosteroids, long-acting anticholinergic drugs, or theophylline. A total of 1523 patients were randomized to roflumilast or placebo in the first study and 1568 patients were randomized in the second study. Because outcomes of the trials were similar, authors reported much of the data combined. Prebronchodilator FEV1 improved by 48 mL with roflumilast compared to placebo (p<0.0001). Moderate-to-severe exacerbations were reduced with roflumilast compared to placebo, with a rate ratio of 0.83 (95% CI, 0.75 to 0.92, p=0.0003). There were significant improvements with roflumilast in postbronchodilator FEV1, preand postbronchodilator FVC, and transition dyspnea index (TDI) score; however, no statistically significant difference occurred in mortality rate or time to death between the groups. The authors concluded that roflumilast improves lung function and reduces the frequency of COPD exacerbations. Because patients were required to discontinue COPD medications, they may have been predisposed to exacerbations, which would be a limitation of the trials.

In 2009, two randomized controlled trials were published

by Fabbri et al.12 to investigate the use of roflumilast in COPD. These were the first studies to examine roflumilast in combination with long-acting bronchodilator therapies (β2-agonists and anticholinergics). In the first trial, 933 patients with Stage II or III COPD were randomized to receive salmeterol 50 mcg twice daily with either roflumilast 500 mcg or placebo. In the second trial, 743 patients with Stage II or III COPD and frequent shortacting β2-agonist use were randomized to receive tiotropium 18 mcg daily with either roflumilast 500 mcg or placebo. The primary endpoint was change in mean prebronchodilator FEV1.

Secondary endpoints included postbronchodilator FEV1 and FVC, TDI score, Shortness of Breath Questionnaire (SOBQ) score, rescue medication use, and rate of COPD exacerbations.

Prebronchodilator FEV1 improved by 49 mL with roflumilast in the salmeterol trial (p<0.0001) and by 80 mL in the tiotropium trial (p<0.0001). Postbronchodilator FEV1 and FVC increased significantly in both trials compared to placebo. Only roflumilast + tiotropium showed significant improvement compared to placebo in TDI score, SOBQ score, and rescue medication use.

Neither roflumilast group demonstrated significant improvement in mean rate of COPD exacerbations. The authors concluded that roflumilast is efficacious in patients already using long-acting bronchodilators for moderate-to-severe COPD. Limitations of these studies included their short duration, exclusion of very severe patients, and insufficient power.

Discussion In each of the trials, although roflumilast was effective, it was also shown to have a higher incidence of adverse events and discontinuation rates compared to placebo.8,9,11,12 Common adverse events include diarrhea (9.5%), weight loss (7.5%), nausea (4.7%), and headache (4.4%).6-12 Roflumilast is associated with an increase in psychiatric adverse events, most frequently insomnia (2.4%). It is recommended to thoroughly evaluate the risks versus benefits before initiating roflumilast in patients with a history of insomnia, depression, or suicidal ideation.

Additionally, the risk of adverse events may be greater when roflumilast is used in combination with oral contraceptives containing ethinyl estradiol or gestodene and cytochrome P450 3A4 or 1A2 inhibitors, as these agents may increase systemic exposure to the drug.6 It should also be noted that while roflumilast is effective in preventing exacerbations, it is not a bronchodilator to be used for the acute treatment of exacerbations. Despite their short duration, several large clinical trials support the efficacy of roflumilast; thus, it is a promising new agent for patients with moderate-to-very-severe COPD, who have limited treatment options.

References: 1. Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. Deaths: Final data for 2007.

National vital statistics reports. Hyattsville, MD: National Center for Health Statistics. 2010. www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf (accessed 2011 Apr 14).

2. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. Bethesda, MD: National Heart, Lung and Blood Institute. Updated 2010. www.goldcopd.org (accessed 2011 Apr 14).

3. Standards for the Diagnosis and Management of Patients with COPD. American Thoracic Society / European Respiratory Society Task Force. New York: NY: American Thoracic Society. Updated 2005. www.thoracic.org/go/copd (accessed 2011 Apr 14).

4. Williams DM, Bourdet SV. Chronic obstructive pulmonary disease. In: Dipiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: a pathophysiologic approach. 7th ed. New York: McGraw-Hill; 2008: 495-517.

5. Alsaeedi A, Sin DD, McAlister FA. The effects of inhaled corticosteroids in chronic obstructive pulmonary disease: a systematic review of randomized placebo-controlled trials. Am J Med. 2002; 113: 59-65.

6. Daliresp (roflumilast) package insert. St. Louis, MO: Forest Pharmaceuticals, Inc; 2011 Feb. 7. Rabe KF. Update on roflumilast, a phosphodiesterase 4 inhibitor for the treatment of chronic obstructive pulmonary disease. Br J Pharmacol. 2011; 163: 53–67.

8. Rabe KF, Bateman ED, O’Donnell, et al. Roflumilast—an oral antiinflammatory treatment for chronic obstructive pulmonary disease: a randomised controlled trial. Lancet. 2005; 366: 563-71.

9. Calverley PM, Sanchez-Toril F, McIvor A, et al. Effect of 1-year treatment with roflumilast in severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2007; 176: 154-61.

10. Grootendorst DC, Gauw SA, Verhoosel RM, et al. Reduction in sputum neutrophil and eosinophil numbers by the PDE4 inhibitor roflumilast in patients with COPD. Thorax. 2007; 62: 1081-7.

11. Calverley PM, Rabe KF, Goehring UM, et al. Roflumilast in symptomatic chronic obstructive pulmonary disease: two randomised clinical trials. Lancet.

2009; 374: 685-94.

12. Fabbri LM, Calverley PM, Izquierdo-Alonso JL, et al. Roflumilast in moderate-to-severe chronic obstructive pulmonary disease treated with longacting bronchodilators: two randomised clinical trials. Lancet. 2009; 374: 695-703.

Arizona Journal of Pharmacy 25

Feature Pharmacist

Innovation, Integrity and Inspiration

by Kellie Miller, Pharm.D.

Cheryl Shafer has experienced incredible change in her pharmacy careeer. You could say, “she’s seen it all.” Receiving her BSPharm from the University of Nebraska, Cheryl’s early Arizona career included employment at the original Mesa Lutheran Hospital and owning a Medicine Shoppe community pharmacy in the late 1970’s. But her first love is hospital pharmacy. She is currently the Director of Pharmacy at Chandler Regional Medical Center (CRMC) in Chandler, Arizona, having worked at the facility for nearly 30 years. During her tenure at CRMC, she has seen the facility grow from a 49-bed community hospital to a 225-bed full-service, acute care medical campus.

Through this transformation, Cheryl was involved in the implementation of computer systems, dispensing systems and a bedside medication verification system for the hospital pharmacy department. She also developed the first clinical pharmacy program at CRMC, including the hiring of a clinical coordinator.

In addition to her role as DOP at CRMC, Cheryl was involved in the planning and completion of the Arizona Orthopedic Surgical Hospital and the successful opening and operation of Mercy Gilbert Medical Center. A patient safety advocate, she is a member of many corporate and association committees on practice standards.

A strong proponent of education, she is a preceptor for Pharm.D. students for several universities, including Midwestern University College of Pharmacy, Creighton University and University of New Mexico.

In 2009, Cheryl was recognized by the Arizona Pharmacy Alliance with the Elias Schlossberg Award, presented to 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.

What was your first position as a pharmacist?

I worked as a staff pharmacist in a hospital in Lincoln, Nebraska.

This was back in the days when everything was done manually and the pharmacist did very little actual clinical duties. Of course, there were not nearly as many drugs then either so our clinical duties were limited. We did not have technicians at that time either, so I was able to do a variety of tasks which made the job very interesting.

Regarding your successes over the years, which was most rewarding to you professionally and/or personally?

I think the most rewarding part of my career has been the ability to set up new pharmacies and develop new processes. I have had the good fortune of starting my own retail pharmacy, helping to build two new hospitals and set up their pharmacy departments, as well as help start up an outpatient surgical center pharmacy. I have also been very instrumental in setting up the first clinical program at the hospital as well as being very involved in the transformation from manual systems to electronic systems.

26 Arizona Journal of Pharmacy

What inspired you to become a pharmacist and what motivates you in your career as a pharmacist now?

I was always interested in the health care field, but did not want to be a nurse. After spending a summer working in the local drug store, I decided this would be a challenging career that would allow me to work in health care but not have to do bedside nursing. I am really proud of the changes that are taking place in pharmacy and I hope that my contributions on a daily basis are contributing to the success of these changes. I have an excellent staff that “makes me look good” and this makes me proud to be a part of an organization that improves the lives of our patients.

Why do you feel it is important for pharmacists and pharmacy technicians to become involved in pharmacy professional organizations?

I have found that the best way to keep up with changes and new innovations is through the professional organizations. They have the resources to keep apprised of new technologies, changes in practice, as well as disseminating best practices in all areas of pharmacy. In addition, the collaboration with others in the profession can be invaluable when challenges arise and one needs support and encouragement from others that have had the same experiences.

What projects/collaborations are you working on now?

This is an exciting time at CRMC. We are six months in to implementing an Antibiotic Stewardship program. We are beginning the design of a new platform for our electronic medical record, which will lead to the implementation of Computerized Physician Order Entry (CPOE). We are in the process of the design and build of a new 100 bed tower. In this tower we have designed work areas for the pharmacists so they can continue to work beside the nurses and physicians, as well as adding a satellite pharmacy in the ICU for the preparation of first doses.

On a smaller note, I am working toward adding an emergency department pharmacist to my decentralized group of pharmacists in the next fiscal year. With healthcare evolving so fast, it seems like we are always in the middle of “change” which makes it a very exiting time to be a pharmacist.

How do you see health system pharmacy practice evolving in the future?

In hospitals there is going to be continued emphasis on clinical pharmacy, with the dispensing functions taking a back seat to these issues. Patient safety is going to continue to be a big push. I am very proud that we were one of the first hospitals in the valley to institute bedside medication verification which significantly increases the patient’s safety at the bedside. I believe the physicians are going to rely more and more on the pharmacist to follow patients for anticoagulation therapy, renal dosing, patient education, especially in the critical care areas. The pharmacist of today has a lot to contribute to the management of the patient and this knowledge is going to continue to be recognized over the next few years. These skills make the pharmacist a very important member of the health care team.

Feature Pharmacist In light of the recent changes in health care policy both locally and nationally, what do you see as the largest opportunity and largest challenge for the pharmacy profession at this time?

One of the biggest opportunities that I see is for the pharmacist to become much more involved in the care of the patient. We are the medication experts and we should be managing the patient’s medication needs in collaboration with the physician. In the hospital setting we are able to use a lot of protocols, which enables us to be more involved in the patient’s care, and these opportunities should be available to patients in all settings.

One of the largest challenges is ensuring that as professionals we receive compensation and recognition for our activities. We have a lot to contribute, which will save money and lives in the long run and we should be recognized for these contributions, both monetarily as well as professionally.

What advice do you have for a new pharmacist who is just entering the profession?

A new pharmacist should be willing to be flexible in their expectations. They need to be willing to do numerous tasks, which include those “mundane” things like checking a technicians work, as well as doing the clinical duties that they were trained to do in school. They need to be willing to ask questions and continue to learn. Working in the real world is different than what happens in the educational environment and they need to understand that it takes a while to adapt to these new experiences. Finally, they need to be proud of their profession.

Pharmacists are a very important part of the health care team and they need to share this with the patients and the community.

What advice do you have for a student who is just starting pharmacy school?

A new student needs to make sure that they are going into pharmacy for the right reasons. If they are doing it for the money then they will find the profession to be very unsatisfactory. They need to look at all options available to them and decide which one is most appealing, that is, retail, hospital, home care, etc.

Depending on which way they decide to go they need to consider the possibility of doing a residency or post graduate work. We also are going to need new leaders in the future as the current group of directors and managers reach retirement age, so some of them need to be looking at following the leadership tract. They need to follow the proposed changes that are taking place in the field through their state and national organizations so that they have input into shaping their career for the future. Finally, they need to feel a passion for what they do because this profession is not always an easy one to pursue. They need to be able to enjoy what they do on a daily basis.

Cheryl Shafer, R.Ph., Director of Pharmacy, Chandler Regional Medical Center

AzPA Career Center - Here for You As your primary resource for professional development and services, the Arizona Pharmacy Alliance offers a full-service Career Center designed especially for employers and job seekers in the pharmacy industry.

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Please contact Janet Weigel, AzPA Marketing and Communications Coordinator, at janet@ azpharmacy.org with any questions you may have about using the Career Center.

The Arizona Pharmacy Alliance Career Center Your Industry • Your Community • Your Career

Arizona Journal of Pharmacy 27

Feature Pharmacist

An Inspirational Leader and Mentor

by Ushma Kanzaria, Pharm.D. Candidate, Midwestern University – College of Pharmacy, Glendale, Class of 2011 Who is Dr. Lindsay Davis? Dr. Davis is a faculty member at Midwestern University – College of Pharmacy, Glendale (MWUCPG). She is a decentralized staff pharmacist at Banner Estrella Medical Center. Above all, Dr. Davis is a mentor and role model for her students and peers. As I stepped into Dr. Davis’s office, I could already see that she has an enthusiastic personality. Her walls are decorated with fun facts, photos, inspiring quotes, and bright inviting colors.

Dr. Davis has an interesting, and truly inspirational story.

Starting at a young age, Dr. Davis knew that she had a passion for academia. She was always in awe of her grade school teachers and even proclaimed that she “feels at home in the educational environment.” At The University of Arizona - College of Pharmacy, Dr. Davis had the opportunity to work with her mentor Dr. JoLaine Draugalis in a faculty academic rotation. This was where it clicked for her: a perfect combination of pharmacy and teaching.

Upon graduating from pharmacy school, Dr. Davis was at a crossroad. She had the choice of either entering community pharmacy or completing a residency. After being in school for so long, Dr. Davis decided that she wanted to “simply live life.”

Dr. Davis worked in community pharmacy, got married, and had two children. All the while, an ultimate career in academia remained at the forefront of Dr. Davis’s mind. Six years later, Dr. Davis completed a PGY1 Residency Program focused in Internal Medicine at the Phoenix Veterans Affairs Healthcare System.

When asked if it was tough to enter a PGY1 Residency Program after spending six years in community pharmacy, Dr. Davis responded that it all boiled down to her enthusiasm and passion. She admitted that she was “rusty on the fundamentals,” but that she brought a different perspective to her fellow residents through her past work experience. She also stated that in regard to a big pay cut, “it was the year I was least compensated as a pharmacist but most professionally satisfied.” Dr. Davis used the residency year to focus on improving herself, and acquiring the tools and knowledge needed to effectively give back to her community of patients, peers, and students.

Dr. Davis puts a great deal of time and effort into her teaching.

Before preparing any presentation, she asks herself “who is my audience and what do they need to take away to be prepared pharmacists.” For one hour of lecture, she spends up to 20 hours preparing. At MWU-CPG, Dr. Davis focuses on not only providing students with information, but teaching them how to learn, and how to take away the most important facts. Dr. Davis acknowledges that “learning is messy.” She compares learning in school to her own children learning how to feed themselves.

Before succeeding to eat with minimal disarray, her daughter made a mess “with her small amount of food finding its way to as far as her toes and across the room.” To learn and truly understand, one must be willing to dive into the “mess of the unknown,” consider the “big picture,” and avoid being caught up in the details. She advises students to also “mind the gap,” and spend time reviewing what they do not know, rather than what they do know. Dr. Davis does not believe in mandatory lectures.

28 Arizona Journal of Pharmacy

Rather, her goal is to make her lectures so worthwhile that students feel as though they are missing out if they do not attend.

One of Dr. Davis’ favorite quotes is a Chinese proverb: "Tell me and I'll forget. Show me and I may not remember. Involve me and I'll understand." She teaches her students to value the process of learning, and engages them in interactive activities during lecture.

Instead of instilling an intent to “memorize information for next Thursday’s test”, she instills an intent of “what to know to practice and to provide the best patient care.” Beyond her lecture notes, she teaches students values, attitudes towards learning, and the importance of active learning.

Dr. Davis feels that it is important to be involved with the Arizona Pharmacy Alliance because it is a way to stay engaged in the profession beyond the workplace. It is a way for pharmacists to come together and stay connected, focusing on the issues facing the profession of pharmacy. Dr. Davis realizes that there is a lack of involvement in the profession. She hopes that all pharmacists can take some time to work toward enhancing their profession by being active, staying involved, and collaborating with their peers in the Arizona Pharmacy Alliance.

Dr. Davis’ passion to do good, whether by helping patients, mentoring students or advocating for the profession, was apparent throughout the interview. When asked how she stays so motivated to achieve her goals, Dr. Davis responded with “When you want something, and you work for it, it will happen.”

Dr. Davis believes that in order to achieve what you desire, it is necessary to “become someone who can state their personal and professional goals.” She encourages students to write out their thoughts and flesh out their goals, and then take it to the next level by brainstorming ideas as to how they will achieve their goals. It is one thing to have the ideas and the goals, it is the next step that is crucial: actively working towards those goals every day. Dr. Davis sums it up well: “To be successful, be engaged, have intent, write to know, and have passion for what you do.”

Dr. Lindsay Davis in her office at Midwestern University (left) and (below) presenting at the HealthSystem Academy Conference on April 2, 2011.

Dr. Davis is the AzPA Health-System Academy Chair-Elect for the 20112012 term.

Compounding and Politics: A Leader in the Midst

by Alexandria Smith, Pharm.D. Candidate, The University of Arizona College of Pharmacy, Class of 2011 I had the pleasure to interview one of the most innovative pharmacy leaders within our community: Michael Blaire, R.Ph. Mr. Blaire was born in New York, where he was able to explore a variety of professional interests including microbiology, literature, and pharmacy. Upon graduation from St. John’s University College of Pharmacy and Allied Health Professions, he worked within the retail setting for thirteen years before moving to Arizona with his family. In Arizona, Mr. Blaire practiced at Walgreens Pharmacy as the manager for seven years before deciding to open up his own compounding pharmacy, specializing in animals.

Mr. Blaire’s interest in compounding began at Walgreens Pharmacy where his store was the only one making compounds such as capsules, lozenges and suspensions. In 1997, Walgreens changed how bonuses were being calculated, which was now based on profitability. After a complete analysis of his store, Mr. Blaire determined that compounding was the profitable element and needed to be maximized.

One day Mr. Blaire walked into a veterinarian office and asked if there was a need for compounding in this field. The veterinarian responded by asking if Mr. Blaire could make certain types of medication products. Mr. Blaire confirmed that he could make these products, which was a turning point in his career. In 2001, Mr. Blaire co-founded Diamondbacks Drugs which is a local organization that supplies compounds to zoos, aquariums, and household pets all over the United States.

When asked about his experiences in collaborating with veterinarians compared to physicians, Mr. Blaire replied he enjoys working with veterinarians for many reasons. First of all, compounding is a new field for most veterinarians which allows the pharmacist to play a vital role in the care of the animal.

Secondly, new specialties are emerging for animals including oncology, infectious disease, and diabetes. The pharmacist is able to recommend an appropriate medication for the disease state being treated including the dosage form, strength, frequency, and duration. The pharmacist and veterinarian have an open line of communication with each other and are able to work together toward a common goal.

During the interview, I asked Mr. Blaire to share his favorite experience with me: At the Albuquerque Zoo, a rhinoceros had a pseudomonal infection which required treatment with Bactrim. It was decided the best way for the rhinoceros to take the medication was to grind up the Bactrim and sprinkle it on its food. The rhinoceros did not like the taste of Bactrim and decided to stop eating entirely. Diamondback Drugs was then contacted to come up with a solution for this situation. Originally the veterinarian wanted a chewable tablet, but that would be difficult with the large dose of medication required (120 grams/ dose which is equal to powder the size of a baseball.) Mr. Blaire and his team came up with the idea of putting the medication into a three foot by five foot rice krispy treat. The rhinoceros loved the rice krispy treat and was able to fully recover from the infection. Mr. Blaire uses his innovational thinking everyday to solve problems such as these.

Feature Pharmacist How do you treat a 3,000 pound rhinoceros with pseudomonal infection?

Ask Mike Blaire.

Mr. Blaire is not only known for his company, Diamondback Drugs, but also for his courage in running for a position in the Arizona House of Representatives. During school and work, Mr. Blaire noticed that the pharmacy profession was always being put on the back burner due to the lack of involvement by pharmacists in politics. Also, compounding was in the crosshairs of the FDA and OSHA. This gave Mr. Blaire the motivation to get involved and make a difference for his profession. Mr. Blaire began to network by joining organizations like International Association of Compounding Pharmacists, National Chain Pharmacy Assocation, and AzPA. At one of the organizational events, Mr. Blaire had the opportunity to meet former Congressman J. D. Hayworth. After their conversation, Mr. Blaire knew that Mr. Hayworth already forgot his name. This situation drove Mr. Blaire to get even more involved by joining the Local Republicans Club. At another event, Mr. Blaire ran into Mr. Hayworth again and this time he made sure that Mr. Hayworth would not forget who he was. To this day, Mr. Blaire and Mr. Hayworth are good friends and Mr. Hayworth supports Mr. Blaire in all of his endeavors.

Mr. Blaire furthered his involvement in politics by becoming a candidate for Arizona House of Representatives for District 8. When asked about his experience, Mr. Blaire replied “It was a grueling, but great experience.” His candidacy allowed Mr. Blaire to meet fantastic people and see how the state government works. He felt very supported by AzPA who hosted two fundraiser events for him. Unfortunately, Mr. Blaire did not get elected to the Arizona Legislature, but he may run again depending on his family and business.

Mr. Blaire is an amazing individual who encompasses the leadership qualities necessary to make a difference in the profession of pharmacy. Mr. Blaire said it best himself: “The government can put out a business overnight, your competitors cannot.” Pharmacists and pharmacy companies need to work together in order to achieve a common goal. “We are the only ones who can protect our profession, no one else will.”

Mr. Blaire also responded to these questions during our interview.

What do you see as the biggest issue facing the profession of pharmacy today?

I feel the biggest issue facing the profession of pharmacy today is reimbursement in all fields of pharmacy. If pharmacists do not get paid for their services, then we cannot practice our profession.

An opportunity is presenting itself with the current state budget situation. Pharmacists need to get involved and show that we are the only health care professionals that can increase value while cutting costs.

Arizona Journal of Pharmacy 29

Feature Pharmacist Compounding and Politics (continued from page 29) What major changes do you see in the future of pharmacy practice?

I see the evolution of having store clinics next to the pharmacy.

This will allow pharmacists and other health care professionals to work together in order to optimize patient care.

What advice do you have for graduating pharmacy students?

I have two pieces of advice for graduating pharmacy students.

First is to be involved in state and national organizations. We need to watch out for our profession and the only way to do that is to be involved. Second is to find an area of pharmacy you love and are passionate about, then pursue it. A Chinese quote sums up this point: “Do what you love and never work a day in your life.”

What advice do you have for pharmacists who want to become more involved?

The first place to start is networking with people. It is important to be involved in state and national organizations. If there is an area you want to pursue and make a difference, then there is always someone out there to share resources with and fight for the same goal.

Have You Used The PEER Portal?

Quick...What Can You Do In 3 Minutes?  Work your abs  Boil an egg  Wait for a stoplight to turn green (unless you're putting on mascara)  Take a shower (unless you're a teenager)  Listen to a song  Microwave a meal  Submit a PEER Portal entry What's the PEER Portal?

It's the Pharmacy and Provider E-Prescribing Experience Reporting Portal.

It's a quick and easy way for pharmacists and technicians to confidentially submit experiences encountered with eprescriptions; for instance:  Did the directions for mouthwash say "apply twice daily to affected area on arms?"  Did the Rx authorize 30 months instead of 30 tablets?  Was an e-prescription for the wrong patient?

By capturing and analyzing this detailed data, industry-wide process improvements can be made, certification standards can be revised, and interventions can be initiated with prescriber and pharmacy technology vendors. Better quality, safety and efficiency for all.

Here's the link: https://www.pqc.net/eprescribe/?refcode=apms.

It's a great use of 3 minutes--while you wait for your microwave meal.

Mike Blaire, R.Ph., owner Diamondback Drugs, and his wife, Dorothy.

Register today!

Arizona Pharmacy Alliance 7th Annual Meeting July 7-10, 2011 Westin La Paloma Resort & Spa Tucson, Arizona

Be part of Arizona’s Largest Pharmacy Meeting!

Pharmacy ROCKS

30 Arizona Journal of Pharmacy

Student Perspective SPA Leadership Conference: The Future Pharmacy Leaders

by Ushma Kanzaria, Pharm.D. Candidate, Midwestern University College of Pharmacy Glendale, Class of 2011; Alexandria Smith, Pharm.D. Candidate, University of Arizona College of Pharmacy, Class of 2011; and Winnie Thi, Pharm.D. Candidate, Midwestern University College of Pharmacy Glendale, Class of 2011 The Student Pharmacist Academy (SPA) Inaugural Leadership Conference was held on April 16, 2011. A total of 48 students attended this event representing both pharmacy schools in the state of Arizona: The University of Arizona and Midwestern University. Each student was hand-picked by their Dean of Pharmacy based on leadership qualities, involvement in their school, and the potential to positively represent the profession of pharmacy.

Ms. Kelly Ridgway R.Ph., Arizona Pharmacy Alliance (AzPA) President and Pharmacy Care Manager at Safeway, began the SPA Leadership Conference with an inspiring speech. She motivated the students to think about their vision for the practice of pharmacy, for themselves, and for their own profession. The only way to accomplish these visions is to have a voice by getting involved with our state and national pharmacy organizations.

There are many opportunities for the profession of pharmacy, but there are “thorns” or “weeds” that make it difficult to achieve these visions. The key is to have passion: passion for your profession and passion to get involved.

After the opening remarks by Ms. Ridgway, Mr. Don Hughes was introduced. Mr. Hughes is the Special Advisor to the Governor for Health Care Innovation. Students had the opportunity to ask questions in a relaxed environment in regard to the Health Care Reform (HCR) and the impact it will have on the profession of pharmacy. Mr. Hughes discussed the current issues relating to the state budget and the effect this will have on the health care profession. His discussion opened the students’ eyes to the different legislative processes taking place including the AHCCCS Program, Accountable Care Organizations (ACOs), and Health Information Exchange (HIE). The goal of these programs is to reduce the state costs, increase productivity, and improve efficiency. The second part of Don Hughes’ discussion related to the money that can be saved by utilizing what a pharmacist can bring to the table in terms of their knowledge and expertise. Mr. Hughes stated that a total of $21 billion dollars can be saved by reducing the amount of medication errors.

Pharmacists play a vital role in reducing adverse drug reactions, drug-drug interactions, and medication errors which in turn will reduce the burden of health care costs.

Following an eventful morning, McKesson sponsored the lunch. Kirk Saltzgaber, the District Sales Manager for McKesson, provided an Independent Pharmacy Ownership Resource presentation. Mr. Saltzgaber discussed the tools and resources McKesson provides for those interested in becoming an independent pharmacy owner. Students were very appreciative for all of the information provided by McKesson, which will enable them to serve as leaders within their own community.

Also during lunch, awards recognizing the Llyn Lloyd Scholarship recipients and the SPA Service Award recipients were announced. The Llyn Lloyd Scholarship recognizes students

who are engaged in and actively participates in a state or national pharmacy organization. The 2011 Llyn Lloyd Scholarship recipients were Bonnie DiLorenzo from Midwestern University and Bernadette Aragon from The University of Arizona.

The SPA Academy Service Award recognizes one student from each campus who actively promotes the Arizona Pharmacy Alliance and the Student Pharmacist Academy. The 2011 SPA Academy Service Award recipients were Scott Hall from The University of Arizona and Andrew Giffords from Midwestern University.

Andrew Gifford accepts the SPA Academy Service Award from Bonnie DiLorenzo, SPA Chair from Midwestern University CPG

Scott Hall accepts the SPA Academy Service Award from Kerry Redman, SPA Chair from the University of Arizona COP

After lunch, Dr. Crane Davis, Assistant Pharmacy Director for Fry’s Food and Drug Stores and the 2008 AzPA President, gave a stimulating lecture on leadership in the profession of pharmacy.

He discussed several essential leadership qualities including tenacity, problem solving ability, prioritizing under pressure, understanding the people you lead, and most importantly being comfortable with making mistakes. He emphasized that leaders cannot let the fear of making mistakes hold them back. Another point that Dr. Davis presented was the “Pharm.D.” brand and the promise associated with it: honesty, accuracy and trustworthiness.

As future pharmacists, it is the students’ responsibility to uphold this brand and not only implement ways to deliver the promise, but also enable others to do the same. Dr. Davis stressed that successor planning (giving your mentee the tools and knowledge to ultimately be your successor) is necessary in any leadership position to assure continued success of an organization.

Dr. Davis utilized the Shouldice Case from the Harvard Business School to solidify the concepts that he presented. Dr. Shouldice created the overwhelmingly successful Shouldice Hospital Limited, which specialized in hernia repair. The Hospital’s success originated from the deep understanding Arizona Journal of Pharmacy 31

Student Perspective The Future Pharmacy Leaders (continued from page 31) Dr. Shouldice had of business leadership, specifically problem solving, successor planning, and branding. The Shouldice Hospital promised consistent quality service in an appealing environment that attracted patients not only to make one visit, but to make numerous follow-up visits year after year. Dr. Davis encouraged students to use the Shouldice case as a model, and incorporate the leadership qualities into their own pharmacy practices.

Following the Shouldice case, Dr. Davis started a thoughtprovoking discussion related to the profession of pharmacy. Prior to the SPA Leadership Conference, students were asked to write a 200 word essay on what they felt was the most important issue facing the profession of pharmacy today. Five major themes surfaced from the essays submitted: HCR/Medical Home/MTM, Promoting the Perception of Pharmacy, Pharmacist-Patient Relationship, Workforce/Workplace, and Education/Residencies.

Many of the essays were very progressive and forward thinking, which provided a new perspective for all participants. Students developed a list of potential solutions concerning the Promotion of Pharmacy Perception and the Pharmacist-Patient Relationship.

Some of these ideas included a check list demonstrating the activities a pharmacist performs for any specific prescription, getting pharmacists more involved in their profession, and utilizing Tech-Check-Tech in order to free up the pharmacist to take part in clinical roles.

During the SPA Leadership Conference, four leaders from different areas of the pharmacy profession had an open discussion with the students. Mr. Butch David R.Ph., AzPA Health-System Academy Chair and Director of Pharmacy at Banner Good Samaritan Medical Center, stated that pharmacists need to detach from the product and focus on outcomes. Banner Good Samaritan Medical Center is a good example of this process by implementing Collaborative Drug Therapy Management (CDTM). This allows the pharmacist to focus on outcomes by taking over vancomycin dosing, medication reconciliation, and much more. Another inspirational speaker was Dr. Sandra Leal, Director of Clinical Pharmacy at El Rio Health Center and Certified Diabetes Educator. Dr. Leal stressed the importance of Collaborative Practice Agreements which allow pharmacists to be integrated within the medical team. Another important point Dr. Leal emphasized was that pharmacists should be making interventions 100% of the time. Also on this panel was Ms.

The Student Pharmacist Academy Leadership Conference Inaugural Class of 2011

32 Arizona Journal of Pharmacy

Teresa Stickler R.Ph., AzPA Community Pharmacy Academy Chair and owner of Melrose Pharmacy. Ms. Stickler took the initiative to further her practice by finding the right tools and resources necessary in order to open her own independent pharmacy. Not only is Ms. Stickler a leader within pharmacy practice, but she is also a leader within her community. The last pharmacist on the panel was Dr. Rose Martin who works at the Medication Management Center in Tucson. Dr. Martin is able to reduce medication errors, drug-drug interactions, and simplify drug regimens for her patients. Dr. Martin stressed the importance of having an open mind during rotations in order to get the most out of each experience. These four exceptional pharmacists represent leadership, dedication, and motivation within the practice of pharmacy. Students at the SPA Leadership Conference now have excellent mentors to look to for guidance during their professional years.

To wrap-up the SPA Leadership Conference, a joint presentation on Power, Politics and You was delivered by Ms. Mindy Smith R.Ph., CEO of AzPA, and Mr. Mark Smith, President of the Da Vinci Group. Mr. Smith stressed the importance of taking the responsibility upon oneself to get involved. If one does not take action, nothing will get done. As HCR begins to fall into place and the scope of practice begins to expand in Arizona, it is more important than ever to understand the value of developing relationships, especially with your legislators. Students discussed the impact of the Governor signing Senate Bill 1298 into legislation, which allows pharmacists to develop collaborative practice protocols with physicians. Many ideas were proposed, such as starting a dialogue concerning collaborative practice between pharmacists and physicians and developing focused collaborative practice protocols in areas such as asthma and diabetes. At the end of the presentation, Ms. Smith challenged every student leader to become a problem solver by thinking of ways to address our workplace challenges.

The SPA Inaugural Leadership Conference was a tremendous success. The current leaders of the pharmacy profession promoted the fundamental qualities of worthy leaders, and inspired the students to embody these traits. By actively striving for life-long learning, continuous self-improvement, involvement in the profession and maintenance of the â&#x20AC;&#x153;Pharm.D.â&#x20AC;? brand in all aspects of life, all student pharmacists can make a difference and continue to drive pharmacy forward.

Features and Articles Launch of CPE Monitor to Streamline Reporting of Continuing Pharmacy Education Activity, Saving Boards Time and Resources Reprinted with permission from the April 2011 NABP Newsletter

The new NABP CPE Monitor service, a collaborative effort between NABP, the Accreditation Council for Pharmacy Education (ACPE)‚ and ACPE providers, will provide a streamlined reporting and compliance verification process for participating state boards of pharmacy. In addition, the service will allow pharmacists and technicians to easily track their ACPE-accredited continuing pharmacy education (CPE) credits beginning in the latter part of 2011.

When pharmacists and technicians complete an ACPEaccredited CPE activity, their participation data will be sent electronically from the provider to ACPE, then to NABP for recording into the matching NABP e-Profile. Then, if the board of pharmacy participates in CPE Monitor, the pharmacists’ or technicians’ CPE credits will be automatically transmitted to the board, saving pharmacists and technicians the trouble and expense of documenting and submitting compliance with statemandated CPE requirements for license renewal or for random audits. This process eliminates paper forms and the overall need to submit paper copies of CPE statements of credit to the board of pharmacy for CPE activities from ACPE-accredited providers. Further, this new service’s central repository of CPE information may also reduce the need for boards to conduct state-based audits of their licensees.

All information will be maintained in a highly secure environment. NABP will not distribute any personal information for commercial purposes without consent.

Identification Numbers Should be Obtained Now As of March 10, 2011, pharmacists and pharmacy technicians may visit www.MyCPEmonitor.net or the NABP Web site, www. nabp.net, to create an NABP e-Profile and obtain their permanent identification number. The Pharmacists section on the NABP Web site, and a new section for pharmacy technicians, provide detailed information on the use of CPE Monitor, and instructions for obtaining the NABP e-Profile ID. In the latter part of 2011, the NABP e-Profile ID plus birth date (MMDD) will be required to receive credit for any CPE activities taken from ACPE-accredited providers. Providers will ask CPE participants to provide the ID either when registering for CPE or when submitting participation data to the provider.

Registrants will then be known in the ACPE provider’s system by two additional identifiers: their month and day of birth (MMDD) and NABP e-Profile ID. Please note that CPE Monitor does not currently track CPE from CPE providers not accredited by ACPE. This feature will be added in Phase 2 of the CPE Monitor service, and, until then, pharmacists and technicians will need to submit proof of credit from CPE providers not accredited by ACPE directly to their board of pharmacy when required to do so.

Communicating to CPE Participants Both ACPE and NABP, coordinating with other stakeholders, have developed communications to inform pharmacists and technicians about this new process for verifying ACPE-accredited CPE credit.

ACPE is partnering with CPE providers to alert CPE participants about the new system and the need to obtain an NABP e-Profile ID. Specifically, ACPE is providing messaging that can be integrated into CPE registration and/or course materials to help educate pharmacists and technicians about CPE Monitor. Further, ACPE will continue to support CPE providers through Webinars presenting the CPE Monitor service.

CPE Monitor at APhA NABP helped to educate pharmacists on the new resource at the American Pharmacists Association (APhA) Annual Meeting and Exposition, March 25-28, 2011, in Seattle, WA. NABP staff provided information and answered questions about the CPE Monitor service, and informed participants how to obtain their NABP e-Profile ID. To encourage pharmacists to participate, those who stopped by the NABP booth had the opportunity to enter a drawing for the chance to win an Apple iPad® valued at $499, along with one of six $50 American Express gift cards.

Benefits for Pharmacists and Technicians The system will benefit pharmacists and pharmacy technicians by streamlining the process of tracking and reporting CPE units to state boards of pharmacy. This new process will be particularly beneficial to pharmacists who are licensed in multiple states, which often have different CPE requirements. Beginning in the latter part of this year, the NABP e-Profile will be available for viewing a comprehensive list of the CPE activities completed 24/7.

NABP will continue to keep boards of pharmacy informed about the CPE Monitor service.

Arizona Journal of Pharmacy 33

Features and Articles AzPA Member Satisfaction Survey Results Thank you to all members who participated in our recent member satisfaction survey. We appreciate the opportunity to hear from you how we can improve the quality of service we provide and how we can better represent you. The survey was available through the AzPA website in March and distributed via member e-mails, through which we had a 15% response rate.

SUMMARY Of the members who responded, 35% have been members of AzPA for over 7 years, 15% have been members for 4-7 years, 34% have been members for 1-4 years, and 16% are new members (<1 year).

Of the programs and services utilized by members, the ACPE accredited continuing education programs were ranked as most utilized by members at 57%, followed by (in order) AzPIN (e-newsletter), the Arizona Journal of Pharmacy, professional development and networking, and certification programs. Other services were rarely utilized by members.

The survey also provided members the opportunity to express their interest in other benefits and services that AzPA could potentially offer (see Table 1,page 35). Membership to Pharmacist’s Letter had the highest demand with over 50%of member requests. Other benefits that generated high levels of interest include travel discounts, discounted registration for national conferences and professional publications, and free professional and/or personal legal advice. Although these services are not currently available to members, AzPA is committed to looking into ways we can potentially provide these member benefits to you in the near future.

COMMENTS We appreciate your comments and will work to address them.

Members requested that the website be updated and more “userfriendly.” As it is currently under construction, the new website will be launched shortly after the annual meeting. One member commented that the publications seemed to focus almost entirely on legislative issues. We can try to include more information on other topics concerning our profession. If you have any suggestions or contributions to include in our publications, please forward them to janet@azpharmacy.org. Another member enquired about career services for unemployed pharmacists in good standing with the state board. Our Career Center is located on our website at www.azpharmacy.org under “Resources,” and allows members to post resumes anonymously and create a free Job Seeker account. It also allows employers to post multiple positions at affordable prices and receive Resume Alerts of recently uploaded resumes.

Many members showed interest in participating in one or more of the many committees or forums under AzPA (see Table 2, pag 35). If you are interested in joining a committee, there are two ways to join: either e-mail alex@azpharmacy.org or update your profile by logging in to www.azpharmacy.org and selecting the option to “view/edit profile.” Scroll down to “Practice Interests” and select the committees or forums of interest to you. To highlight multiple categories, hold the control key while making your selections.

34 Arizona Journal of Pharmacy

AzPA is continually working to pass legislation and provide services that will advance the profession of pharmacy, enhance patient care, and provide pharmacists and technicians with support. The following comments were helpful suggestions from members as to how AzPA can work to better support you: • Focus concentration on improving the profession from the pharmacist's perspective. While promoting increased access to immunizations was good for the profession, it did nothing for the pharmacists who are forced to comply with quotas established by the chains, whose primary focus is on their shareholders.

• Please work politically to get pharmacists "provider" status with CMS & state equivalents.

• Save R.Ph. time and frustrations by working with MD,DO,NP, PA organizations to increase their members' compliance with Rx laws and what is required on a prescription.

• Help improve the patient consultation skill of pharmacists dealing with the public.

• It would seem that the organization is here for big business, not the actual pharmacist. Is legislation in the works that says a pharmacist must live in the US if they provide services to people in Arizona?

• Please show the managed care people how membership benefits them so we can increase interest/membership. As of now, we have nothing to convince them that it's to their benefit to join and participate.

OUTCOMES This data, along with your comments, help us to evaluate and improve the services and programs that members are using most often, and work towards providing more of the services you are requesting. As a member of AzPA, do you know •

•

•

•

AzPA led the initiative on the passage of HB2164 and SB1298 expanding the pharmacist’s scope of practice to allow pharmacists in Arizona to administer vaccines and redefining collaborative practice agreements?

The Pharmacy Network of Arizona (PNA), provides diabetic pharmacy clinical services through a network of pharmacists across the state of Arizona? Pharmacists are getting paid for clinical services through this initiative!

There is a charitable organization, the Arizona Pharmacy Foundation (APF), that awards scholarships to pharmacy students at The University of Arizona and Midwestern University Glendale?

All of these programs and initiatives, plus many more, are part of the Arizona Pharmacy Alliance, the only statewide organization in Arizona representing all pharmacists in all practice settings?

Thank you again for participating in the 2011 Member Satisfaction Survey. We appreciate the feedback and the opportunity to serve you.

Survey results compiled and summarized by Jacqueline Tinimbang Campbell, Pharm.D. Candidate, The University of Arizona College of Pharmacy, Class of 2012.

Features and Articles

We’re in the “Army” Now!

Table 1

by Joe Rowan, R.Ph.

Benefits and Services of Interest Debt collection services Discounted registration for national conferences

Benefits and Services

Discounted professional publications Free professional and/or personal legal advice Discounted emergency preparedness supply kits Discounted exercise membership Credit Card merchant services (VISA/MC) Discounted identity theft protection Pharmacist’s Letter Membership Credit Union Membership Travel Discounts (car rental, hotel, airline, etc.)

0

20

40

60

80

100

120

Number of Responses

Table 2 Committees and Forums of Interest

Public Relations Committee Professional Affairs Committee Pharmacy Reimbursement/ Audit Task Force New Practitioners Forum MTM Task Force Membership Committee Medication Waste Disposal Task Force

Committee or Forum

Legislative Affairs Committee Independent Pharmacy Ow ners Forum Immunization Task Force Hospital Directors of Pharmacy Forum Emergency/Disaster Preparedness Task Force Continuing Education Committee Communications Committee Aw areRx Committee Arizona Pharmacy Foundation Golf Tournament Committee Anticoagulation forum Annual Meeting Steering Committee 0

5

10

15

20

25

Number of Responses

In the summer of 1941, Mr. Casteel, one of the owners of the Gunning-Casteel Drug Company approached me to discuss my future with the drug store chain. I had been working for G&C for two years and at the tender age of 13 I was offered the opportunity to become the Assistant Manager of a newly-acquired drug store at Ft Bliss, Texas. The new store in the G&C chain was Army Drug, so named for its close proximity to the base. At the time, Ft. Bliss was the largest cavalry post in the United States. Mr. Casteel offered me a salary of $65.00 per month, and I jumped on this offer like dirt on a duck!

Army Drug did not have a prescription department but provided a full line of over-the-counter medications, candy, and tobacco and featured complete soda fountain service. My new uniform as part of management was now slacks, shirt and tie. Most of my new duties as assistant manager were confined to the soda fountain, but because the store was rather small, I gained great experience in merchandising, management and employee relations.

This was an awesome responsibility for a high school freshman.

During my two years at Army Drug, the United States was involved in World War II and Fort Bliss was converted to one of the largest training facilities for our troops. The store catered to the GI’s and their families, as well as the civilians employed at the base. We did a terrific noon time business taking phone orders from the various offices at the fort for sandwiches and drinks. In addition, the soda fountain was frequented by the wives of the GI’s for breakfast and lunch. Some of these regular customers complained there was no variety for breakfast. We offered only bacon and eggs or ham and eggs with toast. Relying on my creativity as a soda jerk, I concocted a breakfast sandwich of a fried egg, piece of ham or bacon, slice of cheese, onion, and pickle on toast. This went over so well I had an army of followers who requested this strange combo for breakfast and lunch. Customers were asking for this delicious tidbit at other Gunning-Casteel stores as well. After a while, “those in the know” decided the breakfast sandwich was a passing fancy and I was asked to discontinue this menu item. I complied, but I still prepared it for my favorite old customers - who Arizona Journal of Pharmacy 35

Features and Articles We’re in the Army Now (continued from page 35) were pledged to secrecy. Imagine my chagrin when McDonald’s introduced its revolutionary breakfast many years later. Oh, what a patent on that sandwich would have meant to this naive high school kid!

During the heaviest part of World War II rationing was a big issue for our stores. This led to some wheeling and dealing on everyone’s part. Meat, gas and cigarettes were in especially high demand. To supplement the amount of meat we needed for the soda fountain, the drug store would trade cartons of Lucky Strike cigarettes for meat stamps with the owner of the Red and White Grocery Store. The gas station owner would trade us gas stamps for two cartons of Camels. These popular brands of cigarettes were very difficult to get because all the brand names were shipped to the boys overseas.

Real ice cream was also a premium because the first allocations of milk and eggs were reserved for the Army PX’s and USO Clubs. Our contracted supplier was Borden, but they had a difficult time supplying us with enough real ice cream. A driver from another dairy, Price’s, would bring us whatever ice cream the PX couldn’t use that day. We had to pay him in cash so we wouldn’t compromise our Borden contract.

Both the Borden driver and the Price’s driver were very popular individuals with all of the merchants who would attempt to pry even more ice cream from them on each delivery.

My first manager at Army Drug was Mike Diaz.

Each day after working at Army Drug, Mike would work as a pharmacist in another store across the border in Juarez, Mexico. He taught me the value of

36 Arizona Journal of Pharmacy

hard work and long hours which I would soon need when Mike joined the Navy. My new manager Lamar “Popeye” Powers, so nicknamed for the thick eyeglass lenses he wore. “Popeye” was a good fellow, but he enjoyed visiting the liquor store next door to the drug store which resulted in frequent messages left at Cathedral High School saying that I needed to work the night shift. My mother objected to my working on school nights. I didn’t have a car so I had to take a Ft. Bliss streetcar to and from work and I got home at well past 11:00 pm most nights. In order to keep my job, I had to invent other reasons, such as Red Cross meetings, working on the school annual, and whatever else came to mind that would allow me to be out of the house at night. I am sure Mom realized what was really happening, but never really took me to task. Many of the original Rowan clan can relate to these messages, as my wife and partner, Mims, often left similar messages for our children at Flagstaff High when emergencies arose with our employees at our Flagstaff Pharmacy.

After two years at Army Drug, I left that store and began my training in the profession of pharmacy. I became a drug clerk and worked at several GunningCasteel stores to learn the ins and outs of pharmacy before heading off to pharmacy school and the beginning of my career as a pharmacist.

This is the second in a series of reflections from Joe Rowan, R.Ph., longtime Arizona pharmacist and AzPA member. The first installment - Pills, Potions, Potato Salad and People appeared in the Spring 2011 issue. Follow Joe’s memoirs in future issues of the Arizona Journal of Pharmacy.

Features and Articles

A Look Back - Pill Silverer

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

Pill making machines were invented in Germany about 1750 and came to colonial America a few years later. Handmade pills were a labor-intensive process, which required rolling out a tubular mass that was cut into tiny cubes, rounded, and coated using a pill finisher.

Pill coaters, or silverers, were used throughout the 18th and 19th century. For coating purposes, spherical boxes on a circular-footed base were used, wherein the pills could be rolled and tossed. They were usually made of hardwoods such as yew, fruit wood, or, as illustrated above, boxwood. The pill silverer shown with original pills is rare and difficult to acquire.

Handmade pills were moist and tended to stick together. For this reason, they were coated with fine talc or ground roots. For important patients, pills were coated with mucilage, placed in a pill coater with gold or silver leaf, and shaken until coated.

Arizona Journal of Pharmacy 37

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.

CAN I GET SUED FOR THAT? One of the questions that I get asked a lot is, “Can I get sued for that?” Unfortunately in today’s world, I have to answer yes; almost anyone can sue for almost any reason.

While there are rules against filing frivolous lawsuits, the filing has to be pretty egregious to be considered frivolous.

There are two better questions that get to the heart of what pharmacists really want to know; Do I have exposure for that activity and Do I have coverage for it?

Since the bar is pretty low for the filing of a lawsuit, it is almost a given that you can be sued for any activity.

However, that doesn’t reflect your exposure in that case.

Filing a suit is quite different from winning a suit. The plaintiff will still have to prove the four elements of negligence in order to win their case. Let’s use pharmacistadministered vaccinations as our example. An analysis and evaluation of the pharmacist’s duties and possible breaches of those duties is the first step. Was the protocol followed, was the patient a proper recipient under the protocol, was the proper vaccine given, was it given properly, was the patient given proper information about the risks and benefits of the vaccine? If the answer to all of these questions is yes, then the pharmacist’s exposure is low. If not, then additional analysis is needed to see if the breach (or breaches) was the direct cause of the patient’s injury.

For example, the patient was allergic to eggs, but received the vaccine and suffered an allergic reaction. If this were true, then the pharmacist’s exposure is higher.

For any new service, the pharmacist should consider what duties are required for them to provide the service, the possible ways that those duties could be breached, and the possible injuries that could result from that breach. In this way, the pharmacist can evaluate their exposure for providing any new service. As you can see, this is more in depth than merely asking if you can be sued if you administer vaccines.

The second important question is whether there is insurance coverage for the activity in question. Insurance policies typically provide two types of coverage; loss coverage and defense coverage. Loss coverage is the 38 Arizona Journal of Pharmacy

portion of the policy that covers the damages exposure that we have already discussed. This is obviously very important to have for any activity that a pharmacist performs. Equally important is the defense coverage. This is the portion of the policy that pays for defense attorneys, expert witnesses, court reporter fees, etc. Defense coverage is available in two forms. In one version, the defense costs are included in the loss coverage limit. In this version, if $50,000 is spent on defense costs, then only $950,000 of a $1 million limit is left to pay a loss. This becomes very important in a case that is long and expensive to defend. In the other version, the defense coverage is separate from the loss coverage and doesn’t erode the loss limits. In either case, if the loss is covered, the defense coverage provides for the defense of the suit, no matter how frivolous or low the exposure might be. Because of the high cost of legal services, the defense coverage can be an important asset for any pharmacist to have. Even defending a frivolous suit could cost thousands of dollars.

Can a pharmacist be sued for a given activity? The answer is almost certainly yes. But that should not stop a pharmacist from providing inventive, progressive patient care. A more in-depth analysis of the true exposure is required along with verification of insurance coverage for that exposure. There may be activities that are determined to be too risky, but that shouldn’t stop pharmacists from continually striving to provide the best possible care for their patients. © 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

Continuing Education

Prevalence, Causes, and Impact of Type II Diabetes on the Local Pima Indians of Arizona by: Tricia Marie Rader, Pharm.D., Laura Hanson, Pharm.D., Debbie Brown, R.Ph.; Scottsdale Healthcare Goal: This home-study CPE activity has been developed to educate pharmacists on the prevalence and identified etiologies of Type 2 diabetes mellitus in the Pima Native American population, to facilitate understanding of the impact of the disease on this population and to make recommendations as to how to reduce the detrimental impact of this epidemic on Pima youth.

Objectives: 1. Distinguish the pathophysiology of Type 1 diabetes mellitus from Type 2 diabetes mellitus and be familiar with diagnostic tests used to differentiate between Type 1 and Type 2 diabetes mellitus.

2. Recognize the differences among races with regards to incidence of Type 2 diabetes mellitus among youth and be familiar with predictors for Type 2 diabetes mellitus in Pima Indians specifically.

3. Identify the impact of Type 2 diabetes mellitus in Pima Indian youth and describe potential measures that can be taken to prevent negative outcomes associated with the disease.

Introduction The American Diabetes Association classifies diabetes by one of two broad etiopathogenetic categories.1 Historically, Type 1 (insulin-dependent) diabetes mellitus (T1DM), caused by the inability of the β-cells of the pancreas to secrete insulin, has been most prevalent in children and adolescents and was formerly known as juvenile-onset diabetes. Conversely, Type 2 (noninsulin-dependent) diabetes mellitus (T2DM), caused by insulin resistance at the cellular level, has traditionally been the type occurring most commonly in adults and was formerly known as adultonset diabetes. However, T2DM is no longer primarily a disease of adulthood.

In fact, the occurrence of T2DM among children and adolescents has drastically increased within the past four decades, with a particularly dramatic increase seen among the local Pima Indians of central Arizona.2 What was once a rare

disease for this population has quickly developed into a local epidemic. The goal of this article is to review the history of T2DM in Pima youth, expose the current evidence on causes and health-related impact of T2DM in youth, and suggest recommendations to potentially mitigate the negative consequences associated with this epidemic.

Background The relatively recent emergence of diabetes in the Pima Indians has mirrored the economic and nutritional trends of this community. Once successful commercial agriculturists, the Pima endured severe poverty from roughly 1890 to 1960 as a direct result of drought and periodic flooding that eroded their cultivating practices. It was not until the 1980s that employment opportunity and economic development in the Gila and Salt River Valleys allowed the Pima to thrive once again. However, the loss of their farming practices coupled with increased wages, welfare, and government nutrition programs resulted in a significant change in the Pima diet. Having once survived on a traditional diet of crops, cattle, and fish, the Pima shifted to a diet low in fiber and high in fat and carbohydrates during the 1980s.2 Definitive differentiation of T2DM from T1DM among Pima youth has been done via testing for islet cell autoantibodies and C-peptide levels.

Islet cell autoantibodies are a marker of β-cell destruction. As T1DM is usually due to autoimmune destruction of the pancreatic β-cells, resulting in an absolute deficiency of insulin secretion, presence of this marker is indicative of T1DM. Knowler et al. (1979) noted in their study of 46 diabetic and 46 non-diabetic Pima Indians that islet cell autoantibodies were found in only two diabetics; no islet cell autoantibodies were found in the non-diabetic subjects. The lack of islet cell autoantibodies within this population indicates that diabetes in the Pima Indians is almost exclusively that of Type 2.3 C-peptide, a byproduct of insulin production, is another marker used to distinguish between T1DM and T2DM. Since Type 1 diabetics do

not produce insulin, the presence of C-peptide strongly excludes T1DM as an etiopathogenetic cause of diabetes. Katzeff et al. (1985) contributed to determining the usefulness of C-peptide measurement for diabetes classification among patients being treated with insulin in their study of C-peptide plasma concentration and urinary excretion. Based on previously shown studies associating T2DM with Pima Indians and T1DM with Caucasians, the researchers sought out to compare C-peptide levels in Pima and Caucasian diabetics to determine differences between diabetic types. All subjects were diagnosed prior to 21 years of age and were receiving insulin therapy at the time of the study. Results found both plasma and urinary C-peptide measurements to be significantly higher (p < 0.001) in the Pima group compared to the Caucasian group,4 suggesting that C-peptide levels can be used to effectively differentiate between T1DM and T2DM even among insulin-treated patients. Based on the results of these two studies, as well as a generalized lack of association with ketoacidosis or insulin dependence,5 it can be concluded that T2DM is much more common than T1DM in the Pima population.

Prevalence of T2DM The high prevalence of T2DM in individuals younger than 20 years of age is a particularly concerning aspect of the diabetes epidemic within the Pima population. Between 1967 and 1996, the prevalence rate of T2DM among 10-19 year-olds roughly doubled.5 Today the Pima pediatric population maintains one the highest prevalence rates of T2DM in the world, and it is likely that these incidence rates will continue to grow at alarming rates.

In an effort to reliably document prospective changes in diabetes type and prevalence in United States (US) youth among all ethnic groups, the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) funded a multicenter, epidemiological study entitled SEARCH for Diabetes in Youth. This study has been conducted in Arizona Journal of Pharmacy 39

Continuing Education (continued from page 39) six geographically dispersed populations throughout the US since 2000. Physiciandiagnosed diabetes prevalence rates among youth less than 20 years of age have been categorized by age, gender, and racial/ethnic groups. Studies on associated complications, levels of care, and the overall impact on US youth are ongoing.6 In 2001, approximately 3.5 million children were documented through the SEARCH centers. Of this patient population, 6,379 youth were identified as having diabetes â&#x20AC;&#x201C; a prevalence estimate of 1.82 cases per 1000, or 0.18%. Extrapolation of this data to the entire US population less than 20 years of age estimates 154,369 youth with physician-diagnosed diabetes in 2001. As expected based on historical trends, T2DM accounted for less than 20% of diagnoses in children of all ethnicities younger than 10 years of age. T1DM is far more common in this younger age group. The proportion of T2DM:T1DM did increase among youth of all ethnicities aged 10 years and older; however, T2DM was more prevalent than T1DM only among the American Indians in this older age group. The proportion of T2DM varied dramatically among ethnic groups with 6% in non-Hispanic white, 33% in African American, 40% in Asian/Pacific Islander, and 76% in American Indian7 (Figure 1).

2002-2003 SEARCH data was consistent with previous findings in regard to the American Indian population. This ethnic group continues to have the highest rates of T2DM compared to other ethnic groups, with incidence rates of 25.3 and 49.4 per 100,000 person-years in the 10-14 and 15-19 year-old age groups, respectively.9 Predictors for T2DM in Pima Youth The dramatically increased incidence of T2DM in the Pima Indian pediatric population and potential for serious health consequences associated with this increase has led to significant research regarding potential causes of this epidemiological phenomenon.

Insulin Resistance and Hyperinsulinemia Insulin resistance has been found to be a major risk factor in the development of T2DM in Pima Indians.10 In an effort to quantify insulin resistance, Lillioja et al. (1991) performed a hyperinsulinemic euglycemic clamp test on non-diabetic Pima Indians and Caucasians with similar clinical characteristics. Results showed a 17% higher rate of insulin resistance in Pimas compared to Caucasians. The role of insulin resistance was later determined to be an independent risk factor for T2DM in a 9-year prospective study on Pima

Figure 1. Rate of New Cases of Type 1 and Type 2 Diabetes Among Youth Ages Younger than 20 Years, by Race/Ethnicity, 2002-20058.

Source: SEARCH for Diabetes in Youth Study NHW=non-Hispanic whites; NHB=non-Hispanic blacks; H=Hispanics/Latinos; API=Asian/Pacific Islander Americans; AI=American Indians

40 Arizona Journal of Pharmacy

Indians aged 26 + 6 years of age.11 Hyperinsulinemia may prove to be an early indicator for diabetes risk in young Pima children since normoglycemia can be a common finding in the presence of insulin resistance. Pettit et al. (1993) found the incidence of hyperinsulinemia to be an early abnormality in young Pima children. In groups of Pima and Caucasian youth matched based on age and weight, higher fasting insulin concentrations were found in the Pima group. These findings are important for diabetes prevention as the data suggests that T2DM in this population may manifest as fasting hyperinsulinemia prior to presentation with the classic symptoms and clinical findings associated with the diagnosis of diabetes mellitus.12 Although the primary reason for increased hyperinsulinemia in the Pima population remains unknown, it has been hypothesized that increased parasympathetic activation of the pancreas may be a contributing factor, as this has been shown in rodent models.13 . Weyer et al. (2001) supported this hypothesis in their study of pancreatic polypeptide, a plasma marker for vagal control of insulin secretion. Among 43 children between 5 and 8 years of age, it was found that Pimas had a 2-fold higher fasting insulin concentration (p < 0.001) and a 57% higher fasting pancreatic polypeptide concentration (p < 0.05) compared to age and sex-matched Caucasians. While this does not prove a direct relationship, these results are suggestive of primary hypersecretion of insulin due to increased parasympathetic tone; thus it is plausible that increased parasympathetic drive may be a contributing factor to the high prevalence of insulin resistance and diabetes in the Pima Indian population13. Further studies evaluating the effect of vagal attenuation on plasma insulinemia may prove effective as an option for prevention of insulin resistance and T2DM in humans.

Weight and Intrauterine Exposure to Diabetes Prior to the SEARCH study, Dabelea et al. (1998) determined the prevalence of T2DM in Pima children aged 5 years and older. Analysis was based on standard biannual examinations that were conducted between 1967 and 1996. During this study period, a total of 5,274 Pima

Continuing Education (continued from page 40) children received research examinations that included a 75 gram oral glucose tolerance test. Diabetes was diagnosed by a 2-hour plasma glucose greater than or equal to 200 mg/dl. Height, weight, blood pressure, and medical history were also recorded. Prevalence rates were similar to that determined by the SEARCH study with more cases of T2DM diagnosed among older youth compared to younger youth. It is apparent that T2DM is rare among Pima children less than 10 years of age with two cases being diagnosed from 1967-1976, one case from 19771986, and no cases from 1987-1996. More concerning were that the results showing that diabetes prevalence increased among 10-19 year-olds over time (p < 0.0001) for both boys and girls (Figure 2). The incidence of T2DM diagnosed in this age group roughly doubled in 30 years time, representing the rapidly progressive nature of this disease in the Pima pediatric population.

Additionally, the findings of this study showed that both weight and the percentage of Pima children exposed to diabetes in utero increased over time (p < 0.0001). Based on logistic regression analyses controlled for age and sex, the researchers concluded that the effects of weight and intrauterine exposure to diabetes accounted for the majority of increased prevalence of T2DM in this population.5 These findings have been documented in other studies as well,14-16 suggesting two variables that should be targeted in future management of the T2DM epidemic in Pima youth.

Impact of T2DM on Pima Youth Diabetes is a serious disease that carries with it the potential for significant morbidity and mortality.

Children diagnosed with diabetes are at increased risk of microvascular (retinopathy, neuropathy, nephropathy) and macrovascular complications leading to increased incidence of cardiovascular disease.17 A diagnosis of diabetes also carries with it the burden of many

physician visits and potentially the need to take medications regularly, both of which can be very disruptive to the life of a child or adolescent. The following are evidencebased assessments of the potential impact of T2DM in the Pima pediatric population.

boys (p = 0.02). Based on these findings, interventions to improve HRQOL among T2DM youth may include management with insulin therapy and consideration of gender differences for critical management within varying age groups.18

Health-Related Quality of Life for Pima Youths with T2DM Naughton et al. (2008) were the first researchers to study the impact of T2DM diagnosis and treatment on the healthrelated quality of life (HRQOL) for youths and to compare this measure between children with type 1 and type 2 diabetes mellitus. Baseline data was obtained from the cross-sectional SEARCH for Diabetes in Youth Study. Participants included select populations throughout six US states, three American Indian populations from health service beneficiaries, and the Pima Indian population from the study performed by Knowler et al.

(1978).18-19 HRQOL was determined by using the Pediatric Quality of Life Inventory (PedsQLTM). This 23-item self-report form assesses physical and mental health, as well as emotional, social, and school functioning. It is designed for children and is tailored for use in four distinct age groups (sample reports can be viewed at: http://www.pedsql. org/pedsql13.html).20 In total, 2,445 participants ranging in age from 8 to 22 years were included in the Naughton et al.

(2008) study. The most significant finding was that youths with T2DM reported a considerably lower HRQOL than did those with T1DM. Within the T2DM subgroup specifically, however, there were several factors that indicated a higher HRQOL: 1) use of insulin injections versus use of oral or no diabetes medication (p = 0.03), 2) among boys, a longer duration of diabetes (p = 0.04), and 3) among girls, no emergency visits compared with two emergency visits (p = 0.03). Additionally, there was a significant age and sex interaction found among Pima youth with T2DM, such that HRQOL was lower in older group girls and higher in older group

End-Stage Renal Disease and Mortality in Pima Youths with T2DM While diabetic nephropathy is a rare cause of kidney failure during childhood, pediatric-onset T2DM has been associated with substantially higher rates of endstage renal disease (ESRD) and mortality by middle age.21-22 Pavkov et al. (2006) conducted a longitudinal, populationbased study in Pima Indians between 1965 and 2002 to document the incidence of ESRD and mortality between two age groups: 1) T2DM onset prior to 20 years of age (youth-onset), and 2) T2DM onset between 20 and 55 years of age (adultonset). In total, 1856 Pima diabetics were enrolled, 96 of whom had youth-onset T2DM. After adjusting for age and sex, results showed a 4.6-fold increase and a 2.1-fold increase in diabetic ESRD and mortality incidence, respectively, among youth-onset diabetics compared to adultonset diabetics. Additionally, participants with youth-onset T2DM had a 3-fold increase in mortality incidence compared to non-diabetic participants. These results indicate that the increasing prevalence of T2DM among Pima youth is likely to increase the frequency of kidney disease and mortality in this population.22 As early structural changes within the glomeruli have been documented in diabetic Pima Indians prior to any clinical findings of renal insufficiency (e.g. microalbuminuria, loss of glomerular filtration rate)21, therapeutic intervention with angiotensin-converting enzyme (ACE) inhibitors during adolescence may be warranted for prevention of increased middle-aged diabetic nephropathy and associated mortality.

Figure 2. Sex-specific prevalence of diabetes in Pima children. Adapted from Dabelea et al. 19985.

Prevalence of T2DM in Boys

10-14 years 15-19 years 0% 2.43% 1967-1976 1.40% 3.78% 1987-1996

Prevalence of T2DM in Girls

10-14 years 15-19 years 0.72% 2.73% 1967-1976 2.88% 5.31% 1987-1996

Future Management/Conclusion It is evident that the increasing prevalence of T2DM among Pima Indian children and adolescents has potentially devastating health consequences. Public health measures directed at this population should emphasize weight control with proper diet and physical activity, as this has the potential to reduce the incidence of T2DM and promote general health.

Arizona Journal of Pharmacy 41

Continuing Education (continued from page 41) Educating and encouraging women to control their diabetes during pregnancy will also help to prevent the disease, as research has shown a strong link between intrauterine exposure to uncontrolled diabetes and development of the disease in childhood. If T2DM does develop in this population, disease management according to quality-of-life preferences (e.g. use of insulin vs. oral agents) may help to increase compliance. Early plasma insulin screening could also be useful in this population, as the data suggests that hyperinsulinemia may manifest prior to presentation of hyperglycemia. Awareness of the prevalence, causes, and quality-oflife factors surrounding T2DM in Pima youth will help to determine strategies such as those listed above to avoid the myriad potential negative consequences associated with this epidemic. Future studies on prevention strategies that may prove to be beneficial for the Pima, as well as for other populations with high emerging prevalence rates of T2DM, include: evaluation of the effect of vagal attenuation on plasma insulinemia and insulin resistance, and therapeutic intervention for prevention of diabetic nephropathy in adolescents diagnosed with T2DM. References: 1. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care.

2010;33(suppl 1):S62-S69.

2. Benyshek DC, Martin JF, Johnston CS. A reconsideration of the origins of the type 2 diabetes epidemic among Native Americans and the implications for intervention policy. Med Anthropol.

2001;20:25-64.

3. Knowler WC, Bennett PH, Bottazzo GF, et al. Islet cell antibodies and diabetes mellitus in Pima Indians.

Diabetologia. 1979;17:161-4.

4. Katzeff HL, Savage PJ, Barclay-White B, et al. C-peptide measurement in the differentiation of type 1 (insulin-dependent) and type 2 (noninsulin-dependent) diabetes mellitus. Diabetologia.

1985;28:264-8.

5. Dabelea D, Hanson RL, Bennett PH, et al.

Increasing prevalence of type II diabetes in American Indian children. Diabetologia. 1998;41:904-10.

6. Diabetes Public Health Resource. “Children and diabetes: SEARCH for Diabetes in Youth”. Atlanta, GA: Centers for Disease Control and Prevention (CDC), 2011. Accessed electronically on March 5, 2011 via http://www.cdc.gov/diabetes/projects/ diab_children.htm#5.

7. SEARCH for Diabetes in Youth Study Group, Liese AD, D’Agostino RB, Jr., et al. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics.

2006;118:1510-18.

8. Centers for Disease Control and Prevention.

National Diabetes Fact Sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.

9. Writing Group for the SEARCH for Diabetes in Youth Study Group, Dabelea D, Bell RA, et al.

Incidence of diabetes in youth in the United States.

JAMA. 2007;297:2716-24.

10. Lillioja S, Mott DM, Spraul M, et al. Insulin resistance and insulin secretory dysfunction as precursors of non-insulin-dependent diabetes mellitus: prospective studies of Pima Indians. N Engl J Med. 1993:329:1988-92.

11. Lillioja S, Nyomba BL, Saad MF, et al.

Exaggerated early insulin release and insulin resistance in a diabetes-prone population: a metabolic comparison of Pima Indians and Caucasians. J Clin Endocrinol Metab. 1991;73:86676.

12. Pettit DJ, Moll PP, Knowler WC, et al.

Insulinemia in children at low and high risk for NIDDM. Diabetes Care. 1993;16:608-15.

13. Weyer C, Salbe AD, Lindsay RS, et al.

Exaggerated pancreatic polypeptide secretion in Pima Indians: can an increased parasympathetic drive to the pancreas contribute to hyperinsulinemia, obesity, and diabetes in humans? Metabolism.

2001;50:223-30.

14. Knowler WC, Pettitt DJ, Saad MF, et al. Diabetes mellitus in Pima Indians: incidence, risk factors and pathogenesis. Diabetes Metab Rev. 1990;6:1-27.

15. Dabelea D, Hanson RL, Lindsay RS, et al.

Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: a study of discordant sibships. Diabetes. 2000;49:2208 –11.

16. Franks PW, Hanson RL, Knowler WC, et al.

Childhood predictors on young-onset type 2 diabetes.

Diabetes. 2007;56:2964-72.

17. Fowler MJ. Microvacular and macrovascular complications of diabetes. Clin Diabetes.2008;26 (2):77-82.

18. Naughton MJ, Ruggiero AM, Lawrence JM, et al. Health-related quality of life of children and adolescents with type 1 or type 2 diabetes mellitus.

Arch Pediatr Adolesc Med. 2008;162:649-57.

19. Knowler WC, Bennett PH, Hamman RF, et al.

Diabetes incidence and prevalence in Pima Indians: a 19-fold greater incidence than in Rochester, Minnesota. Am J Epidemiol. 1978;108:497-505.

20. Varni JW. Pediatric quality of life inventory (PedsQLTM). Version 4.0. Child report (ages 8-12), 2011. Accessed electronically on March 10, 2011 via http://www.pedsql.org/pedsql13.html.

21. Lemley KV. Diabetes and chronic kidney disease: lessons from the Pima Indians. Pediatr Nephrol.

2008;23:1933-40.

22. Pavkov ME, Bennett PH, Knowler WC, et al.

Effect of youth-onset type 2 diabetes mellitus on incidence of end-stage renal disease and mortality in young and middle-aged Pima Indians. JAMA. 2006;296:421-6.

ACPE UAN # 0100-0000-11-021-H01-P

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42 Arizona Journal of Pharmacy

Continuing Education

Calcium and Vitamin D Supplementation Update for the Prevention and Treatment of Osteoporosis

by Kimberly A.B. Cauthon, Pharm.D., CGP, Assistant Professor, and Shannon Li, Pharm.D. Candidate, Class of 2011, Midwestern University College of Pharmacy-Glendale Goal The goals of this home-study CPE activity are to 1. Recall the basic physiologic roles of calcium and vitamin D. 2. Identify appropriate calcium and vitamin D supplementation dietary reference intakes and new tolerable upper limits set by the Institute of Medicine (IOM) for osteoporosis prevention and treatment.

3. Discuss recent information investigating the risks of calcium/vitamin D on cardiovascular health.

4. Compare and contrast the different types of calcium and vitamin D supplements and dosing strategies.

5. Develop effective counseling strategies for calcium and vitamin D use, dosing, and adverse effects.

Objectives At the conclusion of this lesson, successful participants should be able to: 1. Recall the basic physiologic roles of calcium and vitamin D. 2. Identify appropriate calcium and vitamin D supplementation dietary reference intakes and new tolerable upper limits set by the Institute of Medicine (IOM) for osteoporosis prevention and treatment.

3. Discuss recent information investigating the risks of calcium/vitamin D on cardiovascular health.

4. Compare and contrast the different types of calcium and vitamin D supplements and dosing strategies.

5. Develop effective counseling strategies for calcium and vitamin D use, dosing, and adverse effects.

Introduction Hippocrates (460 BC – 370 BC) was known as the Father of Western Medicine and one of his most notable works was the Hippocratic Oath that health care professionals still abide by to this day.

The oath includes the promise “to abstain from doing harm” and to treat the patient only if the benefit outweighs the risk.1 Pharmacists are constantly at the frontlines of balancing the beneficial and harmful effects of medications and supplements for

patients.

Conflicting information for calcium and vitamin D has been reported that makes it unclear for pharmacists whether calcium and vitamin D supplements are preventing harm by decreasing osteoporosis, falls, and fractures or causing harm by increasing the risk of cardiovascular events. The evidence for how efficacious they are in preventing falls and fractures continues to be debated but it is largely accepted that they are important for their beneficial effects on bone density.2-9 Osteoporosis is a major health concern in the elderly population and heart disease continues to be the leading cause of death in men and women.10 One in three persons sixty-five years and older will fall once this year and twenty to thirty percent of those falls will result in moderate to severe injury, such as fracture.11,12 One in five patients with hip fracture will die within a year of their injury; therefore appropriate osteoporosis prevention and treatment is of immense importance.12,13 The appropriate amounts of calcium and vitamin D continue to be examined and questioned. The Institute of Medicine (IOM) released a new report on the Dietary Reference Intakes (DRI’s) for calcium and vitamin D on November 30, 2010 and has decreased the calcium upper limit from its previous report.14 There is also conflicting information on the proper form of vitamin D and when a vitamin D level is important to obtain.14-16 The calcium and vitamin D information presented in this continuing education program addresses the physiologic roles, IOM report, dietary supplementation, cardiovascular effects, treatment doses, guideline review, and counseling parameters.

Physiologic Role of Calcium Calcium is an essential inorganic electrolyte that is found mostly in the bones and teeth.17 Calcium is critical for mediating vascular contraction and vasodilation, muscle function, nerve transmission, intracellular signaling, and hormonal secretion. Since 99% of the body’s calcium is found as calcium hydroxyapatite (Ca10[Pa4]6[OH]2) in

bones and teeth, the need for calcium is determined by the skeletal requirements.

Calcium is constantly being lost and replenished in the bones and it is essential that the replenishment of supply outweighs the amount being lost. In different stages of life, the amount of bone formation and resorption changes and therefore calcium intake recommendations are dependent upon age. Up until the age of 25, bone formation is still dominant over bone resorption. After an adult reaches 25 years of age, the peak bone mass has been achieved as the rate of bone formation and resorption are at an equilibrium. In older adults, bone resorption exceeds bone formation. When a woman goes through menopause, the drop in estrogen is considered the predominant factor for accelerated bone loss.8,18 Calcium balance in the body is determined by absorption from the intestines, storage in the bones, and elimination or reabsorption from the kidneys. It is absorbed mostly in the duodenum and proximal jejunum of the small intestine and is dependent on vitamin D and its activation by parathyroid hormone (PTH). Calcium is not arbitrarily absorbed from the intestines and a majority is lost in the feces. An acidic intestinal pH is usually necessary for ionization of calcium and ionized calcium is the form of calcium that is absorbed.

Decreased ionized calcium in the blood circulation will increase PTH synthesis and release. PTH will work immediately to increase the circulation of calcium by promoting the movement of calcium from the bone to the plasma. PTH influences the reabsorption of calcium from the kidney’s distal tubule and indirectly increases intestinal absorption by stimulation of vitamin D synthesis.

By inducing bone resorption to maintain calcium serum levels, this decreases the skeletal mass. Normal total serum calcium ranges from 8.5 to 10.5 mg/ dL. Calcium is transported in the blood bound to albumin, complexed with sulfate, phosphate, or citrate or in a free ionized state. The serum calcium does not reflect the bone content of calcium; therefore the Arizona Journal of Pharmacy 43

Continuing Education (continued from page 43) serum calcium is not routinely checked during calcium supplementation for osteoporosis treatment and prevention.

The calcium level is unlikely to be elevated due to the protective mechanisms in place unless the patient has poor renal function.17,19 The serum calcium level should be checked on initial exam for osteoporosis. If the calcium is high, it could indicate hyperparathyroidism and if it is low indicates vitamin D deficiency or gastrointestinal malabsorption.

Calcium intake is important in all states of life but the focus of this paper is on the middle-aged and elderly as their balance of bone formation and destruction is compromised. As a person ages, the calcium intestinal absorption is decreased and the renal tubular re-absorption is decreased. Common reasons for calcium deficiency in the bones include poor calcium intake, poor intestinal absorption, and vitamin D deficiency.8 Adequate amounts of calcium are recommended in all osteoporosis treatment and prevention guidelines because of calciumâ&#x20AC;&#x2122;s physiologic role as the bone building block but it is still being studied due to lack of information on its efficacy alone for fall and fracture outcomes. Most studies have looked at the combination of calcium and vitamin D together but in general it is thought that calcium has a modest effect on preventing osteoporotic fractures.7 Physiologic Role of Vitamin D Vitamin D is a fat-soluble vitamin and a steroid hormone that is necessary for calcium to be absorbed and plays an important role in bone health. Vitamin D is involved in neuromuscular function, the immune system, and multiple other body systems. It has been actively researched in the last few years regarding its potential benefits other than bone health. Emerging research has shown a reduced risk for type 1 diabetes, some cancers, autoimmune diseases, and infectious diseases with vitamin D supplementation.9,20 There are generally considered to be two ways the body can acquire Vitamin D. It can be made endogenously through ultra-violet rays from sun exposure or through consumption of Vitamin D rich foods or supplements. Vitamin D3 (cholecalciferol) is produced from the conversion of 7-dehydrocholesterol in the epidermis and dermis in humans by UV 44 Arizona Journal of Pharmacy

rays, and vitamin D2 (ergocalciferol) is produced in mushrooms, yeast, and plants.

Usually, cholecalciferol in the diet is from animal sources and ergocalciferol is from plant sources. The chemical difference between vitamin D2 and D3 is in the side chain. In contrast to vitamin D3, vitamin D2 has a double bond between carbons 22 and 23 and a methyl group on carbon 24.9,17,19 Vitamin D2 and D3 must undergo a set of two hydroxylations in order to become the active form. The first addition of a hydroxyl group occurs in the liver and converts vitamin D to 25-hydroxyvitamin D [25(OH)D], also known as calcidiol.

Calcidiol is the transport and storage form of vitamin D in the blood circulation and mirrors the amount stored in muscles and fat. The second addition of a hydroxyl group occurs in the kidney and forms the physiologically active 1,25-dihydroxyvitamin D [1,25(OH)2D], also known as calcitriol. The enzyme 25-hydroxyvitamin D3 1-alphahydroxylase is responsible for the conversion of calcidiol to calcitriol in the kidneys.

PTH controls the release of this enzyme depending on whether calcium and phosphate levels are low in the blood circulation. When the body senses low serum calcium levels, it will increase the production of 25-hydroxyvitamin D3 1-alpha-hydroxylase and therefore, more calcitriol (the active form of vitamin D) will be produced. Calcitriol will increase the uptake of calcium from the gastrointestinal tract into the blood, decrease the transfer of calcium from blood to the urine by the kidney, decrease PTH production, and increase the release of calcium into the blood from bone.

Calcitriol promotes intestinal calcium absorption by increasing the expression of epithelial calcium channel protein which increases transport of calcium across the membrane.17,19, 21 It might seem counterintuitive that the same hormone that causes an increase in serum calcium levels could also lead to demineralization of bone. However, calcitriol indirectly affects bone mineralization by causing demineralization of bone only when serum calcium concentrations fall below the range level needed for normal bodily functions. It is an emergency mechanism in order to use the stores of calcium in

bones but only when necessary.

Adequate amounts of vitamin D are recommended in all osteoporosis treatment and prevention guidelines due to its overall role in increasing calcium concentrations.

IOM Recommended Daily Allowances for Calcium and Vitamin D The IOM new dietary reference intakes for calcium and vitamin D were released in 2010 and are presented in Table 1.22 The IOM used bone health as the basis for their recommendations on dietary reference intakes with the goal to serve as a guide for good nutrition. The new IOM report was requested by the United States and Canadian governments to assess the current data and provide an update from the 1997 report for recommended intakes and disease state indicators.

The report provides recommendations on calcium and vitamin D estimated average requirements, recommended dietary allowances, and tolerable upper intake levels. The amount of vitamin D recommended was based on the assumption of minimal sun exposure.

Estimated average requirements (EAR) reflect the estimated median requirement or the adequate amount for 50% of individuals. EAR is commonly used for planning and assessing intakes for groups of people such as elementary school meals or the nutrition label. The EAR for calcium for adults 31 to 50 years of age and males up to 70 years of age is 800 mg day and is increased to 1,000 mg per day for all adults greater than 70 years of age and females between 51 to 70 years of age. The EAR for vitamin D is 400 IU per day in all persons 31 years of age and older. Recommended dietary allowance (RDA) is derived from the EAR and meets or exceeds the requirement for 97.5% of the healthy population. This is usually seen as the goal for dietary intake by healthy people.

RDA is the amount that should decrease the risk of osteoporosis but does not necessarily replace calcium and vitamin D if the patient has a condition that causes inadequate absorption. It also does not mean that it is the amount needed if the patient already has the disease state from lack of that nutrient, such as osteoporosis.

The calcium RDA is 1,000 mg daily for adults 31 to 50 years of age and males up to 70 years of age and changes to 1,200

Continuing Education (continued from page 44) mg daily for females 51 to 70 years of age and all persons greater than 70 years of age. The vitamin D RDA is 600 IU daily for all adults 31 to 70 years of age and 800 IU daily for all adults greater than 70 years of age. Tolerable Upper Intake Level (UL) means that if the intake increases above the UL, the risk of adverse effects increases. The UL is the highest average daily intake that is not likely to pose risk of adverse effects in almost all individuals in the general population. For calcium, the UL is 2,500 mg daily for adults ages 31 to 50 years and 2,000 mg for all persons 51 years of age and older. For vitamin D, the UL is 4,000 IU for all persons ages 31 and older.2,22,23 Some of the changes from the 1997 report include that the UL for calcium for all adults 51 years of age and older has decreased to 2000 mg per day compared to 2,500 mg per day.24 The IOM report states that postmenopausal women may be getting too much calcium, thereby increasing their risk of kidney stones.

The vitamin D amounts for the RDA and UL increased from the 1997 report. The IOM reports that the population vitamin D intake is below their stated requirement yet the general population blood levels of vitamin D are above goal. Therefore, the IOM conclusion is that vitamin D acquired from sunlight might be playing an important role in the synthesis of vitamin D in Americans.

For many of the questions the IOM set out to answer, the conclusions were that more information was needed before a recommendation could be made.

Outcomes related to chronic disease indicators such as cardiovascular disease could not be linked reliably with calcium or vitamin D intake and were often conflicting. The following were also identified as uncertainties in the report: the tendency for study protocols to administer a combination of calcium and vitamin D so that each nutrient could not be assessed independently; that individuals who experience sun exposure might have a more uncertain dietary requirement greater than for those who do not; the lack of clarity concerning the validity of the serum 25(OH)D measure as a biomarker and the variability surrounding measures of serum 25(OH)D concentrations owing to different laboratory methodologies.

The serum 25(OH)D cut-points defined as indicative of deficiency for vitamin D have

not undergone a systematic, evidencebased review. This was of concern due to the classification of 25(OH)D levels up to 75 nmol/L (30 ng/mL) as being deficient versus less than 50 nmol/L (20 ng/ml) and patients are being treated with vitamin D doses which are much higher than the amount recommended by the IOM report..25 Calcium and Vitamin D Dietary and non-supplement Sources and Recommendations Adults in the United States consume, on average, 600 to 700 mg of calcium per day in their dietary intake.26 Calcium is found in dairy products, fruits, vegetables, and grain products. Approximately 75% to 80% of calcium in the diet is from dairy products. Patients should be advised to increase their dietary calcium consumption through calcium rich foods or calcium fortified products before taking supplements to meet their RDA. However, increased consumption of dairy products could lead to increased intake of saturated fat as well. Therefore, a variety of calcium rich foods should be recommended in order to maintain a heart healthy diet while obtaining the necessary calcium needed.8,25 Patients should be made aware of the RDA and advised to keep track of how much calcium they are ingesting daily to determine if they are meeting their RDA. An easy calculation to estimate daily calcium intake is to multiply the number of the following servings by 300 mg and add them together: 8 ounces of milk or yogurt or 1 ounce of cheese and multiply the number of the following servings by 150 mg: 4 ounces of cottage cheese or ice cream.27 Calcium may be poorly absorbed with certain vegetables that have the acids of oxalates that bind to the calcium. Examples of vegetables with these acids are spinach, collard greens, sweet potatoes, rhubarb, and beans. For more detailed amounts of foods high in calcium, refer to Table 2. There are several calcium calculator websites. One example is the International Osteoporosis Foundation (IOF) website, which is based on the World Health Organization calcium intake recommendations at http://www. iofbonehealth.org/patients-public/calciumcalculator.html.

Adults can get vitamin D3 activation from the sun UVB rays or can ingest

Vitamin D in their diet. Cloud cover reduces UV rays by 50% and any sunscreen with a sun protection factor (SPF) greater than eight will prevent the production of vitamin D3. UVB radiation also does not penetrate glass, therefore sun exposure through a window or car door will not allow for vitamin D3 formation. Despite the bodyâ&#x20AC;&#x2122;s natural mechanism of vitamin D production, the American Academy of Dermatology does not recommend that vitamin D should be obtained from unprotected exposure to UVB radiation.28 Their position statement includes that there is no scientifically validated, safe threshold level of UV exposure from the sun that allows for maximal vitamin D synthesis without increasing the skin cancer risk. In addition, as a person gets older, the body becomes less efficient at producing vitamin D from sunlight. Dietary intake for the elderly population is more important, especially those in a nursing home or who reside mostly indoors. Other factors that affect vitamin D activation by the sun include geographic location, time of day, darker skin tones, and the calendar season.9 Adults in the United States consume approximately 200 IU of Vitamin D a day from their diet.26 Natural food sources of Vitamin D are limited and include the flesh of certain fish such as mackerel, salmon, and tuna. Small amounts of vitamin D are found in fish liver oils, mushrooms, egg yolks, beef liver and cheese. Due to this small selection of natural Vitamin D in foods, Americans obtain most of their Vitamin D from fortified foods such as milk, cereal and calcium fortified juices/ drinks. D2 is used to fortify milk and cereals.29,30 An easy calculation to estimate vitamin D intake is to multiply every eight ounce serving of milk by 100 to estimate the IU per day.27 For more detailed dietary vitamin D information, refer to Table 3.

Calcium and Vitamin D and Cardiovascular Risk A lot of talk has been buzzing around the meta-analysis by Bolland et al. published in 2010, suggesting that calcium supplementation may increase the risk of heart attacks.31 Concern has been raised if patients should continue their calcium supplements. Previous studies have been conducted that showed calcium had slight benefit in decreasing blood pressure and calcium is a component of Arizona Journal of Pharmacy 45

Continuing Education (continued from page 45) the recommended hypertension treatment diet.8 The Dietary Approaches to Stop Hypertension (DASH) diet recommends two to three servings of low fat milk and milk products daily for a 2,000 calorie diet.32 High dietary intake of calcium was associated with less heart disease mortality in the Iowa Women’s Health Study.33 There have been no randomized, doubleblind, placebo controlled trials that have studied calcium supplements with the primary endpoint of cardiovascular events so Bolland and authors conducted this meta-analysis.

The meta-analysis goal was to examine cardiovascular events in randomized trials with calcium supplements. The studies included were double blind, placebocontrolled trials with doses of calcium supplements ≥ 500 mg/day in patients over 40 years of age. The studies also had to have enrolled 100 or more patients and had to have lasted for greater than one year. Trials were excluded if vitamin D was given to the calcium group and not the placebo group, if calcium was given by diet only, and if the patients had major disease states other than osteoporosis. The primary end points for the meta-analysis were time to first myocardial infarction, time to first stroke, and time to first event for the composite end point of myocardial infarction, stroke, or sudden death. The secondary endpoint was time to death (allcause mortality).

Two analyses were conducted within the meta-analysis: one for studies with trial level data and one for studies with patient level data analysis. Eleven studies with almost 12,000 participants were analyzed with the trial level data. There were 166 myocardial infarctions in the calcium group versus 130 in the placebo group. The risk of myocardial infarction was found to be higher in the calcium group (HR 1.27, 95% CI 1.01 to 1.59, p=0.038). Five studies with the patient level data included over 8,000 patients.

There were 143 myocardial infarctions in the calcium group versus 111 in the placebo group. The risk of myocardial infarction was found to be higher in the calcium group (HR 1.31, 95% CI 1.02 to 1.67, p=0.035). The study suggests those patients who take more than the median dietary intake of calcium without vitamin D supplementation, have a 30% increased risk of myocardial infarction.

The average dose of calcium supplements 46 Arizona Journal of Pharmacy

was 1,000 mg daily. There was not a statistical difference between groups for stroke, the composite endpoint, or death but the numbers were increased in the calcium group. The authors proposed that treatment of 1,000 people with calcium for five years would cause an additional fourteen myocardial infarctions and prevent twenty-six fractures. Limitations of the meta-analysis were that none of the studies used were designed to primarily examine the link of cardiovascular disease and calcium supplements. The metaanalysis authors counted events rather than the number of people with events.

Wang et al published a systematic review on vitamin D and calcium supplementation in prevention of cardiovascular events shortly after the previous meta-analysis.34 The goal of the review was to assess if vitamin D, calcium, or the combination reduced the risk of cardiovascular events. They included seventeen prospective cohorts or randomized controlled trials that reported cardiovascular events. Four were specifically randomized trials for calcium supplementation alone and there were more cardiovascular events reported in the calcium group but none had statistical significance. This could have been due to the low number of participants and power was not met. The systematic review’s conclusion was that there was limited data. From the limited data, vitamin D supplements may reduce cardiovascular events and calcium has little effect on events.

The mechanism for the increase in myocardial infarctions is unclear but it is proposed that calcium is found in atherosclerotic lesions and also contributes to vessel calcification. Manson et al. conducted a study that measured coronary artery calcium nested within the Women’s Health Initiative (WHI) trial.35 The study sample size was 754 women ages 50 to 59. The two groups were a placebo compared to calcium/vitamin D 1,000 mg/400 IU daily. There was no statistical difference in coronary artery calcium scores between the groups. Previous studies, such as the WHI calcium-vitamin D randomized controlled trial showed that vitamin D might be used as a supplement to counteract the potential cardiac risk seen with patients taking only calcium or showed no difference.36-38 As with calcium, there have been

no randomized trials that have studied a primary endpoint of cardiovascular events with vitamin D supplementation.

Pittas et al. conducted and published a meta-analysis in 2010 that looked at vitamin D supplementation and blood pressure lowering did not find a significant decrease in the systolic or diastolic blood pressure.39 The International Osteoporosis Foundation (IOF) briefly mentions that vitamin D deficiency has been implicated as a contributing factor to cardiovascular disease but there is not enough information at this time to make a definitive link.15 Observational studies have demonstrated that low 25(OH)D levels are associated with cardiovascular events.40,41 Pittas et al. reported there was no decrease in cardiovascular risks after increasing the 25(OH)D level.

More randomized, controlled trials are recommended to establish these relationships along with the best vitamin D dose and 25(OH)D levels.42 A current, prospective, randomized trial is the Vitamin D and Omega-3 Trial (VITAL) that is currently enrolling 20,000 participants in the United States. The study groups are a combination of vitamin D and fish oil, vitamin D only, fish oil only, or placebo. The participants will be followed for cardiovascular events and other disease states. The website is www.vitalstudy.org.

At this time, it would be best to counsel patients to obtain as much of the RDA calcium from their diet and not surpass the recommended UL as there is no evidence that dietary calcium increases cardiovascular events. Recommend calcium supplements only if the dietary calcium does not meet the RDA. Continue to recommend vitamin D supplementation based on the IOM recommendations.

Calcium Supplement Treatment Doses, Guideline Recommendations, and Counseling Points The calcium dose that is most effective for osteoporosis prevention has been stated by IOM, but the dose needed for fall and fracture prevention in patients with osteoporosis or osteopenia is provided by several organizations. The prevention and treatment calcium doses continue to be studied but the current recommendations up to this point are presented here. The National Osteoporosis Foundation (NOF), the North American Menopause Society (NAMS), Osteoporosis Canada, and

Continuing Education (continued from page 46) the American Association of Clinical Endocrinologists (AACE) recommend 1,200 mg of calcium daily.26,30,43,44 Table 4 compares the recommended calcium and vitamin D recommendations from the organizations. The product labeling of all bisphosphonates includes that correction of calcium and vitamin D deficiency is mandatory before initiating therapy.45-47 None of the guidelines recommend more than 1,500 mg per day of calcium. The length of treatment with calcium is usually considered to be indefinite.

One exception to calcium 1,200 mg daily is if the patient is taking chronic corticosteroids. Corticosteroids decrease calcium intestinal absorption and increase urinary excretion. If a patient is taking chronic corticosteroids (such as prednisone 7.5 mg daily for 3 months), the American College of Rheumatology recommends 1,500 mg of elemental calcium per day.48 There are many products and formulations for calcium and patients often present with questions regarding the differences. No formulation is superior to another, but the decision should be based upon the patientsâ&#x20AC;&#x2122; needs, cost, convenience, and availability. The formulations differ in the salt forms and this causes variation in elemental calcium.

Calcium carbonate and citrate are the most common and are usually considered the salt forms of choice. Patients should be instructed to read the supplement facts label to determine the elemental calcium amount and look at the serving size, as it could be representing more than one tablet. Tablet 5 presents examples of combination calcium and vitamin D products. Note that calcium and Vitamin D do not need to be taken together in order to achieve the synergistic benefit.8 Calcium carbonate is the most common calcium supplement on the market. It is usually from sources such as rock deposits, limestone, or oyster shell. The lead amount found in oyster shell is not clinically significant since it is such a small amount. Calcium carbonate has the highest elemental calcium content of 40% and should be taken with food since it is better absorbed in an acidic environment. Therefore, it should not be taken in conjunction with histamine-2 blockers or proton pump inhibitors and is not the appropriate form to use in patients taking these medications. Since calcium

carbonate supplementation requires gastric acid for optimal absorption, older individuals with reduced gastric acid production should switch to a formulation that doesnâ&#x20AC;&#x2122;t have pH requirements.

Carbonate is preferred in patients with renal failure due to its ability to bind with phosphate in the intestines. Calcium carbonate is the most cost effective formulation since a single dose of 500 mg elemental calcium can be packaged into one tablet.22,23,30,43 Calcium citrate contains 21% of elemental calcium and does not have a pH requirement for absorption. It is more soluble than calcium carbonate, has better absorption, and may be taken without regard to meals. Some clinicians prefer the citrate form in the older adult because it is better absorbed, less likely to cause constipation, and the older adult is more likely to have GERD and gastric achlorhydria with the use of histamine-2 blockers and proton pump inhibitors.

Calcium citrate is an alternative for those who get gastrointestinal effects from taking calcium carbonate. However, calcium citrate is difficult to compact into tablets and therefore multiple tablets must be taken per serving in order to achieve the same amount of elemental calcium as calcium carbonate. Calcium citrate is generally more expensive. 22,23,30,43 Calcium side effects can include constipation, bloating, and flatulence.

Advise the patient to take calcium with food, increase his or her fluid intake and eat more high-fiber foods. If this does not help, it is best for the patient to switch to a different formulation that is better tolerated. Hypercalcemia is not common from administration of oral calcium unless the patient has chronic renal failure. Kidney stones are found to occur when the calcium daily amount exceeds 2,150 mg.22, 30 The body has a protective mechanism against calcium intoxication by decreasing the efficiency of absorption as consumption increases. Due to this protective mechanism, the body absorbs calcium more efficiently if the patient ingests less than or equal to 500 mg at one time. Therefore, it is recommended that the patient take divided doses throughout the day. If a patient is starting calcium supplements for the first time, advise him or her to titrate up slowly in order to avoid side effects.26 Drug interactions are common with

calcium as calcium can reduce the absorption of many other medications.

Separate calcium from bisphosphonates to prevent reduced absorption. Calcium can also decrease the absorption of iron, levothyroxine, fluoroquinolones, and tetracycline antibiotics.23 Vitamin D Supplement Treatment Doses, Guideline Recommendations, and Monitoring The dose that is most effective for osteoporosis prevention has been stated

by IOM, but the dose needed for fall and fracture prevention in patients with osteoporosis or osteopenia has different recommendations from several organizations. The treatment vitamin D dose continues to be studied but the current recommendations up to this point are presented here.

The pharmacist can choose between two types of vitamin D supplements: D2 (ergocalciferol) or D3 (cholecalciferol).

Calcitriol is not usually recommended for osteoporosis treatment and prevention due to the statistically significant increase in the risk of hypercalcemia.3 Vitamin D3 is preferred per many of the organizations but it is not clear if one is superior.15,26,30,44,49 Vitamin D3 products are industrially synthesized from irradiation of 7-dihydrocholesterol from lanolin in sheepâ&#x20AC;&#x2122;s wool. Certain individuals might want to avoid using animal products and in those cases, Vitamin D2 would be preferred since it is from plant sources.

Lanolin is also a common cause of allergic dermatitis and there have been case reports of cholecaciferol allergies because of this cross-reaction.9 With daily dosing, D2 and D3 appear equally potent but with weekly or monthly dosing D3 appears three times more potent than D2. Some reports cite that D2 and D3 are equivalent but there is not a definite conclusion. It might be that high doses of vitamin D2 are less potent.9 A majority of the guidelines recommend around 800 IU daily of vitamin D. 15,26,30,43, 44,49 Vitamin D products are often combined with calcium products for ease of patient adherence.

The usual dose of Vitamin D in a calcium supplement ranges depending on the formulation. In general, combination products will contain between 100 to 600 IU of Vitamin D. Single ingredient vitamin D products include over the counter D3 products of 400 IU tablets, 1000 IU tablets and capsules, 2000 IU capsules, and 5,000 Arizona Journal of Pharmacy 47

Continuing Education continued from page 47) IU tablets. Vitamin D3 (cholecalciferol) 50,000 IU capsules can be found over the counter at health food stores and online sites. Vitamin D2 (Drisdol速) 50,000 IU is a prescription capsule.29 The duration for vitamin D supplementation is usually considered indefinite.

The dosing amount and frequency for vitamin D deficiency and prevention of falls and fractures has been recommended and studied in a variety of ways. A common dosing schedule seen in practice for vitamin D deficiency is 50,000 IU weekly for six to eight weeks and this regimen can be repeated if the 25(OH) D level does not reach 75 nmol/L (30 ng/ml).21 Vitamin D 50,000 IU can also be given every two to four weeks to maintain the 25(OH)D level. IshShalom et al. published results from a study in 2008 that compared vitamin D daily, weekly, and monthly dosing.50 The doses were all diluted in one milliliter of solution and were D3 1,500 IU daily, 10,500 IU weekly or 45,000 IU every 28 days. This was a small study with 48 female participants with hip fracture for a duration of eight weeks. There was not a statistical difference in the 25(OH) D levels at the end of the eight weeks between the groups. The authors propose that the dosing regimen be chosen based on adherence.

Sanders et al conducted a study to determine whether a single annual dose of vitamin D3 500,000 IU would improve adherence and reduce the risk of falls and fracture in women.51,52 Their trial was published in 2010. The study was a single center, double-blind, randomized, placebo controlled trial in Australian women.

Participants were included if they were at higher risk of hip fracture such as history of maternal hip fracture, past self-fracture, or self-reported faller. There were a total of 2,256 participants with an average age of 76 years and a median follow up of 2.96 years. The 25(OH)D measurement was only done in a subset of 131 patients.

Seventy-four percent of 1,131 women in the vitamin D group and 68% of 1,125 women in the placebo group had at least one fall. One hundred fifty-five women taking vitamin D had 171 fractures and 125 taking placebo had 135 fractures. The vitamin D group fracture rate was 4.9 per 100 person years vs. 3.9 in the placebo group. This vitamin D dose should not be recommended to patients.

48 Arizona Journal of Pharmacy

The 2010 International Osteoporosis Foundation (IOF) position statement reports that the serum 25(OH)D concentration is the best available clinical indicator of vitamin D status.15 Other organizations generally agree that it is a good biomarker of exposure but it has not been correlated well to outcomes.9 The IOF statement includes that the 25(OH) D concentration declines with age but that the concentration response to a dose of vitamin D3 is not affected by age. It also acknowledges that the serum 25(OH)D levels vary across commonly used assays.

The NOF recommends measurement of 25(OH)D in patients at risk of vitamin D deficiency such as patients with low bone mass.26 The NOF recommends that serum 25(OH)D levels be checked in patients with malabsorption syndromes (such as celiac disease), chronic renal insufficiency, and homebound patients.

Osteoporosis Canada recommends that all patients taking medications for osteoporosis should have a 25(OHD) D level checked along with patients who have had a fracture or a comorbid condition (including corticosteroid use) for vitamin D deficiency.44,49 It is not meant to be checked in healthy individuals.

Vitamin D deficiency is generally considered to be less than 50 nmol/L (20 ng/ml). The majority of the IOF Working Group members recommend a target level of 75 nmol/L (30 ng/ml) for older adults and several members voted for 50 to 75 nmol/L (20 to 30 ng/ml) as the target level for fall and fracture prevention.15 To convert between 25(OH)D nmol/L and ng/ml, multiply nmol/L by 0.4 to get the ng/ml.53 AACE recommends levels between 75 and 150 nmol/L (30 and 60 ng/mL). A 25(OH)D is not recommended to be higher than 150 nmol/L (60 ng/ ml).43 IOM reported that 50 nmol/L (20 ng/ml) is sufficient for bone health and levels over 75 nmol/L (30 ng/ml) have not consistently been shown to have health benefits.22 The estimated average vitamin D requirement for older adults to reach a serum 25(OH)D level of 75 nmol/L (30 ng/ml) is 800 to 1,000 IU per day. The IOF does not recommend higher intakes than the general recommendation of 1,000 IU per day for older adults due to a lack of the higher dose evaluation in clinical trials.15 For patients who are obese, have osteoporosis, or receive

limited sun exposure, 2,000 IU per day is recommended. A general calculation is each 100 IU of added vitamin D will increase the serum 25(OH)D level by about 2.5 nmol/L (1 ng/ml).30,43 Other studies have shown 25(OH)D levels increase in response to increased vitamin D intake but the relationship might not be linear. The amount of the increase depends on the starting serum level and duration of supplementation.53 Another source said 1,700 IU/day was needed to raise 25(OH) D from 50 to 80 nmol/L (20 to 32 ng/ml).9 The treated individual should be retested after three to four months to determine if the 25(OH)D level has increased to the desired target.30,44 The half-life of 25(OH)D is 15 days, so there is no need to retest the level sooner.

Vitamin D toxicity symptoms include vague symptoms of anorexia, polyuria, and heart arrhythmias. Hypercalcemia leading to kidney stones is a consequence of vitamin D toxicity. Doses greater than 10,000 IU/day increase the risk of hypercalciuria and hypercalcemia. Drug interactions include prednisone which impairs vitamin D metabolism. Orlistat and cholestyramine prevent absorption of vitamin D. Phenobarbital and phenytoin increase the metabolism of vitamin D to inactive forms and reduce calcium absorption.9,29 Conclusion The conclusions are not straight forward. The optimal supplement amount of calcium and vitamin D conflict between studies and guidelines and a moderate decision is appropriate at this time. In a patient with osteoporosis, calcium 1,200 mg and vitamin D 800 IU daily is appropriate. The link between calcium and cardiovascular risk is preliminary, but the take away point is to encourage dietary calcium be the main source of the 1,200 mg and only recommend a supplement when it is lacking in the diet.

It is imperative to continually reexamine the most current knowledge regarding calcium and vitamin D in order to make sound professional judgments for the safety of patients. New information continues to be reported; refer to Table 6 for references to keep up to date on calcium, vitamin D, and osteoporosis.

Pharmacists must keep in mind that first, do no harm, and treat the patient if the benefit outweighs the risk.

Continuing Education (continued from page 48) References 1. Hippocratic Oath. History of Medicine Division.

National Library of Medicine. National Institutes of Health. Accessed online via http://www.nlm.nih.gov/hmd/ greek/greek_oath.html on April 15, 2011.

2. Chung M, Balk EM, Brendel M, et al. Vitamin D and calcium: a systematic review of health outcomes. Evidence Report No. 183. (Prepared by the Tufts Evidence-based Practice Center under Contract No. HHSA 290-200710055-I.) AHRQ Publication No. 09-E015. Rockville, MD: Agency for Healthcare Research and Quality. August 2009.

3. Avanell A, Gillespie WJ, Gillespie LD, and O’Connell D. Vitamin D and vitamin D analogues for preventing fractures associated with involutional and postmenopausal osteoporosis (review). Cochrane Library.

2009 (2).

4. Kalyani RR, Stein B, Valiyil R, et al. Vitamin D treatment for the prevention of falls in older adults: systematic review and meta-analysis. J Am Geriatr Soc. 2010: 58:1299-1310.

5. Gillespie LD, Robertson MC, Gillespie WJ, et al.

Interventions for preventing falls in older people living in the community (review). Cochrane Library. 2010 (10).

6. Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomized controlled trials. BMJ. 2009; 339:b3692.

7. Qaseem A, Snow, V, Shekelle P, et al. Pharmacologic treatment of low bone density or osteoporosis to prevent fractures: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008; 149: 404415.

8. National Institutes of Health. Dietary Fact Sheet for Health Care Professionals: Calcium. Accessed online via http://ods.od.nih.gov/factsheets/calcium on February 15, 2011.

9. National Institutes of Health. Dietary Fact Sheet for Health Care Professionals: Vitamin D. Accessed online via http://ods.od.nih.gov/factsheets/vitamind on February 15, 2011.

10. Heart disease fact sheet. Centers for Disease Control and Prevention. Accessed online via http://www.cdc.gov/ dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm on May 1, 2011.

11. Falls among older adults: an overview. Centers for Disease Control and Prevention. Accessed online via http://www.cdc.gov/HomeandRecreationalSafety/Falls/ adultfalls.html on May 1, 2011.

12. Hip fracture among older adults. Centers for Disease Control and Prevention. Accessed online via http://www. cdc.gov/HomeandRecreationalSafety/Falls/adulthipfx.html on May 1, 2011.

13. Facts and statistics about osteoporosis and its impact.

International Osteoporosis Foundation. Accessed online via http://www.iofbonehealth.org/facts-and-statistics.html on May 2, 2011.

14. Ross AC, Abrams SA, Aloia JF, et al. Report brief: dietary reference intakes for calcium and vitamin D. Institute of Medicine accessed via www.iom.edu on December 7, 2010.

15. Dawson-Hughes B, Mithal A, Bonjour JP, et al. IOF Position Statement: Vitamin D recommendations for older adults. Osteoporos Int. 2010 published online 27 April 2010.

16. Dawson-Hughes B, Heaney RP, Holick MF, et al.

Estimates of optimal vitamin D status. Osteoporos Int. 2005; 16:713-716.

17. Sherwood L. The peripheral endocrine glands. In: Human physiology from cells to systems. 3rd ed. Belmond, California: Wadsworth Publishing Company; 1997: 686692.

18. NIH Consensus Conference. Optimal calcium intake.

JAMA. 1994; 272(24): 1942-1948.

19. Molina PE, “Chapter 5. Parathyroid land & Ca2+ & PO4– Regulation” Molina PE: Endocrine Physiology, 3e: http://www.accessmedicine.com/content. aspx?aID=6169587.

20. Barnard K and Colon-Emeric C. Extraskeletal effects of vitamin D in older adults: cardiovascular disease, mortality, mood, and cognition. Am J Geriatr Pharmacother. 2010; 8:4-33.

21. Holick MF. Vitamin D deficiency. N Engl J Med. 2007; 357:266-81.

22. Ross AC, Taylor CL, Yaktine AL, et al. Committee to review dietary reference intakes for vitamin D and calcium; Institute of Medicine. Summary of dietary reference intakes for calcium and vitamin D. http://www. nap.edu/catalog/13050.html. Accessed January 3, 2011.

23. American Hospital Formulary Service Drug Information. Calcium salts monograph. Bethesda, MD: American Society of Health-System Pharmacists; 2011.

24. 1997 RDA Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary reference intakes: calcium, phosphorus, magnesium, vitamin D, and fluoride. Washington, DC: National Academy Press; 1997.

25. IOM (Institute of Medicine). Dietary reference intakes for calcium and vitamin D. Washington, DC: The National Academies Press: 2011.

26. National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2010.

27. Fosnight SM, Zafirau WJ, and Hazelett SE. Vitamin D supplementation to prevent falls in the elderly: evidence and practical considerations. Pharmacotherapy. 2008; 28(2):225-234.

28. American Academy of Dermatology. Position statement on vitamin D. Accessed online via http://www.aad.org/ forms/policies/uploads/ps/ps-vitamin%20d.pdf on March 3, 2011.

29. Drug Facts and Comparisons, vitamin D monograph, accessed electronically via Facts and Comparisons eAnswers on March 30, 2011.

30. Position Statement. Management of osteoporosis in postmenopausal women: 2010 position statement of the North American Menopause Society. Menopause. 2010.

17(1): 25-54.

31. Bolland MJ, Avenell A, Baron JA, et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ. 2010; 341:c3691.

32. Dietary Approaches to Stop Hypertension. DASH Eating Plan. US Department of Health and Human Services. NIH Publication No. 06-4082, Originally Printed 1998, Revised April 2006. http://www.nhlbi.nih.gov/health/ public/heart/hbp/dash/new_dash.pdf 33. Bostick RM, Kushi LM, Wu Y, et al. Relation of calcium, vitamin D, and dairy food intake to ischemic heart disease mortality among postmenopausal women.

Am J Epidemiol. 1999; 149(2):151-61.

34. Wang L, Manson JE, Song Y, and Sesso HD. Systematic review: vitamin D and calcium supplementation in prevention of cardiovascular events. Ann Intern Med. 2010; 152: 315-323.

35. Manson JE, Allison MA, Carr JJ, et al. Calcium/ vitamin D supplementation and coronary artery calcification in the women’s health initiative. Menopause.

2010; 17(4): 683-691.

36. Hsia J, Heiss G, Ren H. Calcium/Vitamin D supplementation and cardiovascular events. Circulation.

2007; 115: 845-854.

37. LaCroix AZ, Kotchen J, Anderson G, et al. Calcium plus vitamin D supplementation and mortality in postmenopausal women: the women’s health initiative calcium-vitamin D randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2009; 64(5): 559-567.

38. Vaysman AM and Gleason T. Calcium supplementation and cardiovascular risk. US Pharm. 2011; 36(2): 51-57.

39. Pittas AG, Chung M, Trikalinos T, et al. Systematic review: vitamin D and cardiometabolic outcomes. Ann Intern Med. 2010;152:307-314.

40. Kim DH, Sabour S, Sagar UN, et al. Prevalence of hypovitaminosis D in cardiovascular diseases (National Health and Nutrition Examination Survey 2001 to 2004).

Am J Cardiol. 2008; 102:1540.

41. Kendrick J, Targher G, Smits G, et al. 25(OH)D deficiency is independently associated with cardiovascular disease in the Third National Health and Nutrition Examination Survey. Atherosclerosis. 2009; 205:255.

42. Geleijnse JM. Vitamin D and the prevention of hypertension and cardiovascular diseases: a review of the current evidence. American Journal of Hypertension.

Online publication 16 Sept 2010.

43. Watts NB, Bilezikian JP, Camacho PM, et al. American Association of Clinical Endocrinologists (AACE) medical guidelines for clinical practice for the diagnosis and treatment of postmenopausal osteoporosis. Endocrine Practice. 2010 Nov/Dec; 16(Suppl3):1-37.

44. Papaioannou A, Morin S, Cheung AM, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. Early release October 12, 2010.

45. Boniva package insert. San Francisco, California: Genetech; 2011 January.

46. Actonel package insert. Norwich, New York: Norwich Pharmaceuticals; 2011 February.

47. Fosamax package insert. Whitehouse station, New Jersey: Merck & Co., Inc.; 2011 January.

48. Grossman JM, Gordon R, Ranganath VK,et al. American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care and Research. 2010 Nov; 62(11): 1515-1526.

49. Hanley DA, Cranney A, Jones G, et al. Vitamin D in adult health and disease: a review and guideline statement from Osteoporosis Canada. CMAJ. 2010; 182(12):E610-E618.

50. Ish-Shalom S, Segal E, Salganik T et al. Comparison of daily, weekly, and monthly vitamin D3 in ethanol dosing protocols for two months in elderly hip fracture patients. J Clin Endocrinol Metab. 2008; 93: 3430-3435.

51. Sanders KM, Stuart AL, Williamson EJ, et al. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA. 2010 May 12; 303 (18): 1815-1822.

52. Dawson-Hughes B and Harris SS. High-dose vitamin D supplementation: too much of a good thing? JAMA. 2010 May 12; 303(18): 1861-1862.

53. Isenor JE and Ensom MHH. Is there a role for therapeutic drug monitoring of vitamin D level as a surrogate marker for fracture risk? Pharmacotherapy.

2010; 30(3): 254¬-264.

54. Dietary Guidelines for Americans, 2005. US Department of Health and Human Services. Accessed online via http://www.health.gov/dietaryguidelines/ dga2005/document/html/AppendixB.htm#appB5 on May 1, 2011.

55. U.S. Department of Health and Human Services.

The 2004 Surgeon General’s Report on Bone Health and Osteoporosis: What It Means to You. U.S. Department of Health and Human Services, Office of the Surgeon General, 2004, page 13.

56. Calcium Calculator. International Osteoporosis Foundation. Accessed online via http://www.iofbonehealth. org/patients-public/calcium-calculator.html on January 15, 2011.

57. Dietary Supplements Labels Database. United States National Library of Medicine. Accessed online via http:// dietarysupplements.nlm.nih.gov/dietary/index.jsp on March 15, 2011.

58. Caltrate Product Labeling. Accessed online via http:// www.caltrate.com/ on March 15, 2011.

59. Calcium supplement facts. Nature Made. Accessed online via http://www.naturemade.com/Products/Segments/ Calcium on March 15, 2011.

60. Tums Drug Facts Labels. Accessed online via http:// www.tums.com/Products/Default.aspx on March 15, 2011.

61. Citracal Product Website. Accessed online via http:// citracal.com/ on March 15, 2011.

62. Oscal Product Website. Accessed online via http:// www.oscal.com/ on March 15, 2011.

ACPE UAN #0100-0000-11-022-H01-P

Arizona Journal of Pharmacy 49

Continuing Education (continued from page 49) Table 1: IOM Dietary Reference Intakes (DRI) for Calcium and Vitamin D22 Life Stage Group 31-50 years of age 51-70 years of age for males 51-70 years of age for females >70 years of age

EAR

Calcium (mg/day) RDA UL

EAR

Vitamin D (IU/day) RDA UL

800

1,000

2,500

400

600

4,000

800

1,000

2,000

400

600

4,000

1,000

1,200

2,000

400

600

4,000

1,000

1,200

2,000

400

800

4,000

EAR: Estimated Average Requirement RDA: Recommended Dietary Allowance UL: Upper Level Intake

Table 2: Selected Food Sources of Calcium54-56 Food

Serving Size

Dairy Products Cheese (cheddar, swiss) 1.5 ounces Cheese, cream, regular 1 tablespoon Cottage cheese, 1% milk fat 8 ounces Frozen yogurt, vanilla, soft serve 4 ounces Ice cream, vanilla 4 ounces Milk (whole, reduced-fat, non-fat) 8 ounces Milkshake 8 ounces Pudding, instant, (chocolate, banana, etc.)

4 ounces made with 2% milk Sour cream 2 tablespoons Yogurt, plain, low-fat, or fruit 8 ounces Fish Salmon, canned, with edible bones 3 ounces Sardines, canned in oil, with edible bones 3 ounces Nuts Almonds 12 Walnuts 12 halves Vegetables Broccoli, raw 8 ounces Soybeans, cooked 8 ounces Spinach, cooked 4 ounces Turnip greens, boiled 4 ounces Fortified Foods Bread 1 slice Cereal 8 ounces Oatmeal, instant 1 packet Orange juice 6 ounces Soy beverage 8 ounces

50 Arizona Journal of Pharmacy

Calcium per serving (mg) 275-336 12 138 103 150 285-302 300 153 32 245-452 181 324 70 38 90 261 120 99 20-31 100-1000 99-110 200-260 80-500

Continuing Education (continued from page 50)

Table 3: Selected Food Sources of Vitamin D9, 27, 54, 55 Food

Serving Size

Cereal, vitamin D fortified Egg yolk Milk, vitamin D fortified Orange juice, vitamin D fortified Salmon (sockeye) Tuna fish, canned in water Yogurt, vitamin D fortified

8 ounces 1 8 ounces 8 ounces 3 ounces 3 ounces 6 ounces

International Units (IUs) per serving 40-100 20 115-124 100 447 154 80

Table 4: Comparison of recommended daily calcium and vitamin D for prevention and treatment of osteoporosis 15,26,30,43,44,48 Organization

Target Population

Recommended Elemental Calcium Amount (mg/day) 1,200 (UL of 1,500)

Recommended Vitamin D Amount (IU/day) 800 to 1,000

Preferred Type of Vitamin D D3

National Osteoporosis Foundation (NOF)

Postmenopausal women and men age 50 and older

North American Menopause Society (NAMS) American Association of Clinical Endocrinologists (AACE) American College of Rheumatology (ACR) International Osteoporosis Foundation (IOF) Osteoporosis Canada

Women age 50 and over

1,200

800 to 1,000 (UL of 2,000)

D3

Postmenopausal women

1,000 to 1,200

400 to 800

No preference stated

Patients taking oral glucocorticoids for any dose or duration Older adults

1,200 to 1,500

800 to 1,000

Not addressed

800 to 1,000 (UL of 2,000)

No preference stated D3

Adults age 50 and over

1,200

800 to1,000 (UL of 2,000)

D3

Arizona Journal of Pharmacy 51

Continuing Education (continued from page 51) Table 5: Common Calcium and Vitamin D OTC Combination Products57-62 Brand Name

Calcium Citrate

Calcium Carbonate

Caltrate® 600 + D (tablets & soft chews)

Amount of Elemental Calcium (per tablet/soft chew/chewable)

Amount of Vitamin D (per tablet/soft chew/chewable)

600 mg

400 IU (D3)

Other Active Ingredients -Magnesium 50 mg Manganese 1.8 mg Boron 250 mcg Zinc 7.5 mg Copper 1 mg Magnesium 40 mg Manganese 1.8 mg Boron 250 mcg Zinc 7.5 mg Copper 1 mg

Caltrate® 600 + D Plus Minerals (tablets)

600 mg

400 IU (D3)

Caltrate® 600 + D Plus Minerals Chewables

600 mg

400 IU (D3)

500 mg

200 IU

--

600 mg

200 IU

--

750 mg

500 IU

Nature Made® Calcium 500 mg with Vitamin D Nature Made® Calcium 600 mg with Vitamin D Nature Made® Calcium 750 mg + D + K Nature Made® Calcium Magnesium & Zinc Oscal® Calcium + D3 Oscal® Chewable Oscal® Extra D3 TUMS® Regular TUMS® Extra TUMS® Smoothies TUMS® Ultra Viactiv® Citrical® Regular Citrical® Petites with Vitamin D Citrical® Maximum Caplets Citrical® Plus with Magnesium

Vitamin K 40 mcg

333 mg

200 IU

500 mg 500 mg 500 mg 200 mg 300 mg 300 mg 400 mg 500 mg 250 mg

200 IU 600 IU 600 IU ----500 IU (D3) 200 IU (D3)

Magnesium oxide 133 mg Zinc 5 mg -------Vitamin K 40 mcg --

200 mg

250 IU(D3)

--

315 mg

250 IU(D3)

--

125 IU(D3)

Magnesium 40 mg Manganese 0.5 mg Boron 250 mcg Zinc 3.75 mg Copper 0.5 mg

250 mg

Table 6: Calcium and Vitamin D Additional Resources Name Institute of Medicine

Web address www.iom.edu/calcium

National Institutes of Health: Office of Dietary Supplements

www.ods.od.nih.gov

The National Osteoporosis Foundation International Osteoporosis Foundation U.S. Department of Health and Human Services: Agency for Healthcare Research and Quality FRAX WHO Fracture Risk Assessment Tool

www.nof.org http://www.iofbonehealth.org/ www.ahrq.gov

http://www.sheffield.ac.uk/FRA X/tool.jsp

52 Arizona Journal of Pharmacy

Information Available Dietary reference intakes for calcium and vitamin D Supplement information with recommended intakes, dietary sources, health outcomes, adverse reactions, and toxicities Osteoporosis information for patients and health care professionals Osteoporosis information for patients and health care professionals Comparative efficacy information for disease states and medications for patients and health care professionals World Health Organization Tool to assess individual patient risk of 10year probability of fracture using bone mineral density and patient clinical risk factors

Continuing Education Quiz 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.

Prevalence, Causes, and Impact of Type II Diabetes on the Local Pima Indians of Arizona

5. Which of the following ethnic groups has the highest incidence of Type 2 diabetes mellitus?

1.Which of the following is caused by an inability to produce insulin? a. Type 1 diabetes mellitus b. Diabetes insipidus c. Type 2 diabetes mellitus d. a and b

8. Which of the following was found to be associated with increased health related quality of life among Pima youth?

a. Use of insulin as compared to oral diabetes medications b. More emergency department visits as compared to less c. Type 2 diabetes mellitus as compared to Type 1 d. a and b

a. Asian/Pacific Islanders b. African Americans c. Non-Hispanic Whites d. American Indians

2. Which of the following tests can be used to differentiate between Type 1 and Type 2 diabetes mellitus?

6. (T/F) Exposure to diabetes in utero is a predictor for development of Type 2 diabetes mellitus in the Pima population.

a. C-peptide b. LDH c. Islet cell antibodies d. a and c

9. Which of the following has been found to manifest first among Pima youth with Type 2 diabetes mellitus?

a. True b. False 7. (T/F) Research has shown a higher incidence of end-stage renal disease and mortality among Pima diabetics diagnosed in youth (before age 20) as compared to those diagnosed in adulthood (after age 20).

3. Which diabetes ‘type’ has historically been considered a disease of adults? a. Type 1 diabetes mellitus b. Type 2 diabetes mellitus

a. Hyperglycemia b. Hypoglycemia c. Hyperinsulinemia (insulin resistance) d. Hyperglucagonemia 10. Which of the following would be (a) useful response(s) to the Type 2 diabetes epidemic among Pima youth? a. Public health measures promoting healthy diet and exercise b. Encouraging pregnant women to control their diabetes during pregnancy c. Taking into account health related quality of life when designing treatment strategies d. All of the above

a. True b. False

4. (T/F) The emergence of diabetes in the Pima Indians mirrors changing nutritional and economic trends in the community. a. True b. False

Arizona Pharmacy Foundation Prevalence, Causes, and Impact of Type II Diabetes on the Local Pima Indians of Arizona

ACPE UAN# 0100-0000-11-021-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. Distinguish the pathophysiology of Type 1 diabetes mellitus from Type 2 diabetes mellitus and be familiar with diagnostic tests used to differentiate between Type 1 and Type 2 diabetes mellitus.

2. Recognize the differences among races with regards to incidence of Type 2 diabetes mellitus among youth and be familiar with predictors for Type 2 diabetes mellitus in Pima Indians specifically.

3. Identify the impact of Type 2 diabetes mellitus in Pima Indian youth and describe potential measures that can be taken to prevent negative outcomes associated with the disease.

AGREE DISAGREE

AGREE DISAGREE

AGREE DISAGREE

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Continuing Education Quiz

Calcium and Vitamin D Supplementation Update for the Prevention and Treatment of Osteoporosis 1. Which of the following factors decrease calcium intestinal absorption? a. Basic pH

b. Vitamin D overdosage c. Tetracycline antibiotics d. A and C e. All of the above

This activity was developed by the Arizona Pharmacy Alliance for pharmacists 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.

7. Which of the following medications interacts with calcium in which the calcium can decrease the intestinal absorption of that medication? a. Prednisone b. Vitamin D c. Ciprofloxacin d. Orlistat

8. Which patient has the best indication for having a vitamin 25(OH)D level checked?

2. Which form of vitamin D is biologically active and a. A healthy 50 year old male enhances intestinal absorption of calcium? b. A healthy 70 year old female who resides in the a. Ergocalciferol b. Cholecalciferol community c. Calcidiol d. Calcitriol c. A 60 year old male who has taken prednisone for 6 months 3. What is the recommended IOM dietary calcium intake d. A 55 year old male with cardiovascular disease for a 52 year old female patient who wants to prevent osteoporosis and has no other health conditions?

9. How much daily vitamin D would be a generally a. 800 mg b. 1,000 mg good recommendation if a nursing home patient has c. 1,200 mg d. 1,500 mg a 25(OH)D level of 20 ng/ml with no prior vitamin D supplementation?

4. Which of the following is the most effective a, 400 IU b. 600 IU and safe recommendation for a patient who would c. 800 IU d. 1,000 IU like to increase her vitamin D intake without using supplements?

10. After starting vitamin D supplementation for a a. Stop use of sunscreens low 25(OH)D level, when should the patient have his b. Increase vegetable intake 25(OH)D level checked again? c. Change to vitamin D fortified foods a. 1 week b. 3 weeks c. 3 months d. 1 year 5. Which of the following is the best recommendation considering the information available on the risk of 11. Which of the following vitamin D dosing myocardial infarction? strategies has the strongest evidence showing it a. Increase dietary calcium before adding a supplement should NOT be used? b. Add vitamin D to the calcium supplement regimen a. 2000 IU po daily c. Discontinue all calcium supplements b. 10,000 IU po weekly c. 50,000 IU po monthly 6. Which patient would calcium citrate be the best salt d. 500,000 IU po yearly form rather than calcium carbonate for osteoporosis treatment?

12. What recommendation can be given to a patient a. Patient with PUD taking omeprazole daily to decrease constipation and bloating from calcium b. Patient with periodic GERD who is not taking any carbonate supplements? medication a. Take it with meals c. Patient with cost constraints b. Take it once daily d. Patient with a history of kidney stones c. Decrease fluid intake d. Take omeprazole at the same time

13. 62 year old postmenopausal female with hypertension and a family history of osteoporosis provides you her dietary intake of calcium per day: two cups of vitamin D fortified milk, one cup of yogurt, and a handful of nuts.

She does not want to increase her calcium containing foods and she applies sunscreen 30 SPF daily. Which of the following calcium/vitamin D supplement regimens (per the IOM report) would you recommend? a. None, she gets enough supplementation from her diet b. Calcium carbonate 500 mg po once daily and vitamin D3 400 IU daily c. Calcium citrate 500 mg po once daily and vitamin D2 50,000 IU monthly d. Calcium carbonate 600 mg po TID and vitamin D3 1000 IU daily 14. A 78 year old patient with osteoporosis is taking Boniva 150 mg one tablet po monthly. The patient is not taking calcium and vitamin D supplementation. She receives approximately 600 mg of calcium and 200 IU of vitamin D from her diet. What additional amount of daily elemental calcium and vitamin D is needed per NOF guidelines? a. Calcium 400 mg and vitamin D 400 IU b. Calcium 600 mg and vitamin D 600 IU c. Calcium 1000 mg and vitamin D 1000 IU d. Calcium 2000 mg and vitamin D 2000 IU 15. Which of the following amounts of daily calcium has shown to increase the incidence of kidney stones in the elderly? a. 1,000 mg b. 1,500 mg c. 2,000 mg d. 2,500 mg

Arizona Pharmacy Foundation Calcium and Vitamin D Supplementation Update for the Prevention and Treatment of Osteoporosis

ACPE UAN #0100-0000-11-022-H01-P. This activity is accredited for 2.0 hours of CPE credit (CEUs 0.20)

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. Recall the basic physiologic roles of calcium and vitamin D

2. Identify appropriate calcium and vitamin D supplementation dietary reference intakes and new tolerable upper limits set by the Institute of Medicine (IOM) for osteoporosis prevention and treatment 3. Discuss recent information investigating the risks of calcium/vitamin D on cardiovascular health

AGREE DISAGREE

AGREE DISAGREE AGREE DISAGREE AGREE DISAGREE AGREE DISAGREE

No

4. Compare and contrast the different types of calcium and vitamin D supplements and dosing strategies

5. Develop effective counseling strategies for calcium and vitamin D use, dosing, and adverse effects

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 ________________________________________________________

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City, State, Zip ___________________________________________________

Poor 1 2 3 4 5 Excellent Activity accredited date: 06-15-2011 Expiration date: 06-15-2012.

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

Certificates will be mailed within 60 days.

Time Capsule Pharmacy Time Capsules Second Quarter 2011 1986—Twenty-five Years Ago:

1911—One Hundred Years Ago:

•

•

• •

Reye’s syndrome warning required to be added to all aspirin labels.

The American Association of Pharmaceutical Scientists (AAPS) was formed with almost 3,000 charter members.

Human Genome Project launched with the object to understand the human genome and therefore provide the continuing progress of medicine.

The US Supreme Court ruled against Dr. Miles Medical Co., which had sued a distributor for selling its products at cut rate prices.

1886—One Hundred Twenty-five Years Ago: •

The University at Buffalo School of Pharmacy and Pharmaceutical Sciences opened.

1961—Fifty Years Ago: •

President Kennedy signed Public Law 87-319 designating the third week in March as National Poison Prevention Week.

1936—Seventy-five Years Ago: •

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.

The use of radiopharmaceuticals began when John Lawrence administered a radioactive isotope of phosphorus-32 to treat chronic leukemia.

Certified Pharmacy Technician

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Continuous Testing and Immediate Pass/Fail Results Now Available The PTCB Certification Program is the only pharmacy technician certification endorsed by the American Pharmacists Association (APhA), the American Society of Health-System Pharmacists (ASHP), the National Association of Boards of Pharmacy (NABP) and other professional pharmacy organizations. In 2008, PTCB tested over 50,000 pharmacy technicians and has certified over 330,000 CPhTs since 1995.

Arizona Journal of Pharmacy 55

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.

PLAN CAREFULLY WHEN IT’S TIME TO MAKE A CAREER MOVE

The days when an employee would spend his or her entire career with the same company appear to be all but gone. Nowadays, beyond simply changing jobs over the course of a career, many workers even take on an entirely new career before they finally reach retirement. When you make a job change, one of the biggest challenges you may face could be deciding what to do with the assets you’ve built up in your former employer’s retirement plan.

Unfortunately, many people look at these funds as a free gift when they change employers, and they choose to take a cash payment and spend it. Keep in mind one of the most important sources of your retirement income is the payments you receive from company retirement plans. By taking the money out in cash, you eat away at this valuable source of retirement income.

Instead of taking the cash, you may want to consider rolling the money from your company-sponsored plan into an IRA. A direct rollover, where the funds from your company plan go directly into an IRA, is a simple way to allow these assets the opportunity to continue to grow taxdeferred, and will help you avoid the temptation to spend these important funds on other things.

Moving from job to job may not be the only change you’re considering. IRA rollovers can also prove useful if you decide that instead of just changing jobs, you want to retire. If you’re younger than 59½ and would like to take withdrawals from a retirement account, you may be able to avoid the IRS 10% early withdrawal penalty as long as the withdrawals qualify for certain exceptions. Let’s take a look at an example to help illustrate the options.

John is 58 years old, and would like to retire early to join his wife Carol, 57, who retired two years ago. Currently, their modified adjusted gross income (MAGI) is $98,000, but if John retires that figure will drop to $48,000. This should still be enough to cover all their expenses, except their mortgage payments. John has a 401(k) balance of $300,000 and an investment portfolio worth another $125,000, while Carol has an IRA with a current value of 56 Arizona Journal of Pharmacy

$25,000. They are considering taking $100,000 out of their retirement nest egg to pay off their mortgage, but if they’re not careful, doing so could require them to pay both income taxes and the IRS 10% early withdrawal penalty on the amount they withdraw.

One option that may help would be to take a $100,000 withdrawal from John’s 401(k) to pay off the mortgage.

This would result in taxable income, but since he would be older than age 55 at retirement, John would qualify for a special “55 or over” exception, meaning he would not face the early withdrawal penalty. The remainder of his 401(k) balance could still be rolled into an IRA. As another alternative, John could roll the money from his 401(k) into an IRA first. He could then use one of three IRS-approved withdrawal methods to take “substantially equal periodic payments” from the IRA without an IRS penalty, and use that money to make their monthly mortgage payments. While these withdrawals would be taxable, this strategy could still allow for greater tax deferral because the entire 401(k) distribution could be rolled over.

As you can see from these examples, it’s important to know what your options are and you may need to consult with financial professionals — including your tax advisor — to sort them all out. Whether it’s your first job change or your last, your retirement nest egg needs to be handled with care. Consider your alternatives so you can make good decisions to keep your savings in line to meet your needs.

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.

CAREER CENTER Searching for a job or looking to fill a position? www.azpharmacy.org

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For more information, visit us online at www.azpharmacy.org

Don’t get caught with your pants down!

Do you have a continuous quality improvement program in place or will you be caught ...

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.

Don’t be caught in an audit without a continuous quality improvement program.

Errors can injure your patients and put your pharmacy in financial jeopardy.

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

PQC is brought to you by your state pharmacy association.