2024 Summer Arizona Journal of Pharmacy

Arizona Journal of Pharmacy O F F I C I A L

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Celebrating the Achievements of Arizona Pharmacy Professionals In This Edition:

If We Don't STOP-IT, Who Will?

Preventing the Unseen Risk: A Review of Venous Thromboembolism Prophylaxis in Hip and Knee Arthroplasty

Independent Pharmacies are NOT Safe from Cyberattacks

Contents Board of Directors 2024-2025 OFFICERS President Jacob Schwarz President Elect Jaime von Glahn Past President Kimberly Langley Treasurer Ryan Gries Secretary Brandy DeChellis Director/CEO Vacant DIRECTORS AT LARGE Community Brianne Spaeth Health System Mary Manning Technician Melinda Browning Misty Brannon Reasol Chino Danielle Gilliam Joseph Pelleriot Yousef Toma LIASIONS University of Arizona Student Chapter Nguyen Pham Dean's Designated Representative Nancy Alvarez Midwestern University Student Chapter Cheleen An Dean's Designated Representative Michael Dietrich Creighton University Student Chapter Sahar Toluee Dean's Designated Representative Jane Stein Legal Counsel Roger Morris

AzPA Staff Chief Executive Officer Vacant Education & Professional Development Dawn Gerber Interim CEO/Events & Strategic Partnerships Cindy Esquer Membership & Volunteer Services Vacant Strategic Programs Kristin Calabro Administrative Services Melina Esquer Editor Cindy Esquer Creative Coordinator Elizabeth Nelson

The interactive digital version of the Arizona Journal of Pharmacy is available for members only online in your member portal.

(480) 838-3385 | admin@azpharmacy.org Editor's Note: Any personal opinions expressed in this magazine are not necessarily those held by the Arizona Pharmacy Association. "Arizona Journal of Pharmacy" (ISSN 1949-0941) is published quarterly by the Arizona Pharmacy Association at: 1845 E. Southern Avenue, Tempe, AZ 85282-5831

COVER STORY pg. 16

Congratulations to the 2024 Award Recipients!

President’s Message 4 AzPA News Welcome New Members 5 University & Alumni News 24 Editorial If We Don't STOP-IT Who Will? 6 Preceptors Corner 9 Independent Pharmacies are NOT Safe from Cyberattacks 31 Advocacy Legislative Review 33 Continuing Education Preventing the Unseen Risk: A Review of Venous Thromboembolism Prophylaxis in Hip and Knee Arthroplasty 18

UPCOMING EVENTS

August 26, 2024 | Virtual

September 21, 2024 | Virtual

September 28-29, 2024 | Glendale

February 15-16, 2025

June 12, 2025 | Tucson, AZ

June 12-15, 2025 | Tucson, AZ 3

EDITORIAL PRESIDENT'S MESSAGE

Dear AzPA Members, As my tenure as President of our esteemed Arizona Pharmacy Association draws to a close, I find myself filled with immense pride and gratitude. The past year has been a remarkable journey, one that has challenged us, united us, and ultimately strengthened us to shape a brighter future for the pharmacy profession.

Looking back, I am humbled by the support and dedication of our members, who have been the driving force behind our collective success. Our community has remained steadfast in the commitment to advancing the profession of pharmacy. We have fostered collaboration, shared knowledge, and advocated for the interests of our members and the patients we serve. Our collective efforts have not only unified us but have also strengthened us to be an influential voice in the Arizona healthcare community.

CAPT Kimberly “Kim” Langley, PharmD, MBA, BCPS, FAzPA CAPT Kimberly Langley is the Chief Financial

A top priority has been advocating for improved workplace conditions and giving pharmacy professionals a voice. We heard directly from members about the challenges they face through townhalls, other meetings, and our first-ever workplace conditions survey to better understand the landscape of pharmacy practice in Arizona. To no surprise, the results highlighted areas of concern like staffing shortages and burnout. There is still so much more to be done. I look forward to using this data and engaging with our members to guide and support future strategic initiatives.

Officer for the DoD Federal Electronic Health Record Modernization office responsible for implementing a single, common federal electronic health record system for Department of Defense, Department of Veteran Affairs, Department of Homeland Security, and the National Oceanic and Atmospheric Administration. CAPT Langley is a

The association achieved other milestones to support our Arizona communities. AzPA partnered with the Maricopa County Department of Public Health to launch the Stop Overdose Deaths Arizona (SODAZ) program. This collaboration has had noticeable success in increasing access to naloxone, a life-saving medication. AzPA is part of the collective effort to combat the opioid crisis in our state.

pharmacist in the U.S. Public Health Service (USPHS) Commissioned Corps and has been on continuous active duty since 2009. She has completed previous USPHS assignments at multiple duty stations across New Mexico and Arizona with Indian Health Service. During this time, CAPT Langley served in several diverse leadership positions including Pharmacy Manager, PGY-1 Residency Program Director,

One of the most anticipated events of the year is our annual convention. This gathering has become a cornerstone of our community, bringing together pharmacy professionals from across the state and beyond. This year’s convention was particularly noteworthy, featuring innovative continuing education presentations and inspiring speakers who shared their insights and experiences, leaving us motivated and energized. The enthusiasm and engagement of our members during this meeting was truly remarkable!

Cardiovascular Clinic Director, and IHS AgencyRepresentative to the Million Hearts Initiative. In 2015, CAPT Langley served as the Chief Pharmacy Officer for her team in Liberia as a part of the Ebola crisis response in West Africa.

CAPT Langley holds a Bachelor of Science in Medical Technology from Georgia Southern University; a Doctor of Pharmacy degree from Medical University of South Carolina; a Master of Business Administration from The Citadel; and completed a Certificate in Business Process

As I have previously noted, change is inevitable. As much as I looked forward to reconnecting and meeting with our members and supporters at our annual convention, I knew that it would also mark the end of an era. One of the most significant changes we faced was the departure of our long-serving CEO, Kelly Fine, who has been an integral part of our association. This association has thrived under her leadership and dedication for more than 13 years. We congratulate Kelly as she starts this new chapter in her career while we also welcome the prospect of new possibilities and perspectives for our organization. With resilience and unity, we embrace this change, recognizing that it is an opportunity to reinvigorate our association and continue to build upon Kelly’s legacy of excellence.

Management from Villanova University. She is also board-certified in Pharmacotherapy and served on multiple technical expert panels for Pharmacy Quality Alliance for the development of cardiovascular and diabetes quality measures.

CAPT Langley is actively engaged in AzPA

In closing, I want to express my deepest gratitude to each member and supporter of our association. Your passion, commitment, and resilience have inspired me on this journey to advance the profession. It has been an honor to serve as your president and to work alongside such a dedicated and talented group of individuals.

activities including serving on the Board of Directors as President, Director-at-Large, APhA House of Delegates Representative, member on several committees, faculty for 2 certificate programs, abstract peer reviewer, and conference speaker. In 2023, she was recognized as a fellow

Together, we have blazed a trail in this remarkable chapter of our history, and I am excited to see to how our journey will continue to unfold. As we transition into this new era, I am excited to witness the continued growth and success of our association filled with even greater accomplishments and lasting impact.

of the Arizona Pharmacy Association. Her leadership experience extends to various roles on multiple USPHS committees, workgroups, and mentoring programs.

It has been an honor to serve as your president, and I am deeply appreciative of the trust you have placed in me. Thank you for the privilege of serving you. I look forward to continuing to work alongside you as we advance the profession of pharmacy together.

CAPT Kimberly “Kim” Langley, PharmD, MBA, BCPS, FAzPA 2023-2024 AzPA President

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WELCOME NEW MEMBERS! 1st Year Practitioner Jaimie Mai Shirley Ricks

Pharmacist Heather Balk Don Bladt Monica Heberling Emily Hennessey BriAnna Lewis James McCarty Jenny Mitchell Wendy Norris Amber Rollo Bina Shah Jean Youssef Sharlyn Zapp

Resident Micah Banawis Breanne Boyette Alejandro Del Rio Verduzco Brenda Francis Olivia Hinojosa Lindsey Johnson James Jolley Hannah Koeller Samantha Koziol Zachary Larson Laura Lee Katherina Marchese Caophi Nguyen April Noonan Ysabel Padilla Laci Quick Eustacia Rosastri Bianna Sallemi Marie Storer John Andrew Valencia Joshua Watkins Kaylee Whitenack Mallory Yan

AZPA NEWS

Student Pharmacist Hoda Alshagra Harmandeep Behniwal Taylor Butler Jasmin Chaparro Martinez Kristin de Jesus Ashley Dorer Henry Gonzales Love Kaur Yogya Sreeharshini Mandali Khalid Muhyieddeen Roger Nguyen Jessica Osuna Michael Pham Adrianne Pugh Urmee Ripon Nora Shara Carla Terrazas Arroyo Shriya Thakrar Madeleine Trail

Retired Randall Deal Stephen Robison

Premium Pharmacist Jessica Lyerly Raquel Sangar

Associate Jacob Ball Michael Lee Samantha Valenzuela

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EDITORIAL HEALTH SYSTEMS

"Trafficking is directed largely by the Sinaloa cartel operating in Mexico who coordinate product delivery of the lethal synthetic opioid, fentanyl, towards AZ schools, playgrounds, shopping malls and other youthattracting venues."

If We Don't STOP-IT, Who Will?

AUTHORS/CONTRIBUTORS Holly Geyer, MD, FASAM, Chair, STOP-IT, Addiction Medicine and Hospital Internal Medicine, Physician Lead of the Mayo Clinic Opioid Stewardship Program, Mayo Clinic AZ

Christi Jen, RPh, Clinical Pharmacy Specialist, Administrative Lead of the Mayo Clinic Opioid Stewardship Program, Mayo Clinic AZ Adena Bernstein, JD, Assistant Arizona Attorney General, Fentanyl Coordinator Mike Kurtenbach,, Co-Chair, STOP-IT, Director of School Safety, Arizona Department of Education (ADE) DISCLOSURE The author(s) declare no real or potential conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honorarium.

FUNDING No funding was provided.

ACKNOWLEDGEMENT The author gratefully acknowledges all pharmacy practice preceptors dedicated to providing high quality learning experiences.

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CONT. HEALTH SYSTEMS Our kids are targets.

wait for an off-campus responder. And with no state requirements for

With more than half of the seized U.S. fentanyl supply coming straight

schools to report potential overdoses or administration of naloxone,

through Arizona, they sit at the epicenter of a three trillion dollar drug

what little data we have on this topic likely underestimates true

war overtaking America.(1) To put this in perspective, that value

prevalence. School education is lacking. And the few private 501(c)3

equates to more than 11% of our 2023 U.S. gross domestic product

and government agencies offering in-person student training are no

(GDP). This past year, the Drug Enforcement Agency (DEA) seized 42

match for the 2000 public schools in need of their curriculum.

million fentanyl pills in our state alone-a logarithmic increase from the 28 million pills seized in 2022, and 12 million the year prior.(2)

So, what is the solution? The problem is massive, deeply rooted, and

Trafficking is directed largely by the Sinaloa cartel operating in Mexico

growing. The epidemic is now endemic and fueling statewide

who coordinate product delivery of the lethal synthetic opioid, fentanyl,

discussions on whether ‘too little too late’ is reversible. All can agree

towards AZ schools, playgrounds, shopping malls and other youth-

that helping our kids escape the entanglement of opioid use disorder

attracting venues.(3)

(addiction) and overdoses requires we build solutions as big as the problems. And when it comes to our kids, everything is on the table.

There are three trillion reasons why our kids are enticing accompaniments to this crime scene. They can be buyers and sellers

The STOP-IT Initiative

to a generation of fellow youth seeking acceptance, entertainment and

Solutions are on the horizon. Thanks to a collaborative effort

relief from mental health ailments. What they offer beyond the fentanyl

between the Arizona Department of Education and a team of

is misperception of safety. Not only has fentanyl been found lacing

medical, behavioral health, government and educational specialists,

virtually every other class of abusable drugs, but it’s frequently

the state of Arizona is in the process of building a comprehensive

pressed into pills that mimic legitimate pharmaceuticals (such as

intervention to tackle drug awareness and overdose prevention in

oxycodone, Oxycontin®, Xanax®).(4) Readily accessible online herbal

schools.

and weight loss supplements are another novel supply chain and an emerging trend is to add flavors and colors that mimic gas station

An initiative titled the ‘School Training Overdose Preparedness

candy. With 7 out of every 10 pills now being confiscated by the DEA

and Intelligence Taskforce’ (STOP-IT) has been authorized to

containing enough fentanyl to kill the average American adult (2 mg),

develop a state-wide, sustainable school opioid overdose education

escaping cartel entrapments seems a delusive venture.(4)

and preparation toolkit for AZ schools (Table 1). In tandem, the project will include tackling school policies, exploratory school

Not convinced? Ask the 75,000 people that lost their lives to synthetic

surveys, overdose monitoring/reporting systems and naloxone

opioids in 2023.(5) That same year, our state observed more than

supply chain plans. The taskforce is comprised of four

1900 opioid-overdose deaths and 4000 non-fatal overdoses.(6) As for

subcommittees, each addressing specific issues:

our kids, the Arizona Child Fatality Review Program recorded at least eighty deaths in children due to opioids between 2021 and 2022, and

1. Survey and Overdose Monitoring Subcommittee: Via a statewide

132 overdose events in 2023.(7) Nationwide, the data shows we lose

school survey (K-12 and post-secondary), the group will thoroughly

a classroom worth of teenagers weekly.(8)

assess the current state of school opioid overdose preparedness (including availability of naloxone and training requirements),

Schools offer a convenient opportunity to employ interventions.

student and staff education processes, barriers to naloxone

However, current AZ laws (Ariz. Rev. Stat. § 15-341(A)(43)) fall short

procurement and school viewpoints on student risks. The

of enforcing requirements to ensure educational institutions are

subcommittee will also address the creation of a statewide school

equipped with naloxone or that staff are trained to administer

opioid overdose reporting system. Follow-up surveys are planned

it. Likewise, there are no state or federal requirements for schools to

following the intervention to measure impact.

train students on the topics of fentanyl, overdose management, or

2. Best Practices for Staff/Student Training Subcommittee: This

addiction.Recognizing the investment needed to create an overdose-

subcommittee will evaluate currently available curriculum for

prevention and management protocol, a number of AZ schools—

students and staff on the topics of opioids, opioid use disorder

including public, private and charter—have elected to defer

(OUD), opioid overdoses and naloxone usage. The subcommittee

management of overdoses to emergency responders. With a mere

aims to develop a training product that meets the needs of diverse

three minutes to save a brain deprived of oxygen, few can afford to

learners and learning environments, limits the need for in-person

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CONT. HEALTH SYSTEMS 1.

The STOP-IT initiative is readily underway. Commencing its first

2. training requirements and is adaptable to changing trends in the

subcommittee meetings this past May, the team holds to a robust

drug market. Social influencers will be integrated to help sell

deadline of December 31st. STOP-IT meetings are held monthly

important points.

and are open to the public. With less than six months left ahead of

3. Policy Subcommittee: This subcommittee will review the current

them, the more than fifty members donating their time and energy

school district policies on opioid overdose management and

to this life-saving project are to be commended. This undertaking

compare to those developed in other states as well as policies

represents the first of its kind in the nation and holds the potential

written for other medical disorders. Their goal is to create

to be reproduced in other states. With careful attention to ensure

standardized school district policy language able to be adapted

each intervention is paired with trackable outcomes, the value of

across the state. The group will also correct gaps in the

this project will ultimately prove self-evident.

‘Emergency Guidelines for Schools’ documents and evaluate the necessity of legislation in these activities.

It’s time we end the generational impact of the opioid epidemic.

4. Opioid Antagonist Procurement Subcommittee: This subcommittee

Equipped with the right tools and knowledge, our youth can make

will address existing barriers to opioid antagonist procurement and

the wise decisions that will save their lives and release the cartel’s

develop long-term supply chain solutions to ensure adequate

grip on their future. The STOP-IT initiative is a clear call to action

district, staff and student access.

for Arizona communities to work together to solve this crisis. After all, if we don’t STOP-IT, who will?

References 1.Cheri Oz. More than half of the fentanyl pills seized by the DEA came through Arizona. Here’s why. KJZZ New Report. June 10th, 2024. https://www.kjzz.org/news/2024-06-10/more-than-half-thefentanyl-pills-seized-by-the-dea-came-through-arizona-heres-why 2.Year in Review: DEA innovates to fight fentanyl. https://www.dea.gov/press-releases/2024/01/18/yearreview-dea-innovates-fight-fentanyl.January 18, 2024.

3. Justice Department Announces Charges Against Sinaloa’s Cartel’s Global Operations. https://www.justice.gov/opa/pr/justicedepartment-announces-charges-against-sinaloa-cartel-s-globaloperation. April 14, 2023.

4.DEA.org. Share One Pill Can Kill Materials. https://www.dea.gov/onepill. Accessed June 22, 2024.

5.U.S. Overdose Deaths Decrease in 2023, First Time Since 2018. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2 024/20240515.htm. May 15, 2024.

6.Arizona Department of Health Services. https://www.azdhs.gov/opioid/dashboards/index.php#nonfataloverdoses. Accessed June 22, 2024.

7.Fowler, Merilee. Arizona Child Fatality Review Program.

Interviewed December, 2023.

8.Friedman, et al. The Overdose Crisis among U.S. Adolescents.

N Engl J Med 2024;390:97-100. January 26, 2024.

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EDITORIAL PRECEPTOR CORNER

What's Your Why? AUTHORS/CONTRIBUTORS

Janet Cooley, PharmD, BCACP Director of Experiential Education, Department of Pharmacy Practice and Science, R. Ken Coit College of Pharmacy, University of Arizona Lindsay E. Davis, PharmD, BCPS, BCCP, ASH-CHC, TTS, FAzPA, FCCP, Medical Science Liaison, Pfizer Suzanne Larson, PharmD, Director of Experiential Education, Department of Pharmacy Practice, Midwestern University College of Pharmacy

"Reflecting on our own professional upbringing can cause our minds to shift from the present to the future. What are our current opportunities to share these qualities with others? How are we paying it forward to the next generation of pharmacy professionals?"

Erin Raney, PharmD, BCPS, BC-ADM, FCCP, Professor of Pharmacy Practice, Midwestern University DISCLOSURE The author(s) declare no real or potential conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honorarium.

FUNDING No funding was provided.

ACKNOWLEDGEMENT The author gratefully acknowledges all pharmacy practice preceptors dedicated to providing high quality learning experiences.

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CONT. PRECEPTOR CORNER Reflection

Linking the initial questions posed in this article with the Golden

Think for a moment about someone who has positively impacted your

Circle structure, we can reflect upon how connected we currently are

professional upbringing. Who are some of the individuals that come to

to our “WHY.” We may ask ourselves questions such as, Why am I a

mind? Perhaps you think of an influential professor, a passionate

pharmacist? Why was I inspired to go into this profession? Why am I

preceptor, a family member who fiercely believed in you, or a manager

a preceptor? A manager? Why am I involved in the professional

who saw your potential. What was the impact of those people on your

organizations that I’m involved in?

professional growth? What attributes do those individuals possess?

How have those attributes molded the type of pharmacist, preceptor,

Dr. Joseph S. Alpert, Cardiologist and Professor of Medicine at the

mentor, and leader that you are striving to become?

University of Arizona and Editor-in-Chief for the American Journal of Medicine recently wrote a commentary titled: “The Meaning of Life:

Reflecting on our own professional upbringing can cause our minds to

To Serve Others” opining on this very topic.³ He shared his reflective

shift from the present to the future. What are our current opportunities

process stating “I spent a long time asking myself what my true north

to share these qualities with others? How are we paying it forward to

was, and how had this given my life meaning. I decided that my true

the next generation of pharmacy professionals? As we answer these

north evolved as my life progressed.” He goes on to share “Now in

questions, we may find ourselves listing examples of volunteerism,

the final decades of life, I wondered whether my true north had

precepting, and role-modeling. But do we fully understand the “WHY”

changed and, if so, where was north now? Immediately, the thought

behind these actions?

came to me: I want to continue to serve and to be useful to others including members of my family, my patients, my students and

The Golden Circle

trainees, my colleagues, my institution, and my community. Once

Popularized in Simon Sinek’s viral TEDx Talk from 2009 based upon

again, others must judge whether I will have been successful in

his book “Start with Why,” the Golden Circle visually describes that the

achieving this final quest for service.”

success of our endeavors, personal and professional, begins first with a strong understanding of “Why” we do what we do.¹‚² This naturally

As you consider your “WHY,” you may be inspired by pharmacist

flows to the “How”, and ends with the “What,” depicted as a series of

colleagues who responded to our call for examples of why individuals

three concentric circles (Figure 1). Although the most effective

serve as healthcare preceptors. The responses we collected from

communication emanates outwardly from an individual or an

colleagues are represented in a 3-minute video montage viewable on

institution’s “WHY” and connects people on a fundamental level

YouTube. What’s Your "Why"? The Habits of Preceptors Project -

grounded in beliefs, values, and emotions, our attention is more

May 2024 (3 min) (youtube.com)

commonly fixated on the “What,” limiting the potential impact of what is most important to us.

The Habits of Preceptors

Figure 1: The Golden Circle ¹‚²

Discovering and building upon our “WHY” is at the heart of the Habits of Preceptors Project, created to improve healthcare by cultivating the growth of clinician educators. It represents a passion project born out of a collaboration of like-minded individuals who sought a way to articulate habits of effective pharmacy preceptors, benchmark their level of skill acquirement, and provide a clear picture of growth as one advances along their precepting journey. The Golden Circle of the Habits of Preceptors Project is displayed in Figure 2.

The Habits of Preceptors (HOP) website, www.habitsofpreceptors.org, is based upon the HOP Framework of 11 preceptor habits encompassed within three domains: clinician educator is a practice role model, clinician educator is an effective educator, and clinician educator provides high-quality assessment of learners.⁴ Full access to the website requires free registration.

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CONT. PRECEPTOR CORNER Figure 2. The Habits of Preceptors Project Golden Circle.

The suite of tools is designed to guide you through a personalized

• Accurate self-assessment is enhanced when information from

journey (Figure 3) of growth and development grounded in your

multiple perspectives is included. Key stakeholders in precepting

“WHY.” Examples of some of these tools are described below:

include learners, mentors, co-preceptors, colleagues, trainee/site coordinators, and patients who receive care

• The Habits of Preceptors Questionnaire (HOP-Q) enables you to

delivered by learner: preceptor teams. For this reason, the

self-assess your precepting capabilities within each of the 11

External Review process was created to allow you to request

habits and indicates your performance level as Newly Developing,

specific feedback from trusted individuals on elements of your

Developing, Proficient, Accomplished, and Master.

precepting capabilities.

• Based on the results of the HOP-Q, you are prompted to identify a

habit of focus and craft a SMART goal aligned with your chosen

Conclusion

habit. The platform provides space for goal setting, reflections, and

We hope that as you reflect on your current and potential

revisiting your identified goal.

opportunities to help guide the next generation of pharmacy

• The Preceptor Resources portion of the website encourages you

professionals, you are inspired to activate your “WHY” by

to engage with a variety of resources curated by the HOP Forum

engaging with the Habits of Preceptors Project at

members that specifically aligns with your habit of focus.

www.habitsofpreceptors.org.

Resources can be searched by type (e.g., video, podcast, journal article), habit, cost (freely accessible, may require membership/payment), and estimated completion time. For example, if you are seeking resources to help support the acquisition of Habit 3.1 focused on optimizing learner feedback, you can easily find freely available podcasts on effective feedback principles that are less than 30 minutes in length.

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CONT. PRECEPTOR CORNER Figure 3. Creating a Personalized HOP Journey.

References 1. Sinek S. How great leaders inspire action [TEDx Talk].

TEDxPuget Sound; 2009. Simon Sinek: How great leaders inspire action | TED Talk Accessed 2024 May 24.

2. Sinek S. Start with why: How great leaders inspire everyone to take action. London: Penguin Books; 2009.

3. Alpert JS. The Meaning of Life: To Serve Others. Am J Med. 2023 Oct;136(10):949-950. doi: 10.1016/j.amjmed.2022.11.006.

PMID: 36473501.

4. Habits of Preceptors Project [Internet]. www.habitsofpreceptors.org. Accessed 2024 May 24.

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EDITORIAL FALL CONFERENCE

REGISTER

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EDITORIAL ANNUAL CONVENTION

Thank You for Attending!

36 CE Sessions 292 Attendees 42 Sponsors & Exhibitors 29 Award Winners 16 Pharmacy Leaders - Reverse Exhibit Hall

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EDITORIAL ANNUAL CONVENTION

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COVER STORY 2024 AWARD WINNERS

Elias Schlossberg Denise Erickson Bowl of Hygeia Jacqueline Campbell

CONGRATULATIONS TO OUR 2024 AWARD RECIPIENTS!

Pharmacy Appreciation Nancy Alvarez Melinda Burnworth Jacqueline Campbell Brenna Darling Chandima Deegala Chris Edwards Ivan Gong Raman Kaur Kimberly Langley Tincy Maroor Erin Raney Valerie Richards Jacob Schwarz Thalia Vega Katherine Vodovoz Corporate Appreciation Boesen & Snow Law Incoming President Award Jacob Schwarz NCPA Pharmacy Leadership Kimberly Langley

WELCOME TO THE 2024-2025 BOARD OF DIRECTORS! OFFICERS President: Jacob Schwarz President-Elect: Jaime von Glahn Past President: Kimberly Langley Treasurer: Ryan Gries Secretary: Brandy DeChellis CEO: Vacant DIRECTORS AT LARGE Community Pharmacy: Brianne Spaeth Health System Pharmacy: Mary Manning Technician: Melinda Browning Director at Large: Misty Brannon Director at Large: Reasol Chino Director at Large: Danielle Gilliam Director at Large: Joseph Pellerito Director at Large: Yousef Toma

Distinguished Young Pharmacist Mohanad Znbaqa Excellence in Innovation Tincy Maroor Exemplary Patient Care Linda Williams Student of the Year Mikayla Gerdes Technician of the Year Nick Ruiz Pharmacist of the Year Sophia Galloway Pharmaceutical Associates of the Year Lindsay Davis Angela Feldman Legacy Interns Marlen Cherop Celine Evbuomwan Ivan Gong Leah Rios Maria Sarwar Christina Yamada Sepideh Zakikhani Hall of Fame Matthew Bertsch Mark Boesen Melinda Browning Vanthida Huang Stephanie Spark

LIAISONS University of Arizona Student Chapter: Nguyen Pham Dean’s Designated Representative: Nancy Alvarez Midwestern University Student Chapter: Cheleen An Dean’s Designated Representative: Michael Dietrich Creighton University Student Chapter: Sahar Toluee Dean’s Designated Representative: Jane Stein Legal Counsel Roger Morris

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CONTINUING EDUCATION

Preventing the Unseen Risk:

Pharmacist Learning Objectives: 1. Explain the pathophysiological mechanisms underlying venous thromboembolism (VTE), specifically in hip and knee arthroplasty patients 2. Identify risk factors that contribute to increased VTE risk, specifically in hip and knee arthroplasty patients 3. Summarize different approaches for VTE prophylaxis, including both pharmacological and mechanical methods.

4. Explain current clinical practice guideline for VTE prophylaxis in the setting of hip and knee arthroplasty.

A Review of Venous Thromboembolism Prophylaxis in Hip and Knee Arthroplasty AUTHORS/CONTRIBUTORS

Jake Cormier, PharmD, PGY1 Acute Care Pharmacy Resident, Banner Boswell Medical Center, Arizona Nicole Tinta, PharmD, BCPS, Oncology Clinical Specialist Pharmacist, Department of Pharmacy, Banner Boswell Medical Center, Arizona FUNDING - This research was not funded DISCLOSURES - The authors have no relevant financial relationship to disclose CONTINUING EDUCATION INFORMATION Target Audience: Pharmacists Activity Type: Knowledge

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CONT. CONTINUING EDUCATION Introduction Venous thromboembolism (VTE) is a critical and significant postoperative complication that can commonly follow total hip replacement (THR) and total knee replacement (TKR). VTE can be defined as either a deep vein thrombosis (DVT), where clots form in deep veins, or as a pulmonary embolism (PE), when clots are found in the lungs. It is estimated that by the year 2030 there will be about 2.7 million total hip and knee arthroplasty procedures performed in the United States annually.¹ In patients who undergo these procedures some studies have estimated that 1.19% will have a development of a VTE.² This underscores an increasing health concern due to possible long-term complications of VTE that can include post-thrombotic syndrome and chronic pulmonary hypertension.³ Furthermore, it can lead to an increase in mortality, morbidity, and burden on the healthcare system.

Effective VTE prophylaxis strategies are paramount to improve patient outcomes and reduce healthcare costs associated with this complication. This paper aims to review current guidelines and clinical evidence in VTE prophylaxis following total hip and knee arthroplasty, including pharmacological and mechanical methods, patient-specific risk factors, and emerging trends in prophylaxis.

Pathophysiology The pathophysiological mechanisms of VTE in the setting of total hip and knee arthroplasty are multifaceted and can include genetic, environmental, and procedural factors that predispose patients to thrombus formation. Increased risk of VTE after total hip and knee arthroplasty stems from Virchow’s triad; venous stasis, endothelial injury, and hypercoagulability.⁴‚⁵

Figure 1: Virchow’s triad

Venous Stasis⁵ For patients undergoing total hip and knee arthroplasty, decreased mobility during surgery and recovery causes venous stagnation. Additionally, there is a lack of contraction and relaxation of muscles that impedes blood flow during surgery, thus creating an environment favorable for clot formation.

Endothelial Injury⁵ Surgical trauma to the endothelium results in a chain of events that can lead up to clot formation. During surgical procedures, damage to the endothelial cells exposes underlying collagen and tissue factor which then trigger the coagulation cascade. Activation of the coagulation cascade combined with the release of proinflammatory cytokines increases VTE risk.

Hypercoagulability⁵ Surgery itself can lead to a hypercoagulable state where there is increased production of clotting factors while natural anticoagulant levels fall simultaneously. Other risk factors like patient’s age, hormonal therapies, cancer, and genetic predispositions can increase the risk for developing a thrombus. Increased activity in the blood coagulation processes with decreased fibrinolytic activity after surgery contribute to the hypercoagulability state of patients who undergo total hip and knee arthroplasty.

Risk Factors Individual patient risk factors also play a role in the development of VTE after total hip and knee arthroplasty.

One systematic review conducted on risk factors for VTE of total join arthroplasty examined potential risk factors in a population of more than one million patients over the course of 10 years.⁶ It was reported that factors such as age greater than 70 years, female gender, body mass index (BMI) greater than 30, and a surgery time greater than two hours were associated with increased risk of VTE after THA and TKA.⁶ Pharmacological Prophylaxis The landscape of venous thromboembolism (VTE) prophylaxis in hip and knee arthroplasty over the last few decades continues to be shaped using various anticoagulant and antiplatelet agents. Each pharmacological agent offers a different mechanism to affect different parts of the clotting cascade to inhibit clot formation. Some of the most commonly used chemoprophylactic agents are vitamin K antagonists, low molecular weight heparin (LMWH), aspirin, and factor Xa inhibitors.⁷

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CONT. CONTINUING EDUCATION Vitamin K Antagonists⁷ Warfarin is a traditional oral anticoagulant that works by inhibiting the synthesis of vitamin K-dependent clotting factors (II, VII, IX, X). Specifically, this occurs by preventing vitamin K from being metabolized into its active form which is needed to produce the clotting factors. Dosing is often highly individualized and targeted towards a goal international normalized ratio (INR) of 2.0 to 3.0 for patients for VTE. Due to the high risk of VTE after THR or TKR, it is recommended to bridge warfarin with LMWH or unfractionated heparin until INR is therapeutic.⁸ LMWH⁷ Low molecular weight heparin, such as enoxaparin, are derivatives of heparin that is naturally produced in the body by our anti-inflammatory cells. LMWH works by binding indirectly to factor Xa and causing a conformational change that will inhibit the conversion of prothrombin to thrombin. The dosing for VTE prophylaxis is typically 40 mg subcutaneous (SUBQ) once daily, however, this can differ depending on patient specific factors such as BMI and renal function.

Factor Xa Inhibitors⁷ Factor Xa inhibitors can bind both indirectly and directly to factor Xa depending on the individual agent. Common oral direct anticoagulants (DOACs) for factor Xa are apixaban and rivaroxaban. Unlike LMWH, these agents bind directly to factor Xa, which then inhibits clot formation by binding to antithrombin. The recommended dosing for VTE prophylaxis is apixaban is 2.5 mg oral twice daily and rivaroxaban 10 mg oral once daily. Apixaban requires no dosage adjustment for renal function. Rivaroxaban should be avoided in patients with a creatine clearance less than 30 mL/minute. Routine coagulation testing is not needed to monitor therapy.

Aspirin⁷ Aspirin (ASA) is the only pharmacological agent discussed here that does not work directly on the coagulation cascade.

Instead, aspirin is an antiplatelet agent that works by binding to and acetylating cyclooxygenase-1 or cyclooxygenase-2 irreversibly. This inactivates the enzyme that is needed for platelets to aggregate and form clots. Due to it binding irreversibly, the effects last the entire lifetime of the platelet, which is about 7 to 10 days. There has been a variety of different dosing strategies when used for VTE prophylaxis after total hip or total knee arthroplasty. Dosing can range from 81 mg oral once daily to 325 mg oral twice daily.⁹

Guidelines There are a variety of different guideline recommendations for VTE prophylaxis following total hip and knee replacement.

However, some of these are becoming outdated with more recent data from clinical trials and meta-analyses over the last couple years. Recommendations also tend to differ in terms of the preferred pharmacological agent to be used for VTE chemoprophylaxis. Although there is no clear consensus on choice of agent and duration, all the guidelines agree that VTE prophylaxis is needed in this patient population.¹⁰ American Society of Hematology 2019 The American Society of Hematology (ASH) 2019 guidelines for the management of VTE provide recommendations for the prevention of VTE in patients undergoing hip or knee surgery.¹¹ For these individuals the panel suggested using aspirin or anticoagulants, DOACs being the preferred anticoagulant over LMWH. If the patient is unable to use a DOAC, it is recommended to use LMWH over warfarin. The ASH guidelines also advocate for the use of mechanical prophylaxis methods, using intermittent compression devices, in addition to pharmacologic prophylaxis.

National Institute for Health and Care Excellence (NICE) 2018¹² The guidelines on "Venous Thromboembolism in Over 16s: Reducing the Risk of Hospital-Acquired Deep Vein Thrombosis or Pulmonary Embolism" published in 2018 offer additional insights on the prevention of postoperative VTE in patients aged 16 and older undergoing total hip or knee surgery. These recommendations were created by the National Institute for Health and Care Excellence based in the United Kingdom. Treatment recommendations are given for both elective hip replacement and elective knee replacement.

For patients undergoing elective hip replacement surgery it is recommended that if VTE risk outweighs risk of bleeding that patients receive chemoprophylaxis. One VTE prophylaxis option is LMWH for 10 days followed by aspirin (75 mg or 150 mg once daily) for an additional 28 days. Another treatment option is LMWH alone for 28 days with compression stockings while admitted. Rivaroxaban can also be used; however, no dose or duration recommendations are provided.

VTE prophylaxis is recommended for patients who are undergoing elective knee replacement whose VTE risk outweighs risk of bleeding. Either aspirin (75 mg or 150 mg once daily) for 14 days, LMWH alone for 14 days with compression stockings until discharge, or rivaroxaban.

American Academy of Orthopedic Surgeons (AAOS) 2012 The AAOS guidelines on preventing VTE in patients undergoing elective hip and knee arthroplasty were published in 2012 with evidence-based recommendations reducing the incidence of postoperative VTE.¹³ They suggest the use of

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CONT. CONTINUING EDUCATION Table 1: Guidelines on preventing VTE Guideline

AAOS 2021

NICE 2018

Pharmacologic prophylaxis recommended

• ·ASA for 14 days • ·LMWH for 14 days • ·Rivaroxaban

ASH 2019

Surgical Procedure

TKA

• ·LMWH for 10 days

THA

Pharmacologic prophylaxis recommended

pharmacologic agents and/or mechanical compressive devices for the prevention of VTE in patients undergoing elective hip or knee arthroplasty if the individual risk of developing a VTE was higher than the risk of bleeding.

However, they were unable to give specific agent recommendations, stating that current evidence is unclear which therapy options are optimal or suboptimal.

Aspirin, LMWH, or DOAC? As mentioned previously, the optimal VTE prophylaxis agent is currently unknown and could be considered an evolving landscape as new studies compare the efficacy and safety of different therapy options. One topic that has gained a lot of attention over the last decade is the use of aspirin versus LMWH. A recent meta-analysis of randomized controlled trials studying VTE prophylaxis after total knee arthroplasty was recently published in 2023.¹⁴ The primary outcome of the study was the total incidence of VTE confirmed from diagnostic imaging. The meta-analysis included a total of six randomized control trials with a total of 6772 patients included for final analysis. Five of the included studies used aspirin 100 mg oral daily, only one used aspirin 325 mg oral daily. For LMWH five of the studies used enoxaparin 40-60 mg SUBQ daily and one study used dalteparin 2500 units SUBQ daily. Duration of treatment was either 14 or 30 days.

The overall pooled data showed a statistically significant increased risk of VTE in those receiving aspirin compared to LMWH with a reported relative risk of 1.45 (95% CI: 1.16 to 1.84). There was no difference found in

followed by ASA for 28 days • ·LMWH for 28 days • Rivaroxaban

• ·ASA for greater than 3 weeks • ·Anticoagulants • (DOACs preferred over LMWH) for

greater than 3 weeks

• ·ASA greater than 3 weeks • ·Anticoagulants • (DOACs preferred over LMWH) for

greater than 3 weeks

bleeding complication rates between groups. A strength of this study is including recent large-scale randomized controlled trials, which helps improve the reliability of the findings on the effectiveness and safety of aspirin versus LMWH for VTE prophylaxis after TKA. A limitation is that the participants were not blinded to treatment groups, which introduces potential bias. In conclusion, this meta-analysis found that aspirin had a higher risk of VTE when compared to the use of LMWH in patients undergoing TKA. Another meta-analysis that was recently published in January 2024 looked at antithrombotic prophylaxis following total hip arthroplasty.¹⁵ This was a Bayesian network meta-analysis that included data from 14 randomized controlled trials with a total of 31,705 patients. The objectives were rates of DVT, PE, and hemorrhage. It was found that apixaban 2.5 mg oral twice daily, fondaparinux 2.5 mg SUBQ daily, and rivaroxaban 30 mg oral twice daily were the most effective in reducing the rates of DVT.¹⁵ Rivaroxaban 30 mg twice daily was only used in one article that evaluated the dose-response relationship with rivaroxaban and VTE prophylaxis in THR.¹⁶ However, major bleeding incidence increased dose dependently. It is important to note that rivaroxaban 30 mg twice daily is not used in clinical practice. Dabigatran 220 mg oral daily, apixaban 2.5 mg oral twice daily, and aspirin 100 mg oral daily were more effective in reducing rates of PE.15 Apixaban 2.5 mg oral twice daily and aspirin 100 mg oral daily had the lowest rate of major hemorrhage.¹⁵ A strength of this study is the systematic

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CONT. CONTINUING EDUCATION approach and incorporating a Bayesian network meta-analysis of multiple treatment options. This approach allowed for an effective comparison across different antithrombic regimens. A limitation is that the study included only randomized controlled trials, which may not represent everyday clinical practice and limit its external validity. In conclusion, apixaban 2.5 mg oral twice daily is the most effective at preventing VTE while carrying a low risk of hemorrhage.

Conclusion Prevention and proper management of VTE in total hip and total knee arthroplasty patients is extremely important and plays a crucial role in reduction of perioperative complication. Additionally, it helps reduce postoperative readmission and medical burdens to the healthcare system. This article illuminates the complex pathophysiology of VTE including the three essential factors of the clotting triad, venous stasis, endothelial injury, and hypercoagulability. Patient specific factors such as age, gender, BMI, and prolonged surgery, all play important roles in the process as well. Collectively, this information emphasizes the need for patient-tailored prophylaxis, including combined pharmacologic and mechanical methods. Vitamin K antagonists, LMWH, factor Xa inhibitors, and aspirin represent a range of pharmacologic options for preventing VTEs. Each agent has a unique mechanism of action and side effect profile. A balance is thus found between efficacy in clot prevention and bleeding risk in order to individualize care for patient specific risk factors. Recent meta-analyses provide critical insight into the relative effectiveness of different prophylactic agents. The recent literature is pointing towards LMWH over aspirin in reducing VTE risk post TKR. However, agents such as apixaban and rivaroxaban have also shown to be effective. Ultimately, in order to prevent VTE in patients who receive total hip and knee arthroplasty, there needs to be a personalized approach based on patient individual risk factors to provide optimal patient outcomes.

References 1. Singh JA, Yu S, Chen L, Cleveland JD. Rates of Total Joint Replacement in the United States: Future Projections to 2020–2040 Using the National Inpatient Sample. The Journal of Rheumatology. 2019;46(9):1134-1140. doi:10.3899/jrheum.170990 2. Simon SJ, Patell R, Zwicker JI, Kazi DS, Hollenbeck BL. Venous Thromboembolism in Total Hip and Total Knee Arthroplasty. JAMA Network Open. 2023;6(12):e2345883. doi:10.1001/jamanetworkopen.2023.45883 3. Lutsey PL, Zakai NA. Epidemiology and prevention of venous thromboembolism. Nat Rev Cardiol. 2023;20(4):248-262. doi:10.1038/s41569-022-00787-6 4. Fisher WD. Impact of venous thromboembolism on clinical management and therapy after hip and knee arthroplasty. Can J Surg. 2011;54(5):344-351. doi:10.1503/cjs.007310 5. Santana, D. C., Emara, A. K., Orr, M. N., Klika, A. K., Higuera, C. A., Krebs, V. E., Molloy, R. M., & Piuzzi, N. S. (2020). An Update on Venous Thromboembolism Rates and Prophylaxis in Hip and Knee Arthroplasty in 2020. Medicina (Kaunas, Lithuania), 56(9), 416. https://doi.org/10.3390/medicina56090416 6. Zhang Z hao, Shen B, Yang J, Zhou Z ke, Kang P de, Pei F xing. Risk factors for venous thromboembolism of total hip arthroplasty and total knee arthroplasty: a systematic review of evidences in ten years. BMC Musculoskeletal Disorders. 2015;16. doi:10.1186/s12891-015-0470-0 7. Etscheidt J, Shahien A, Gainey M, et al. Review of Therapeutic Options for the Prevention of VTE in Total Joint Arthroplasty. Geriatrics. 2020;5(1). doi:10.3390/geriatrics5010018 8. Baser O, Supina D, Sengupta N, Wang L. Anticoagulation Bridging Therapy Patterns in Patients Undergoing Total Hip or Total Knee Replacement in a US Health Plan: Real-World Observations and Implications. Am Health Drug Benefits. 2011;4(4):240-248 9. Shafiei, S. H., Rastegar, M., Mirghaderi, P., Siavashi, B., & Mortazavi, S. M. J. (2023).

Comparison of low-dose (162 mg) and high-dose (650 mg) Aspirin prophylaxis following total joint arthroplasty: a prospective cohort study. Annals of medicine and surgery (2012), 85(5), 1461–1467. https://doi.org/10.1097/MS9.0000000000000366 10. Muscatelli SR, Charters MA, Hallstrom BR. Time for an Update? A Look at Current Guidelines for Venous Thromboembolism Prophylaxis After Hip and Knee Arthroplasty and Hip Fracture. Arthroplast Today. 2021;10:105-107. Published 2021 Jul 15. doi:10.1016/j.artd.2021.06.015 11. Anderson DR, Morgano GP, Bennett C, et al. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Advances. 2019;3(23):3898-3944. doi:10.1182/bloodadvances.2019000975 12. Overview | Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism | Guidance | NICE. Published March 21, 2018. Accessed March 29, 2024. https://www.nice.org.uk/guidance/ng89 13. Mont MA, Jacobs JJ. AAOS clinical practice guideline: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg.

2011;19(12):777-778. doi:10.5435/00124635-201112000-00008 14. Meng J, Liu W, Xiao Y, Tang H, Wu Y, Gao S. The role of aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis after total knee arthroplasty: a meta-analysis of randomized controlled trials. Int J Surg. 2023;109(11):3648-3655. Published 2023 Nov 1. doi:10.1097/JS9.0000000000000656 15. Migliorini F, Maffulli N, Velaj E, et al. Antithrombotic prophylaxis following total hip arthroplasty: a level I Bayesian network meta-analysis. J Orthop Traumatol. 2024;25(1):1. Published 2024 Jan 9. doi:10.1186/s10195-023-00742-2 16. Eriksson, B. I., Borris, L. C., Dahl, O. E., Haas, S., Huisman, M. V., Kakkar, A. K., Misselwitz, F., Muehlhofer, E., & Kälebo, P. (2007). Dose-escalation study of rivaroxaban (BAY 59-7939)--an oral, direct Factor Xa inhibitor--for the prevention of venous thromboembolism in patients undergoing total hip replacement. Thrombosis research, 120(5), 685–693. https://doi.org/10.1016/j.thromres.2006.12.025

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Continuing Education Assessment 1.Which of the following is a key component of Virchow's triad as discussed in the context of VTE in hip and knee arthroplasty?

A) Arterial stiffness B) Bacterial Infection C) Myocardial Infarction D) Venous stasis 2.What is the recommended dosing of apixaban for VTE prophylaxis in patients undergoing hip or knee arthroplasty?

A) 5 mg oral twice daily B) 2.5 mg oral twice daily C) 10 mg oral once daily D) 40 mg subcutaneous once daily

AZPA CONTINUING EDUCATION 4. True or False: Venous thromboembolism (VTE) in hip and knee arthroplasty patients is primarily caused by factors outside of Virchow's triad, such as bacterial infections and arterial stiffness.

5. True or False: According to the 2019 guidelines from the American Society of Hematology (ASH), aspirin is one of the recommended treatment options for VTE prophylaxis in patients undergoing hip or knee surgery.

3.The 2019 guidelines from the American Society of Hematology (ASH) recommend which of the following for VTE prophylaxis in patients undergoing hip or knee surgery?

A) Aspirin or direct oral anticoagulant (DOAC) B) Warfarin over aspirin C) Unfractionated heparin over DOACs D) Mechanical methods alone

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EDITORIAL UNIVERSITY & ALUMNI

Rick G. Schnellmann, PhD Dean, University of Arizona College of Pharmacy

Nano-scale ionic liquids prove key to drug repurposing UArizona scientist develops novel therapies for infectious diseases The drug delivery mission An Assistant Professor of Pharmaceutical Sciences at the R. Ken Coit College of Pharmacy and Director of its Drug Preformulation, Repurposing and Delivery (D-PReD) laboratory, Abhijit Date, PhD, is on a mission .

“Since as long as I can remember, all I've been thinking about is pharmaceutical sciences, drug delivery, and how we can really make drugs better, safer,” he said.

From his drug delivery studies as an undergraduate to predoc in Mumbai, India, to his work on treatments for infectious diseases in his postdoc and faculty appointments across the United States, Date’s work in the pharmaceutical sciences has focused on bringing vital, effective, accessible and appropriate treatment to those in need.

“The issue is that with such diseases, the drug discovery efforts are fairly limited,” said Date, “so what we are left with is reimagining the tools that are currently there.”

So, scientists like Date must repurpose known drugs, adjusting their form and delivery to create viable treatments for diseases that do not benefit from new drug discovery research.

From a translational perspective, Date emphasized that ease of scalability also impacts drug development and affordability. Keeping this in mind, any reformulation he works on uses readily available components.

Nano-scale ionic liquids

First drawn to the field through an interest in chemistry, Date credits his undergraduate and graduate research mentors Mrs. Sulabha Phadnis, Vandana Patravale, PhD, and Mangal Nagarsenker, PhD, for creating an engaging learning experience, increasing his awareness of drug chemistry, human physiology, disease pathology and other elements related to pharmaceutical science.

Understanding of each of these, Date says, is key to developing effective drugs with appropriate delivery mechanisms.

With an extensive background in drug development and delivery, Date’s recent research has earned him the Coit College of Pharmacy’s A. Jay Gandolfi New Investigator Award in December 2023. Honored to receive the award, Date attributes the nomination to his work on repurposing drugs using nano-scale ionic liquids.

“University of Arizona,” he said, “provided excellent opportunities, facilities, and fantastic support to be able to expand further on the research that I was doing.”

Why repurpose drugs?

Research into anti-infective agents, particularly antibacterial and antifungal agents, Date said, is slow when compared to research into cancer treatment or certain antivirals. Companies invest less in drug development in these areas because it is considered less profitable.

Abhijit Date, PhD

Date’s recent reformulations and their scalability are made possible through technology he has patented since beginning his appointment at UArizona.

Ionic liquid is a delivery technology that allows Date to modify the physicochemical properties of drugs – including highly hydrophobic or highly hydrophilic ones, which are the most challenging to deliver – reformulating them to have better solubility, permeability and bioavailability. Combined, this allows for more effective treatments with fewer side effects, since these improvements help target the affected areas, with a minimal dose.

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CONT. UNIVERSITY & ALUMNI Ionic liquid technology can be applied to various drugs, allowing Date to utilize these liquids in multiple repurposing efforts – often in combination with nanoparticles.

Because nanoparticles are so small, they have excellent translocation capabilities, allowing them to move across barriers like tissue or cell membranes. Despite their size, when correctly engineered, these nanoparticles can contain a large quantity of the drug – or drug converted into ionic liquids – inside them and even prolong its release, allowing for fewer doses.

Key repurposing efforts At UArizona, Date is working on repurposing and delivery of drugs targeting two main viral infections – herpes simplex virus (HSV) and human immunodeficiency viruses (HIV) – and cryptococcal meningitis, a fungal infection caused by Cryptococcus neoformans.

Ocular HSV In 2022, Date began work as a co-PI on a five-year, translational research grant, awarded by the National Eye Institute, that funds research into a novel treatment of ocular HSV infections, which are a leading cause of infectious disease-related blindness. Since the current treatment involves taking eye drops five to nine times a day, patients are greatly in need of improved delivery.

Together with the PI on the grant, Deepak Shukla, PhD, with the University of Illinois, Chicago, Date has been leading the repurposing and reformulation of an FDAapproved low-cost drug, phenylbutyric acid sodium, to treat ocular HSV infection.

“We have excellent data now,” Date said. “This drug and its reformulated version are really excellent in terms of efficacy.”

If all goes well, Date said, they may be able to file an Investigational New Drug (IND) application in a few years.

If approved, they could begin human clinical trials.

In a separate project focused on the mission of developing once-daily antiviral eye drops for ocular herpes therapy, Date, in collaboration with Shukla, has been able to create a nano-scale ionic liquid of antiviral drug that reveals excellent therapeutic outcomes in mouse models.

Cryptococcal meningitis On another project in collaboration with Kirsten Nielsen, PhD, with the University of Minnesota, and Qing-Yu Zhang, PhD, at UArizona, Date works to repurpose a class of deworming agents, called anthelmintic benzimidazoles, to treat a fungal infection caused

by Cryptococcus neoformans.

For the immunocompetent (those whose immune system is not compromised) this fungus is typically not detrimental, says Date. However, when people are

immunocompromised because of HIV infection, a recent organ transplant or other factors, these fungi can cause issues with the lungs before invading the brain and causing cryptococcal meningitis – a life-threatening condition with a high mortality rate across the globe.

Current treatments for cryptococcal meningitis are few, are highly cost prohibitive and have many side effects.

Because most of the readily available deworming agents are intended for local action in the gut rather than translocation to the brain, Date has again utilized nanoscale ionic liquid technology to reformulate them.

“We have succeeded already,” said Date.

In mouse models, the fungi are so invasive that within 20 days, there is a 100% fatality rate in the untreated mice, Date said. When a particular benzimidazole is administered orally that rate declines to about 50%.

“But if we convert this drug into this delivery technology called ‘ionic liquids,’ coupled with nanoparticles, we don’t have any mortality in the infected animals even after 75 days with good safety and low or no traces of fungi in the brain,” Date said. “So this is a very, very remarkable data and we have already filed another provisional patent on this data.”

HIV In his third recent endeavor, Date has utilized this same nano-scale ionic liquid to develop more targeted anti-HIV drugs.

A widespread disease, HIV is an immunocompromising disorder that currently requires a lifetime of treatment to mitigate the effects of the illness, but never fully eradicate it.

“Any discontinuation can actually lead to the rebound of the virus,” Date said, “because even though on the drug therapy, you are able to get the virus below the detectable level in your blood or in your plasma, the other sites – such as brain, or such as lymph nodes, or gut, or spleen or genital tract – they will still harbor the virus in its latent form and act as sanctuary sites for HIV. And the drugs actually are not able to adequately penetrate these sites.”

Date explains that while he had taken a break from research into HIV treatments, he has been able to renew his efforts due to the recent grant from the National Institute of Infectious Diseases, the breakthroughs in the patented ionic liquids technology and the institutional support he receives from the University of Arizona.

With these in place, Date said he has good, early data to indicate his reformulated drugs will penetrate the sanctuary sites more efficiently than the currently available formulations of anti-HIV drugs.

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EDITORIAL UNIVERSITY & ALUMNI continued from page 25 Patient-centric research As a pharmaceutical sciences researcher who also teaches pharmacy students in the clinical track, Date emphasizes that the two are interconnected – and the main goal of each is to deliver better patient care.

For pharmacists, this takes the form of direct patient interaction, personalizing patient therapies and calculating doses. While in work like Date’s in the pharmaceutical sciences, the aim of the research is to develop better therapies and technologies for patients.

“That,” said Date, “really is the ultimate goal.”

Written by Rachel Richardson.

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EDITORIAL UNIVERSITY & ALUMNI

Midwestern University College of Pharmacy Mitchell R. Emerson, PhD Dean, Midwestern University College of Pharmacy

Greetings from the College of Pharmacy at Midwestern University!

Greetings from the College of Pharmacy at Midwestern University. As we get ready to welcome summer, we are reminded of the many accomplishments of our faculty, staff, students, alumni, and friends. As always, we want to highlight and celebrate all our milestones.

Campus life has been busy with the Class of 2024 Graduation ceremony on Thursday, May 30th. The final day of rotations was May 10th and we hosted the class for an Awards Ceremony and BBQ. Graduation is scheduled on May 30th at 12pm with a festive reception following the ceremony. All are welcome to celebrate the Class of 2024.

The Class of 2024 will assume a tremendous variety of roles in their careers from community opportunities to residency and fellowship pursuits. The Class of 2024 had the highest percentage of the class match into a residency program to start their career! We wish all our graduates the best of luck as they pursue their pharmaceutical dreams all over the nation.

We are excited to get a refresh in Cholla Hall (home to much of the pharmacy program) this summer. We are set to welcome the Class of 2027 to campus for orientation starting May 28th and the first day of class on June 3rd.

There is a full quarter of professional and personal development for the new students as we work with them to become exceptional pharmacists. A highlight of the first quarter is the CPG Alumni and Student Ice Cream Social.

We are finalizing the date and will send out the information to our alumni and preceptors soon!

We are looking forward to catching up with all of you and connecting at a future event. If you’re ever in the Glendale area, please reach out and stop by the campus. So much has changed, but still remains the same welcoming place.

Did you know we have a Midwestern University Job Board? If you’re looking to hire or looking for a new opportunity, please click here for more information https://www.midwestern.edu/alumni/alumnijob-finder.

If you’ve recently moved or relocated, please ensure we have your updated contact information. Please email updates to your Manager of Alumni Relations, Kimberly Hastings at KHastings@midwestern.edu To follow us and learn more about our events and wins, join the MWU Pharmacy social media community: Like us on Facebook: Midwestern University Follow us on Twitter: @MWUpharmacy Follow us on Instagram: @MWUpharmacy

The events continue as we host our annual College of Pharmacy Dessert Reception in conjunction with the annual AzPA conference at the Hilton Phoenix Resort at the Peak.

We hope you will plan to join us on Friday, June 7th on the Fountain Terrace at 7:00pm.

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EDITORIAL UNIVERSITY & ALUMNI

Creighton University College of Pharmacy Jane Stein, PharmD Assistant Professor, Creighton University College of Pharmacy

Health Sciences Students in Phoenix Collaborate for a Stroke Simulation Collaboration in healthcare is essential in ensuring quality patient care, so health sciences students at Creighton receive an interprofessional education.

The Creighton University Health Sciences Campus – Phoenix recently hosted an interprofessional event in its dedicated simulation space. Faculty and staff divided students into groups to run through a stroke simulation with standardized patients. Each group included a student representing one of seven healthcare professions: medicine, nursing, physician assistant, occupational therapy, pharmacy, physical therapy and paramedicine. The students then worked as a team to formulate the patients’ care plans from onset to discharge.

Chelsea Sandidge is the program manager for the Center for Interprofessional Practice, Education and Research (CIPER) at the Phoenix campus, and she believes that the stroke simulation truly captured the meaning of interprofessionalism.

“Every step of this simulation was a testament to collaboration and dedication to teamwork, from the faculty who planned the event to the students who participated.

Together, we’re not just learning—we’re preparing to make a real difference in future patient care,” Sandidge says.

The simulation allowed students to showcase their role in the care of a stroke patient while learning about communication and team-based care. Students were able to better understand how their peers contributed to the care plan, which resonated with pharmacy student Delaney O'Brien.

"The stroke simulation was an extraordinary educational experience. We could see what it takes to treat a patient and how everyone has a part in it. I worked with nursing students, reviewing the medication, doses and times they needed to be dosed and worked with the MD and PA students to make sure the medications were suitable for the patient,” O’Brien says.

Faculty from each of the seven healthcare professions guided students through the simulation and imparted their interprofessional wisdom onto the students. Jane Stein, PharmD, assistant professor of pharmacy, values the event and its interprofessional perspective in practicing healthcare.

“This event allowed pharmacy students to hone their clinical skills within a team environment, improve communication skills within the team, enhance interdisciplinary collaboration for decision making and contribute to the delivery of high-quality care for patients,” Stein says.

An interprofessional education at the Creighton Phoenix campus does not end with events like the interprofessional stroke simulation. Students participate in Interprofessional Education Passport activities and work with students outside of their health profession. The Virginia G. Piper Charitable Trust Health Sciences Building is also home to a 35,000-square-foot interprofessional simulation space, where students practice skills with standardized patients and debrief afterwards.

Through interprofessional training, our faculty and staff prepare the next generation of healthcare professionals to provide team-based, collaborative care.

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Pharmacist-Directed Hormonal Contraception Training The Arizona Pharmacy Association is happy to announce that 2 years after the passage of SB1082 Arizona pharmacists can now dispense Self-Administered Hormonal Contraceptives to women 18 years and older pursuant to the newly adopted ADHS Statewide Standing Order!

Any pharmacist wishing to dispense self-administered hormonal contraceptives pursuant to this statewide Standing Order must be prepared to do the following: Complete a 3-hour Training -AzPA has created one that is compliant with ARS 32-1979.01 and AAC R4-23-407 and R4-23-408-409.

Obtain necessary equipment to measure blood pressure.

Review the Standing Order, Standard Procedures, and Self-Screening Questionnaire.

Establish SOP’s to ensure your pharmacy is compliant with all state laws.

REGISTER NOW 30

EDITORIAL PAAS NATIONAL

Independent Pharmacies are NOT Safe from Cyberattacks Have you ever had your credit card stolen, lost your wallet, or misplaced your social security card? Whether it has happened to you or not, you can imagine the pit of despair that settles in your stomach knowing that one malicious actor is all it takes to create dreadful issues in your life by misusing your information. The compulsion to protect your own credit cards and social security number has likely been engrained into your brain and safeguarding the information is second nature. What may surprise you, is that a valid set of payment card details is only worth a little over $5 on the black market and a social security number is only valued at around $0.50, according to a Trustwave Global Security Report1. What is even more surprising is the value of a health care record – one record goes for around $250. Some comprehensive health care records may even be valued as high as $2,000!

The data clearly shows there is a large financial incentive for malicious actors to target the healthcare sector. The 2022 Annual Report to Congress on Breaches of Unsecured Protected Health Information2 showed 68% of breaches reported to the Office for Civil Rights that affected 500 or more individuals were from health care providers, which supports the fact that all health care providers should be taking action to ensure the safety and security of their protected health information (PHI).

The 2022 Annual Report to Congress also indicated 74% of those breaches were reportedly due to hacking/IT

incidents of electronic equipment or a network server. The compulsion to protect the pharmacy’s electronic PHI (ePHI) needs to be as important to pharmacy personnel as protecting their own credit card information and social security number. The first step in that process is educating staff on cybersecurity. Whether you are the owner or an employee at a high-volume, multi-store pharmacy or a low volume, single-store independent pharmacy, your data is enticing to malicious actors and no pharmacy is safe from cyberattacks.

The IBM Cost of a Data Breach Report 20233 found that a malicious insider accounted for about 6% of the data breaches but was the most costly type of data breach, resulting in an annual cost of around $4.9 million dollars.

Phishing and stolen or compromised credentials had an associated annual cost of $4.76 million and $4.62 million, respectively, but were more prevalent accounting for over 30% of the breach attack vectors. Additionally, only one in three organizations identified a breach using their organization’s own security team or tools—meaning, two out of three organizations had their breaches reported to them by law enforcement or the entity that unlawfully accessed their records (like when a ransom request was received to release their data). It also took an average of over 200 days from the date of the breach to identify that the breach occurred and another 73 days to contain the breach. Most pharmacies will take a full year to recover from a large data breach.

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CONT. PAAS NATIONAL Rather than getting wrapped up in the financial and timeconsuming repercussions of a large breach, be protective.

Cybersecurity training is essential to protecting your business, your reputation, and your ePHI. Having a tailored policy and procedure for protecting ePHI is only as good as the staff that adhere to those policies and procedures. A single careless or negligent employee can be the weak link broken by bad actors and may be the end of the pharmacy’s good reputation…and hard-earned money.

PAAS Tips: • Know the top threats facing healthcare cybersecurity: • Network connected medical device security • Insider accidental, or malicious data loss • Loss or theft of equipment and data • Ransomware • Social engineering • Understand the components, and importance of a HIPAA Security Risk Analysis • Perform and accurate and thorough assessment of the potential risk and vulnerabilities to the confidentiality, integrity, and availability of the pharmacy’s ePHI • Identify and implement reasonable and appropriate physical, technical, and administrative safeguards as required by the HIPAA Security Rule

• Know the terms • Vulnerability – a flaw or weakness in system security

procedures, design, implementation or internal controls • Threat – the potential for a person or thing to exercise a specific vulnerability (natural, human, and environmental) • Risk – a function of the probability that a threat will attack a vulnerability and the resulting impact to the organization • PAAS’ FWA/HIPAA Compliance Program4 provides pharmacies with a HIPAA Risk Analysis and Cybersecurity training

By Trenton Thiede, PharmD, MBA, President at PAAS National®, expert third party audit assistance, FWA/HIPAA and USP 800 compliance.

References: 1. https://www.trustwave.com/hubfs/Web/Library/Documen ts_pdf/D_15350_2018-trustwave-global-security-reportprt.pdf 2. https://www.hhs.gov/sites/default/files/breach-report-tocongress-2022.pdf 3. https://www.ibm.com/account/reg/us-en/signup? formid=urx-52258 4. https://paasnational.com/fwac-hipaa/ Copyright © 2024 PAAS National, LLC. Unauthorized use or distribution prohibited. All use subject to terms at https://paasnational.com/terms-of-use/.

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ADVOCACY LEGISLATIVE UPDATE

Legislative Review The 2024 Arizona State Legislature ended Sine Die the 56th regular legislative session on June 15, 2024, which was the 160th day after lawmakers narrowly passed a $16.1 billion budget filled with sweeps and cuts to state agencies and infrastructure projects. The legislative session was reminiscent of Tombstone, Arizona the “town too tough to die” and Wyatt Earp’s famous shootout at the O.K. Corral! However, outside of this the AzPA legislative team was able to have a productive session.

On Wednesday, March 20, 2024, the annual AzPA Pharmacy Day at the Capitol was held. It was an enormous success! Over one hundred pharmacy professionals (Pharmacists, Pharmacy Technicians and Pharmacy Students) had meetings with forty legislators.

Seventy-five legislators joined AzPA members for lunch and conversation at the Wesley Bolin Plaza across from the Capitol. We had successes and setbacks with legislation.

The following Bills were introduced: i. SB 1085 Test & Treat: AzPA partnered with the Arizona Retailers Association, who introduced the bill. The bill failed to progress! We plan to take ownership of this bill in the next legislative session. ii. SB 1021 Sunrise Repeal: Signed on 04/24/2024; Chapter 75. This success will make it easier for expansion of scope of practice bills in the future. iii. SB 1164 Pharmacy Benefits Coverage; Exemptions: Passed House and awaiting Rules Committee action.

This bill allows for coverage of existing non-formulary medications when a patient joins a new health plan. iv. SB 1165 Pharmacy Audit Procedures; Prohibitions: Signed on 03/29/2024; Chapter 51. This bill will eliminate some penalties and procedures for the pharmacy being audited.

v. Provider Status. AzPA was planning to introduce a pharmacist provider status bill this session. However, Blue Cross Blue Shield of Arizona reached out to AzPA with a unique proposal that would allow pharmacists to be recognized as providers within the BCBSAZ Commercial provider network.

The upcoming legislative year will bring changes and new beginnings. This being an election year there will be fresh players at both the state and federal levels, AzPA will experience a change as Kelly Fine, AzPA Chief Executive Officer (CEO), has left us to assume a new chapter in her life serving as the Chief Executive Officer (CEO) of House of Refugee Sunnyslope. Mark Boesen and I want to thank Kelly for the tremendous successes she had leading AzPA. Especially in the legislative arena, because of her hard work the profession of pharmacy has achieved profound respect among the Governor and Arizona Legislature members and staff. The AzPA Legislative Committee wishes Kelly success in her new endeavor. However, Kelly will not leave us completely, as she will be involved in the PAPA program. And lastly a thank you to Diane McAllister of Public Policy Partners (P3). Diane serves as the AzPA lobbyist, who has worked tirelessly to help AzPA navigate the complexities of the Arizona Legislature.

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