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

P U B L I C AT I O N

O F

A R I Z O N A

In This Edition: The Future of Hyperlipidemia Treatment: New Non-Statin Medications

P H A R M A C Y

A S S O C I AT I O N

W I N T E R

Pharmacy Day at the Capitol Compounding Difficulties

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Contents Board of Directors 2023-2024 OFFICERS President Kimberly Langley President-Elect Pro-Tempore Jacob Schwarz Immediate Past President Dawn Gerber Treasurer Ryan Gries Secretary Brandy DeChellis Director/CEO Kelly Fine

COVER STORY pg. 6

DIRECTORS AT LARGE Community Brianne Spaeth Health System Mary Manning Technician Melinda Browning Joseph Pellerito Jimmy Stevens Reasol Chino Misty Brannon Danielle Gilliam LIASIONS University of Arizona Student Chapter David Elias-Campa Dean's Designated Representative Nancy Alvarez Midwestern University Student Chapter Shams Rehman Dean's Designated Representative Michael Dietrich Creighton University Student Chapter Haley DeMartinis Dean's Designated Representative Jane Stein Legal Counsel Roger Morris

AzPA Staff Chief Executive Officer Kelly Fine Education & Professional Development Dawn Gerber Events & Strategic Partnerships Cindy Esquer Membership & Volunteer Services Marques Bottorf Strategic Programs Kristin Calabro Administrative Services Melina Esquer Editor Kelly Fine Co-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

President’s Message 4 AzPA News Welcome New Members 5 Az-ASHP State Affiliate News 9 University & Alumni News 23 Editorial Spring Clinical 6 Preceptors Corner 11 Compounding Difficulties 31 Advocacy Pharmacy Day at the Capitol 33 Continuing Education The Future of Hyperlipidemia Treatment 14

UPCOMING EVENTS

February 3, 2024 | Virtual

February 24-25, 2024 | Phoenix, AZ

March 20, 2024 | Phoenix

April 20-21, 2024 | Glendale

June 6, 2024 | Phoenix, AZ

June 6-9, 2024 | Phoenix, AZ

EDITORIAL PRESIDENT'S MESSAGE Dear AzPA Members, Happy New Year! The new year always brings about the opportunity of a fresh new start. I personally have given up on the idea of new year’s resolutions (just ask my family about the resolutions throughout the years that didn’t make it past the first month!). Despite not sticking with resolutions, I have been committed to doing things a little different each year to hopefully bring about more positive change.

CAPT Kimberly “Kim” Langley, PharmD, MBA, BCPS, FAzPA CAPT Kimberly Langley is the Chief Financial 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 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, 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 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 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 of the Arizona Pharmacy Association. Her leadership experience extends to various roles on multiple USPHS committees, workgroups, and mentoring programs.

In 2023, our Board of Directors and committees put plans into action that I look forward to seeing getting stronger in this new year. Our Board of Directors ended 2023 with first steps to address workplace conditions in our state with the first town hall dedicated to focusing on this issue. While the solution to this complex issue will take many forms and approaches, undoubtedly, it will not be achievable without the collective voices of our members and pharmacy community. This year I look forward to more opportunities to engage and use these opportunities to strive towards better workplace conditions for the advancement of our profession. One opportunity to raise our collective voices is the 2024 Pharmacy Day at the Capitol. This event scheduled for March 20th gives our pharmacy community the chance to share their stories of accomplishment and challenges. Who is better prepared to share the narrative of our profession with Arizona lawmakers than Arizona pharmacy professionals? I invite all of our members to express their pride in the profession on this impactful day. In addition to workplace conditions, access to care will become increasingly more challenging for patients in different areas of the country. Some patients have experienced reduced access to pharmacy care as closures of large retail community pharmacies have been implemented. As of one the most accessible healthcare providers, pharmacists often have built long-lasting, trusted relationships with the patients they serve. These closures have the potential to broaden the health disparities that already exist in communities across the nation. As the models for healthcare delivery continue to shift, pharmacy professionals are in the unique position to promote awareness and implement strategies to achieve health equity. We are at a point in our profession where the potential for positive impact is limitless. Let us be pioneers of change, advocates for progress, and champions of patient-centered care. As members of this association, we have the opportunity to shape the narrative and lead our profession into a new era of prominence. Let us embrace the future of pharmacy and blaze a path towards excellence, innovation, and unwavering dedication to the well-being of all those we serve. CAPT Kimberly “Kim” Langley, PharmD, MBA, BCPS, FAzPA 2023-2024 AzPA President

WELCOME NEW MEMBERS! 2nd Year Practitioner

Kim Carroll Pharmacist

Claudia Avilez Janet Buchner Samantha Chapman Paul Chefor Claudia Chiesa Cambria Crawford Nathan Crow Jon Cyr Kelly Erdos Thomas Fong Bianca Glab Sudan Gordon Amer Hakam Jeremy Hall Alexis Hayes-Porter Pauline Hoang Michaela Konecnik Victor Kujawski Megan Lopez Samantha Low Geneva MAckey Evan Michalski Logan Moore Kyle Nguyen Anthony Pauls Derek Pohlmeyer Ridge Smidt John Thierer Samantha Turk Kurt Weibel Leanne Werdy Lukas Westendorf Linda Williams Premium Pharmacist

Suzanne Banaszak Julie Carter Daniel Diggins Stephanie Felton Arian Harris Teri Miller Tai Pham Kendall Van Tyle

Resident

Stephanie Earl Anne Marie Guthrie Rambo Le Kathleen Meehan Victoria Sjoblom Retired

Daniel Boesen Paul Forsyth Student Pharmacist

Safa Abdulqader Omaima AL Garaawi Ola Allababidi Ola Alnoman Regina Arellano Ashley Banaszak Amber Brewer Tiffany Cabrera Katie Collins Ed Evangelista Lakin Gardner Hannah Hardy Robert Isbell Maria John Betsy Johnson Lishan Liu Kathleen Maro Alyx Meilinger Jihan Nawara Kimberlyy Osborn Gabriela Rajic Tate Russell Megan Schmidt Janet Siqueiros Mariam Takla Emily Tran Jasmine Tuason Kayleen Tubbs Andrianna Walsh Gilbert Yniguez Suzie Yoon Gabriella Young

AZPA NEWS Tech in Training

Cynthia Bilagody Robin Whittaker Technician

Matthew Alvarado Parth Babariya Rachael Freerking Melinda LeGrand Krystal Meek Sheli Nelson Theresa Ramirez Alberta Silveri Millie Spengel Evany Valenzuela Rebecca Wagoner Associate

Gianna Bryan Rahul Deshmukh Rita Devani Gavin Engle

EDITORIAL SPRING CLINICAL

Saturday, February 24 7:00AM – 7:45AM | COFFEE/NETWORKING 7:45AM – 8:15AM | WELCOME & CE OVERVIEW 8:15AM – 9:45AM | GENERAL SESSION-ENDING THE OPIOID CRISIS Christi Jen, PharmD, BCPS, BCEMP, FASHP, FAzPA; Holly Geyer, MD Pharmacist Learning Objectives: 1. Identify the role of overprescribing in opioid-related complications. 2. Analyze the difference between opioid misuse and addiction. 3. Identify opioid use disorder. 4. Describe safe opioid prescribing recommendations. 5. Describe safe opioid administration recommendations. Technician Learning Objectives: 1. Identify the role of overprescribing in opioid-related complications. 2. Analyze the difference between opioid misuse and addiction. 3. Identify opioid use disorder. ACPE UAN: 0100-0000-23-182-L08-P/T 10:00AM - 11:00AM | UPDATES IN GERIATRIC MEDICINE: A MUSICAL JOURNEY Jacob Schwarz, PharmD, MBA, BCIDP, BCCCP, BCPS, FAzPA; Jacob Lahti, BS; CMD; Pranav Pillai, MBBS; Samantha Russell, MD; Walter Nieri, MD Pharmacist Learning Objectives: 1. Describe how to determine if a paper adds to the evidence base. 2. Discuss three recent papers in the geriatric literature. ACPE UAN: 0100-9999-23-169-L01-P 10:00AM - 11:00AM | THANKS FOR THE FEEDBACK- FREQUENT, IMMEDIATE, SPECIFIC, AND CONSTRUCTIVE FEEDBACK FOR PHARMACY RESIDENTS Kelly Erdos, PharmD, BCACP, CACP; Michaela Konecnik, PharmD, BCPS; Daniel Bell, PharmD, BA, BCPS Pharmacist Learning Objectives: 1. Describe the four elements needed to provide effective feedback to residents. 2. Interpret feedback from residents and resident evaluations to determine how to improve feedback to residents. 3. Discuss the importance of implementing a preceptor development program. ACPE UAN: 0100-0000-23-183-L99-P

11:15AM - 12:15PM | MANAGING CHRONIC DISEASE IN FRAIL OLDER ADULTS IN THE OUTPATIENT SETTING Rosemary Browne, MD, FACP, AGSF Pharmacist Learning Objectives: 1. Describe Age Friendly Health Systems. 2. Discuss prognostication as a tool to help prioritize medical decision making. 3. Explain the concepts of multi-complexity and multi-morbidity. 4. Describe patient priorities care. Technician Learning Objectives: 1. Describe Age Friendly Health Systems. 2. Describe patient priorities care. ACPE UAN: 0100-9999-23-166-L01-P/T 11:15AM - 12:15PM | FOCUS ON ANTICOAGULATION: ANTICOAGULATION REVERSAL: WHEN THE CLOCK IS TICKING Jacob Schwarz, PharmD, MBA, BCIDP, BCCCP, BCPS, FAzPA; John Robinson, PharmD, BCCCP Pharmacist Learning Objectives: 1. Distinguish between approved anticoagulation reversal agents specific to oral anticoagulants. 2. Identify reversal agents currently in development. 3. Design a treatment plan on the presentation of a patient in need of emergent reversal of their anticoagulation. ACPE UAN: 0100-0000-23-184-L01-P 1:30PM - 2:30PM | ELEVATING PHARMACY PRACTICE: MANAGING UP FOR PHARMACY PROFESSIONALS Kimberly Langley, PharmD, MBA, BCPS, CPBPM Pharmacist & Technician Learning Objectives: 1. Explain the concept of managing up for effective employeeemployer relationships. 2. Review strategies for effective employee-employer relationship through managing up. 3. Describe strategies for facilitating communication with your supervisory leadership. 4. Discuss guidance for improvement when the employeeemployer relationship becomes challenging. ACPE UAN: 0100-0000-23-185-L04-P/T

1:30PM - 2:30PM | FOCUS ON ANTICOAGULATION: THE REVERSAL RUMBLE: ANTICOAGULATION CLINICAL DEBATE Jacob Schwarz, PharmD, MBA, BCIDP, BCCCP, BCPS, FAzPA; John Robinson, PharmD, BCCCP Pharmacist Learning Objectives: 1. Critique the evidence for using fixed-dose 4F-PCC in the reversal of anticoagulation in patients receiving warfarin. 2. Evaluate the evidence of 4F-PCC and andexanet alfa in the reversal of rivaroxaban and apixaban. ACPE UAN: 0100-0000-23-186-L01-P 2:45PM - 3:45PM | FOCUS ON ANTICOAGULATION: STAY IN THE KNOWac ABOUT THE DOACs: A PEDIATRIC PERSPECTIVE Lauren Campis, PharmD; Tran Nguyen, PharmD, BCPPS, BS Pharmacist Learning Objectives: 1. Describe the common indications for use of the DOACs in pediatric patients. 2. Interpret the current literature for use of the DOACs in pediatric patients. 3. Compare the differences between use of DOACs in pediatric and adult populations. ACPE UAN: 0100-0000-23-173-L01-P 2:45PM - 3:45PM | CREATING A CULTURE OF POSITIVE FEEDBACK AND RECOGNITION FOR PHARMACY TECHNICIANS Kristine Smith, B.S., CPhT-Adv, CSPT; Nick Ruiz, CPhT-Adv, CSPT, FAPC; Matthew Alvarado, CPhT, CSPT Pharmacist & Technician Learning Objectives: 1. List various feedback models. 2. Describe how to effectively give feedback. 3. Explain how feedback directly impacts engagement. ACPE UAN: 0100-0000-23-187-L04-P/T 4:00PM - 5:00PM | GENERAL SESSION - NATIONAL PHARMACY POLICY UPDATE AND WORKFORCE PRIORITIES Anna Dopp, PharmD, CPHQ, Senior Director, Government Relations ASHP

EDITORIAL SPRING CLINICAL

Sunday, February 25 7:00AM – 7:45AM | COFFEE/NETWORKING 7:45AM – 8:15AM | WELCOME & CE OVERVIEW 8:15AM – 9:45AM | GENERAL SESSION - PHARMACY LAW UPDATE Roger Morris, RPh, JD; Catherine Lavinge, JD; Bailey Walden, JD Pharmacist & Technician Learning Objectives: 1. Describe ramifications of recent pharmacy-related court cases. 2. List recent changes in Federal Pharmacy Law. ACPE UAN: 0100-0000-23-188-L03-P/T 10:00AM - 11:00AM | LET YOUR VOICE BE HEARD: A DISCUSSION OF ADVOCACY AND ASHP HOUSE OF DELEGATES Janelle Duran, PharmD, BCPS; Chris Edwards, PharmD, BCPS, FASHP; Christi Jen, PharmD, BCPS, BCEMP, FASHP, FAzPA; Jacob Schwarz, PharmD, MBA, BCIDP, BCCCP, BCPS, FAzPA Pharmacist Learning Objectives: 1. Describe ways Arizona pharmacy professionals can get involved in advocacy through state and national pharmacy associations. 2. Discuss the role of Arizona delegates to the ASHP House of Delegates. 3. Discuss the potential impact of selected policies coming before the ASHP House of Delegates in June to the practice of pharmacy in Arizona and to pharmacy personnel. Technician Learning Objectives: 1. Describe how a pharmacy technician may contribute to ASHP policies. 2. Recognize how policies may impact pharmacy technicians. ACPE UAN: 0100-0000-23-189-L99-P/T

Accreditation Information The Arizona Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education (CPE). Continuing Education Sessions approved for CE credits are indicated by the CE icon, an ACPE number, and the number of CEUs in the session listing. To obtain CPE credit for any of the LIVE sessions, learners must attend the session live, enter the session code, and complete the assessment quiz and evaluation for each session attended. The session code and further instructions will be provided at the end of each LIVE session. Learning Level: Varies Activity Type: Knowledge and Application-based Target Audience: Pharmacists and Technicians Disclosures Disclosures will be announced at the beginning of each session and can be found in the Event Program under each speaker(s) biography. AzPA CE staff declare no conflicts of interest or financial interests in any product or service mentioned in this activity. View Disclosures. Conflicts of interest have been resolved through content review by the AzPA CE Committee Department and Committee.

EDITORIAL SPRING CLINICAL 10:00AM - 11:00AM | OUR JOURNEY TO BECOMING PALS Brandy DeChallis, PharmD; Mikayla Gerdes, PharmD Candidate; Bradley Nash, BS Biochemistry, PharmD Pharmacist Learning Objectives: 1. Discuss how to recognize life-threatening emergencies such as cardiac arrest in pediatric patients. 2. Describe Pediatric Advanced Life Support (PALS) Certification. 3. List the resources available for PALS training. 4. List common medications used during a pediatric code. 5. Describe the role of the pharmacist attending a code within a high-performance team. Technician Learning Objectives: 1. Discuss how to recognize life-threatening emergencies such as cardiac arrest in pediatric patients. 2. Describe Online Pediatric Advanced Life Support (PALS) Certification. 3. List the resources available for PALS training. 4. List common medications used during a pediatric code. ACPE UAN: 0100-0000-23-190-L04-P/T 11:30AM – 1:00PM | JOURNAL CLUB Jeffrey Bezard, PharmD; Monica Heberling, PharmD; Jkiya Jackson, PharmD; Michael Constant, PharmD; Daniel Otis, PharmD; Kimberly Johnson, Victor Camargo, PharmD Pharmacist Learning Objectives: 1. Discuss the results compiled in the phase 2 study of lenacapavir for use in new start HIV treatment. 2. Describe potential treatment regimens utilizing lenacapavir. 3. List current available long-acting injectable formulations of antipsychotics. 4. Discuss drawbacks of utilizing long-acting injectable versions of antipsychotic medications. 5. List challenges in the treatment of Opioid Use Disorder (OUD) with buprenorphine and naltrexone. 6. Describe evidence-based practices to determine an individualized treatment plan for patients diagnosed with OUD. 7. Describe the results of the Nonprescription Drugs Advisory Committee on Phenylephrine. 8. Describe the efficacy of phenylephrine as described in the study. ACPE UAN: 0100-0000-23-192-L01-P

11:30AM – 1:00PM | NEW DRUG UPDATE Christina Meridew, PharmD Candidate; Courtney Cianci, PharmD Candidate; Jasmina Hukic, PharmD Candidate; Jose Espinoza, PharmD Candidate; Joseph Zeppa, PharmD Candidate; Lyndy Abdelsayed, PharmD Candidate; Monique Cazares, PharmD Candidate; Mikayla Gerdes, PharmD Candidate; Dawn Gerber, PharmD, BCGP, FASCP, FAzPA Pharmacist Learning Objectives: 1. Describe pharmacological mechanisms of action of newly available medications. 2. Describe the clinical efficacy of newly available medications. 3. Describe the adverse effect profile of newly available medications. 4. Identify patient counseling points for newly available drugs. Technician Learning Objectives: 1. Describe pharmacological mechanisms of action of newly available medications. 2. Describe the storage requirements of newly available medications. 3. List the indications of newly available medications. ACPE UAN: 0100-0000-23-191-L01-P/T

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AzPA HEALTH SYSTEM SPECIAL INTEREST GROUP (AZ-ASHP)

AZ-ASHP AFFILIATE NEWS

When we use the term “time flies” we aren’t kidding! Can you believe that 2023 has come and gone? As we move into 2024, let’s take an abbreviated look at important advocacy work that is being done at ASHP and is supported by AzPA. 1. Empower Pharmacists to provide a broader scope of patient care services through expansion of patient services, adoption of institutional privileging, collaborative practice arrangements across healthcare settings and advocating for pharmacist to have a greater role in responding to the opioid epidemic. 2. Secure payment for pharmacist patient care services through collaboration with various organizations to highlight the value of pharmacists and pharmacy technicians within the healthcare team. Advocating for: a. pharmacists to be recognized as providers across all payers and care settings including providing incident to a physician to be billed consistent with the complexity of services provided. AzPA has been a strong driver of implementing pharmacist payment for services by BCBS and hope to add additional payers this next year. b. payment of pharmacist-led treatment of conditions such as medication-assisted treatment for opioid use disorder, PEP & PrEP for HIV, and initiating antivirals for COVID-19 and flu. 3. Advocate for solutions to pharmacy workforce challenges by advancing efforts to support pharmacist roles in public and population health. Defending funding for PGY1 residencies and expand funding to PGY2 programs. Advocate for interstate pharmacist licensure to expand pharmacist ability to practice across state lines. Advocate for workplace safety as well as promote tools for those struggling with burnout. 4. Promote the role of qualified pharmacy technicians by advocating for the development of advanced roles for pharmacy technicians including an expanded scope in efforts to recruit and retain the technician workforce. 5. Protect patient access to safe and affordable medication use by working with federal agencies to strengthen the drug supply chain, adopt health-system compounding regulations consistent with USP, and oppose state barriers to the adoption of technologies that support compounding practices. Advocate for the development of safe, effective, and interchangeable biosimilar medications. 6. Address societal barriers to patient care through advocating for policies to address health disparities in access to medication therapies and utilization of pharmacists to meet patient care needs in medically underserved areas. 7. Protect the sustainability of health-system pharmacy by defending the 340B Drug Pricing Program which supports patient access to care. Ensure that PBMs can no longer undermine patient care or health-system pharmacy sustainability or access to limited distribution drugs. If you find any of these issues important to you and your practice of pharmacy, I’d like to urge you to get involved. Beginning your involvement can be as simple as attending a meeting or conference. The AzPA Spring Clinical Conference is right around the corner! Come join us February 24-25, 2024 by using this link to register!

Mary Manning, PharmD, MBA, BCPS AzPA Board of Directors-Health System

Learn More Here

Mary Manning, PharmD, MBA, BCPS Mary Manning, PharmD, MBA, BCPS AzPA Board of Directors-Health System

EDITORIAL PRECEPTOR CORNER

"Preceptors are in a unique position to model professional behavior for student and resident pharmacists. These impressionable learners observe modeled behavior, which is impactful to a developing pharmacist."

The Continuous Professional Development Model in Pharmacy AUTHORS/CONTRIBUTORS Savannah Cook, PharmD Candidate, Midwestern University College of Pharmacy Glendale Campus

Alana Brown, PharmD Candidate, Midwestern University College of Pharmacy Glendale Campus Suzanne Larson, PharmD, Director of Experiential Education, Department of Pharmacy Practice, Midwestern University College of Pharmacy Janet Cooley, PharmD, BCACP Director of Experiential Education, Department of Pharmacy Practice and Science, R. Ken Coit College of Pharmacy, University of Arizona 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.

CONT. PRECEPTOR CORNER What is Continuous Professional Development? Continuous Professional Development is a concept that pharmacists will have varying degrees of familiarity with. Some pharmacists may be entrenched in a CPD practice, while others may be learning about CPD for the first time in this article. The Accreditation Council for Pharmacy Education (ACPE) defines continuing professional development (CPD) as “a self-directed, ongoing, systematic and outcomes-focused approach to lifelong learning that is applied into practice. It involves the process of active participation in formal and informal learning activities that assist individuals in developing and maintaining continuing competence, enhancing their professional practice, and supporting achievement of their career goals.”1Continuous professional development may encompass a vast array of topics that can allow pharmacists to grow within their professional career. CPD focuses on professional development that provides real or applied benefits after graduation and is carried on throughout one’s career. Through a commitment to continuous and practicebased education, pharmacists learn the essentials of pharmacy practice that are not obtained from a lecture hall. CPD requires pharmacists to develop dedication to learning and continuing education, even after their formal education is completed. The CPD Process The CPD process is broken into specific steps that are completed in a cyclical fashion: Reflect, plan, learn, evaluate, and record. In addition, pharmacists are expected to apply what they are learning into their practice. To adequately achieve CPD goals, time must be dedicated to each element of the process. Reflection Reflection is the starting point of CPD and is intended to lay a foundation for the other steps of the process. Reflection can assist pharmacists in discovering areas in our professional lives that need improvement. For example, pharmacists may ask themselves, “What are some clinical and non-clinical areas that I need to develop or improve upon? What skills or knowledge will help serve patients better? What elements of my practice setting could I learn more about?” This piece of the process is individualized to the specific pharmacist. An understanding of one’s own areas of opportunity fosters an individualized approach to CPD, which will provide a tailored, customized plan for professional growth. Plan The next crucial step is to develop a plan, which involves processes to identify activities that will strengthen skills and knowledge

identified during there flection stage of CPD. This step includes brainstorming specific actions that will propel learning forward to achieve identified goals. For instance, if there are specific patient care areas that you are lacking knowledge in, such as women’s health, there are certificate programs, CE programming, journal articles, workshops, and professional meetings in this area that may widen your knowledge. There are also informal opportunities for growth, such as through podcasts and connecting with mentors who have expertise in that area. During this planning stage, it is helpful to set specific and measurable tasks with a tentative timeline. It allows one to create a path forward including action items and specific opportunities for learning. Learn The third step is to engage in the learning opportunities identified in the previous step. This step is where you combine the previous two steps of reflection and planning and participate in learning opportunities. Participation and action are taken during this element as one completes the steps needed to reach the determined goals. As mentioned earlier, the learning opportunities are individualized to each pharmacist, so the actions will differ from person to person. Evaluate and Record The final steps in CPD are to evaluate and record. Were the learning goals met? Are there additional steps to be enacted to achieve the specified goals? This phase allows pharmacists to document the actions taken, and to record the results of learning. This sets pharmacists up for future CPD cycles because it allows them to discover additional areas of learning needs. One can visualize their growth by checking off items that were completed and gain motivation through progress. Apply While engaging in the CPD process, it is important to apply the information and content learned into practice. When using the information gained in self-directed learning, one can more accurately assess how well they retained the information and what further gaps they may have. As described in the “Evaluate and Record” steps of the process, as pharmacists apply their learning, they will be better able to engage in the entire CPD process and reflect on future learning needs for their individual practice. Importance of CPD Why is it important for pharmacists to be involved in CPD? It may 12 be easy to find comfort once settled into a career. After

CONT. PRECEPTOR CORNER graduation, there may be a sense of relief and a feeling that the “hard part” is now over. However, it is crucial to continue learning and advancing professional knowledge. Gaining a diploma may signify the finish line of formal education but sets a new starting line for the practical knowledge and experience that will come with the career. In fact, it becomes more crucial to continuously educate and focus on the areas in which you need improvement. CPD provides structure, guidance, and an opportunity for self-evaluation and to continuously become better versions of ourselves.

which is impactful to a developing pharmacist. As learners witness their preceptors identify their own learning needs and enact plans to address those needs, they can understand that their preceptors are also a work in progress, and the road to professional development is a journey, not a destination. Additionally, precepting provides extensive opportunities for continuous learning through working with students and residents. Purposeful modeling of CPD by preceptors can develop the next generation of pharmacists invested in their own lifelong learning.

Pharmacists possess a vast amount of drug knowledge and application, but it is also critical to recognize that this knowledge is ever changing. The landscape of healthcare is constantly evolving, with new research developments and drug approvals, which provides countless opportunities to be engaged in CPD. The ability to stay current on best practices and appropriate medication therapies is an expectation of all pharmacists. This ensures that one’s patients are being cared for with the most up-to-date and accurate care, leading to optimally achieving the patient's health goals.

Conclusion As pharmacists, we take an oath to “accept lifelong obligation to improve [our] professional knowledge and competence” to protect our patients and always provide them with the best care possible.2 Through CPD, pharmacists can ensure accurate and complete knowledge on varying areas of pharmacy practice.

Implications for Preceptors Why might it be important for pharmacist preceptors to engage in CPD? Preceptors are in a unique position to model professional behavior for student and resident pharmacists. These impressionable learners observe modeled behavior,

! W O N R E REGIST

REFERENCES 1. Continuing Professional Development [Internet]. Accreditation Council for Pharmacy Education [cited 2023 Nov 25]. Available from: https://www.acpeaccredit.org/continuing-professional-development/ 2. Oath of a Pharmacist. American Pharmacist Association [cited 2023 Nov 25]. Available from: https://www.pharmacist.com/About/Oath-of-a-Pharmacist

February 3, 2024 | VIRTUAL

A practice-based activity designed for pharmacists and healthcare professionals in all practice settings. Through lecture and discussion, you'll explore the foundations of MI. In this one-day course, you'll learn step by step how to refine your communication style to increase positive outcomes with your patients. Through lecture, analysis, and discussion, you'll learn to use a compassionate, curious effort to elicit your patient’s own arguments for change.

CONTINUING EDUCATION

The Future of Hyperlipidemia Treatment: New Non-Statin Medications

Pharmacist Learning Objectives: 1. Describe the mechanisms of action of new non-statin medications, including PCSK9 monoclonal antibodies (mAbs), inclisiran, and bempedoic acid.

AUTHORS/CONTRIBUTORS

Taylor Tellez, PGY1 Pharmacy Practice Resident, Phoenix VA Health Care System, Phoenix, AZ Dawn Gerber, PharmD, BCGP, FASCP, FAzPA Associate Professor, Midwestern University College of Pharmacy-Glendale, Glendale, AZ FUNDING - This research was not funded

2. Identify patients who may benefit from non-statin medications. 3. List potential adverse effects associated with non-statin medications. 4. Describe recent changes in

DISCLOSURES - The authors have no relevant financial relationship to disclose

recommendations for the 2022

CONTINUING EDUCATION INFORMATION

(ACC) expert consensus

Target Audience: Pharmacists Activity Type: Knowledge

American College of Cardiology discussion pathway in regard to the role of PCSK9 mAbs, inclisiran, and bempedoic acid. 5. List potential drug-drug interactions associated with bempedoic acid.

CONT. CONTINUING EDUCATION Introduction Despite new pharmacological agents and public health initiatives, cardiovascular disease (CVD) is still the leading cause of morbidity and mortality across the globe, as it has been in the United States (US) since 1950. This has been speculated to be a consequence of poor management of lifestyle and health risk factors such as diet, exercise, tobacco use, diabetes, hypertension, and hyperlipidemia.1 Hyperlipidemia, and more specifically the reduction of low-density lipoprotein cholesterol (LDL-C), is arguably one of the most reliable ways to reduce a patient’s risk of complications and death from CVD. However, according to the National Health and Nutrition Examination Survey (NHANES), from 2015-2018, 27.8% of adults in the US had elevated LDL-C levels ≥ 130mg/dL and less than 35% of those patients were effectively managed with lipid lowering therapy. 2 For the last 30 years statins have been the gold standard for hyperlipidemia treatment but considering long-term adherence issues, a trend in underdosing, and similar statistics to the one above, it begs the question if statins alone are sufficient to provide the best outcomes for patients. LDL-C drug targets Throughout the last decade new non-statin medications with unique mechanisms of action (Figure 1) have entered the drug market. Drug targets of these medications include: proprotein convertase subtilisin/kexin type 9 (PCSK9), PCSK9 messenger ribonucleic acid (mRNA), and adenosine triphosphate citrate lyase (ACL). PCSK 9 monoclonal antibodies (mAbs), previously known as PCSK9 inhibitors, target PCSK9 proteins, which are responsible for the degradation of low-density lipoprotein receptors (LDL-R). PCSK9 mRNA, the target of inclisiran, is responsible for PCSK9 protein production, increasing the number of PCSK9 proteins available to bind and degrade LDL-R. Finally, bempedoic acid targets ACL, an enzyme in Figure 1. Mechanism of action for antihyperlipidemic drugs

the cholesterol biosynthesis pathway that is responsible for converting citrate to acetyl CoA, which is a step upstream from 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase. Recent studies of these medications have shown significant reductions in LDL-C and cardiovascular benefits when used adjunctly with a maximally tolerated statin,3 making them appealing options for patients who may have been unable to reach their LDL-C goals with statin monotherapy. It is also equally important to recognize the medications that are commonly prescribed to patients that can increase LDLC4, as they can reduce the overall benefit provided by lipid-lowering agents. See Table 1. Table 1. Medications that can increase lipids4 Medications that Can Increase Lipids

Beta-blockers Corticosteroids Diuretics Efavirenz Growth Hormones Immunosuppressants Progestins Protease Inhibitors Need for additional LDL-C reductions Statins are the first pharmacologic intervention when treating hyperlipidemia, but are they enough for the large majority of patients? Studies suggest that anywhere from 20-65% of patients do not reach their LDL-C goal while taking a statin.5 This could be due to a variety of reasons, but nonadherence because of adverse effects and trends in underdosing are most common. Approximately 10% of patients discontinue their statin due to adverse effects or fear of adverse effects, namely muscle symptoms and new-onset diabetes. This is far more frequent than what has been reported in clinical trials (less than 1%) and in other countries (2-4%). Patients’ exposure to news media may be a contributing factor to this negative drucebo effect (a combination of DRUg and plaCEBO or noCEBO); a study in Denmark found that statin discontinuation increased from 6% in 1995 to 11% in 2010 and was significantly associated with negative news stories about statins and their side effect profiles.6 In AHA’s 2022 report it was found that in patients with an LDL-C ≥ 190mg/dL, 58% were prescribed a statin, but only 31% were prescribed a high intensity statin.2 Studies have continued on next page

CONT. CONTINUING EDUCATION also reported that some patients will typically be started on lower doses of statins, regardless of risk, to try and mitigate the incidence of myalgias and myopathies or their statin is instantly discontinued when they first complain of muscle symptoms instead of being re-trialed with another statin or trying an alternative dosing schedule7 as is recommended by guidelines. Additionally, it is well known that statins reduce cardiovascular risk through inhibiting HMG-CoA reductase, but they also upregulate PCSK9 levels by 25-35%.6 This ultimately decreases the net cardiovascular benefit provided to patients. Although statins play an undeniable role in reducing LDL-C, there are additional benefits that can be obtained when combined with PCSK9 mAbs, inclisiran, or bempedoic acid. Medications It is important to note that all of the new non-statin medications have been studied and are recommended to be used in adjunct with a maximally tolerated statin.8-11 Although, these medications have shown to significantly decrease LDL-C, they are very expensive, costing several thousands of dollars that may prove a barrier to access for many patients. Table 2 provides a brief comparison of the advantages and disadvantages of the medications. Evolocumab and Alirocumab PCSK9 mAbs are fully humanized monoclonal antibodies that bind to PCSK9 proteins and prevent the proteins from binding to and degrading LDL receptors. This allows for an increase in LDL receptor recycling back to the hepatocyte surface, ultimately increasing the clearance of LDL-C. Unlike statins, these medications are given via subcutaneous route every 2 or 4 weeks depending on the dose. Reductions in LDL are seen within a few days after administration and results are sustained for approximately 2 weeks. However, PCSK9 mAbs are concentration dependent until saturation of PCSK9 binding is reached, so at higher concentrations their dosing intervals are extended.3 In the ODYSSEY OUTCOMES and FOURIER trials, alirocumab and evolocumab, respectively, significantly reduced the risk of major adverse cardiovascular events (MACE) when compared to placebo.3,9,10 PCSK9 mAbs are generally considered safe and well-tolerated, with the most common adverse reaction being injection site reactions. They require no dose adjustments for renal or hepatic impairment and no additional monitoring other than periodic lipid profiles. There are currently no recommendations for PCSK9 mAb use in pregnancy due to limited date; however, providers are encouraged to report any mAb use in pregnant women.9,10 PCSK9 mAbs are also currently being investigated for their use in

atherosclerosis since they have been shown to negate the inflammatory responses that PCSK9 initiates.3 Counseling points for PCSK9 mAbs are provided in Figure 2. Figure 2. PCSK9 mAb counseling points

Inclisiran Inclisiran is a synthetic small interfering ribonucleic acid (siRNA) molecule that selectively inhibits the production of PCSK9 by cleaving mRNA required for PCSK9 translation, reducing the PCSK9 available to bind to LDL receptors. Thus, inclisiran inhibits production of PCSK9 at an intracellular level, unlike PCSK9 mAbs, which extracellularly bind to the protein after it’s been produced.3 Inclisiran is long acting, only requiring two administrations per year after the first initial titration (injection at day 1 and day 90 day then every 6 months thereafter),8 which may be beneficial in patients who struggle with adherence to daily regimens. As the newest non-statin medication to be FDA approved, there is no available data on cardiovascular outcomes at this time; however, the ORION-4 trial, which is investigating inclisiran’s effects on MACE, is currently being conducted and results are expected to be published sometime in 2024 or 2025.3 Dose adjustments are not required for renal and hepatic impairment even though the medication is renally eliminated. Additional monitoring outside of lipid profiles is not required. While not studied, inclisiran is recommended to be discontinued promptly upon recognition of pregnancy, owing to its mechanism of action.8 Counseling points for inclisiran are provided in Figure 3.

CONT. CONTINUING EDUCATION Table 2: Drug comparison table Drug

MOA

Administration

LCL-C Lowering (%)

Statins

Inhibits HMG-CoA reductase

Orally once daily

PCSK9 mAbs

Inhibits PCSK9 from binding to LDL-C receptors

Inclisiran

Inhibits production of PCSK9 and blocks PCSK9 from binding

Bempedoic Acid

Inhibits ACL and prevents cholesterol synthesis

CV Benefit

ADR

Cost ($/year)

30-50+

Myalgias, rhabdomyolysis, new onset diabetes, hepatic damage

250

SQ every 2 or 4 weeks

45-65

Injection site reactions, upper respiratory tract symptoms

6,000

SQ twice a year after titration

48-52

Being investigated

Injection site reactions

6,500

Orally once daily

17-18

Gout, thrombocytopenia, leukopenia, upper respiratory tract symptoms

4,800

Figure 2. PCSK9 mAb counseling points

ACL = adenosine triphosphate citrate lyase, ADR = adverse drug reaction, CV = cardiovascular, HMG-CoA = 3-hydorxy-3methylglutaryl coenzyme A, LDL-C = lowdensity lipoprotein, mAb = monoclonal antibody, MOA = mechanism of action, PCSK9 = proprotein convertase subtilisin/kexin type 9, SQ = subcutaneously

Figure 3. Inclisiran counseling points

Bempedoic acid Bempedoic acid is a prodrug activated by very-long-chain acyl CoA synthetase A, expressed in the liver and kidneys. It inhibits ACL from producing acetyl CoA which ultimately prevents cholesterol synthesis. Like statins, bempedoic acid is taken orally once daily.11 In the recently published CLEAR Outcomes trial, bempedoic acid was reported to significantly decrease the risk of MACE compared to placebo.12

Bempedoic acid is generally considered safe and welltolerated; however, it does have more notable adverse effects than PCSK9 mAbs and incilisrian3 like anemias, tendon rupture, and hyperuricemia. Therefore, uric acid levels and a CBC is recommended to be obtained before starting therapy. There are no dose adjustments required for renal or hepatic impairment. Bempedoic acid does have clinically significant drug-drug interactions as it inhibits OATP1B1/1B3 which can cause serum concentrations of medications that are substrates of those enzymes to increase when bempedoic acid is taken concurrently. Bempedoic acid exhibits significant drug-drug interactions with simvastatin at doses exceeding 20mg and pravastatin at doses surpassing 40mg;11 concurrent use will double the serum concentration of the statins and increase the risk of myopathies. Interestingly, no dose adjustments are needed for atorvastatin or rosuvastatin; the reason for this is currently unknown.3 Although not studied, bempedoic acid is recommended to be discontinued as soon as pregnancy is recognized, due to its mechanism of action.11 Counseling points for bempedoic acid are provided in Figure 4.

CONT. CONTINUING EDUCATION Figure 4. Bempedoic acid counseling points

Clinical Application The new non-statin medications have recently started to find their place in guidelines for secondary prevention in patients with clinical atherosclerotic cardiovascular disease (ASCVD). PCSK9 mAbs, inclisiran, and bempedoic acid currently do not have an established place in therapy for primary prevention, unless patients have a baseline LDL ≥ 190 mg/dL, due to insufficient evidence.13 This is currently a topic of research.

Figure 5. Adapted from the 2018 ACC/AHA blood cholesterol guidelines secondary prevention pathway for patients with clinical ASCVD.

2018 American College of Cardiology and the American Heart Association (ACC/AHA) guidelines In 2018, ACC/AHA guidelines recommended a non-statin medication for the first time. PCSK9 mAbs were recommended as an adjunct therapy for patients with clinical ASCVD who were on a maximally tolerated statin and ezetimibe, but still had not reached an LDL-C goal of less than 70mg/dL.14 At the time of publication inclisiran and bempedoic acid were not yet approved. See Figure 5 for a summary of the 2018 guidelines treatment pathway for patients with clinical ASCVD. 2022 American College of Cardiology (ACC) expert consensus discussion pathway In 2022, ACC published an expert consensus discussion pathway (ECDP) with updated recommendations including all of the new non-statin medications. PCSK9 mAbs are now considered a second line option, along with ezetimibe, for patients with clinical ASCVD or secondary prevention with genetic hypercholesterolemia who have not met their LDL-C goal on a maximally tolerated statin. PCSK9 mAbs should be considered if the patient needs greater than 25% reduction in LDL-C to reach their goal and ezetimibe if less than 25% reduction is needed. If the patient is still unable to reach their LDL-C goal on a maximally tolerated statin and either/and PCSK9 mAb or ezetimibe, then bempodic acid can be considered. Since inclisiran does not have published cardiovascular outcomes yet, it is recommended to replace a PCSK9 mAb with inclisiran only if the patient has adherence or intolerance issues with the PCSK9 mAb.15 See Figure 6 for a summary of the 2022 ECDP.13

Figure 6. Adapted from the Pyrls Cholesterol Pharmacotherapy Review Pathway based on the 2018 ACC/AHA guidelines and 2022 ACC ECDP.

CONT. CONTINUING EDUCATION How Low Is Too Low? LDL-C goals have changed drastically through the years. In the 1988, desirable LDL-C was less than 130mg/dL and in 2001 that goal was lowered to less than 100mg/dL for highrisk patients. In 2012, the Cholesterol Treatment Trialist (CTT) contributors found that a reduction of 1mmol/L in LDL-C resulted in a 20-25% decrease in the risk of major cardiovascular events as well as decreasing mortality by 12%, which really catalyzed the reduction in LDL-C goals. Based on this finding, it would be thought that there would be little to no pushback on further lowering LDL-C goals; however, clinical trials that were published several years earlier were cause for hesitancy. These trials reported that low LDL-C levels were associated with increased incidences of adverse events like hemorrhagic stroke, dementia, depression, hematuria, and cancers. However, recent studies have not been able to replicate these concerns, if anything they’ve shown just the opposite. The JUPITER trial (Justification for the Use of Statins in Primary

Prevention: An Intervention Trial Evaluating Rosuvastatin) trial showed that patients with an LDL-C less than 50mg/dL had decreased cardiovascular events but similar adverse reaction rates to patients with an LDL-C greater than 50mg/dL. A meta-analysis by Robinson et al. showed that patients who had LDL-C levels less than 25mg/dL or less than 15mg/dL while taking alirocumab did not have an increase in adverse effects compared to those with high LDL-C levels.18 Table 3 gives a brief overview of guideline recommended LDL-C goal targets in recent years, but patient specific factors must always be considered when determining an appropriate goal.14-18, 20 Studies are currently investigating deeper into the safety and efficacy of low LDL-C levels,18 so it is possible that LDL-C goals may change again as more clinical trials are showing that “lower [LDL-C] is better.”19

Table 3. Summary of LDL-C goals recommended by guidelines/consensus Guideline/Consensus

LDL-C Goal (mg/dL)

Patient Population

≤100

Primary prevention

≤70

Secondary prevention

≤100

Primary prevention not at high risk

≤70

Primary prevention at high risk Secondary prevention not at high risk

≤55

Secondary prevention at very high risk

≤116

Low risk

≤100

Moderate risk

≤70

High risk

≤55

Very high risk

≤40

Very high risk and has had a CV event within 2 years despite being on a maximally tolerated statin

2018 ACC/AHA14

2022 ACC15

2019 EAS/ESC20

ACC = American College of Cardiology, AHA = American Heart Association, EAS = European Atherosclerosis Society, ESC = European Society of Cardiology, LDL-C = low-density lipoprotein cholesterol

continued on next page

CONT. CONTINUING EDUCATION Pharmacists' Role Pharmacists are essential to the management of hyperlipidemia either by providing direct management of the disease state or through medication management in the community setting. A study done in 2019 investigated pharmacists’ impact and value on adherence to 2018 ACC/AHA blood cholesterol guidelines. The results displayed in Figure 7 clearly showed the crucial role pharmacists play in the management of LDL-C. The pharmacists’ recommendations ranged from stopping ineffective LDL-C lowering agents, adding ezetimibe or a PSCK9 mAb if patients had not reached their LDL-C goal on a maximally tolerated statin, adding appropriate intensity of statins to patients who had never been offered a statin, and increasing the intensity of a statin for eligible patients.21 As pharmacists are an integrated part of the patient care team, they have the opportunity to decrease the gap between evidence-based medicine and clinical practice implementation. Conclusion Currently, statins remain as the first line pharmacologic recommendation in the treatment of hyperlipidemia. When LDL-C target goals cannot be obtained by statin monotherapy or the patient experiences intolerable adverse effects, alternative or combination therapy is warranted. Within the last decade, several new medications have entered the market which have shown impressive efficacy and safety outcomes which have given them a place in the most recent guidelines/consensus. PCSK9 mAbs, bempedoic acid, and inclisiran have changed the way hyperlipidemia is managed. These new non-statin medications have the ability to aid patients in achieving their LDL-C goals that may have been unobtainable from statin therapy alone and ultimately reducing their risk of CVD events and mortality. Although further research is needed on cardiovascular outcomes and head-to-head comparisons between these new medications, pharmacists will play a major role in the incorporation of these medications into patient regimens.

Figure 7. Summary of results from AlAhmad et al.19 study that investigated the value and impact pharmacist interventions had on adherence to the 2018 ACC/AHA guidelines for blood cholesterol.

Assessment Questions 1. According to NHANES (2015-2018), what percentage of adults in the US had elevated LDL-C levels ≥ 130mg/that were effectively managed with lipid-lowering therapy? A. Less than 35% B. 50% C. 65% D. 75% 2. Which enzyme does bempedoic acid target? A. ACL B. ATP citrate lyase C. HMG-CoA reductase D. PCSK9 3. In the ODYSSEY OUTCOMES and FOURIER trials, which two PCSK9 monoclonal antibodies significantly reduced the risk of major adverse cardiovascular events (MACE)? A. Alirocumab and bempedoic acid B. Bempedoic acid and inclisiran C. Evolocumab and alirocumab D. Evolocumab and inclisiran 4. What is inclisiran’s mechanism of action? A. Binding to PCSK9 proteins B. Inhibiting HMG-CoA reductase C. Inhibiting PCSK9 production D. Preventing cholesterol synthesis 5. According to NHANES (2015-2018), what percentage of adults in the US had elevated LDL-C levels ≥ 130mg/dL? A. 20.8% B. 27.8% C. 35.8% D. 40.8%

CONT. CONTINUING EDUCATION 5. How often is inclisiran administered after the initial titration? A. Biannually B. Daily C. Monthly D. Weekly 6. What is the primary route of administration for PCSK9 monoclonal antibodies? A. Intramuscular B. Intravenous C. Oral D. Subcutaneous 7. According to the 2022 ACC expert consensus discussion pathway, when should bempedoic acid be considered in hyperlipidemia treatment? A. After statin monotherapy fails B. As first-line therapy C. In combination with PCSK9 monoclonal antibodies D. Only in primary prevention 8. What change in LDL-C goals was catalyzed by the Cholesterol Treatment Trialist (CTT) contributors' findings in 2012? A. Decrease to 100mg/dL B. Increase to 130mg/dL C. Lowering for high-risk patients D. No change in goals 9. What remains as the first-line pharmacologic recommendation in the treatment of hyperlipidemia at this time? A. Bempedoic acid B. Inclisiran C. PCSK9 monoclonal antibodies D. Statins

References 1. Centers for Disease Control and Prevention. High cholesterol facts (2023). https://www.cdc.gov/cholesterol/facts.htm (accessed 2023 Apr 4). 2. Tsao CW, Aday AW, Almarzooq ZL et al., for the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics – 2022 update: a report from the American heart association. Circulation. 2022;145:153-639. 3. Bardolia C, Amin NS, Turgeon J. Emerging non-statin treatment options for lowering lowdensity lipoprotein cholesterol. Front Cardiovasc Med. 2021; 8:1-14. 4. Herink M, Ito MK. Medication induced changes in lipid and lipoproteins. In: Feingold KR, Anawalt B, Blackman MR, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK326739/ 5. Schleyer T, Hui S, Wang J et al. Quantifying unmet need in statin-treated hyperlipidemia patients and the potential benefit of further LDL-C reduction through and HER-based retrospective cohort study. J Manag Care Spec Pharm. 2019;25(5):544-54 6. Newman CB, Preiss D, Tobert JA et al., for the American Heart Association Clinical Lipidology, Lipoprotein, Metabolism and Thrombosis Committee. Statin safety and associated adverse effects: a scientific statement from the American heart association. Arterioscler Thromb Vasc Biol. 2019;39:38-81. 7. Bosco G, Di Giacomo Barbagallo F, Spaminato S et al. Management of statin intolerant patients in the era of novel lipid lowering agents: a critical approach in clinical care. J Clin Med. 2023;12:232-44. 8. Leqvio (inclisiran) prescribing information. East Hanover: Novartis Pharmaceutical Corporation; 2021 Dec. 9. Repatha (evolocumab) prescribing information. Thousand Oaks: Amgen Inc; 2015 Aug. Revised 2021 Sep. 10. Praluent (alirocumab) prescribing information. Tarrytown: Regeneron Pharmaceuticals Inc; 2015 Jul. Revised 2021 Apr. 11. Nexletol (bempedoic acid) prescribing information. Ann Arbor: Esperion Therapeutics Inc; 2020 Feb. Revised 2022 Jun. 12. Nissen SE, Lincoff AM, Brennan D et al., for The CLEAR Outcomes Investigators. Bempedoic acid and cardiovascular outcomes in statin-intolerant patients. N Engl J Med. 2023;388:135364. 13. Cholesterol pharmacotherapy review. In: Pyrls [online database]. Pyrls (accessed 2023 Apr 10). 14. Grundy SM, Stone NJ, Bailey AL et al., for the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. J Am Coll Cardiol. 2019;73:285-350. 15. Lloyd-jones DM, Morris PB, Ballantyne CM et al., for the American College of Cardiology Solution Set Oversight Committee. 2022 ACC expert consensus decision pathway on the role of nonstatin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk. J Am Coll Cardiol. 2022;80:1366-418. 16. Goodman DS, Hulley SB, Clark LT, et al. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Arch Intern Med. 1988;148(1):36–69. 17. Ridke PM, Danielson E, Fonseca FA, et al. JUPITER Study Group, Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med 2008;359 (21) 2195- 2207. 18. Bandyopadhyay D, Qureshi A, Ghosh S et al. Safety and efficacy of extremely low LDLcholesterol levels and its prospects in hyperlipidemia management. J Lipids. 2018;67:123-32. 19. Marston NA, Giugliano RP, Park JG, et al. Cardiovascular benefit of lowering low-denisty lipoprotein cholesterol below 40mg/dL. Circulation. 2021;144:1732-34. 20. Mach F, Baigent C, Catapano AL et al., for the Task Force for the management of dyslipidemias. 2019 ESC/EAS guidelines for the management of dyslipidemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;41:111-88. 21. AlAhmad MM, AlAbdin SZ, AlAhmad K, et al. Value of the clinical pharmacist interventions in the application of the American college of cardiology (ACC/AHA) 2018 guideline for cholesterol management. PloS one. 2023;37:128-43.

R U O Y E U WE VAL ! K C A B D E FE

AZPA NEWS

Arizona Pharmacy Workforce and Workplace Survey Participate here or scan the QR code!

Dear Arizona licensed pharmacy professionals, The purpose of this survey is to assess the prevailing workplace conditions for pharmacy professionals across Arizona. By engaging in this feedback process, The Arizona Pharmacy Association (AzPA) aims to gain valuable insight into the experiences and challenges related to pharmacy work environments in the state. Information from this survey will inform strategic decision-making, enabling us to engage with stakeholders (e.g. Arizona Board of Pharmacy, Arizona Legislators, etc.) to implement targeted interventions and policies that address specific concerns and enhance the overall workplace experience for our pharmacy professionals. Ultimately, this initiative is rooted in our dedication to fostering a positive and supportive workplace culture that reflects our organization's values and prioritizes the well-being of our Arizona pharmacy professionals. This survey is being administered by AzPA and all responses will be completely anonymous. Individual results will not be shared with anyone but rather only aggregate data and percentages.

View complete list of awards and criteria here! General Guidelines: • Self Nominations are allowed. • Multiple nominations from differing sources encouraged/strengthen application. • You must be an AzPA member to nominate someone for these awards and in some cases the nominee also needs to be a member. AzPA Awards • Committee will consider the quantity, quality, and source(s) of nominations as well as nominees participation within AzPA. • If you are nominating someone for more than 1 award you will need to fill out a separate survey for each award.

Each year the Arizona Pharmacy Association encourages its members to nominate individuals in the pharmacy profession who they feel have gone above and beyond the call of duty.

tell us who inspired you this year!

Nominations must be received no later than midnight on January 31, 2024. Click here or scan the QR code to nominate!

EDITORIAL UNIVERSITY & ALUMNI

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

Bernadette Cornelison named 40 Under 40 Honoree by Tucson Hispanic Chamber of Commerce Bernadette Cornelison, PharmD, MS, BCPS, an assistant clinical professor at the University of Arizona R. Ken Coit College of Pharmacy, has been selected as one of the honorees for the 2023 Class of 40 Under 40 Honorees by the Tucson Hispanic Chamber of Commerce. The individuals chosen for this honor exemplify leadership and commitment within the community. The 40 Under 40 Awards also recognize and acknowledge individuals who contribute to the advancement and improvement of their local community. Dr. Cornelison is among 40 honorees who will be celebrated during the 40 Under 40 Awards Breakfast on December 8.

In collaboration with the Tucson Family Advocacy Program, the local International Rescue Committee and with teachers who instruct English as a Second Language, she created resources for underserved communities to help individuals gain a better understanding of pharmacy services. These resources and the process developed to create them have been recognized both locally and internationally.

“This award is symbolic of the impact I have on my community, especially with my patients and students,” Dr. Cornelison said. “This profession sometimes requires time away from family, so this award is a humbling recognition of the service we provide to the community, in addition to our personal commitment and responsibilities.” In addition to co-coordinating the self-care therapeutics course for first-year pharmacy students and over-the-counter medications for undergraduates to undergraduate students, Dr. Cornelison is an ambulatory care clinical pharmacist at Banner Health. Dr. Cornelison was nominated by Brian Erstad, PharmD, MCCM, FCCP, FASHP, BCPS, a professor and head of the Department of Pharmacy Practice and Science at the Coit College of Pharmacy. Among the qualities he highlighted were positivity and optimism. “The theme of optimism weaves into her daily perspective on life and in her teaching of hundreds of students,” Dr. Erstad said. “She also works with several patients every year that have uncontrolled diabetes, high blood pressure, high cholesterol, and patients who want to quit using tobacco.” Ensuring equal access to healthcare is a top priority for Dr. Cornelison. Regardless of the barriers to accessing medications, whether economic, cultural, or linguistic, she works diligently to meet patients’ specific health needs and desired health outcomes.

Bernadette Cornelison, PharmD, MS, BCPS

“Working with underserved populations, I have witnessed many patients aren’t just battling their health or medical issues, but sometimes also racial or cultural challenges,” she said. “Sometimes, just making an extra phone call or spending an extra minute to understand the true challenges of each individual, can really make an impact on someone’s life.” Dr. Cornelison’s selflessness also extends into the classroom. She mentors at least 10 students every year and continues to mentor students as they navigate their careers in pharmacy. As a faculty member and a mentor, she hopes her students gain the knowledge and expertise to provide high-quality patient care within their community. “No matter where our students end up practicing, whether it be research and development, community, hospital, or ambulatory care pharmacy, we serve our communities to protect them from a myriad of risks,” she said. continued on next page

CONT. UNIVERSITY & ALUMNI Dr. Brian Erstad selected to co-chair international panel Brian Erstad, PharmD, MCCM, FCCP, FASHP, BCPS, a professor and head of the Department of Pharmacy Practice and Science at the University of Arizona R. Ken Coit College of Pharmacy, has been appointed co-chair of an international panel for the Society of Critical Care Medicine. The Society of Critical Care Medicine is the largest nonprofit medical organization dedicated to promoting excellence and consistency in the practice of critical care. Dr. Erstad will lead efforts to develop guidelines concerning the use of treatments for critically ill adult patients that need to receive sustained paralysis in the intensive care unit setting to help ameliorate various disease states and potentially reduce mortality. “The intent is to help ensure patients receive the most appropriate use of the class of medications known as neuromuscular blocking agents.” Dr. Erstad said. “These medications paralyze skeletal muscles, so despite their potential usefulness, they have potential adverse effects related to prolonged paralysis such as venous thromboembolism, muscle weakness after discontinuation, and decubitus ulcers.” As an international panel, the guidelines developed by Dr. Erstad and the panel will be used by all healthcare professionals who practice in critical care settings. The impact of which will contribute to improved patient safety and better patient outcomes.

“Dr. Erstad’s years of experience make him an ideal cochair for the Society of Critical Care Medicine,” said Rick Schnellmann, PhD, dean of the Coit College of Pharmacy and the Howard J. Schaeffer Endowed Chair in Pharmaceutical Sciences. “He will make an immediate impact in this role and advance healthcare practices for those who are most vulnerable.” Dr. Erstad's involvement in this panel is not his first experience in this role. He previously led the development of clinical practice guidelines for stress ulcer prophylaxis for the American Society of HealthSystem Pharmacists. He has also served on development panels for other clinical practice guidelines with organizations such as the University HealthSystem Consortium, the American College of Chest Physicians, and the American College of Surgeons. Additionally, he is currently serving as a methodologist on a guideline panel for the American Thoracic Society. “The Society of Critical Care medicine has many physician, pharmacy and nursing leaders in the field of critical care,” he said. “It is an honor to co-chair a distinguished panel of health professionals for the organization.”

Brian Erstad, PharmD, MCCM, FCCP, FASHP, BCPS

EDITORIAL UNIVERSITY & ALUMNI

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

Seasons Greetings from the College of Pharmacy at Midwestern University! We are thankful for all our faculty, staff, students, alumni, and friends and continue to celebrate our blessings and accomplishments. December is a fantastic time for the College as we celebrate the amazing accomplishments of our faculty and students. The ASHP Midyear Clinical Meeting was held in Anaheim, CA and the College was well represented: • Over 35 students presented posters. • Seven faculty gave ten podium presentations. • We showcased our PGY-1 Community Residency programs. • Recruited for our PGY-2 programs and Infectious Diseases fellowship. • Featured our Student Societies and Clinical Skills Teams. • Celebrated awards for Dr. Kellie Goodlet and Ms. Nour Khankan (CPDG24).

Not to be outdone by December, the last day of September and October were humming with our White Coat Ceremony and the activities of National Pharmacy Month. On September 30th we officially welcomed the Class of 2026 by awarding their White Coat at a special ceremony and reception. The next week, we ushered in National Pharmacy Month with guest speakers, displays featuring the unique areas of pharmacy practice, and concluded with an interactive pharmacy carnival. This hands-on event let the campus know the outstanding contributions the pharmacist makes to patient care and the medical team. We continue to be immensely proud of our students and alumni as they are the voice and future of our profession.

On Sunday, December 3rd, we hosted the College of Pharmacy Alumni and Friends reception in Anaheim in conjunction with the American Society of Health System Pharmacists (ASHP) conference. We had an incredible reception at The House of Blues-Anaheim. Thank you to all our faculty, staff, alumni, students and friends who stopped by to join us. I hope you had the chance to see the beautiful holiday decorations in and around the Disneyland Resort, the parks, and Anaheim Convention Center during your stay.

White Coat Ceremony

Alumni Reception

CONT. UNIVERSITY & ALUMNI 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/alumni-job-finder. We are looking forward to catching up with all of you and connecting at a future event. If you’re ever back in the Glendale area, please reach out and stop by the campus. So much has changed, but still remains the same welcoming place. 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-College of Pharmacy Follow us on Twitter: @MWUpharmacy Follow us on Instagram: @MWUpharmacy

White Coat Ceremony

EDITORIAL UNIVERSITY & ALUMNI

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

Creighton University addresses healthcare inequities with Institute for Population Health Healthcare disparity in the U.S. is pronounced. Consider these facts: • In 2022, the U.S. spent $4.3 trillion – or $12,000 per person – on healthcare, more than any other country. • Still, life expectancy in the U.S. is lowest amongst the world’s wealthiest countries. • The social and structural imbalances separating those with access to proper healthcare and those who without are widening.

“As the Arizona population continues to grow and age, Creighton’s Institute for Population Health (IPH) will play a pivotal role in promoting equitable health care, including promoting vaccinations, patient-centered care and service to underserved populations,” says Timothy P. Ivers, PharmD, AAHIVP, on-site coordinator of the Phoenix Pharmacy Pathway and assistant professor of pharmacy practice at Creighton’s School of Pharmacy and Health Professions.

Population health, an emerging healthcare field, seeks to identify, understand and reduce the health disparities facing entire populations by examining the physical, economic and social determinants of health.

IPH initiatives will focus on: • Education and workforce development • Clinical innovation • Research and evaluation • Community engagement • Policy and advocacy

Creighton University recently announced its establishment of the Institute for Population Health (IPH) to advance health justice for all through education, research and advocacy. The institute aligns with Creighton’s tradition of excellence in healthcare education, research and patient care; longstanding community and healthcare partnerships; and Jesuit, Catholic commitment to service and justice. It also builds upon the University’s established national and global programming in Omaha, Central Nebraska, Denver, Anchorage, Phoenix and the Dominican Republic.

Timothy P. Ivers, PharmD, AAHIVP

The University officially celebrated the launch of the institute and explored issues related to population health during a public symposium at its Omaha campus on Oct. 23 and 24. More than 250 in-person and online attendees learned from local and national experts on ways to improve health equity and population wellness via professional and community collaboration during the two-day conference, Building Bridges for Healthier Communities. Sessions included: • How population health builds healthier communities • What programs and services Creighton currently offers that address population health and health equity • How healthcare leaders use human centered design to bring diverse populations together to identify, brainstorm and iteratively develop solutions to meet a population’s needs by focusing on the end-user’s experience and on engaging stakeholders as those solutions are developed The importance of partnerships among health systems, social services, schools and universities, policymakers, public health and businesses to address the fundamental social determinants of health

EDITORIAL UNIVERSITY & ALUMNI • The importance of partnerships among health

systems, social services, schools and universities, policymakers, public health and businesses to address the fundamental social determinants of health • The barriers facing many women in accessing culturally sensitive maternal care and the role of doulas in reducing health disparities and improving mental health outcomes • How urban and rural leaders are working to expand access to care in their communities

By working in tandem with communities and the community leaders of affected populations, building bridges with healthcare systems and educating tomorrow’s healthcare professionals how to combat health disparities, the Institute seeks health justice for communities today. Because better health equals a better world, for all.

The Institute for Population Health exemplifies the Jesuit value of cura personalis, or care for the whole person, and Creighton’s commitment to social justice. Collaboration, as demonstrated by Creighton Phoenix’s partnership with CyncHealth, will b central to its success. Additionally, “the Phoenix Health Sciences campus serves the community interprofessionally through the St. Vincent DePaul medical clinic in the southern valley and continues to expand its role in similar settings” to bring Creighton healthcare to numerous populations, Ivers adds.

AZPA NEWS

It's time to nominate yourself or a colleague! 2024 AzPA Board of Directors AzPA is looking for new leaders to serve on our Board of Directors. Consider giving back to your profession and organization by lending your time, talent, and resources to advance the profession and organization forward. It is your privilege as a dues paying member to run for office and serve on the Board of Directors. Please refer to information below about the duties and responsibilities. Should you have any questions please contact staff at admin@azpharmacy.org. This year we are looking for 6 individuals: • President • President-Elect • 4 Directors at Large (DAL)

NOMINATE HERE OR SCAN THE QR!

ONE (1) PRESIDENT Term: The President shall be elected for a term of one year and shall ascend to the position of Past President in year 2. Duties: The President shall be the principal official of the AzPA. The President shall serve as Chair at all membership and Board of Directors meetings of the organization. The President, with approval of the Board of Directors, appoints the Chairs and members of all Committees. Except as otherwise provided, the President shall fill all vacancies by appointment. The President shall serve as the Chair of the Board of Directors. The President shall be a member of the Nominating Committee. Qualifications: Must be a pharmacist who has served on the APF, PNA or AzPA Board of Directors for at least one year

ONE (1) PRESIDENT-ELECT Term: The President-Elect shall be elected for a term of one year and shall ascend to the position of President in year 2 then Past President in year 3. Duties: The President-Elect shall perform the duties of the President when the President is unable to do so. The President-Elect shall be a member of the Board of Directors and shall serve as its Vice-Chair. The President-Elect shall be a member of the Nominating Committee. The President-Elect shall serve on the Board of Directors for the Arizona Pharmacy Foundation (APF) as the official AzPA representative. Qualifications: Must be a pharmacist who has served on the APF, PNA or AzPA Board of Directors for at least one year.

FOUR (4) GENERAL DIRECTORS AT LARGE Term: Director at Large positions shall serve a term of two (2) years. Duties/Qualifications: General Director at Large shall be a pharmacist from any practice setting who will represent the interests of all association members.

NEW ON-DEMAND PROGRAM! 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.

EDITORIAL Rx AND THE LAW

Compounding Difficulties

This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and the Arizona Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

The Food and Drug Administration (FDA) has a number of lists concerning compounding, especially compounding from bulk drug substances. There are lists for both 503A and 503B compounders and there are substantial differences in the lists for these two types of compounders. This article is focused on 503A compounding. The relevant lists are: bulk drug substances that can be used to compound, the withdrawn or removed list, and the Demonstrably Difficult to Compound list. One current issue is the addition of bio-identical hormones being added to the Demonstrably Difficult to Compound list. Under current law, pharmacies wishing to compound preparations using bulk drug substances under Section 503A of the Food, Drug and Cosmetic Act must use bulk drug substances that meet one of the following criteria: (a) comply with an applicable United States Pharmacopeia (USP) or National Formulary (NF) monograph if one exists, and the USP chapter on pharmacy compounding, (b) are components of FDAapproved drug products if an applicable USP or NF monograph does not exist; or (c) appear on FDA’s list of bulk drug substances that can be used in compounding if such a monograph does not exist and the substance is not a component of an FDA-approved drug product. Provision (c) is the list of bulk drug substances that are permitted to be used for compounding for humans. Pharmacies' compounded preparations that meet

these criteria are exempted from some requirements of the Food, Drug and Cosmetic Act, such as the New Drug approval requirements, labeling with adequate directions for use, and current Good Manufacturing Practices requirements. Compounding by pharmacies that is not done within this framework is not exempted from the Food, Drug and Cosmetic Act requirements and those products are considered misbranded and/or adulterated. The Demonstrably Difficult to Compound list is intended to identify drug products that are, as the name implies, difficult to compound. These difficulties result in an adverse effect on the safety or effectiveness of the preparation. Inclusion of a drug product on the Demonstrably Difficult to Compound list also precludes it being exempted from the Food, Drug and Cosmetic Act requirements as outlined above. The current battle is over the inclusion of bio-identical hormones on the Demonstrably Difficult to Compound list. Pharmacy groups, especially pharmacy compounding groups, are opposing the addition due to the long safety record of compounded bio-identical hormone use and the potential reduction in therapy choices for patients. The FDA commissioned a report by the National Academies of Sciences, Engineering, and Medicine to investigate compounded bio-identical hormone therapy. Their report was published in July 2020 and recommends the inclusion of hormone compounds on the Demonstrably Difficult to Compound list.

CONT. PAAS NATIONAL The controversary here is the rationale on which the committee based the recommendation. The stated basis for inclusion on the Demonstrably Difficult to Compound list is complexities involving the formulation, the drug dose delivery mechanism, the dosage form, the ability to control bioavailability, analytical testing, or the compounding process itself. The presence of one or more of these complexities then causes a negative effect on the safety or effectiveness of the compounded preparation. The report cites the lack of data regarding the safety and effectiveness of bio-identical hormone therapy, but does not necessarily cite that this concern stems from the difficulty in compounding these preparations. The concern is the lack of safety and effectiveness data that meets the standards of FDA approved products. Preparations compounded within the regulatory framework are exempt from meeting the New Drug approval requirements. It seems like a very circular argument that a preparation should not be allowed to be compounded because of the lack of safety and effectiveness data that it is not required to have. This could be said for any compounded preparation, not just bio-identical hormones. Another concern was the lack of complete labeling for compounded bio-identical hormones. Preparations compounded within the regulatory framework are exempt from the labeling requirements of the Food, Drug and Cosmetic Act. Again, not meeting a requirement that they are not required to meet.

The report highlights other risks and complexities associated with compounding in general that are not necessarily restricted to only compounded bioidentical hormones, with the exception of pellets. One of the givens of compounding is that the resulting preparation is not approved by FDA and FDA does not evaluate these medicines for safety, effectiveness, and quality. However, compounded preparations are prescriptions; there is a provider prescribing the compounded drug, it is labeled according to state pharmacy regulations, and pharmacists are performing drug utilization reviews and counseling patients. Regardless of the basis for inclusion, adding bioidentical hormones to the Demonstrably Difficult to Compound list will remove exemptions from meeting requirements of the Food, Drug and Cosmetic Act and regulatorily prohibit their compounding. Bioidentical hormones have not been added to the list yet, so the battle is not over. The conflict will certainly continue in the courts if they are added. © Don R. McGuire Jr., R.Ph., J.D., is General Counsel, Senior Vice President, Risk Management & Compliance 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.

ADVOCACY PHARMACY DAY

Pharmacy Day at the Capitol

PURPOSE

Meet with state legislators to discuss current issues relating to pharmacy and health care. Highlight the advanced patient care services pharmacists provide throughout our community. Network with our pharmacists, students and technicians in an effort to help raise awareness about our profession. AGENDA 9:00AM

Set-Up

10:00AM

Legislative Briefing (all attendees)

11:00AM

Education and Lunch

12:30PM

Clean Up

1:00PM

Recognition on House and Senate Floor

1:30PM

Group Photo

11:00AM - 4:30PM

Capitol Visits

LOCATION

Arizona State Capitol Complex 1700 W. Washington St | Phoenix, AZ 85007 Parking Information: CLICK HERE Map: CLICK HERE

MEETINGS If you wish to meet with your legislator please register using the form below. Note: You will need to know what district you live and work in to register: CLICK HERE We will make every effort to book as many appointments as we can. You will be paired with other pharmacy professionals attending the event.