Pharmacy Practice+Business - November 2017

NOVEMBER 2017

Palliative care of patients with dementia

Are you ready to be rated?

PM 42940023

EMBRACING THE EHR

“Way cooler than counting pills” is how Adam Silvertown describes his specialty compounding practice

New! From the publishers of Pharmacy Practice+ and Pharmacy Business

CanadianHealthcareNetwork.ca

Ź

34

Contents

ON THE COVER

Small and mighty! PACE Compounding Pharmacy is growing among the giants through specialization and relationship-building discounts.

NOVEMBER 2017

OPINION 7 Editor’s Message

Crafting a future in specialty practice

YOUR PRACTICE 9 Drug News

A review of new launches, new indications, new dosage forms and Health Canada advisories

15 Practice Experts Adverse Reactions; Practical Diabetes

21 5 Tips: Pearls for your practice

Managing co-morbid issues in patients on methadone maintenance therapy

24 In Sync

27 Clinical feature

Cover photography: Jaime Hogge

Palliative care in patients with dementia

MIND YOUR BUSINESS 39 Pharma Finance

Value drivers to sell your pharmacy at the highest price

34

40 Private Eye

What’s your score from Green Shield?

42

Report from the National Community Pharmacists Association conference

15

48 Back Talk/ Managing

Embracing the EHR

27

47 Classified section

Debunking myths about med sync and ABM

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[Vol.4 No.9] NOVEMBER 2017

5

YOUR ALLY WHEN TAKING ANTIBIOTICS

, the only probiotic approved by Health Canada to have demonstrated an efficacy in the prevention of AAD and C.difficile.*

65

%

Reduces the risk of antibiotic-associated diarrhea*

95

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Reduces the risk of Clostridium difficileassociated diarrhea in hospitalized patients*

*Gao et al. 2010. AM J Gastroenterology. 105(7); 1636-1641

THE #1 PROBIOTIC MOST RECOMMENDED IN CANADA † Pharmacy Practice+ and Profession Santé 2016 Survey on OTC Counselling and Recommendations

†

EDITOR’S MESSAGE

/ Vicki Wood

GROUP BRAND DIRECTOR, HEALTHCARE Janet Smith VICE PRESIDENT/DIRECTOR, EVENTS & MARKETING Michael Cronin EDITOR Vicki Wood CONSULTING CLINICAL EDITOR

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Crafting a sustainable practice I’ve wanted to profile our cover subject Adam Silvertown since he had the exhibit booth next to ours at Pri-Med 2017, the country’s largest inter-professional CME conference.

I already knew Adam as a creative pharmacist who understands the importance of marketing—he was an early adopter of Twitter, Facebook and customer e-newsletters. I was impressed that he’d invested in a booth at Pri-Med—what a great way to promote your specialty pharmacy and compounding services to more than 3,700 physicians, nurse practitioners and pharmacists.

With my tunnel vision, all I saw was Silvertown’s business savvy in using the event to reach professionals who might wish to refer patients to his pharmacy. And that was how I asked our writer, Anne Bokma, to approach her subject: as a pharmacist who really “gets” how to market his services to potential clients.

Well, as it turns out, our subject had a completely different story to tell (p. 34). And, as the universe so often arranges, that story converges with a much bigger phenomenon we’re tracking.

While Anne was interviewing Adam, I was at the other end of the continent learning about what many believe is the next wave of pharmacy innovation and sustainability: Community Pharmacy Enhanced Specialty Networks. As you’ll read on page 42, advanced practice pharmacies across the U.S. are linking together, and with other healthcare professionals, to form neighbourhood networks of high-quality patient care. They’re doing this as a way to survive, even benefit from, the new quality- and outcomesbased reimbursement models being enforced by health payers.

Just creeping into Canada through Green Shield’s new valuebased pharmacy rating initiative (see page 40), quality-based reimbursement is already entrenched in U.S. healthcare. Medicare payments are based on the ratings that GSC is impementing here.

When this trend expands in Canada, proactive pharmacies like Adam’s will be ready. These pharmacies are already investing in enhanced specialty services and creating connected care networks in their communities.

An article in Pharmacy Times magazine likened the specialty network movement to the advent of craft breweries in the beer industry: there will always be a market for cheap, mass-market suds, but those who care about quality find more satisfaction, autonomy and reward in crafting a high-quality product at a premium.

It’s no stretch to liken specialty pharmacists, whether compounders, disease specialists or appointment-based consultants, to craft brewers, slow-food artisans or small-batch winemakers. If you think of yourself that way, you’re ready for the future.

Just, please (sorry, but I have to say it): remember to let people know what you’re doing.

vwood@ensembleiq.com @Ppr_plus

[Vol.4 No.9] NOVEMBER 2017

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YOUR PRACTICE š Drug

News

ÕÞ´Ê×× ÖÞÛĂ?Ă˜ĂŒĂ‘ RPh, BScPhm, ACPR is a consulting clinical editor for Pharmacy Practice +Business and drug information consultant for Pharmacist’s Letter and Prescriber’s Letter.

A review of new launches, new indications, new dosage forms and Health Canada advisories

Tresiba third basal insulin analogue in Canada (insulin degludec injection; 100 U/mL and 200 U/mL solution IRU LQMHFWLRQ LQ SUHĆŹOOHG P/ )OH[7RXFK PXOWLGRVH GLVSRVDEOH SHQV 1RYR 1RUGLVN

INDICATIONS Once-daily treatment of adults with diabetes to improve glycemic control. In type 2 diabetes, can be used in combination with oral antidiabetic agents (OADs), when OAD treatment does not achieve adequate glycemic control, but should not be combined with a thiazolidinedione OAD (e.g., pioglitazone).

Can be used in combination with rapidacting or short-acting insulin, with or without metformin, in type 2 diabetes when basal, basalbolus or premix insulin therapy with or without metformin does not achieve adequate glycemic control. In patients with type 1 diabetes, must be used in regimens containing rapid-acting or shortacting insulin to cover mealtime insulin requirements.

Not recommended for treatment of diabetic ketoacidosis.

ACTION Classified as an ultra-long-acting basal insulin analogue. Forms multihexamers when injected into subcutaneous (SC) tissue, resulting in a SC depot of insulin degludec. Has a protracted time–action profile primarily due to delayed absorption of insulin degludec from the SC tissue to the systemic circulation and to a lesser extent due to binding of insulin degludec to circulating albumin. Mean maximum glucose lowering effect (GIRmax) occurs at a median of 12 hours after the first SC dose. Steady state serum concentrations are reached after three to four days of once-daily SC administration. The glucose-lowering effect lasts for more than 42 hours once the drug is stopped after eight days of once-daily injections. The elimination half-life is about 25 hours and is independent of dose.

DOSAGE Should be individualized and titrated according to the patient’s metabolic needs and glycemic control target. Insulin-naïve patients: For those with type 1 diabetes, start with approximately one-third to one-half of the total daily insulin dose (generally, the initial total daily insulin dose in insulin-naïve patients with type 1 diabetes is 0.2–0.4 units/kg). The remainder of the total daily insulin dose should be administered as a short-acting insulin and divided between each daily meal. Recommended starting dose

in insulin-naĂŻve patients with type 2 diabetes is 10 units once daily. Consult product monograph for dosage guidelines when switching from another insulin therapy to insulin degludec. Note than 1 U of insulin degludec corresponds to 1 U of insulin glargine 100 U/mL or 1 U of insulin detemir.

ADMINISTRATION Inject SC once daily, at any time of day, in the thigh, upper arm or abdominal wall. Rotate injection sites within the same region, to reduce the risk of lipodystrophy. If patients miss a dose, advise them to inject their daily dose upon discovering the missed dose and to make sure that there is at least eight hours between consecutive injections. Should not be given intravenously (may cause severe hypoglycemia), intramuscularly (may change the absorption) or via an insulin infusion pump.

ADVERSE EFFECTS MOST COMMON: Hypoglycemia, weight gain. Lipodystrophy occurs rarely if injection sites are rotated. Can occasionally cause injection site reactions (e.g., hematoma, pain). MOST SERIOUS: Severe hypoglycemia, hypersensitivity and allergic reactions (can occur with any insulin product).

SUPPLIED The 100 U/mL (U-100) pen contains a total of 300 units and provides insulin in increments of 1 U, with a maximum dose per injection of 80 U. The 200 U/mL (U-200) pen contains a total of 600 units and provides insulin in increments of 2 U, with a maximum dose per injection of 160 U. STORAGE Store in the refrigerator (2°C–8°C). After first opening (or when carried as a spare), the FlexTouch pen can be stored at room temperature (not > 30°C) or in the refrigerator for up to eight weeks. Keep the cap on the pen in order to protect from light.

Other new products Glatect JODWLUDPHU DFHWDWH PJ P/ VROXWLRQ IRU VXEFXWDQHRXV LQMHFWLRQ P/ SUHĆŹOOHG V\ULQJH 3HQGRSKDUP 3KDUPDVFLHQFH

INDICATIONS Treatment of ambulatory patients with relapsing remitting multiple sclerosis. This includes [Vol.4 No.9] NOVEMBER 2017

9

(Other new products continued)

patients who have experienced a single demyelinating event and have lesions typical of multiple sclerosis on brain magnetic resonance imaging (MRI) scans. Used to decrease the frequency of clinical exacerbations and reduce the number and volume of active brain lesions identified on MRI. DOSAGE 20 mg once daily administered

by SC injection. Can be injected into any of the following sites: back of the upper arms, front and outside of thighs, upper buttocks/rear of hips and abdomen.

Rotate the injection site daily.

COMMENTS A biosimilar (subsequententry drug) to the Canadian Reference Product, Copaxone (Teva). Copaxone is supplied in both 20 mg/mL (once-daily) and 40 mg/mL (three times-a-week) strengths.

New indications Epclusa

(sofosbuvir/velpatasvir tablets), Gilead Sciences.

EXPANDED INDICATION Indications section now notes that the safety and efficacy have been established in hepatitis C virus-infected patients, with or without cirrhosis, who are co-infected with HIV-1.

DOSAGE One tablet (400 mg/100 mg sofosbuvir/velpatasvir) orally once daily, with or without food, for 12 weeks.

Keytruda

(pembrolizumab injection), Merck.

NEW INDICATION Monotherapy treatment of refractory or relapsed classical Hodgkin lymphoma in adults who have failed autologous stem cell transplant (ASCT) and brentuximab vedotin, or who are not ASCT candidates and have failed brentuximab vedotin. Issued marketing authorization with conditions for this indication, pending the results of studies to verify the drug’s clinical benefit.

10

EXPANDED INDICATION Treatment of metastatic nonsmall cell lung carcinoma (NSCLC) as monotherapy, in adults whose tumours have high PD-L1 expression [(tumour proportion score ≥ 50%)] as determined by a validated test, with no EGFR or ALK genomic tumour aberrations, and no prior systemic chemotherapy treatment for metastatic NSCLC. (Previously indicated only for use in the treatment of unresectable or metastatic melanoma, and for the treatment of metastatic NSCLC as monotherapy, in adults whose tumours express PD-L1 and who have disease progression on or after platinumcontaining chemotherapy.)

DOSAGE Refractory or relapsed Hodgkin lymphoma: 200 mg administered as an intravenous infusion over 30 minutes every three weeks. Metastatic nonsmall cell lung carcinoma (previously untreated): 200 mg administered as an intravenous infusion over 30 minutes every three weeks until disease progression, unacceptable toxicity or up to 24 months in patients without disease progression.

Ultibro Breezhaler

(indacaterol/glycopyrronium inhalation powder hard capsules), Novartis.

EXPANDED INDICATION Now approved for the reduction of exacerbations of chronic obstructive pulmonary disease (COPD) in patients with a history of exacerbations. This is in addition to the original indication: long-term once-daily maintenance bronchodilator treatment for airflow obstruction in patients with COPD, including chronic bronchitis and emphysema.

DOSAGE Oral inhalation of the contents of one capsule once daily using the Ultibro Breezhaler.

Xalkori

(crizotinib capsules), Pfizer.

NEW INDICATION Monotherapy for use in patients with ROS1-positive (ROS1 is a receptor tyrosine kinase) locally advanced or metastatic nonsmall cell lung cancer. The drug was previously approved only for use in the treatment of anaplastic lymphoma kinase (ALK)-

NOVEMBER 2017 [Vol.4 No.9]

New generics

• Adenosine Injection

(adenosine 3 mg/mL injection; 2 mL and 4 mL prefilled syringes), Fresenius Kabi.

• Apo-Erlotinib (erlotinib HCl

25 mg, 100 mg and 150 mg tablets), Apotex. Generic alternative to Tarceva.

• Moxifloxacin Injection (moxifloxacin 1.6 mg/mL; 250 mL freeflex bag), Fresenius Kabi.

• Mylan-Pregabalin

(pregabalin 25 mg, 50 mg, 75 mg, 150 mg, 300 mg capsules), Mylan.

Generic alternative to Lyrica.

• Sandoz Deferasirox

(deferasirox 125 mg, 250 mg and 500 mg tablets; blister packs of 28 tablets), Sandoz. Generic alternative to Exjade.

positive locally advanced or metastatic nonsmall cell lung cancer.

DOSAGE 250 mg twice daily, with or without food. Swallow capsules whole.

Continue treatment for as long as the patient is deriving clinical benefit.

New dosage form Omnitrope

(somatropin [rDNA origin] solution for injection), Sandoz.

New higher strength pen cartridge (15 mg/1.5 mL) joins the existing 5 mg/1.5 mL and 10 mg/1.5 mL pen cartridge strengths, and the 5.8 mg/vial lyophilized powder for solution, with diluent.

Health Canada advisories Solu-Medrol Act-O-Vial:

hypersensitivity reactions

Solu-Medrol Act-O-Vial 40 mg (methylprednisolone 40 mg) contains bovine-sourced lactose as an excipient.

Intravenous or intramuscular administration can lead to serious allergic reactions (e.g., bronchospasm, anaphylaxis) in patients allergic to cow’s milk proteins.

This product is contraindicated in patients with a known or suspected hypersensitivity to cow’s milk.

[ CUSTOM CONTENT ]

GAYLE ROMANETZ LOOKS FOR TOUCHPOINTS TAKING THE

CUSTOMER EXPERIENCE TO THE NEXT LEVEL

BY DONALEE MOULTON

Gayle Romanetz is Loblaw Companies Limited’s senior director of pharmacy operations. Ensuring customers have a great experience is integral to her job. She spoke with Pharmacy Business about how a pharmacy team can stand out from the crowd – and stand out in their patients’ minds.

“ PHOTO BY BRANDON GRAY

Today’s customer wants more than a prescription filled with medication by a generic pharmacist; they are looking for a partnership and holistic approach to health.

You have talked about striving to create an innovative experience for customers. Tell us why this is so important, and how you go about creating such an experience.

We put a lot of pressure on ourselves when we confuse invention with innovation.

Invention is a thing, whereas innovation is synonymous with continuous improvement. The implementation of innovative ideas keeps things fresh; it drives colleague and customer engagement while appealing to a new patient base. If you want to be an innovator, you have to think like one and that means resisting the status quo; start small and build upon the wins one at a time. No one expects you to be the next Thomas Edison!

Truly helping people to manage their health demonstrates value and builds loyalty. How does Loblaw achieve this goal?

What would you recommend pharmacists do to enhance their value to customers?

Today’s customer wants more than a prescription filled

with medication by a generic pharmacist; they are looking for a partnership and holistic approach to health. Challenge your team to take some risks and go beyond medication management.

Earlier this year we launched Wellness kiosks in our Loblaw stores which allow our patients to track their blood pressure, body mass index and more. By connecting this information to our pharmacies, we can better assist by providing our patients with a whole view of their health and help them to make positive changes.

You mentioned that one of your goals is to create a great experience for customers. What constitutes a great experience?

How do you know when you have succeeded in doing this?

A great experience is just that; it doesn’t have to be complicated.

You leave feeling valued and in our profession, it goes even deeper. A customer needs to know that their health matters.

I see hundreds of stories each week from customers who provide feedback about

how the pharmacy teams help them. Sometimes the story is lifesaving, however, most days we hear from people who sincerely appreciate how their pharmacist helped them navigate a complicated healthcare system.

How can pharmacists enhance compliance? Are there essential ingredients to success?

Compliance is top of mind for pharmacists and we need to keep things simple amid today’s fastpaced technology and the need to satisfy busy lifestyles. With day-to-day demands getting in the way, it’s not surprising many people accidentally miss a dose or delay refilling a prescription.

Digital tools are a convenient solution that allows customers to access their drug profile, medication information, and order refills from their computer or smartphone anywhere, anytime.

Creating touchpoints with customers is vital. How can pharmacies of all sizes do this?

The customer experience starts anywhere your pharmacy can be seen through a website, advertisement, in-store marketing or in person. Map out your workflow and what touchpoints will have the most value always considering the customer’s perspective. The size, format, and value proposition of your store will drive your workflow; it is not one size fits all. The one constant and “do no wrong” is to develop a personal connection with your customer, and that always starts and ends with a name.

Leaders in Pharmacy, including this independently written article, is supported by Pfizer Canada Inc.

(Health Canada advisories continued)

Canagliflozin:

risk of lower limb amputation

Products containing canagliflozin, a sodium glucose co-transporter type 2 (SGLT2) inhibitor used as an oral antihyperglycemic agent in patients with type 2 diabetes, can increase the risk of lower limb amputation. The increased risk occurs as early as the first 26 weeks after starting canagliflozin therapy. The absolute risk is higher in patients with previous amputations, existing peripheral vascular disease or neuropathy.

Healthcare providers should check the patient history for factors that may increase amputation risk (e.g., previous amputation, existing peripheral vascular disease or neuropathy), preferably before starting treatment with canagliflozin.

They should also: • closely monitor patients with risk factors for amputation; • advise patients of the importance of routine preventive foot care and good hydration; • inform patients of the signs and symptoms of volume depletion; • monitor patients for volume depletion and ensure adequate hydration to prevent volume depletion (diuretic use may worsen dehydration); • advise patients to notify a healthcare provider if they develop sores, ulceration, discolouration, infection,

face (use only on small darkened areas or spots); apply a UVA/UVB sunscreen after each application; discontinue use and consult a healthcare provider if hyperpigmentation (dark spots) develops or worsens after using hydroquinone; avoid contact with the eyes, mucous membranes and broken or irritated skin; do not use on children or during pregnancy or if breastfeeding; and return any unused hydroquinone product to the pharmacy for safe disposal.

new lower extremity pain or tenderness; and • discontinue canagliflozin if a patient develops a significant complication that may precede amputation, such as lower-extremity skin ulcer, infection, osteomyelitis or gangrene.

Effient:

severe skin side effects

Cases of severe skin side effects have been reported by the manufacturer of Effient (prasugrel). However, a Health Canada’s review concluded that there is insufficient information to establish a link. Health Canada will continue to monitor this risk.

Further details about these advisories and safety reviews can be obtained from the MedEffect Canada website: https://www.canada.ca/en/health-canada/ services/drugs-health-products/medeffectcanada.html and https://www.canada.ca/en/ health-canada/services/drugs-health-products/ medeffect-canada/safety-reviews.html.

Hydroquinone:

higher concentrations to switch to Rx status

Health Canada will be adding topical hydroquinone at concentrations > 2% to the Prescription Drug List as of August 29, 2018. Concentrations > 2% applied topically have been associated with a higher risk of severe skin redness, burning/stinging, dryness/cracking, blisters/oozing and skin discolouration.

Hydroquinone has also been shown to cause cancer in lab animals (and potentially in humans) and is also harmful to the environment. Healthcare providers should reinforce the following points regarding topical hydroquinone: use only for the recommended duration according to product label directions; do not apply to large surfaces of the body or

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INTRODUCING: PHARMACY PRACTICE + BUSINESS

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YOUR PRACTICE š Practice

ADVERSE REACTIONS

Experts

SANDRA KNOWLES

Our pharmacist experts share information and ideas to support your daily practice.

BScPhm is a drug information pharmacist with Sunnybrook Health Sciences Centre in Toronto.

Antibiotic adverse events in hospitalized patients

Getty Images

Antibiotics are used in approximately 50% of patients admitted to hospital. Although antibiotics are life-saving for many patients, overuse can be associated with adverse drug events (ADEs) including allergic reactions, development of antibioticresistant organisms and Clostridium difficile infections.

In order to determine the incidence of antibioticassociated ADEs in adult inpatients receiving systemic antibiotic therapy, medical records were examined for 30 days after antibiotic initiation for the development of antibiotic-associated ADEs, and up to 90 days for the development of C. difficile infections.

The study included 5,579 patients (median age: 59 years) admitted to a general medicine ward in a US tertiary care facility. During the study period, 1,488 (27%) patients received antibiotics for at least 24 hours. The most frequently prescribed antibiotics were third-generation cephalosporins (41%), parenteral vancomycin (37%) and cefepime regimens (28%).

A total of 298 patients (20%) experienced at least one antibiotic-associated ADE. Most reactions occurred during hospitalization, but 27% occurred after hospital discharge including 11 patients who Judicious developed C. difficile antibiotic infection and 44 patients who developed prescribing, multidrug-resistant regardless whether organism infections. in hospital or in The most common an ambulatory ADEs involved the gastrointestinal system setting, is needed (42%), kidney (24%) to reduce the harm and blood (15%). associated with Additionally, the study investigators antibiotics. determined that 19% of antibiotic regimens were not clinically indicated, most commonly because of treatment of asymptomatic bacteriuria or treatment of noninfectious lower respiratory tract conditions. Among these patients, 56 (20%) experienced an ADE, including seven cases of C. difficile infection. Every additional 10 days of antibiotic therapy increased the risk of developing an ADE by 3%.

Implications for pharmacists Use of antibiotics in patients admitted to hospitals is common. This study found that almost 20% of patients experienced at least one antibiotic-associated adverse event during or following their hospital admission.

Judicious antibiotic prescribing, regardless whether in hospital or in an ambulatory setting, is needed to reduce the harm associated with antibiotics.

REFERENCE Tamma PD, Avdic E, Li DX, et al. Association of adverse events with antibiotic use in hospitalized patients. JAMA Intern Med 2017;177:1308-15.

Mortality related to menopausal hormone therapy The Women’s Health Initiative (WHI) hormone therapy trials assessed the benefits and risks of menopausal hormone therapy used for chronic disease prevention.

Health outcomes from these studies have been reported, although none have focused on all-cause and causespecific mortality. The present report is based on mortality data after a cumulative follow-up of 18 years.

A total of 27,347 postmenopausal women were recruited from 1993 to 1998; 16,608 women with a uterus were randomized to receive daily oral conjugated equine estrogen (CEE) plus medroxyprogesterone acetate (MPA) or placebo (median duration 5.6 years), and [Vol.4 No.9] NOVEMBER 2017

15

PRACTICAL DIABETES

YOUR PRACTICE

SHELLEY DIAMOND

10,739 women with a hysterectomy were randomized to receive daily oral CEE or placebo (median duration 7.2 years).

A total of 7,489 deaths were documented. All-cause mortality in the overall pooled cohort was 27.1% with hormone therapy vs 27.6% with placebo. For the individual trials, allcause mortality was 26.4% for CEE plus MPA vs 26% for placebo, and 28.3% for CEE alone vs 30.% for placebo.

Cardiovascular mortality was 8.9% in the hormone therapy group vs 9% in the placebo group, without any differences between trials. As well, no difference was noted between groups for coronary heart disease and stroke mortality. Cancer mortality rates were also similar between the intervention groups (8.2%) and the placebo group (8%).

Implications for pharmacists Using data from the WHI trials, menopausal hormone therapy using either combination therapy (CEE plus MPA) or CEE alone did not increase the risk of death after 18 years of follow-up.

Similar findings were noted for all-cause mortality as well as for cardiovascular and cancer mortality. An accompanying editorial notes that these findings are reassuring, especially for women considering hormone therapy for treatment of vasomotor symptoms, premature menopause or early-onset osteoporosis.

REFERENCES North American Menopause Society. The 2017 hormone therapy position statement of the North American Menopause Society. Menopause 2017;24:728-53. www. menopause.org/docs/default-source/2017/nams-2017hormone-therapy-position-statement.pdf (accessed September 19, 2017).

Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal hormone therapy and long-term all-cause and causeöóèæìĤæ ðòõ÷äïì÷ü ÷ëè àòðèñđö Ñèäï÷ë Òñì÷ìä÷ìùè Ûäñçòðìýèç Trials. JAMA 2017;318:927-38.

McNeil M. Menopausal hormone therapy: understanding ïòñê¡÷èõð õìöîö äñç åèñèĤ÷ö ÓÊÖÊ " !' #!( )!!¡#

16

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BScPhm is a pharmacist and co-founder of www. diabetescarecommunity.ca, an extensive online resource for Canadians living with diabetes, their families and healthcare professionals..

Microalbuminuria in patients with type 2 diabetes ASKING THE RIGHT QUESTIONS Microalbuminuria is the term used to describe a “moderate” amount of albumin in the urine—defined as a urine albuminto-creatinine ratio (ACR) of ≥2 mg/mmol or a 24-hour urine collection of albumin of 30–300 mg/day.(1)

What is the connection between microalbuminuria and renal disease?

Albumin normally resides in the blood; however, when there is damage to the kidneys, permeability is affected and albumin leaks through the glomerulus and passes into the urine. Albuminuria is therefore a marker of diabetic nephropathy.(2) A diagnosis of chronic kidney disease is made based on two of three ACR levels taken over a three-month period, or an estimated glomerular filtration rate (eGFR) < 60mL/min at three months.(1)

NOVEMBER 2017 [Vol.4 No.9]

Why assess microalbuminuria in people with prediabetes and diabetes?

Microalbuminuria in people with prediabetes is associated with a higher likelihood of progressing to diabetes and a lower chance of reversing to normoglycemia. Aggressive intervention is therefore indicated in those with prediabetes and microalbuminuria.(3) For people with diabetes, albuminuria is currently the earliest clinical marker for diabetic nephropathy. Since diabetic nephropathy is the most common cause of end stage renal disease and is associated with cardiovascular disease, early detection is vital.(4)

When should people with type 2 diabetes be screened for diabetic nephropathy?

A random ACR and a serum creatinine (to calculate the eGFR) should be done at the time of diagnosis of type 2 diabetes, and then annually.(1)

How is microalbuminuria managed?

An angiotensin-converting enzyme

YOUR

PRACTICE

inhibitor (ACEI) or an angiotensin II receptor blocker (ARB) should be started to delay the progression of chronic kidney disease. More recently, the EMPAREG OUTCOME trial showed that empagliflozin, an SGLT2 inhibitor, slows progression of nephropathy when added to standard care.(5)

What additional monitoring is required for those on an ACEI, ARB or SGLT2 inhibitor?

Potassium and serum creatinine should be checked at the start of therapy and then within one to two weeks. This also applies to anytime when therapy is being titrated or during periods of acute illness.(1) Monitor for kidney damage (increased serum creatinine and decreased eGFR), which typically occurs in the first month

of therapy. Patients should be advised to report any swelling of the legs or feet or a reduction in urination.

NOTE: If patients become ill and cannot maintain an adequate fluid intake, or if they are dehydrated due to gastrointestinal upset, which may result in an acute decline in renal function, ACEIs, ARBs and SGLT2 inhibitors should be held until the patient is no longer dehydrated or renal function improves.(7)

What about combination therapy?

Currently there is no evidence that combining an ACEI and ARB slows the progression of kidney disease compared to an ACEI or ARB used alone. When combinations are used, the risk for adverse effects is increased.(8)

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What else should be monitored to reduce the risk or slow the progression of nephropathy?

Glucose control and management of blood pressure are essential for helping to reduce the progression of kidney damage.(1)

What is the hope for the future?

In most cases, significant renal impairment has already occurred even before the presence of microalbuminuria, so earlier markers are needed and are currently being studied.

Summary

Check to make sure your patients with diabetes are screened for microalbuminuria; this should be high on your list.

Early intervention can slow the loss of kidney function and improve patient outcomes. .

REFERENCES 1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada.

Can J Diabetes 2013;37(suppl 1):S329-31. http:// www.canadianjournalofdiabetes.com/article/S14992671(13)00079-8/pdf (accessed August 20, 2017).

2. Mogensen CE, Chachati A, Christensen CK, et al.

Microalbuminuria: an early marker of renal involvement in diabetes. Uremia Invest 1985-1986;9(2):85-95.

3. Dutta D, Choudhuri S, Mondal SA, et al. Urinary albumin:creatinine ratio predicts prediabetes progression to diabetes and reversal to normoglycemia: role of associated insulin resistance, inflammatory cytokines and low vitamin D. J Diabetes 2014;6:316-22.

4. Fiseha T. Urinary biomarkers for early diabetic nephropathy in type 2 diabetic patients. Biomark Res 2015;3:16. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4491239/ (accessed August 20, 2017).

5. Wanner C, Inzucchi SE, Lachin JM, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med 2016;375:323-34.

6. FDA Drug Safety Communication. FDA strengthens kidney warnings for diabetes medicines canagliflozin (Invokana, Invokamet) and dapagliflozin (Farxiga, Xigduo XR). https://www.fda.gov/downloads/Drugs/DrugSafety/ UCM506772.pdf (accessed August 20, 2017).

7. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Appendix 7 (2015) Sick day medication list. http://guidelines.diabetes.ca/browse/ appendices/appendix7_2015 (accessed August 20, 2017).

8. Cupp M. ACEI, ARB, and aliskiren comparison. Canadian Pharmacistâ&#x20AC;&#x2122;s Letter 2016;32(3):320328.

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Many patients enrolled in MMT have medical issues in addition to their primary problem of addiction. Individuals residing in rural communities must often travel some distance to receive their witness and carry methadone doses.

MMT patients may visit your pharmacy with a prescription for a medication related or unrelated to their use of methadone. They may be reluctant to admit to receiving MMT because of the associated stigma, but will usually readily mention their MMT in order to prevent a drug interaction or interference with a urine drug screen. Pharmacists can help manage common problems in patients receiving MMT by following the five practical tips outlined in this article.

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1

Managing co-morbid issues in patients on methadone maintenance treatment

BY SUSAN HALASI, MScPhm, RPh

The number of patients on methadone maintenance treatment (MMT) has grown tremendously. Although many provinces do not keep precise statistics, a Canadian Executive Council on Addictions (CECA) review revealed an enrolment increase from 700 patients in 1996 to 29,743 in 2010 in Ontario alone.(1) CECAâ&#x20AC;&#x2122;s 2016 survey results are expected to be released later this year.(2)

OTC products containing dextromethorphan or doxylamine should be avoided because they might cause a false-positive result for opiates.

revent tainting a urine drug P screen with OTC products

Patients on MMT must provide an observed urine specimen weekly in order to receive methadone carry doses.

Individuals failing this test lose their carry privileges and suffer the inconvenience of daily returns to the pharmacy for a witnessed methadone drink. Urine drug screen panels are generally similar from clinic to clinic, but it is important to recommend OTC products that will not interfere with the analysis. A typical panel monitors the urine for five agents: methadone, oxycodone, other opiates in general (including fentanyl), cocaine and benzodiazepines.(3) OTC products containing dextromethorphan or doxylamine should be avoided because they might cause a false-positive result for opiates.(3,4) Assays with high sensitivity may falsely detect the presence of opiates if a person has ingested a large quantity of food containing poppy seeds (e.g., cakes, bagels, muffins).(5)

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21

2

mphasize the importance of E smoking cessation

Smoking rates in people with alcohol and other drug dependencies are two to four times those of the general population.(6) The risks of lung, larynx and liver cancers may also be substantially increased in MMT individuals.(7) Pharmacists can help reduce these serious outcomes by suggesting smoking cessation therapy for MMT patients who smoke.

A combination of pharmacotherapy and behavioural support increases smoking cessation success.(8)

3

Promote good oral hygiene

Patients receiving MMT therapy tend to be younger (25–35 years), often suffer from malnutrition, depend on social assistance, and have lower oral hygiene standards.(9) Their poor oral health may be due to several reasons. Methadone and other opioids suppress salivary secretion, allowing for bacterial plaque accumulation. Caries in the canines and premolar teeth are common in this population (presenting as missing teeth in the lower jaw). Methadone activates µ and ĸ-opioid receptors, resulting in a craving for sugary foods and beverages.

Poor brushing and flossing habits, coupled with high plaque accumulation, frequently result in early tooth loss. Many have dental anxiety, leading to delays in appointments for cleaning or treatments.

Methadone may also contribute to increasing the severity of a dental problem by masking pain caused by oral disease. Finally, this population suffers a higher incidence of bruxism, which may lead to enamel wearing, mandibular joint disorders and myofascial pain.(9)

4

ealize that MMT may affect R erectile function

Male patients often voice sexual complaints associated with MMT. The International Index of Erectile Function uses a self-administered questionnaire to assess erectile dysfunction, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction.(10) MMT patients have poor scores in most of these domains. Although low plasma testosterone levels and hypogonadism have been attributed to MMT, multivariate analysis has demonstrated that these 22

factors are not the main cause of sexual dysfunction.(10) Literature estimates of sexual dysfunction in MMT patients range from 16%–33%. One report investigating men with sexual dysfunction correlated MMT with improvement in potency. Patients in this study were divided into low MMT (< 50 mg/d), medium MMT (50–110 mg/d) and high MMT (> 110 mg/d). They were also stratified according to duration of MMT: recent (< 1 yr) or chronic (> 1 yr).

The study found that neither dose nor duration of MMT had an impact on functional improvement, rather the initiation of MMT, having a constant partner, and abstinence from heroin use were factors in potency improvement.(10) Another study found that 60.5% of 157 men receiving MMT suffered from erectile dysfunction. Men with diabetes, heart or vascular disease were excluded from the trial. In an effort to increase potency, these men were given escalating doses of trazodone (starting at 50 mg/d, progressing to 100 mg/d and in some cases reaching as high as 200 mg/d to achieve a satisfactory response) over a period of six weeks.(11) Significant improvement in erectile function with trazodone therapy was seen in men who had been receiving a lower dose of methadone and had been on MMT for a shorter period of time (study did not specify dose or duration of MMT).(11)

5

ppreciate that MMT induces A hyperhidrosis

A lesser-known side effect of MMT is excessive sweating (hyperhidrosis). Patients may find themselves drenched in sweat while doing daily activities. This effect has been attributed to methadone’s modulation of central temperature regulation via muscarinic receptor stimulation. A case report of a 35-year-old male receiving methadone100 mg/d documented the successful use of oxybutynin 5 mg four times daily, with the hyperhidrosis completely resolving within two days of starting oxybutynin.(12) An alternate theory to explain excessive sweating with MMT suggests that opioids cause degranulation of mast cells, resulting in the release of histamine. Pursuing this theory, clinicians treated two MMT patients (one receiving methadone 50 mg/d, the other 90 mg/d),

NOVEMBER 2017 [Vol.4 No.9]

with desloratadine 5 mg daily. At a onemonth follow-up, both patients reported the sweating ended within one day of starting the antihistamine.(13)

Summary

Patients receiving MMT have specialized needs. Pharmacists can play a key role in supporting adherence to MMT programs by ensuring that patients with carry doses continue to receive this privilege. They can reduce the incidence of carcinogenicity and dental disorders by encouraging good lifestyle habits. Finally, recognizing and lobbying prescribers to address unwanted side effects of MMT will promote successful outcomes in this patient population.

Susan Halasi (modac@rogers.com) received her Master of Science in Pharmacy at the University of Toronto. She is currently a pharmacist at the Burnham Medical Pharmacy in Peterborough, Ontario.

REFERENCES 1. Luce J, Strike C. A cross-Canada scan of methadone maintenance treatment policy developments. A report prepared for the Canadian Executive Council on Addictions. www.ceca-cect.ca/ (accessed March 16, 2017).

2. Sondergaard L, National Priority Advisor, Canadian Centre on Substance Abuse. Written communication; April 30, 2017.

3. McFadden J, Charge nurse, Hunter Street Clinic Peterborough, Ontario. Verbal communication; May 12, 2017.

4. Rogers SC, Pruitt CW, Crouch DJ, et al. Rapid urine drug screens: diphenhydramine and methadone cross-reactivity.

Pediatr Emerg Care 2010;26:665-6.

5. Smith ML, Nichols DC, Underwood P, et al. Morphine and codeine concentrations in human urine following controlled poppy seed administration of known opiate content.

Forensic Sci Int 2014;241:87-90.

6. Apollonio D, Philipps R, Bero L. Interventions for tobacco use cessation in people in treatment for or recovery from substance use disorders. Cochrane Database Syst Rev 2016;11:CD010274.

7. Grinshpoon A, Barchana M, Lipshitz I, et al. Methadone maintenance and cancer risk: an Israeli case registry study.

Drug Alcohol Depend 2011;119(1-2):88-92.

8. Stead LF, Koillpillai P, Fanshawe TR, et al. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev 2016;3:CD008286.

9. Brondani M, Parker PE. Methadone and oral health—a brief review. J Dent Hyg 2011;85(2):92-8.

10. Zhang M, Zhang H, Shi CX, et al. Sexual dysfunction improved in heroin-dependent men after methadone maintenance treatment in Tianjin, China. PLoS One 2014;9(2):e88289. doi:10.1371/journal.pone.0088289.

11. Tatari F, Farnia V, Nasiri RF, et al. Trazodone in methadone induced erectile dysfunction. Iran J Psychiatry 2010;5:164-6.

12. Hong J, Lee J, Totouom-Tangho H, et al. Methadoneinduced hyperhidrosis treated with oxybutynin. J Addict Med 2017;11:237-8.

13. Al-Adwani A, Basu N. Methadone and excessive sweating.

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PRACTICE / In Sync

Exploring the appointment-based model of pharmacy practice.

FROM FICTION TO FACT

Debunking the myths about med sync and ABM

BY DONALEE MOULTON

The appointment-based model (ABM) is improving the way many pharmacists work and enhancing the relationship they have with patients. Still, misconceptions persist about the patient-centred approach to pharmacy services developed by California pharmacist John Sykora more than 20 years ago. This article debunks the top myths and misunderstandings:

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in the online version of this article. Visit

CanadianHealthcareNetwork.ca/pharmacists

portant and when issues regarding that medication can be effectively addressed. Med synchronization and ABM do both. “The biggest challenge for pharmacists is figuring out how to get time to interact with patients and find out why a patient is not adherent,” says David Edwards, associate dean with the Faculty of Science at the University of Waterloo. Ongoing interaction is built into the ABM, and better adherence is the result. Holdford and Inocencio found that enrollment in ABM makes patients three to six times more likely to be adherent.(1) Al Chilton, president and CEO of Rubicon Pharmacies Canada Inc., in Regina, points out that ABM is about sustaining and nurturing interactions with patients—and that leads to greater adherence. “People you’ve built a relationship with, and who trust you, are more likely to take their medications,” he notes.

MYTH #3. Revenues decline with fewer pharmacy visits. On the surface, this commonly-held belief makes

MYTH #1. It will take a lot of time to train staff and reengineer workflow. There is a learning curve

to any new process. However, implementing medication synchronization and ABM does not and should not overwhelm staff or disrupt workflow. Moving patients to a regular prescription pickup requires some setup time on the front end, but once that’s done, ABM streamlines workflow, says Scarborough pharmacy owner Laura Furdas, who prints a list each day of patients who need to be called about medication refills. “It really does improve operations,” she notes. “Prescriptions are filled proactively, not reactively. We don’t have that same swamped feeling.”

MYTH #2. ABM will not help improve adherence rates or patient outcomes. Adherence improves when patients understand why their medication is im-

24

NOVEMBER 2017 [Vol.4 No.9]

MYTH #4. Patients won’t like ABM. The facts shows otherwise—definitively. A 2015 study found the majority of patients were highly satisfied with the medication synchronization program offered. And there was no significant differentiation based on age, gender, health, income or other patient demographics.(2) As McCullough notes, the ABM actually frees up blocks of time, providing greater opportunity for such one-onone services as medication checks and reviews.

This improved adherence leads to better patient outcomes. But ABM is not about numbers, it’s about people.

Michael Wright, chief business development officer at Rubicon Pharmacies, remembers one patient who wrote a poem about the impact ABM had on their life. Bottom line: they felt in greater control of their health.

REFERENCE 1. Holdford D,Inocencio T. Adherence and persistence associated with an appointment-based medication synchronization program, J.Am Pharm.Assn. 2013; 53:6: 576-583.

2.Butler KT, Rulsinger JF, Bates J, Prohaska ES, Melton BL. Participant satisfaction with a community-based medication synchronization program. J Am Pharm Assoc.

2015; 55(5)

Illustration by Martin Bregman

sense. Not so in reality, says Jesse McCullough, who has implemented the appointment-based model in more than 4,500 U.S. pharmacies. “We often think that the more people come into our store, the more they will purchase. Research shows this isn’t the case.”

As well, studies have consistently shown that patients in medication synchronization and/or appointment based model programs will pick up 84 more days of refills compared to those not in the program.(1)

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our population ages, people are increasingly living with chronic diseases, including dementia. The Alzheimer Society reports that 25,000 new cases of dementia are diagnosed every year in Canada, and in 2016, 1.1 million Canadians were affected directly or indirectly by the disease at an annual cost of $10.4 billion.(1) It can be particularly challenging to provide care to people with dementia who are near the end of life. To assist pharmacists in providing palliative care to these patients, this article explains the concepts of palliative care, frailty, dementia and delirium. The role of medications for memory loss and for the behavioural and psychological symptoms of dementia is briefly discussed. The article also outlines how community pharmacists can support palliative patients with dementia and their caregivers, including assisting with deprescribing near end of life.

CLINICAL FEATURE

Palliative care in patients with dementia How pharmacists can assist patients and caregivers

BY CAROLEE AWDE, RPh, BScPhm

What are dementia, palliative care and frailty?

Dementia is progressive and irreversible loss of memory and thinking skills that impair functioning.

Alzheimer’s disease is the most common form of dementia. Vascular dementia and mixed vascular and Alzheimer’s dementia are also very common.

Progression of dementia in Alzheimer’s disease occurs at a rate of about two years per stage (mild, moderate, severe), but is less predictable in patients with vascular comorbidity.(2) Other rarer dementias exist and should be diagnosed and managed by a geriatrician.

Dementia is a progressive disease. Some patients are still able to make personal care decisions when tasks such as management of medications and money—the first notable losses—have become problematic. All demented patients need individual and recurring assessment (see Patient assessment tools below). Patients with a history of delirium or mild cognitive impairment (i.e., intact function despite cognitive concerns) have a higher risk of dementia.(3) Palliative care is care directed at comfort. It is not limited to end-of-life care and does not necessarily exclude active treatment of symptoms or underlying conditions. The goal is to maximize quality of life until the natural end of life.(4) Misconceptions about palliation can often delay palliative care in patients with dementia.

The need for palliative care arises when a medical condition is not curable and the patient becomes frail.

[Vol.4 No.9] NOVEMBER 2017

27

Frailty, a multidimensional reduction in physiological reserve, is a measure of functional decline. A frail patient is unable to plan and organize management of a chronic illness or day-to-day activities.

Both physical and cognitive frailty should be considered when care planning for concurrent illness. For example, when renal, cardiac or respiratory compromise is added to a “fragile brain” (history of delirium, known dementia), there is a risk of permanent functional and cognitive loss from aggressive interventions.(5)

At the end of life, several issues become apparent: inability for self-care, inability to make decisions, behavioural symptoms and physical frailty.

Palliative care in patients with dementia

Two distinct streams of dying demented patients require palliative care: those dying of another illness whose care is complicated by dementia and the consequent inability to communicate or comprehend clearly, and those whose dementia has reached end stage.

Disease management in demented persons is no different than in anyone else with the same specific disease,

but symptom assessment can be more challenging. Regardless of the type of lifethreatening disease, patients need to be kept free of distressing symptoms, often (but not exclusively) with medications, and caregivers need to be supported.

MANAGEMENT OF END-STAGE DEMENTIA

than the presentation of dementia. Current research is focused on early diagnosis and monoclonal amyloid antibody treatment at the early stage. Trials of solanezumab and aducanumab are ongoing in Canada, with the hope of more promising results with earlier intervention compared to use in patients who already have documented cognitive impairment.(10,11)

Medication for memory loss Cognitive enhancers (donepezil, rivastigmine, galantamine) are of limited usefulness and are only effective in the early and middle stages of Alzheimer’s dementia.(8) They should be offered, but continued only if well tolerated. The goal of treatment is to improve quality of life, with adverse effects weighed against potential benefit.

Funded provision of cognitive enhancers may be limited to patients within a specific range of Mini–Mental State Examination (MMSE) scores.

Memantine has some evidence for improving attention and memory in Lewy body dementia.(9) With improvements in diagnostic imaging, Alzheimer’s disease has been determined to have a much earlier onset

Medication for BPSD (responsive behaviours) As dementia progresses, patients may exhibit behavioural and psychological symptoms of dementia (BPSD), now called responsive behaviours, the newer term for BPSD. They may become agitated and irritable. There may be paranoia and refusal to cooperate with care, including medication-taking. Patients may appear confused, as they are unable to recall information or instruction. Inappropriate behaviour can be challenging to deal with, but is often a sign used to communicate important personal, social or physical changes (Box A).(12) Behavioural management strategies are first-line therapies for responsive behaviours; antipsychotics should only be used to supplement behavioural management.(13) Addressing pain, bowel care and mood can reduce the need for antipsychotics.(14) Cholinesterase inhibitors are not helpful for improving behaviour, and may worsen frontal-temporal dementia.(15) Specific drugs may be preferred for managing certain symptoms: quetiapine for agita-

At the end of life, several issues become apparent(6): inability for self-care, inability to make decisions, behavioural symptoms and physical frailty; more detail is available in the Alzheimer Society’s “Progression” series resource.(7) The following sections discuss the management of key issues in patients with end-stage dementia.

BOX A

BEHAVIOUR AS A FORM OF COMMUNICATION Help caregivers understand that the patient’s responsive behaviour may be a form of communication to express(12): • Pain (chronic undertreated or acute e.g., osteoporotic spontaneous fractures, injuries from an unwitnessed fall) • Constipation or urgency • Acute illness

• Sensory (vision, hearing, proprioception) loss (may manifest as fear and confusion)

• Processing deficit (cognitive decline) (may manifest as anxiety and intolerance of change) • Awareness of problems (may manifest as frustration, anger, control issues).

• Loneliness, boredom, depression, confusion, frustration, fear

28

NOVEMBER 2017 [Vol.4 No.9]

BOX B

DELIRIUM RISK FACTORS

The mnemonic “I WATCH DEATH” can be helpful in recognizing risk factors and causes of delirium(19):

• Infectious (encephalitis, meningitis, urinary tract infection, pneumonia) • Withdrawal (alcohol, barbiturates, benzodiazepines)

• Acute metabolic disorder (electrolyte imbalance, hepatic or renal failure) • Trauma (head injury, postoperative)

• CNS pathology (stroke, hemorrhage, tumour, seizure disorder, Parkinson’s)

• Hypoxia (anemia, cardiac failure, pulmonary embolus)

• Deficiencies (vitamin B12, folic acid, thiamine)

• Endocrinopathies (thyroid, glucose, parathyroid, adrenal)

• Acute vascular (shock, vasculitis, hypertensive encephalopathy)

• Toxins, substance use, medication (alcohol, anesthetics, anticholinergics, narcotics) • Heavy metals (arsenic, lead, mercury)

tion in Lewy body dementia(16); a selective serotonin receptor inhibitor antidepressant for irritability (being cognizant of the risk of cognitive decline, hyponatremia and increased bleeding)(17); and perhaps carbamazepine for agitation.(18) Recognizing and managing delirium Delirium—acute confusion with disorganized thinking and a change in level of arousal—is a potentially reversible condition. It may be superimposed on dementia and must be distinguished from it. Box B summarizes risk factors and causes of delirium.(19) The hallmark feature is fluctuation in attention. Another good marker is a family member reporting “this is not my parent.” The patient may be agitated or withdrawn. Delirium is difficult to recognize clinically and its recognition may be complicated by the use of neuroleptics, which can be both a treatment and a potential cause of delirium.(20) The first step in delirium management is to identify and address the cause.(21) In the elderly, delirium is often caused by an occult infection (e.g., urinary tract infection [UTI]) that goes unrecognized because of a reduced febrile response to infection. Treating the UTI may lead to a resolution of the delirium. However, there is also concern that UTIs are being over-diagnosed and treated, which may promote antimicrobial resistance.(22) Help the family understand that

BOX D

RESOURCES FOR PATIENTS/ CAREGIVERS • Alzheimer Society www.alzheimer.ca/en/We-canhelp/Resources/AlzheimerSociety-brochures-andpublications (free of charge online, hardcopy and personal support at Society offices) • Dementia, a Caregivers Guide http://shop.baycrest. org/collections/dementia-acaregivers-guide/products/ dementia-a-caregivers-guide (for sale)

• OMA Guide to Caring for Persons with Dementia https:// www.oma.org/wp-content/ uploads/oma_ebook_dementia. pdf. (free)

BOX C

ASSESSING A COGNITIVELY IMPAIRED PATIENT • Obtain history from caregiver (the patient may deny deficits)(24)

• Directly observe the patient

• Monitor signs (e.g., heart rate, respiratory rate, ease of arousal, specific countable behaviours) instead of symptoms.

• Use rating scales (numeric or faces for pain or other distressing symptoms, specific scales for frailty)(25,26)

 Cohen-Mansfield Agitation Inventory(29) – many versions • Divides behaviours into Physical or

Verbal, Aggressive or Nonaggressive and quantifies them (for each listed behaviour, check the rating that indicates the average frequency of occurrence over the last 2 weeks, scale 1–7 from never to every hour)

FORMAL COGNITIVE ASSESSMENT TOOLS

 Mini–Mental State Examination (MMSE)(27) or Montreal Cognitive Assessment (MoCA)(28) • Both measure orientation to time and

place, registration and recall, attention and calculation, and the ability to follow complex commands. Both are copyright protected.

• MMSE is in multiple versions and languages,

medicine is an art as well as a science and sometimes the best medication solution for managing delirium (e.g., adding an antipsychotic or discontinuing some medications), is found by trial and error. That said, the longer the delirium persists the less likely it will fully clear and the more likely it will recur, so delirium is properly considered a medical emergency.(23)

• MMSE scores out of 30 points: > 26 is considered normal; mid-20s—family notices changes; low 20s—friends notice changes; upper teens—patient needs help with personal care, supervision and direction; < 10— responsive behaviours may diminish, becoming bedridden, stop memory enhancers at this point

 Clock drawing tests(30) - Also used in driving tests; variation in scoring (out of 3 or 4) • 1 point each for circle, numbers, spacing (may be included with point for numbers), correctly placing hands at 10 past 11 with hour hand clearly indicated.

Patient assessment tools

Tools for assessing cognitively impaired patients (Box C)(24-30) are used in an attempt to objectively quantify frailty and cognition. They also provide a common language for caregivers and allow for evaluation of both disease progression and efficacy of interventions.

BOX E

RESOURCES FOR PHARMACISTS

• SpeakUpOntario.ca (advance care planning)

• Steps forward https://www. stepsforward.org/modules/endof-life-planning (advance care planning letter to my doctor template)

• Alzheimer Society www.Alzheimer.ca • Beers list (updated 2015) American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults (http://onlinelibrary.wiley.com/ doi/10.1111/jgs.13702/pdf). Review by Cheryl Sadowski: (www.canadianhealthcarenetwork. ca/pharmacists/clinical/ health-index-therapeutics/ geriatrics/practice-issuesgeriatrics-19596)

• National Parkinson Foundation www.parkinson.org/ understanding-parkinsons/nonmotor-symptoms/speech-andswallowing •O ther disease organizations, e.g., Heart and Stroke Foundation, Lung Association, Parkinson’s Society

• Deprescribing.org for detailed advice and supporting documentation to provide prescribers

[Vol.4 No.9] NOVEMBER 2017

• Medication assessment article by Suzanne Singh: (www.canadianhealthcarenetwork. ca/pharmacists/clinical/ special-reports/clinical-featurepreparing-for-the-silverstorm-37732.)

• Rx files for a comprehensive and current summary of medication use in Canada, with a specific publication on geriatrics (Rxfiles.ca).

• Portal of Geriatrics Online Education (pogoe.org), for geriatrics generally

• Registered Nurses’ Association of Ontario. Delirium, dementia and depression screening: Screening_for_Delirium_ Dementia_and_Depression_in_ the_Older_Adult.(pdf)

29

According to the Canadian Medical Association, 10 times more informal caregivers than paid caregivers support patients at home.

Supporting caregivers

According to the Canadian Medical Association, 10 times more informal caregivers than paid caregivers support patients at home.(31) This is caregiving that cannot be replaced by current social and health programs.

It is not necessary for pharmacists to be experts on behaviour management and caregiving so long as they offer helpful resources and do not undermine the care plan. Encourage a broad range of resources. For example, information dealing with swallowing difficulties is available from the Heart and Stroke Foundation and the Parkinson’s Society (see Box D). The Alzheimer Society can provide strategies to understand and manage behaviour even if the underlying dementia is not Alzheimer’s disease. Any chronic disease website will generally have a section on managing caregiver stress. Some resources for caregivers and for pharmacists are listed in Boxes D and E.

BOX F

 MEDICATIONS that increase the risk of falls from ataxia, orthostatic hypotension or hypoglycemia.

Reconsider meds that can increase potassium, or decrease sodium, blood pressure or blood glucose.

 MEDICATIONS that are no longer needed (e.g., sedatives, herbal/ vitamin treatments for conditions that have resolved); prophylactic treatments whose benefits will not be achieved in patients with limited life expectancy (e.g., bisphosphonates, statins)

Inform caregivers that agitated behaviour can respond well to thoughtfully targeted interventions instead of medication.

Reinforce the following simple advice(32,33): 1. Agree (validate) and redirect, rather than confront and argue.

2. Use short simple sentences in a calm slow manner.

3. Provide direction one step at a time.

4. Reduce clutter and overstimulation.

5. Make things “just happen” rather than discuss them in advance.

(Don’t say “We are going to an event tomorrow.” Instead, say “Here is your coat, we are going out now.”)

• Refusal of drugs may occur due to paranoia/agitation (consider deprescribing [Box G])

 PLAN AHEAD FOR MEDICATION ADMINISTRATION • Offer compliance packaging: weekly dosette boxes are helpful to keep people oriented to the day. If boxes are not managed correctly, switch to bubble packs while the patient still has enough short-term memory for new learning.

30

MEDICATIONS TO DEPRESCRIBE

• Loss or difficulties with the oral route may occur from dysphagia due to dementia or treatment, or reduced level of consciousness (use patches or liquids, avoid injections where possible)

HOW PHARMACISTS CAN ASSIST WITH DEMENTIA PATIENT CARE  DEVELOP therapeutic relationships with patients of the pharmacy early in their care. Obtain consent to consult with family caregivers. This will contribute to effective and timely future palliative care.

BOX G

 INCORPORATE health promotion and health teaching into your practice.  KNOW where support services and assistive devices can be accessed in your community.

Obtain and display business cards and brochures for peer support groups and community services, other health professionals and professional services.

NOVEMBER 2017 [Vol.4 No.9]

 ANTIPSYCHOTICS(34) • They are known to increase mortality(35) • As disease progresses, responsive behaviour may diminish as awareness of, and thus frustration by, losses wanes • Wean slowly and be willing to resume when needed Several successful studies/ pilot projects of antipsychotic deprescribing (in conjunction with behavioural supports) in supportive care facilities have shown a reduction in drug use without regression in behaviour.(36-38)

6. Create busywork and memory boxes to occupy the patient.

7. Play music from the era of the patient’s young adulthood.

Some of these techniques may also help defuse interactions with agitated people in the pharmacy.

Families may struggle with this approach, feeling that the parent is being treated like a child or is being disrespected.

It is helpful if all care providers, including community pharmacists, reframe this strategy as responding to the changes in the patient’s brain. Geriatric programs and consultations will provide targeted suggestions for specific behaviours (see Box D).

Support the family caregiver and the care

 USE the skills from smoking cessation training to actively listen to patient and caregiver concerns.

 UTILIZE pharmacy technicians to their full scope, freeing the pharmacist for consultations.

 CHRONIC DISEASE MANAGEMENT • Perform regular medication reviews and intervene in drug-related problems. Reduce anticholinergic burden with therapeutic substitutions, dose adjustments and deprescribing (Box G). In-home reviews can reveal compliance issues not apparent in the pharmacy. Ensure that bowel care is in place (to help prevent constipation and diarrhea), and that pain is managed (often with routine use of acetaminophen).(14)

• As frailty increases, actively encourage deprescribing (Box G).

Identify and target both positive and negative signs and symptoms to monitor when deprescribing.

Remind caregivers and prescribers that decisions can be revisited.

Simplify medication regimens, to help ensure drugs are taken and to minimize errors in administration.

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PATIENT EDUCATION Help your patients become more engaged in self-managing eczema symptoms and flare-ups by providing them with an understanding of key aspects of the condition.

IMPAIRED SKIN BARRIER FUNCTION

TRIGGERS

Skin affected by eczema has a reduced ability to hold water, which results in dry, irritated skin. The compromised skin is then more sensitive to irritants and eczema flare-ups.2

Examples of the kinds of conditions, irritants and allergens that may provoke eczema symptoms and flare-ups include: cold weather, excessive sweating, frequent hand washing, antibacterial soaps, cleaning products, foods, dust, clothing fibres, plastic and plants.2,3

Self-management strategy Moisturizing is essential to managing eczema. Keeping skin well hydrated is crucial to successfully managing eczema symptoms and flare-ups. A rich moisturizer should be applied frequently throughout the day—particularly in cold weather—to replenish moisture and create a barrier to protect the skin.2,3 Moisturizing should continue even when skin is healthy.3

Self-management strategy Avoid/minimize triggers. Patients should be proactive about • avoiding and/or minimizing factors that trigger eczema symptoms and flare-ups. a trigger diary. Suggest that your patients keep a diary • toKeep track items or situations that seem to provoke symptoms and flare-ups.

For more information about Glysomed skin care products, visit www.glysomed.ca.

1. Nielsen, August 2017.

2. Canadian Dermatology Association. Eczema. www.dermatology.ca/skin-hair-nails/skin/eczema/#!/skin-hair-nails/skin/eczema/what-is-eczema-2/ (accessed November 18, 2016).

3. Eczema Society of Canada. About Eczema. Hand Eczema. Treatment. www.eczemahelp.ca/en/index.html (accessed November 18, 2016).

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plan developed by the interdisciplinary team. Family members may not all have same understanding of the patient’s diseases or prognoses. Encourage family meetings so everyone hears the same information.

What can pharmacists do?

In addition to supporting caregivers (discussed above), community pharmacists are well positioned to identify and address issues that affect the care of patients with dementia. The pharmacy staff may be among the first to identify functional decline, when there are difficulties with prescription renewals, management of compliance packaging or changes in the patient’s appearance and behaviour.

Box F summarizes key ways pharmacists can assist in supporting palliative patients with dementia. These include developing early therapeutic relationships with patients, planning ahead for potential medication administration issues, performing regular medication reviews and managing drug-related problems. In addition, as frailty increases deprescribing can be helpful; a decision-making framework for deprescribing is outlined in Box G.(34-38) Health promotion in the pharmacy can also support protective strategies for cognitive health: physical exercise, intellectually challenging activities, healthy diet, and a strong social network.(39)

Summary

Pharmacists are increasingly providing more comprehensive medication management to patients. As our society supports “aging in place,” the population in the community is becoming frailer and more likely to remain at home when demented. Broader understanding of the communication and caregiving issues will help pharmacists provide effective pharmaceutical care.

Carolee Awde (cawde_sa@yahoo.ca) recently retired as a geriatric assessor at the Geriatric Assessment and Intervention Network clinic, Peterborough Regional Health Centre in Peterborough, Ont. She also has experience as a diabetes and asthma educator, and as a palliative care and renal pharmacist.

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NOVEMBER 2017 [Vol.4 No.9]

REFERENCES 1. Alzheimer Society: Rising tide. The impact of dementia on Canadian society. 2010. www.alzheimer.ca/~/ media/Files/national/Advocacy/ASC_Rising_Tide_Full_Report_e.pdf (accessed June 20, 2017).

2. Alzheimer Society. Stages of Alzheimer’s. http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp (accessed June 20, 2017).

3. Alzheimer Society. Mild cognitive impairment. www.alzheimer.ca/~/media/Files/national/Other-dementias/ other_dementias_MCI_e.pdf (accessed June 20, 2017).

4. WHO definition of palliative care. www.who.int/cancer/palliative/definition/en/ (accessed June 20, 2017).

5. Torpy JM, Lynn C, Glass RM. Frailty in older adults. JAMA 2006;296:2280 6. Alzheimer Society. Progression. Late stage. www.alzheimer.ca/~/media/Files/national/Progression-series/ progression_latestage_e.pdf (accessed June 20, 2017).

7. Alzheimer Society. Alzheimer Society brochures and publications http://www.alzheimer.ca/~/media/Files/ national/Progression-series/progression_endoflife_e.pdf (accessed June 20, 2017).

8. Kumar A, Singh A, Ekavali. A review on Alzheimer’s disease pathophysiology and its management: an update.

Pharmacol Rep 2015;67:195-203.

9. Wesnes KA, Aarsland D, Ballard C, et al. Memantine improves attention and episodic memory in Parkinson’s disease dementia and dementia with Lewy bodies. Int J Geriatr Psychiatry 2014;30:46-54.

10. Consortium of Canadian Centres for Clinical Cognitive Research. Alzheimer’s disease trials. http://c5r.ca/ current-studies/alzheimers-disease-trials/ (accessed June 20, 2017).

11. The A4 study. Anti-amyloid treatment in asymptomatic Alzheimer’s study. http://a4study.org/about/ (accessed June 20, 2017).

12. Ontario Medical Association. Your guide to caring for a person with dementia (p. 3). https://www.oma.org/wpcontent/uploads/oma_ebook_dementia.pdf (accessed June 20, 2017).

13. Thompson CJ, Abbott R, Rogers M, et al. Interventions to reduce inappropriate prescribing of antipsychotic medications in people with dementia resident in care homes: a systematic review. J Am Med Dir Assoc 2014;15:706-18.

14. Sandvick R, Selbaek G, Seifert R, et al. Impact of a stepwise protocol for treating pain intensity in nursing home patients with dementia. Eur J Pain 2014;18:1490-500.

15. Tsai RM, Boxer AL. Treatment of frontotemporal dementia. Curr Treat Options Neurol 2014;16:319.

16. Boot BP. Comprehensive treatment of dementia with Lewy bodies. Alzheimers Res Ther 2015;7(1):45.

17. Seitz DP, Adunuri N, Gill SS, et al. Antidepressants for agitation and psychosis in dementia. Cochrane Database Syst Rev 2011;2:CD008191.

18. Leibovici A, Tariot PN. Carbamazepine treatment of agitation associated with dementia. J Geriatr Psychiatry Neurol 1988;1:110-2.

19. Family Medicine Reference. Delirium differential diagnosis – I WATCH DEATH. www.fammedref.org/mnemonic/ differential-diagnosis-i-watch-death (accessed June 20, 2017).

20. Ballard CG, Waite J, Birks J. Atypical antipsychotics for aggression and psychosis in Alzheimer’s disease.

Cochrane Database Syst Rev 2012;1:CD003476.

21. Alagiakrishnan K Delirium: practice essentials, background, pathophysiology. http://emedicine.medscape.com/ article/288890-overview (accessed June 20, 2017).

22. Lim VH, Whitehurst T, Usoro E, et al. Management of urinary tract infections in elderly patients: strategies for improvement. BMJ Qual Improv Report 2014;3:1.

23. Inouye SK, Westendorp R, Saczynski JS. Review: delirium in elderly people. Lancet 2014;383:911-22.

24. Palliative and Therapeutic Harmonization Clinic. Screening for frailty: instructions for using the FACT (Frailty Assessment for Care planning Tool). http://pathclinic.ca/wp-content/uploads/2015/04/FACT-instructionsword-doc-April-2015.pdf (accessed June 20, 2017).

25. Dalhousie University Faculty of Medicine. Clinical Frailty Scale. http://geriatricresearch.medicine.dal.ca/clinical_ frailty_scale.htm (accessed June 20, 2017).

26. Victoria Hospice Society. Palliative Performance Scale (PPSv2). http://www.npcrc.org/files/news/palliative_ performance_scale_PPSv2.pdf (accessed June 20, 2017).

27. Mini-Mental State Examination (MMSE). www.dementiatoday.com/wp-content/uploads/2012/06/ MiniMentalStateExamination.pdf (accessed June 20, 2017).

28. Dementia.org. Diagnosing dementia: the Montreal Cognitive Assessment (MoCA). https://www.dementia. org/diagnosing-dementia-the-montreal-cognitive-assessment (accessed September 8, 2017).

29. American Psychological Association. Cohen-Mansfield Agitation Inventory. www.apa.org/pi/about/ publications/caregivers/practice-settings/assessment/tools/cohen-mansfield.aspx (accessed June 20, 2017).

30. Clock Drawing Test. http://seniorfriendlyhospitals.ca/files/Clock%20Drawing%20Scoresheet_0.pdf (accessed June 20, 2017).

31. Canadian Medical Association. Policy framework to guide a national seniors strategy for Canada, August 2015. https://www.cma.ca/Assets/assets-library/document/en/about-us/gc2015/policy-framework-to-guideseniors_en.pdf (accessed June 20, 2017).

32. Alzheimer Society. Progression. Middle stage. http://www.alzheimer.ca/~/media/Files/national/Progressionseries/progression_middlestage_e.pdf (accessed June 20, 2017).

33. Ontario Medical Association. Your guide to caring for a person with dementia (p. 4-8). https://www.oma.org/ wp-content/uploads/oma_ebook_dementia.pdf (accessed June 20, 2017).

34. Bjerre LM, Farrell B, Hogel M, et al. Deprescribing antipsychotics for behavioural and psychological symptoms of dementia (BPSD) and insomnia: an evidence based clinical practice guideline (2016). www.open-pharmacyresearch.ca/evidence-based-deprescribing-algorithm-for-antipsychotics/ (accessed June 20, 2017).

35. Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2005;294:1934-43.

36. Kirkham J, Sherman C, Velkers C, et al. Antipsychotic use in dementia. Can J Psychiatry 2017;62:170-81.

37. Iyer S, Naganathan V, McLachlan AJ, et al. Medication withdrawal trials in people aged 65 years and older: a systematic review. Drugs Aging 2008;25:1021-31.

38. Canadian Foundation for Healthcare Improvement. New national results: taking seniors off antipsychotics shows dramatic improvement in care. May 16, 2016. www.cfhi-fcass.ca/SearchResultsNews/2016/05/16/newnational-results-taking-seniors-off-antipsychotics-shows-dramatic-improvement-in-care (accessed June 20, 2017).

39. Alzheimer Society. Heads up for healthier brains. www.alzheimer.ca/~/media/Files/national/Heads-up/heads_ up_healthier_brains_e.pdf (accessed June 20, 2017).

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MIGHT Niche pharmacy sets the Pace in downtown Toronto

By Anne Bokma Photography by Jaime Hogge

34

NOVEMBER 2017 [Vol.4 No.9]

be

IT’S A DAVID AND GOLIATH-STYLE SCENARIO: a modestly-sized independent specialty pharmacy that’s thriving within a stone’s throw of almost a dozen chain drugstores on one of the country’s busiest downtown thoroughfares. Pace Pharmacy, the brainchild of 38-year-old old Adam Silvertown, has only been in business 10 years but it has gained a reputation as the city’s leading destination for specialty compounded products. It’s even on friendly terms with a lot of those neighbouring chains that operate close to its location near Toronto’s Yonge Street—many of them refer patients with complex compounding prescriptions to his pharmacy.

TY Adam Silvertownâ&#x20AC;&#x2122;s PACE Pharmacy has only been in business 10 years, but has already gained a reputation as the cityâ&#x20AC;&#x2122;s leading destination for specialty compounded products.

[Vol.4 No.9] NOVEMBER 2017

35

“I literally have five Shoppers Drug Marts within one kilometre of my store,” says Silvertown. “They send me a lot business—I’m doing the stuff they can’t or won’t do.”

That “stuff ” includes customized dosage forms that aren’t commercially available—including suppositories, lollipops, transdermal gels/ointments, suspensions and lozenges—as well as medications without lactose, sugar, dyes or alcohol. His client base includes midlife women seeking bio-identical hormone replacement therapy, patients with HIV, AIDS and hepatitis, as well as vegetarians and vegans looking for animal-free products such as gelatin-free capsules. And being situated near the heart of one of Toronto’s BUILDING largest LGBT communities, a A SECOND recent unanticipated area of new growth is supplying hormone COMPOUNDING therapies for the emerging LAB WAS A “WELL transgender population.

“

CALCULATED CHOICE” TOWARDS BECOMING A MAJOR DESTINATION FOR COMPOUNDED PRESCRIPTIONS.

Investing in his specialty

Although Silvertown launched PACE (an acronym for Pharmacy and Compounding Experts) with the plan to offer specialty compounding services, after five years in operation it became clear that those services were actually driving the business. That’s when Silvertown decided to make a major (almost sixfigure) investment to build a second compounding lab, including a separate, full sterile clean room. It was the culmination of a long-held dream; what he describes as a “well-calculated choice,” toward becoming a major destination for compounded prescriptions. “In order to provide high quality and safe products, I needed a higher-tech facility. A lot of pharmacies can call themselves a compounding

4

THE 4 BEST DECISIONS HE’S MADE

36

1. Investing in high-tech compounding: “I spent a lot of time and money getting properly educated and trained at my own expense in the art and science of compounding.”

pharmacy but you need specially trained people and you need special equipment. Now we can compound products we couldn’t do before—we’ve upped our quality and we can also accommodate a higher volume.”

A case of the frontshop blues

The compounding lab is where he’d rather be—and Silvertown admits managing the frontshop isn’t his forte. That’s why he’s reduced the space he devotes to over-the-counter products to less than 300 sq. ft. of his 1,300 sq. ft. pharmacy, carrying only a limited supply of skin care products, supplements, cough/ cold/allergy remedies and pain relievers. “Of all the things that come with running a pharmacy, managing the frontshop is my least favourite task,” he admits, blaming an early drugstore internship experience when he got yelled at by a manager for not knowing exactly where the advertised laundry detergent was located. “It scared me for life,” he laughs. “That just isn’t for me. I didn’t spend all that time and energy in pharmacy school for that.”

Instead, compounding became his passion.

Concocting custom meds was “way cooler than counting pills.” He compares his job to that of a chef who seeks to perfect a dish for a customer—or a detective who figures out the clue to solving a medication mystery. “Our job is to figure out what our customers’ specific needs are and then try to accommodate them—so we spend a lot of time talking with our customers, getting to know them, and they are very appreciative of that.”

He credits his staff—there are three pharmacists in addition to himself as well as six pharmacy assistants and one pharmacy technician—with providing the kind of personalized service that keeps customers coming back. Compounding is exacting work—one complicated script could take a pharmacist hours to prepare. While a busy chain pharmacy might churn out 200 scripts a day, he says his staff “would

2. Hiring based on personality, not just skills: “I’m picky about who I hire and I’ve made some mistakes. I’d rather have a conversation than do an interview.

If I get a good feeling about someone and think they’d be a good fit with the other staff, that’s the most important thing.”

NOVEMBER 2017 [Vol.4 No.9]

3. Never stop learning: “I can attend more than 10 conferences/ seminars/symposiums every year.

This represents a significant amount of money—running well over fivefigures—every year. Pri-Med [Canada’s largest annual family medicine education conference and medical exposition held annually in Toronto] is a great opportunity to talk to family doctors and specialists.”

MARKETING SNAPSHOT: pass out” if they tried to prepare that many orders.

A typical day has the pharmacy preparing 70-100 scripts, about two-thirds of which are compounded medications. “It’s been gratifying to see our staff take such ownership and pride in the growth of the pharmacy—they feel this is their pharmacy too. I know that means I’ve hired the right people.”

Silvertown has been invited to give talks to pharmacy students and says he always tells them “the same old story: make sure you love what you do, otherwise you will be stuck in a rut and be miserable at your job for 40 years.”

It’s wisdom he gained while doing locums and relief work in the early years after graduating from the University of Toronto. “I didn’t start my own pharmacy for the money—if I worked for someone else I’d have way less stress, more money and probably a lot more hair on my head. But I didn’t find the right place where I was really happy doing what I was doing.”

Instead, he created his own “right place”. And the hard work is paying off—he continues to experience sales growth year over year and is currently mulling over the prospect of opening a second location.

“I could have chosen a different path, but I wanted independence. As a result, I definitely have a lot of professional fulfillment,” he says. “The best thing has been seeing the business grow and knowing how many customers have come to appreciate what we are able to offer.”

Anne Bokma is an award-winning Hamilton writer and former editor of Pharmacy Practice.

4. Ensuring work-life balance: “I used to be open from 9 a.m. to 7 p.m.

Then one summer I started closing the pharmacy at 6 p.m. so I could make it to my recreational softball games. I never looked back. I also stay closed on Sundays and long weekends.”

7 SURE WAYS TO GET NOTICED HERE ARE SEVEN MARKETING INITIATIVES THAT HELP PACE STAND OUT FROM THE CROWD: 1. BILL YOURSELF AS THE BEST: Pace promotes itself as “Toronto’s best compounding pharmacy” and the only fully equipped compounding pharmacy that offers free delivery anywhere in the city.

2. LEVERAGE THE POWER OF SOCIAL MEDIA: Expand your reach beyond your brickand-mortar pharmacy by ensuring you have an online presence. An early adopter of Twitter, Pace has 3,600 followers and Silvertown regularly tweets on everything from new clinical studies to general healthcare advice.

3. OFFER SUPPORT TO PATIENT GROUPS: To show support to his LGBT client base, Silvertown sponsors monthly meetings of a local AIDS support group and has put together a Pace Pharmacy team to participate in a local AIDS walk. He’s also donated wall space to a local shelter for clients to display their artwork.

4. ALIGN WITH OTHER PHARMACIES: Area pharmacies often refer patients to Pace for complicated compounding prescriptions that they might find challenging to fill. In turn, Silvertown has referred patients with chronic conditions, such as diabetes, to local pharmacies with expertise in specific areas of disease management.

5. MEET FACE TO FACE WITH PHYSICIANS: Silvertown takes advantage of every opportunity he can to meet in person with area physicians to ensure he’s more than just a voice on the other end of the phone. When doctors call the pharmacy he asks for a meeting, and often invites them for a tour of his compounding facility. “That way they can be assured of the quality of our work and our high standards,” he says.

6. KEEP ADVERTISING LOCAL AND TARGETED: Pace doesn’t spend a lot on traditional advertising.

Instead, he participates in neighbourhood campaigns such as running digital ads in the elevator of a neighbouring condo building and offering a 10% discount on frontshop products to employees at a nearby office building.

7. NOTHING BEATS WORD-OF-MOUTH: A happy customer inevitably brings in more customers.

“A lot of our customers refer their friends and neighbours to us because they like our patient-focused approach— that’s still the best form of marketing,” says Silvertown.

[Vol.4 No.9] NOVEMBER 2017

37

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MIND YOUR BUSINESS / Pharma

Finance

The information you need to help you make the most of your hard-earned wealth.

MIKE JACZKO

BScPhm, RPh, CIM

VALUE DRIVERS TO SELL YOUR PHARMACY AT THE HIGHEST PRICE

Warren Buffett has said: “Price is what you pay, value is what you get.”

We have often written about how to arrive at the theoretical price when selling your pharmacy. Today we focus on the importance of paying attention to the factors that drive the value of your pharmacy business. The benefits of this are two-fold: first, if you pay attention to the factors that improve the cash flow of your business, you will make more money; second, when you finally decide to sell, your pharmacy business will be worth more.

Over a series of articles, we are going to focus on 10 pharmacy-specific drivers that will add value to your pharmacy business. After all, valuation is not about determining what you think your pharmacy is worth; it is what that next guy is prepared to pay! Marketing your pharmacy is a process in “price discovery.” So, look at these value drivers as a guide to help you evaluate your pharmacy business through the eyes of a Valuation potential buyer. It is through this lens that we will draw your attention to three of the is not about 10 pharmacy-specific drivers of value. determining Think of a value driver as either a what you think characteristic of your pharmacy business reduces the risk associated with owning your pharmacy that the pharmacy business, or a component that is worth; it is enhances the prospect that the pharmacy what that next business will grow further in the future. Of course, the corollary is the greater the risk, guy is prepared the less a buyer is prepared to pay.

The better your pharmacy business scores to pay! in the areas that we’ll cover, the greater the probability that your pharmacy business will make you more money while you own it and will garner more interest and a higher sale price when you sell it in the future. The end result will be that your pharmacy business valuation will garner a higher earnings multiple.

Remember: Value = Cash Flow X Earnings Multiple

#1 Financial performance

“Cash flow is king.” Everything you have worked for boils

MAX BEAIRSTO

B.Sc.Pharm, MBA, CVA

down to how much cash flow your pharmacy business generates year-over-year on a predictable basis. A predictable pattern will garner a premium price when selling. It’s all about “risk.” The lower the risk of losing the cash flow in a transfer of ownership, the higher the value to the buyer.

It goes beyond stability of the earnings, however; the cash flow from your pharmacy business needs to be both substantial enough to attract a buyer but proportionately in keeping with industry norms. The absolute value of your cash flow should be over a certain threshold to entice the buyer and allow him to withstand market fluctuations. Your cash flow as a proportion of top-line sales should also be commensurate to that of your peers.

#2 Growth and scalability

Acquirers typically pay the most for businesses with the greatest growth rate and potential to grow. In rare cases, an acquiring company may even buy a business that scores high on growth potential but low on other attributes, because the acquirer sees a way to leverage some of its own assets to help the business grow much more quickly than it could under its current owner.

#3 Recurring revenue

Businesses with recurring and predictable revenues are the number one greatest creator of wealth for astute pharmacy business owners. Businesses that create recurring and predictable revenues will always attract interested buyers. This is why retiring pharmacy owners are often able to sell their practices for considerably more money than a doctor or lawyer who sells his/her practice. We refer to such practices as “zero-based” revenue businesses. Buyers are willing to pay more when they perceive that the cash flow of your pharmacy business is substantial, predictable, growing and recurring.

In our next installment, we will discuss the role of “concentration risk:” why reliable financial information plays an important role in your valuation and how important it is to “you-proof ” your business.

THE NEXT THREE INSTALMENTs IN THIS SERIES CAN BE FOUND AT PHARMACYU.CA AND CANADIANHEALTHCARENETWORK.CA.

Mike Jaczko (mjaczko@kjharrison.com) is a portfolio manager and partner of KJ Harrison, a Toronto-based private investment management firm. . Max Beairsto (max@enterprisevaluators.com) is a certified valuation analyst and business intermediary with Enterprise Valuators, an Edmonton-based valuation and business sales advisory firm. Their Pharmacy Edge division helps pharmacy entrepreneurs with transactional and valuation advice.

[Vol.4 No.9] NOVEMBER 2017

39

MIND YOUR BUSINESS ¹ Private

KAREN WELDS

Eye

is a journalist and editor specializing in healthcare and åèñèĤ÷ö ìööøèö

A look at private payer and drug plan issues äģèæ÷ìñê óëäõðäæü

WHAT’S YOUR SCORE FROM GREEN SHIELD? Pharmacies across Canada will have received ÷ëèìõ Ĥõö÷ ēÙä÷ìèñ÷¡Òðóäæ÷ ÜæòõèæäõçöĔ éõòð Green Shield Canada (GSC) during the last week of October, marking the official start of the insurer’s ground-breaking—and heavily debated—Value-Based Pharmacy program.

Since GSC announced the program in August, reactions from pharmacists, pharmacy retailers and pharmacy associations have been mixed to say the least.

While pharmacy stakeholders generally support measuring the quality of pharmacists’ services as a way to improve health outcomes, they are concerned about GSC’s specific measures, the fact that it is using a U.S. provider and the risk of multiple programs from multiple insurers. Not to mention concerns about GSC’s plan, in year three, to tie reimbursement to pharmacies’ scores.

“It’s important for the pharmacy association community to get actively engaged in developing an appropriate set of outcome measures for patients and the evaluation of pharmacies in Canada, “It’s important for the that would be available for all private payers to use. The last thing we want pharmacy association is five different sets of measures from community to get five different payers,” says Perry actively engaged Eisenschmid, CEO of the Canadian in developing an Pharmacists Association (CPhA). appropriate set of Had a Canadian system been availoutcome measures able, GSC would have considered it, for patients and says Ned Pojskic, the insurer’s pharthe evaluation of macy strategy leader. However, it did pharmacies in Canada, not pursue the creation of such an that would be available option with pharmacy associations here “because there is a perfectly for all private payers viable system in the U.S., that took a to use.” decade to develop.”

Pojskic adds that GSC’s arrangement with Pharmacy Quality Solutions (PQS), its U.S. provider, is not proprietary. “In the U.S. numerous insurers are a part of it, and it’s available for all Canadian insurers as well.” PQS manages EQuIPP, the online platform where pharmacies can access their scores and a range of analytical reports.

40

NOVEMBER 2017 [Vol.4 No.9]

The measures themselves come from the Pharmacy Quality Alliance (PQA), a non-profit organization established in 2006 to develop standardized performance measures. PQS is one of PQA’s licensed users. More than 200 research and academic institutions, pharmacy associations, community pharmacies, benefits providers, pharmaceutical companies and government agencies are members of PQA, and as such can participate in the creation of measures.

CPhA is in the process of becoming a member of PQA. “We want to get in at the ground floor so we are more informed about their measures, to understand whether they’re appropriate for the Canadian market,” says Eisenschmid. “If not, we could look at what changes would be necessary, or in some cases identify made-inCanada measures. We could also take from work done in other countries.”

“We are 100% supportive if CPhA wants to work with PQA and PQS,” notes Pojskic, but he’s concerned that the development of Canada-only measures will unnecessarily complicate—and delay—matters. “There is nothing U.S. or Canadian about these measures, they are just universally good practices for the pharmacy profession that are ultimately rooted in clinical treatment guidelines.”

According to its website, PQA has developed 18 measures so far, such as the concurrent use of

Pharmacies across Canada have begun receiving monthly PatientImpact Scorecards from Green Shield Canada.

opioids and benzodiazepines and the use of highMatthew Loscher, sales advisor at The Benefits risk medications by the elderly. Many have to do Company in Windsor, Ont. “For years we’ve been with adherence to medications, based on claims data hearing a lot about the importance of getting the proper capturing the proportion of days covered (PDC). prescription and adherence, but the system is not Patients with a PDC of at least 80% for a number of properly set up to manage this. Someone has to pull it specified drugs are deemed adherent. all together and it’s great that Green Shield is willing to “Ensuring that patients get their scripts filled every step into the gap and do that.”

30 days would technically be adherence, based on The time has also come for performance-based how they measure it, but that does reimbursement, says Loscher, who not necessarily lead to good patient predicts public plans will eventually In their score cards, outcomes,” says Eisenschmid. “There jump on board. “Why should there not pharmacies see are better things we could measure that be an expected standard of care? Why are related to adherence and result in not rank pharmacies? Only pharmacies how their patients’ better patient care.” that aren’t performing at a certain level adherence rates GSC is using seven of PQA’s would be negatively affected. This is a compare to the measures, including three to determine no-brainer.” provincial average as PDC-derived adherence rates for Kandy Cantwell, managing partner well as GSC’s goal. drugs to treat hypertension, cholesterol of Montridge Advisory Group in and diabetes. In their score cards, Vancouver, B.C., agrees that Valuepharmacies see how their patients’ Based Pharmacy is a step in the right adherence rates compare to the provincial average as direction. “I applaud Green Shield for trying to bring well as GSC’s goal, which is based on the 60th percentile about a system that has accountability and sustainability of pharmacy performance across Canada. Baseline data built into it. This will help pharmacists identify patients from PQS show that nearly half of pharmacies already who may need more help with adherence.” meet GSC’s targets for 2018. “This is higher than we Cantwell also believes that pharmacy in Canada expected, which is great,” says Pojskic. should take more of a leadership role, whether on its For the next year GSC will focus on raising awareness own or as part of PQA and PQS. “I would like to see among pharmacists by mailing its scorecards and enmore ownership from pharmacy so it can lead to one couraging enrollment in EQuIPP. “Even if you have only system that every insurance company can buy into, so a few GSC patients, you can still use the information to long as there is transparency in how the data is collected improve your practice if you’d like,” says Pojskic. and presented.”

During year two, when scores will be made available to clients and their plan members, only pharmacies with a minimum required number of GSC plan members will be part of the process. The same holds true during year three, when reimbursement enters the equation. GSC’s October Pharmacy Update bulletin states: “While our longer-term plan will be to create a tie to reimbursement, that will occur through dialogue with the pharmacy community and will not be a cost containment initiative…. In the end, our pharmacy reimbursement amounts may in fact go up overall, but the payoff to our clients will come through healthier employees.”

What the benefits side thinks

For their part, benefits advisors appear to be positive overall about GSC’s Value-Based Pharmacy program.

“Our system is in dire need of innovation,” observes

[Vol.4 No.9] NOVEMBER 2017

41

LEFT: NCPA president DeAnn Mullins BELOW: YouTube sensation and physician: ZDoggMD (Dr. Zubin Damania)

could enable both better use of pharmacy resources and improved patient care and adherence. Around 2010, the push at NCPA was towards the rise of the Clinical Community Pharmacist—a patient-focused model that combined the med sync workflow model with enhanced specialty skills to allow pharmacists to differentiate themselves as professionals providing specialty patient care. In recent years, the excitement has centred around an initiative being heralded as the next logical step in this methodical move away from product-dependent pharmacy practice: the rise of Community Pharmacy Extended Services Networks, or CPESNs.

+ REPORT FROM NCPA CONFERENCE:

Community pharmacies form networks to drive change

BY VICKI WOOD

T

here is always abundant energy flowing when large groups gather, and it was no different when 3,000 independent pharmacy owners converged for the annual conference of the National Community Pharmacy Association (NCPA) in Orlando in mid-October. At every professional conference, there’s a topic du jour— the one that keeps popping up in keynotes, theme documents and the most popular sessions—and this event was no exception. And if history is any indication, the next-phase initiative being talked about and tested by pharmacy owners south of the border is likely what’s coming to Canada in the near future.

Two decades ago, the talk at NCPA was all about the advent of managed care and pharmacy benefit managers (PBMs)—healthcare driven by the mandate of cost-conscious third-party payers. In the mid 00s, medication synchronization was being embraced by community pharmacies as a system of workflow and practice transformation that 42

NOVEMBER 2017 [Vol.4 No.9]

Judging by the standing- (and even floor-sitting-) room only crowds packing conference sessions about the new networks, and the steady lineup of pharmacists waiting to talk to someone at the CPESN information booth on the exhibit floor, this is community pharmacy’s Next Big Thing.

So, what’s a Community Pharmacy Enhanced Services Network? According to Coco Beach, Florida, pharmacy owner and outgoing NCPA president, DeAnn Mullins, “CPESNs are independent pharmacy’s only chance to survive,” as public and private payers continue to move towards an outcomes-/quality-based model of payment for services. The networks specifically target Medicaid and Medicare programs that offer bonus payments to pharmacies that can demonstrate their impact on adherence and patient outcomes.

An initiative launched about three years ago, CPESNs are the next logical extension of medication synchronization—the system that facilitates the coordination of patients’ medication refills at one preplanned appointment, where the pharmacist can take the time to provide in-depth counselling and additional patient care services. When NCPA began promoting med sync to its members about a decade ago, it was with the goal of allowing them to differentiate themselves from the low-price-focused chains. The system frees up pharmacists’ and patients’ time to allow for the provision of expanded services that improve adherence and outcomes (and pharmacy revenues). Within a couple of years, national drugstore chains, including the country’s largest, Rite Aid, had jumped on the med sync bandwagon. More recently, Canadian pharmacies, including numerous independents and the Rexall banner, have also begun to roll out versions of med sync.

NCPA believes that CPESNs are the next logical step for community pharmacies. In a nutshell, pharmacists who provide enhanced professional services are forming networks with other pharmacists and healthcare providers in their communities to support each other and be able to offer an umbrella of patient care services within their own regions at a higher level of care that meets or exceeds Medicare benchmarks. There are now CPESNs in 13 U.S. states, with several others in the process of being set up.

Pharmacies can either join the national network or their local regional network, if one exists.

Owned by participating members, each network supports members in becoming more deeply involved

Photos courtesy of NCPA

CPESNs: Community pharmacy’s Next Big Thing

and integrated into the healthcare teams in their communities. Resources include help in creating patient care networks, optimizing care delivery, and creating value-based payment models for pharmacy professional services. Each network also helps members optimize their performance in ways that both enhance patient outcomes and match up with payers’ reimbursement requirements.

If all of this seems like an awful lot of work for pharmacies—well, it is. But it’s the new reality in a world in which payment for services is increasingly linked to quality of care and outcomes. And, according to network participants speaking at the NCPA conference, in the end, patients benefit from a much higher level of care, and participating pharmacists enjoy a satisfying practice in which they feel integral to the patient care team and can see both professional and financial rewards for practising to their highest possible standards.

Time to re-calibrate

While the rise of CPESNs dominated this year’s conference, another underlying theme was the dire need for a re-calibra-

tion of the current healthcare system, hard and loudly—for complete reform.

“Healthcare 2.0 is about technology. which has become so centred around We need Healthcare 3.0,” said Damania. numbers, forms and codes that, accordThis new model still relies on teching to some speakers, the patient has nology; not as a tool to restrict care to almost been forgotten. Keynote speaker narrow algorithms, but to enable real Dr. Zubin Damania, AKA ZDoggMD, relationships between care providers and has become one of the country’s most patients, and between popular and influential healthcare professionals champions of healthcare “PBMs get in the way as a care team. reform. A second-genNPCA CEO Douglas eration physician and of providing patient Hooey echoed their award-winning clinical care while adding sentiments the following teacher, Damania is also absolutely no value morning. The association a comedian who has garhas launched a call to nered a huge following to the system.” investigate the current for his musical parody model, in which health videos that highlight care is dictated by the financial goals and serious issues in healthcare.

“The current PBM-directed system care guidelines of payers, in particular almost completely bars us from provida few pharmacy benefit managers with ing actual patient care,” said Damania. “It a monopoly over non-public health rewards speed, clicks and correctly comspending. “There is an urgent desire pleted paperwork over actual time spent for a new model,” said Hooey, “PBMs listening to, problem-solving with and get in the way of providing patient care taking the very best care of our patients.” while adding absolutely no value to the Both Damania and NCPA’s Mullins system.” stressed that it’s time for all healthcare professionals to break out of their silos and instead, work together to push—very

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BACK TALK ¹ Managing

CARLENE OLEKSYN BSP Pharm, CTH Øúñèõ òé Öèõìçìäñ Ùëäõðäæü ìñ Ü÷òñü Ùïäìñ Êïåèõ÷ä äñç òúñèõ äñç çìõèæ÷òõ òé ÷ëè Ü÷òñü Ùïäìñ Ýõäùèï Ìïìñìæ

Ýëè Ĥõö÷ æäõè óïäñ øóïòäçèç ÷ò ÷ëè óõòùìñæìäï ÎÑÛ úäö éòõ òñè òé ðü óä÷ìèñ÷ö

One small step...

One giant leap for pharmacy

T

ëìö üèäõ ðäõîèç ä öìêñìĤæäñ÷ ðìïèö÷òñè éòõ óëäõðäæü ìñ Ìäñäçä Üò éäõ ì÷ ëäö êòñè ðòö÷ïü øññò÷ìæèç åø÷ ÷ëìö öèèðìñêïü öðäïï ö÷èó ìö ä êìäñ÷ ïèäó éòõúäõç éòõ ÷ëè óõòéèööìòñ Ëèêìññìñê ìñ Üóõìñê " !' æòððøñì÷ü óëäõðäæìö÷ æäõè¡óïäñö ìñ Êïåèõ÷ä æòøïç åè øóïòäçèç äñç ùìèúèç òñ ÷ëè óõòùìñæìäï ÎÑÛ ¤èïèæ÷õòñìæ ëèäï÷ë õèæòõç¥ Ýëìö ðèäñö ÷ëä÷ èùèõü ëèäï÷ëæäõè óõòéèööìòñäï ÷ëä÷ ëäö äææèöö ÷ò ÷ëè óõòùìñæìäï ÎÑÛ æäñ ùìèú óëäõðäæìö÷ æäõè óïäñö Ùëüöìæìäñö ñøõöèö ò÷ëèõ óëäõðäæìö÷ö äñç õèêìö÷èõèç ÷èæëñìæìäñö ¤åò÷ë ìñ ÷ëè æòððøñì÷ü äñç úì÷ëìñ ìñö÷ì÷ø÷ìòñö¥ æäñ äææèöö òøõ æäõè óïäñö äñç óä÷ìèñ÷ éòïïòú¡øóö Ýëèöè æäõè óïäñö äõè ñòú éõòñ÷ äñç æèñ÷õè ìñ ÷ëè óõòùìñæìäï ëèäï÷ë õèæòõç õìêë÷ åèñèä÷ë ÷ëè óä÷ìèñ÷đö çìöóèñöìñê ëìö÷òõü äðòñêö÷ ÷ëè ïìö÷ òé óä÷ìèñ÷ çòæøðèñ÷ö ìñæïøçìñê ïäå õèöøï÷ö ìðäêìñê ÎÛ õèæòõçö çìöæëäõêè öøððäõìèö öóèæìäïìö÷ õèóòõ÷ö äñç ò÷ëèõö Ìäõè óïäñö äõè öìðìïäõ ÷ò ðèçìæä÷ìòñ õèùìèúö ìñ ÷ëä÷ ÷ëèü 48

NOVEMBER 2017 [Vol.4 No.9]

äõè éòæøöèç õèùìèúö òé äñ ìñçìùìçøäïđö ðèçìæäï æòñçì÷ìòñö äñç äööòæìä÷èç ðèçìæä÷ìòñö åø÷ ÷ëèü êò ÷ëè èû÷õä ö÷èó òé æõèä÷ìñê óä÷ìèñ÷¡æèñ÷èõèç êòäïö äñç ðòñì÷òõìñê óäõäðè÷èõö Ýüóìæäïïü ä æäõè óïäñ ìñæïøçèö ÷ëè æòïïèæ÷ìòñ òé ìñéòõðä÷ìòñ ä åèö÷ óòööìåïè ðèçìæä÷ìòñ ëìö÷òõü ¤ËÙÖÑ¥ äñ äööèööðèñ÷ òé èäæë ðèçìæäï æòñçì÷ìòñ äñç ÷ëè ðèçìæä÷ìòñö åèìñê øöèç ÷ò ÷õèä÷ ÷ëè æòñçì÷ìòñö ìçèñ÷ìĤæä÷ìòñ òé çõøê¡õèïä÷èç óõòåïèðö äñç ä óïäñ ÷ò õèöòïùè ÷ëèð Ðòäïö äñç ðòñì÷òõìñê óäõäðè÷èõö éòõ èäæë ðèçìæäï æòñçì÷ìòñ äõè äïöò ìçèñ÷ìĤèç ìñ òõçèõ ÷ò óõòùìçè òñêòìñê æäõè Ìäõè óïäñö äõè ìñ÷èñçèç ÷ò åè ēïìùìñê çòæøðèñ÷öĔ ÷ëä÷ äõè æòñ÷ìñøäïïü øóçä÷èç äö óä÷ìèñ÷ éòïïòú¡øó ìö æòðóïè÷èç óõòåïèðö äõè õèöòïùèç äñç ñèú óõòåïèðö äõè ìçèñ÷ìĤèç Ìòñ÷ìñøäï ðòñì÷òõìñê ùìä éòïïòú¡øóö äõè äïöò öè÷ òø÷ ìñ ÷ëè òõìêìñäï óïäñ Ùõèùìòøöïü óëäõðäæìö÷ æäõè óïäñö úèõè æòðóïè÷èç òñ óäóèõ ÷ëèñ ÷üóìæäïïü Ĥïèç äúäü àì÷ëòø÷ äñ èïèæ÷õòñìæ æòóü ÷ëèõè úäö ñò úäü éòõ ò÷ëèõ ëèäï÷ëæäõè óõòéèööìòñäïö ÷ò äææèöö ÷ëè óëäõðäæìö÷đö óïäñö Ýëìö ëäö äïöò ðèäñ÷ ÷ëä÷ ðòö÷ æäõè óïäñö úèõè ñò÷ åèìñê éòïïòúèç øó òñ åèæäøöè ÷ëè óäóèõ úäö Ĥïèç äúäü äñç úäö ñò÷ ìñ÷èêõä÷èç ìñ÷ò ÷ëè æòðóø÷èõìýèç óä÷ìèñ÷ õèæòõç

Ñäùìñê èïèæ÷õòñìæ äææèöö ÷ò æäõè óïäñö ìö ä ëøêè ïèäó éòõúäõç éòõ æòñ÷ìñøì÷ü òé óëäõðäæèø÷ìæäï æäõè äñç ìñ÷èõ¡ óõòéèööìòñäï æòïïäåòõä÷ìòñ Ýëè Ĥõö÷ æäõè óïäñ øóïòäçèç ÷ò ÷ëè óõòùìñæìäï ÎÑÛ úäö éòõ òñè òé ðü óä÷ìèñ÷ö Öü ÷èäð äñç Ò úòõîèç úì÷ë òøõ öòé÷úäõè ùèñçòõ äñç ÷ëè óõòùìñæìäï ÎÑÛ óõòùìçèõ òùèõ ðäñü ðòñ÷ëö ÷ò ðäîè ÷ëìö ëäóóèñ Õè÷ ðè ÷èïï üòø çèöóì÷è ÷ëè éäæ÷ ÷ëä÷ úè îñèú òøõ æäõè óïäñö úèõè êòìñê ÷ò åè ìñ÷èêõä÷èç ìñ÷ò ÷ëè óõòùìñæìäï ÎÑÛ ì÷ úäö õä÷ëèõ çäøñ÷ìñê ÷ò öèè òøõ òúñ æïìñìæäï ñò÷èö äñç äööèööðèñ÷ö òø÷ ÷ëèõè éòõ ÷ëè úòõïç ÷ò öèè Ò÷ çìç ìñçèèç éèèï ïìîè úè úèõè ö÷èóóìñê ìñ÷ò ñèúïü èûóïòõèç ÷èõõì÷òõü éèèïìñê öòðèúëä÷ ùøïñèõäåïè äö ò÷ëèõ ëèäï÷ëæäõè óõòéèööìòñäïö æòøïç ñòú öèè ¤äñç óèõëäóö íøçêè ÷ëè ôøäïì÷ü òé¥ òøõ óä÷ìèñ÷ æäõè Íèöóì÷è ÷ëìö ìñì÷ìäï äóóõèëèñöìòñ úè ëäùè óèõöèùèõèç ìñ óòö÷ìñê òøõ æäõè óïäñö ÷ò ÷ëè óõòùìñæìäï ÎÑÛ õèæòõç Ò÷ ìö ñò÷ ðäñçä÷òõü ä÷ ÷ëìö óòìñ÷ éòõ óëäõðäæìö÷ö ÷ò øóïòäç ÷ëèìõ æäõè óïäñö ÷ò ÷ëè ñè÷úòõî äñç ÷ëè öòé÷úäõè õèôøìõèç ìö ñò÷ üè÷ äùäìïäåïè éòõ èùèõü çìöóèñöìñê öüö÷èð åø÷ ÷ëìö Ĥõö÷ ïèäó éòõúäõç óòìñ÷ö òø÷ ÷ëè çìõèæ÷ìòñ òé úëèõè óëäõðäæü óõäæ÷ìæè ìö ëèäçèç Ò÷ ìö äñ èûæì÷ìñê ÷ìðè äñç ìñçèèç ä ñèú èõä éòõ óëäõðäæü óõäæ÷ìæè àè ðøö÷ æòñ÷ìñøè ÷ò êò úëèõè ñò óëäõðäæìö÷ ëäö êòñè åèéòõè Òïïøö÷õä÷ìòñ åü Ùè÷è Ûüäñ

Ìõèä÷ìùè ÷ëòøêë÷ö òñ ðäñäêèðèñ÷ éõòð ìññòùä÷ìùè óëäõðäæü òúñèõö

FIND YOUR INNER STRENGTH. Subaru’s core technologies define the Subaru brand and give you the unique driving feel you can only find in a Subaru. These core systems allow Subaru vehicles to live up to their standards in performance, comfort and safety while keeping their promise - to deliver enjoyment and peace of mind to all passengers.

2017

CANADIAN UTILITY VEHICLE OF THE YEAR FORESTER

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