February 2013 VOLUME 35, Issue 2
138th GPhA Convention June 22-25, 2013 Amelia Island, FL Tentative Schedule Inside!
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February 2013 Editor: Jim Bracewell email@example.com Managing Editor: Kim McNeely firstname.lastname@example.org The Georgia Pharmacy Journal® (GPJ) is the official publication of the Georgia Pharmacy Association, Inc. (GPhA). Copyright © 2012, Georgia Pharmacy Association, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including by photocopy, recording or information storage retrieval systems, without prior written permission from the publisher and managing editor. All views expressed in bylined articles are the opinions of the author and do not necessarily express the views or policies of the editors, officers or members of the Georgia Pharmacy Association. ARTICLES AND ARTWORK Those interested in writing for this publication are encouraged to request the official “GPJ Guidelines for Writers.” Artists or photographers wishing to submit artwork for use on the cover should call, write or email email@example.com. SUBSCRIPTIONS AND CHANGE OF ADDRESS The Georgia Pharmacy Journal® (GPJ) (ISSN 1075-6965) is distributed as a regular membership service, paid for through allocation of membership dues. Subscription rate for non-members is $50.00 per year domestic and $10.00 per single copy; international rates $65.00 per year and $20.00 single copy. Subscriptions are not available for non-GPhA member pharmacists licensed and practicing in Georgia. The Georgia Pharmacy Journal® (GPJ) (ISSN 1075-6965) is published monthly by the GPhA, 50 Lenox Pointe, NE, Atlanta, GA 30324. Periodicals postage paid at Atlanta, GA and additional offices. POSTMASTER: Send address changes to The Georgia Pharmacy Journal®, 50 Lenox Pointe, NE, Atlanta, GA 30324. ADVERTISING Advertising copy deadline and rates are available upon request. All advertising and production orders should be sent to the GPhA headquarters at firstname.lastname@example.org. GPhA HEADQUARTERS 50 Lenox Pointe, NE Atlanta, Georgia 30324 t 404-231-5074 f 404-237-8435
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Message From Robert Hatton................................................
Message From Jim Bracewell.................................................
Welcome New GPhA Members..............................................
Pharmacist Clinical Services ..........................
Continuing Education for Pharmacists..........................
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MESSAGE from Robert Hatton Robert Hatton
By now, most of us have started to settle into 2013 and begin getting a handle on the changes that we never know are coming. January has probably become my least favorite month because it’s when we find out what’s been done to us that we didn’t know about. What I do know about GPhA is that we have been hard at work getting the year started. We started with the Executive Committee meeting on Saturday, January 19th at the Wyndham Galleria. This was followed by a meeting with the Council of Presidents which included eighteen past presidents, one of the best attended meetings for the group in a while. Included in this group was the familiar face of Robert Bowles. Due to illness, Robert had not been with us the past couple of years and it was great to see him back in the fold. Sunday, January 20th was our regular Board of Directors meeting followed by the meeting of the GPhA Standing Committees in the afternoon. There appears to be much energy and enthusiasm among our leadership as we go into the year. By the time this article goes to press, I’m hoping that we had one of the largest turnouts for a VIP day yet. 2012 had an attendance of over 300 and we were expecting to eclipse that number in 2013. GPhA has started to earn a reputation for winning in the political arena. A lot of this is possible because we have more state legislators elected to office at the state level than any other state in the union. We currently have four pharmacists in the House of Representatives and one in the State Senate. All are strong advocates for our profession. Please continue to support your legislators at the local, state and federal level so that the voice of pharmacy continues to be heard and our issues understood. Speaking of representing the profession, we are looking for a few good candidates who are ready to handle the job of 2nd VP. If you are interested, or know someone who should be, please call any of us on the Executive Committee. We would love to answer any questions regarding the rewards of representing the profession. Finally this month, I would like to extend a huge thank you to the greatest volunteer organization ever. You give of your time and energy to make GPhA one of the strongest pharmacy organizations in the country. From myself and everyone at GPhA, thanks for everything you do for your profession.
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2013 GPhA Elections Schedule Region Elections Odd numbered region elections will take place at the 2013 Spring Region meetings. GPhA Bylaws state that Region Presidents must select a nominating committee by March 1st for the purpose of selecting candidates for 2013-14 Region Officers for 2013-15 membership years. Board of Pharmacy Nominations come from Region 4. Nominating Committee for 1st and 2nd VPs Friday, February 22, 2013 (120 days prior to Convention) Will meet to discuss names for 1st & 2nd VP nominees. At least one name for 1st VP and two names for 2nd VP Monday, March 24, 2013 (90 days prior to Convention) *Please note that the 90th day falls on Sunday the 23rd so date was moved to next business day. 1st & 2nd VP nominees must be submitted to membership.
Petitions for additional nominees must be submitted to EVP by 12NOON. Ballots Monday, May 13, 2013 (45 days prior to the commencement of Convention) *Please note that the 45th day falls on Sunday the 12th, so date was moved to the next business day. Electronic Ballots must be sent to membership – Election Opens Monday, June 17, 2013 (10 days prior to the commencement of Convention) *Please note that the 10th day falls on Sunday the 16th so moved date to the next business day. Paper ballots must be returned by this date. Tuesday, June 25, 2013 Election closes at 12NOON
Tuesday, April 23rd, 2013 (60 days before Convention)
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MESSAGE Purveyor of Product or Provider of Healthcare?
Now is the time for pharmacy to move into the forefront of healthcare and be recognized and valued by our society, government, and payers of services for the knowledge and value we bring to healthcare. Information is what is available from a computer or the internet. Knowledge is what a learned
Jim Bracewell professional can obtain with that information and create an improved outcome.
Executive Vice President
In 1960, when the United States had been humbled and perhaps embarrassed by the Russian space program, President John F. Kennedy made a stirring speech and challenged the nation to do better. The following are excerpts from that speech. “Now it is time to take longer strides--time for a great new American enterprise--time for this nation to take a clearly leading role in space achievement, which in many ways may hold the key to our future on Earth…..I believe we possess all the resources and talents necessary. But the facts of the matter are that we have never made the national decisions or marshaled the national resources required for such leadership …..I believe that this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the Moon and returning him safely to the Earth.” I want to borrow from that speech and pull together some thoughts for Pharmacy: Now is the time for pharmacy to take longer strides, and take a clearly leading role in healthcare. In many ways we hold the keys to the future of healthcare, but we have never made the decisions nor marshaled the recourses for such a leadership role. Now is the time to commit our profession to achieving that goal of provider recognition. Inventor Robert Metcalfe theorized that the value of a network is roughly equal to the square of the number of people using it. Network is also a metaphor for an association. The power of an association is hard to exaggerate. Metcalfe’s law applies equally to our professional association. As today’s pharmacists we have the knowledge, as an Association, we are the vehicle. We need the desire. At a major pharmacy school a professor gave his class a test. The test was grouped into three categories of questions. He instructed the students to choose one question from each category. The first category contained the hardest questions and was worth 50 points. The second category was not as hard those were worth 40 points. The third category of questions, the easiest, was worth 30 points each. When the pharmacy students had completed the test and turned in their papers, the students who had chosen the hardest (50- point) questions were given As. The students who had chosen the 40-point questions were given Bs and those who chose the 30-point questions were given Cs. The professor did not consider if their answers were right or wrong. The students were upset and confused and asked the professor why he had graded the exams in such a manner. The professor smiled and explained, “Today I was not testing what you have learned. I was testing your desire and ambition to be the best pharmacist you can be.” And so my test to you is this: Will you help to change pharmacy from being a product based practice to that of a knowledge-based health care provider dedicated to patient service?
WELCOME New GPhA Members Decola Johnson- Atlanta, GA Student, Univ. of Maryland Lofer Jobir - Lilburn, GA Associate Member Anh Le- Monroe, NC Student-Wingate Univ. Brooke Albright - Carrollton, GA Active Pharmacist
The Georgia Pharmacy Association is the collective voice of the pharmacy profession, aggressively advocating for the profession in the shaping of public policy, encouraging ethical health care practices, advancing educational leadership while ensuring the professionâ€™s future is economically prosperous.
Vinisha Patel- Atlanta, GA Active Pharmacist Christina Taylor- Kingsland, GA Student - UGA Lauren Zimmerman - Decatur, GA New Graduate (1st year)
The members of GPhA would like to welcome all our new members and encourage them to take advantage of all the benefits membership offers.
Sujal Patel- Kennesaw, GA New Graduate (1st year) Gary Wesley- Kennesaw, GA Active Pharmacist Sarah Alston- Acworth, GA Pharmacy Technician
THANK YOU FOR YOUR MEMBERSHIP! Georgia Pharmacy Association 50 Lenox Pointe, NE, Atlanta, Georgia 30324 t 404-231-5074 f 404-237-8435
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LEGISLATIVE UPDATE from Andy Freeman Andy Freeman Director of Government Affairs
The Georgia General Assembly has convened. 236 legislators (180 in the House and 56 in the Senate) will meet for 40 days to cover a wide variety of issues. This year they are expected to address Medicaid assessment fees, ethics reforms and hundreds of other proposed pieces of legislation. Georgia now has the most pharmacy legislators of any other state in the country with 4 in the State House and 1 in the Senate. With these 5 legislators (and without a couple of legislators that have long been problems for our legislative agenda that were retired by the voters last year) we are hopeful that we will have a great legislative year.
Georgia now has the most pharmacy legislators of any other state in the country with 4 in the State House and 1 in the Senate. With these 5 legislators (and without a couple of legislators that have long been problems for our legislative agenda that were retired by the voters last year) we are hopeful that we will have a great legislative year.
One of the top legislative issues for this session for pharmacy centers around MAC pricing. Pharmacists on a daily basis know that there are certain drugs that they canâ€™t buy dozens of different prescriptions at the rate they get reimbursed for them by PBMs. If a drug goes down in price, the PBM is very quick to let you know that you will be paid at the new lower price but if the price goes up it often takes months for PBMs to raise the reimbursement rate paid to your pharmacy.
When Superstorm Sandy ravaged the Eastern coast of the United States a few months ago, it destroyed the only facility in the United States that manufactures doxycycline in the US. If you can find it, doxycycline will cost you around $700 but most PBMs are still reimbursing you at $20. Stories like this, we hope, will pass legislation to mandate MAC pricing be updated at least once a week. GPhA is also working to change the audit process that PBMs use in your pharmacy. PBMs shouldnâ€™t be allowed to take by the cost of a prescription unless they can prove fraud or abuse by the pharmacist. The auditors that PBMs hire are not looking for fraud but only on nitpicky errors that are technical in nature. These practices must be stopped. This session GPhA is also working on legislation with the Georgia Dental Association to remove our licensing Boards from the Secretary of State and
Continued on next page 6
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Your GPhA legislative team- Andy Freeman GPhA Director of Government Affairs, Representative Ron Stephens, Representative Buddy Harden, Representative Butch Parrish, Senator Buddy Carter, contract lobbyist Cindy Shepherd and Representative Bruce Broadrick. make them autonomous agencies like the Physicians have with the Composite Medical Board. This is something that both professions have been working on for quite sometime. Most feel that this will make our state licensing boards more efficient and better for the professionals they regulate. Last year, we worked on legislation to increase the number of immunizations that Pharmacists can give under Physician protocol. An overwhelming majority of states allow for this to happen and they have seen drastic increases in the number of citizens that receive immunizations. Studies also show that Pharmacists are able to administer vaccines at much lower costs than Physicians with an extremely low rate of adverse reactions. We are hopeful that this is the year that Pharmacists will be able to help improve
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access to healthcare by providing more immunizations to the patients you serve. Not everything will be positive for pharmacists under the gold dome. Every year there are several pieces of legislation that we have to spend a lot of time fighting off. This year will be no different. Already GPhA has been working to stop legislation that seeks to limit a pharmacistâ€™s ability to dispense generics. The legislation hasnâ€™t been introduced at the time of this writing but with the large quantities of name brand prescriptions coming off of their patents, it is something that we will have to continue to fight throughout the entire legislative session. What can you do to help? Contact your legislators and let them know that pharmacy issues are important to you and you hope that they will be important to them.
Elected officials rarely hear from their voters and when they do, most will take action to help out those that contact them. With your help, GPhA can have its best legislative year ever!
Visit gpha.org to keep up with the latest in legistlative updates and visit us on Facebook for news, event information and more!
Call for GPhA Awards!
he GPhA Awards Committee is seeking nominations for the following awards which will be presented at the GPhA 138th Annual Convention in 2013. A brief description and criteria of each award is included below. Please select the award for which you would like to nominate someone and indicate their name on the form below. Deadline for submitting the completed nomination form is March 1, 2013. Nominations will be received by the Awards Committee and an individual will be selected for presentation of the Award at GPhA’s 138th Annual Convention at the Omni Amelia Island Plantation on Amelia Island, FL.
Bowl of Hygeia Award
Recognized as the most prestigious award in pharmacy, the Bowl of Hygeia is presented annually by GPhA and all state pharmacy associations. Selection Criteria: 1) The nominee must be a licensed Georgia pharmacist; 2) The Award is not made posthumously; 3) The nominee is not a previous recipient of the Award; 4) The nominee is not currently serving nor has served within the immediate past two years as an officer of GPhA other than ex-officio capacity or its awards committee; 5) The nominee has an outstanding record of service to the community which reflects will on the profession.
Distinguished Young Pharmacist Award
Created in 1987 to recognize the achievements of young pharmacists in the profession, the Award has quickly become one of GPhA’s most prestigious awards. The purpose of the Award is two-fold: 1) The encourage new pharmacists to participate in association and community activities, and 2) To annually
recognize an individual in each state for involvement in and dedication to the pharmacy profession. Selection Criteria: 1) The nominee must have received entry degree in pharmacy less than ten years ago; 2) Nominee must be a licensed Georgia pharmacist; 3) Nominee must be a GPhA member in the year of selection; 4) Nominee must be actively engaged in pharmacy practice; 5) Nominee must have participated in pharmacy association programs or activities and community service projects.
Innovative Pharmacy Practice Award
This Award is presented annually to a practicing pharmacist who has demonstrated innovative pharmacy practice which has resulted in improved patient care. Selection Criteria: 1) The nominee must have demonstrated innovative pharmacy practice which has resulted in improved patient care; 2) Nominee must be a licensed Georgia pharmacist; 3) Nominee must be a member of the GPhA in the year of selection.
Generation Rx Champions Award
This award is presented annually to a pharmacist who has demonstrated work with prescription drug abuse. This award gives honor the recipient with a plaque and a $500 to the charity of the recipients choice. Selection Criteria: 1) Nominee must a have demonstrated a committed effort to reduce prescription drug abuse 2) Nominee must be a licensed Georgia Pharmacist. 3) Nominee must be a member of the Georgia Pharmacy Association in the year of the selection.
2013 Awards Nomination Form Bowl of Hygeia
Distinguished Young Pharmacist
Innovative Pharmacy Practice
Nominee’s Full Name Home Address
Generation Rx Champions
Practice Site Work Address
College/School of Pharmacy List of professional activities, state/national pharmacy organization affiliations, and/or local civic church activities: Supporting information: Submitted by (optional): Submit this form completed by March 1, 2013 to: GPhA Awards Committee, 50 Lenox Pointe, Atlanta, GA 30324 or complete this form online at www.gpha.org.
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Pharmacy Time Capsule 2013 By: Dennis B. Worthen, PhD, Cincinnati, OH 1988—Twenty-five years ago Medicare Catastrophic Health Care Act passed by Congress but repealed also immediately after outcry by a groundswell of negative reactions. Board of Pharmacy Specialties (BPS) recognizes Pharmacotherapy and Nutritional support as pharmacy practice specialties. 1963—Fifty Years Ago The first measles vaccine was licensed for use in the U.S. in 1963. John Enders developed the vaccine from a strain of measles isolated by Thomas Peebles.
Valium (diazepam) marketed by Hoffman-LaRoche. 1938—Seventy-five Years Ago The Federal Food, Drug, and Cosmetic Act was passed in response to deaths from the use of Massengill’s Elixir of Sulfanilamide. Albert Hofmann of Sandoz Laboratories in Switzerland synthesized LSD (lysergic acid diethylamide). 1913—One hundred Years Ago Alaska passed territorial practice act. 1888—One hundred twenty-five years ago First class of pharmacy students enrolled in the South Dakota State
College (then the State Agricultural College) in Brookings, SD. One of a series contributed by the American Institute of the History of Pharmacy, a unique non-profit society dedicated to assuring that the contributions of your profession endure as a part of America’s history. Membership offers the satisfaction of helping continue this work on behalf of pharmacy, and brings five or more historical publications to your door each year. To learn more, check out: www. aihp.org
Don’t Miss Out On Your Benefits Renew Your Membership Today at gpha.org
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2013 Convention Schedule June 22-25, 2013 Omni Amelia Island Plantation
Friday, June 21, 2013 Certificate Program 2012-2013 Board of Directors Meeting Council of Presidents Reception Saturday, June 22, 2013 Foundation Walk General Session CPE Programs Election Closes Tellers Committee Student Reception Exhibit Hall Opens Presidentâ€™s Reception and Banquet
Monday, June 24, 2013 Golf/Tennis CPE Programs General Session Annual Meeting Alumni Dinners
Tuesday, June 25, 2013 Georgia Pharmacy Coalition Meeting 2013-2014 Board of Directors Meeting (TBA)
Sunday, June 23, 2013 Sunrise Service General Session Academy Lunches CPE Program Resolutions Committee Exhibit Hall Opens PharmPAC Reception
For updated conference information, visit www.gpha.org 10
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Save The Date GPhA 138th Annual Convention Amelia Island, FL June 22-25, 2013
Omni Amelia Island Plantation Resort 6800 First Coast Highway Amelia Island, Florida 32034 Visit gpha.org for more information and registration dates! The Georgia Pharmacy Journal
Pharmacists Clinical Services: The Smart Spend That Pays By Thomas E. Menighan, BSPharm, MBA, FAPhA Executive Vice President and CEO Members of the Pharmacy, Medical, Consumer and Legislative Communities: Just over half of all Americans take at least 2 medications every day and nearly one-third take 4 or more medications. For the Medicare population, medication use is even higher — nearly half of Americans aged 65 and older take at least 4 medications each day. Anyone on a medication, particularly those patients with complex medical conditions, can benefit from pharmacists’ clinical services. Studies and practice-based experience have shown that when pharmacists are involved as members of the health care team, patient outcomes improve, patients report higher rates of satisfaction and overall health care costs are reduced. As medication experts, pharmacists play a critical role in the provision of patient care services, in collaboration with physicians and other providers on the health care team. Pharmacists are capable of providing a range of services, such as medication monitoring, patient education, comprehensive medication reviews, coordination of medications in transitions of care, prevention and wellness and disease management. As outlined in the report Improving Patient and Health System Outcomes Through Advanced Pharmacy Practice: A Report to the Surgeon General 2011 pharmacists’ patient care services have grown beyond functions tied to medication product and delivery. Yet in many, if not most circumstances, pharmacists are not considered “providers” and thus are often left off the health care team. That is a major disservice to patients. The Smart Spend That Pays Pharmacists are using a variety of systems and models to implement patient care services. However, without
As medication experts, pharmacists play a critical role in the provision of patient care services, in collaboration with physicians and other providers on the health care team. a viable business model, these activities will continue to be difficult to initiate and unsustainable. Pharmacists are not recognized as health care providers by the Federal government. This singular fact creates a major barrier to access for patients in today’s fee-for-service health care environment. This not only affects payment from Medicare, but also from Medicaid and most private payers, who model their payment systems after those established by Medicare. Perhaps more importantly, the omission of pharmacists from the list of providers also creates a barrier to the integration of pharmacists into the innovative healthcare delivery models – medical homes, medical neighborhoods and accountable care organizations (ACO) – that are emanating from the Affordable Care Act (ACA). Although current Medicare Part D law compensates pharmacies for limited services, including medication therapy management (MTM) for select patients, the program is restrictive and encompasses only a small set of the services pharmacists are capable of providing. Further, most of these
services are provided by health plans (payers) rather than by pharmacists who have patient and physician relationships. Thus, physicians who rely on pharmacists to help manage medication use may see increased challenges without an ability to bill for those services under newly evolving systems. Without the proper recognition and financial incentives, patients and our health care provider teammates may not have access to our services. To optimize our healthcare spending, Medicare must include pharmacists’ clinical services that are provided in collaboration with physicians and other providers on the health care team. Recognition of pharmacists’ clinical services in the non-physician part of the Social Security Act, and ultimately Medicare Part B, would help to improve patient outcomes and assist physicians and other providers in meeting patients’ complex health care needs. Recognition of pharmacists is “The Smart Spend That Pays.” Continued on next page
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Pharmacists Clinical Services: Continued Achieving Value Recognition and Compensation The recognition and valuation of pharmacists’ clinical services is the top strategic priority for APhA in 2013. Years before our 2012 House of Delegates put the Association on record as supporting “universal recognition of pharmacists as health care providers,” APhA worked toward creating and maintaining viable business models for pharmacists and their services. In January of last year, our Board of Trustees created a task force that is working closely with staff and consultants, as well other national and state pharmacy associations, to develop and implement a plan for taking this issue forward. While, we will seek to earn “provider status” under Medicare Part B, efforts will also be made to gain recognition for pharmacists’ services at the state and private levels. The ultimate goal remains ensuring patient access to pharmacists’ clinical services and optimizing medication use. As an association and as pharmacists, we are committed to working with the pharmacy community to achieve success on this issue. We’ve had an ongoing dialogue with pharmacy stakeholders to develop a cohesive approach to this effort and have stepped up efforts to align with our colleagues at the national pharmacy organizations. We believe a strategic coalition of pharmacy, consumer and other health care organizations is the right approach. We are implementing a comprehensive and cohesive plan that details the value of pharmacists’ services to the American people. We are pleased so many national and state organizations are doing the same, and we will work diligently to marshal our collective strength into one set of principles that everyone – pharmacy, medicine, consumers and legislators – can support. Achieving value recognition and compensation for pharmacists’ clinical services will not be accomplished easily and it will not be immediate. The entire pharmacy community will have to come together with one strong
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and unwavering voice to show federal, state and private payers why we should be recognized and compensated for the clinical patient care we provide. We will need the participation of all pharmacists, to ensure consumers and our health care colleagues have access to our services. Pharmacists’ training and abilities must be applied to the achievement of higher quality at a lower cost in healthcare. Pharmacists must be ready to step forward and assume patient care accountability across the profession and within the new health care delivery system.
We encourage the active engagement by pharmacists to gain public attention and recognition of the value of pharmacists’ clinical services. As pharmacists, our responsibility and commitment to our patients and profession is to ensure patients have access to and value the clinical services we provide. More information about the issues and the new opportunities for pharmacists in the evolving healthcare system will be available at the APhA Annual Meeting & Exposition, March 1-4, 2013 in Los Angeles www. aphameeting.org.
Melvin M. Goldstein, P.C. A T T O R N E___ Y AT
248 Roswell Street Marietta, Georgia 30060 Telephone 770/427-7004 Fax 770/426-9584 www.melvinmgoldstein.com
n Private practitioner with an emphasis on representing healthcare professionals in administrative cases as well as other legal matters n Former Assistant Attorney General for the State of Georgia and Counsel for professional licensing boards including the Georgia Board of Pharmacy and the Georgia Drugs and Narcotics Agency n Former Administrative Law Judge for the Office of State Administrative Hearings 13
Profession-wide effort begins
APhA Advances Provider Status Initiative APhA has announced a major effort to obtain recognition of pharmacists as providers in the health care system. A major component of that recognition is the listing of pharmacists as providers in the Social Security Act. Provider listing in the Social Security Act is an important component in the ultimate goal of providing consumers and other health care providers with access to our services. For patients to achieve the full benefit of their medications, pharmacists must be part of the team. The American Society of Health‐System Pharmacists (ASHP) released a similar statement from its CEO on January 2, following on the heels of an American College of Clinical Pharmacy (ACCP) board action last November and an Academy of Managed Care Pharmacy
(AMCP) position statement approved by its board last June. Other national pharmacy organizations have also expressed interest in participating in provider status efforts. People on all medications, particularly those with complex medical conditions, benefit from pharmacists’ clinical services, APhA will tell Congress. “It’s the smart spend that pays” will be the tagline advocated by APhA, which will cite published literature and practice‐ based experience showing that when pharmacists get involved, overall health care costs go down and quality and patient safety improve. To optimize our health care spending, Medicare must include pharmacists’ clinical services that are provided in collaboration with physicians and other
providers on the health care team. Recognition of pharmacists’ clinical services in the non-physician part of Medicare Part B would help to improve patient outcomes and assist physicians and other providers in meeting complex health care needs of patients. Medicare Part B is not the only important user of the Social Security Act provider list, as accountable care organizations, state Medicaid programs, and other payers usually rely on the Social Security Act provider list to determine payment policies and services covered. “It is time for pharmacists to be recognized for the value they bring to improved patient outcomes,” said Steven T. Simenson, BSPharm, FAPhA, FACA, FACVP, APhA President‐elect and Chair of APhA’s Provider Status Continued on next page
Visit the GPhA Facebook Page! News Information 14
Event Updates Contests The Georgia Pharmacy Journal
Provider Status Initiative Continued Task Force. “Pharmacist advocacy in legislative and private payer arenas is a critical component to achieve pharmacists being paid, as are all other providers, for their clinical decision making. This should apply to all of pharmacy practice, regardless of practice site. “We are pleased to see so many national and state organizations rising up to support provider status, and we will work diligently to marshal our collective strength into one set of principles that all our organizations can support,” said APhA Executive Vice President and CEO Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA. A statement for the pharmacy, medical, and legislative communities was posted on the homepage of pharmacist.com. The APhA Board of Trustees has allocated significant financial and human resources to work on this issue. Although changing the law would literally take an act of Congress, the initiative isn’t just about a legislative fix. The profession is exploring all avenues, including working with the private sector and states. For the past 2 years, APhA has been in dialogue with stakeholders within and outside of pharmacy regarding ways to advance recognition of pharmacists’ patient care services. Recent discussions among the health care reform pharmacy stakeholders have been taking place to come up with a comprehensive and cohesive plan for the profession.
Beyond the national pharmacy organizations, advocacy for provider status has included the U.S. Public Health Service pharmacy report to the Surgeon General a year ago; the Change.org petition started by Sandra Leal, PharmD, CDE, of El Rio Health Center in Tucson, AZ, on November 15, 2011; and just last week, a White House We the People petition, started by student pharmacist Steve Soman of St. John’s University College of Pharmacy and Health Sciences in Queens, NY. If the White House petition amassed 25,000 signatures by January 26, 2013, then the White House must issue an official response. These are examples of the types of advocacy needed by a critical mass of the profession in order to attain the desired recognition. Calling provider status a “top‐priority strategic issue,” ASHP CEO Paul W. Abramowitz, PharmD, FASHP, explained ASHP’s involvement in the profession‐wide push for provider status in his From the CEO column in ASHP InterSections, released January 2. “Achieving provider status under section 1861 of the Social Security Act is important for the profession. It is essential to recognize pharmacists for the patientcare providers that they already are,” Abramowitz wrote. “Achieving provider status will not be easy. It will take a massive grassroots effort by individual pharmacy practitioners and affiliated state societies leading state‐based coalitions. … Achieving provider status will also require a strong and cohesive national
coalition of pharmacy organizations, consumer groups, and other health care organizations that understand the value pharmacists bring to the care of the American people.” In November 2012, the ACCP Board of Regents authorized a new initiative to seek provider status for clinical pharmacists working in all practice settings. Its action is focused more narrowly than that of other national groups. “‘Qualified clinical pharmacists’ will possess credential(s) beyond entry level that are commensurate with the scope of services being proposed for coverage and that assure the clinical pharmacist’s ability to contribute to team‐based, patient‐centered care,” according to the December 2012 ACCP Report article on the initiative. The Academy of Managed Care Pharmacy (AMCP) issued a position statement on Non‐Physician Provider Status for Pharmacists that was approved by the AMCP Board of Directors in June 2012. Provider status would “allow pharmacists to be reimbursed directly from Medicare Part B for providing cognitive services to patients covered under the program,” according to the position statement. “Although current Medicare Part D law reimburses pharmacies for pharmacists providing some cognitive services, including medication therapy management (MTM) to a select subset of patients, the program is restrictive and encompasses only a small set of the services pharmacists are capable of undertaking.”
Membership Milestones A new feature in the GPhA Journal
Share the great news in your life with your GPhA Colleagues! Got married? Graduated? Send a brief 100 word or less writeup and a photo and you will be featured in the GPhA Journal. Send by the 15th of the month for the next month to Kim McNeely at email@example.com. Stories will be edited for length. Please send digital copies of photos.
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Thanks To All Our Supporters
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You are cordially invited to attend the Georgia Pharmacists Reception at APhA’s Annual Meeting & Exposition Date: Sunday, March 3, 2013 Time: 6:00 pm – 7:00 pm Los Angeles Convention Center 1201 South Figueroa Street Room # 501B Hosted by: Georgia Pharmacy Association Mercer University College of Pharmacy & Health Sciences South University School of Pharmacy University of Georgia College of Pharmacy PCOM School of Pharmacy RSVP: Via email to firstname.lastname@example.org or by scanning the QR code with your smartphone by Monday, February 25, 2013 18
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continuing education for pharmacists Volume XXX, No. 11
Common Cold, Sinusitis, Influenza: The Diseases, Prevention, Treatment Mona T. Thompson, R.Ph., PharmD
Dr. Mona T. Thompson has no relevant financial relationships to disclose.
Goal. The goal of this lesson is to provide disease state reviews of the common cold, sinusitis, and influenza. This lesson will also highlight key differences between each disease state, and review current treatment recommendations and prevention when applicable. Objectives. At the completion of
this activity, the participant will be able to: 1. demonstrate an understanding of the basic pathophysiology of the common cold, sinusitis, and influenza; 2. compare the symptoms of these three disease states; 3. list the antibiotics used in the treatment of sinusitis; 4. recognize the appropriate use of antiviral agents in the prevention and/or treatment of influenza; and 5. list the recommendations for the appropriate use of the influenza vaccine.
The Common Cold
The term common cold refers to a collection of upper respiratory symptoms that are caused by an array of viral pathogens. Symptoms include nasal congestion, rhinorrhea, sneezing, sore throat, cough, low-grade fever, headache, and malaise. The average incidence of the common cold is six to eight
episodes per year in preschool children, and two or three per year in adults. Adults who live with young children experience more colds than those who donâ€™t. In infants and young children, symptoms usually peak on day two or day three of the illness and persist for 10 to 14 days. In some children, the cough may last up to three or four weeks. The duration of illness for adolescents and adults is usually seven to 10 days. While generally considered mild and self-limiting, the common cold is associated with a tremendous economic burden due to lost productivity and the cost of treatment. It is estimated that viral respiratory tract infections account for 21 million days of school absence and 20 million days of work absence per year in the U.S. alone. Annually, approximately three billion dollars are spent on over-thecounter cough and cold medications for symptomatic treatment. The pathogens most commonly associated with common cold symptoms are the rhinoviruses. There are over 100 different types that account for 40 to 50 percent of the cases. Other responsible pathogens include coronaviruses and respiratory syncytial virus (RSV). While influenza, parainfluenza, and adenoviruses may be associated with cold symptoms, they often cause lower respiratory and systemic symptoms, in addition to the upper respiratory symptoms characteristic of the common cold. These
infections also present differently in younger children, versus older children and adults. For instance, RSV in older chidren and adults often presents the same as other colds, but in infants and toddlers, it can result in bronchiolitis and involve the lower respiratory tract. Similarly, parainfluenza may present as croup in younger children and as a typical cold in an older child. The cold season begins in late August/September and remains constant until the spring due to the number of viruses. Rhinovirus begins to increase in the early fall. Alternatively, parainfluenza peaks in the late fall and late spring, while RSV and influenza viruses are highest between December and April. Common cold symptoms are associated with each of these outbreaks. An effective vaccine for the common cold is unlikely for two reasons. First, some of these viruses do not cause lasting immunity such as RSV, parainfluenza viruses, and coronavirus which can result in recurrent infections. Second, even though other viruses do produce lasting immunity, there are so many serotypes that a vaccine would not produce a real impact on reducing the frequency of common cold infections. Transmission and Prevention. Colds may be spread through three mechanisms: (1) small-particle aerosols produced from coughing and inhaled by another person;
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(2) large particle droplets produced from saliva that is expelled during a sneeze and lands on the conjunctivae or nasal mucosa of another person; or (3) self-inoculation from touching oneâ€™s own nasal mucosa after touching a person or object contaminated with a cold virus. Hence, poor hygiene and curiosity may be factors that lead to childrenâ€™s increased susceptibility to colds. Hand-washing removes the cold virus from the hands. Virucidal tissues have been shown to reduce secondary transmission. However, alcohol-based hand sanitizers have not been shown to reduce secondary transmission of colds, most likely because rhinovirus is not affected by these products. Treatment. While treatment options differ in adults and children, symptomatic and supportive treatment remains the mainstay for the common cold. The following treatment options do not reduce disease duration. Antibiotics are not indicated unless symptoms strongly suggest a secondary bacterial infection. Antiviral therapy is not available for viruses that cause the common cold. Treatment in Adults. Ipratropium bromide (AtroventÂŽ Nasal Spray), an anticholinergic medication which is administered intranasally, may be helpful in improving symptoms of rhinorrhea and sneezing. Via application to the nasal mucosa, it inhibits mucous gland secretions. However, it does not improve nasal congestion. It is usually dosed as two sprays in each nostril, three to four times a day. Adverse effects include nosebleeds, nasal dryness, and dry mouth. First-generation antihistamines such as diphenhydramine may improve rhinorrhea and sneezing, but their use is limited due to bothersome side effects including sedation and drying of the eyes, nose, and mouth. A systematic review of available data concluded that first-generation antihistamines had a small clinical benefit for relief of rhinorrhea and sneezing, but that this was out-
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weighed by the frequency of side effects. Non-sedating antihistamines, such as loratadine and cetirizine, were not effective. Therefore, antihistamines have minimal benefit in treating the common cold. Cough associated with the common cold is often due to post-nasal drip or nasal obstruction. The American College of Chest Physicians guidelines do not recommend cough suppressants or antitussives, such as codeine or dextromethorphan, for relief of cough associated with upper respiratory infections. Several clinical trials, however, have concluded that dextromethorphan is superior to placebo for cough suppression. Trials examining patients with acute cough due to the common cold found no consistent benefit when codeine was compared with placebo, even though it may be helpful for chronic cough. Topical and oral adrenergic agents such as phenylephrine and pseudoephedrine may temporarily alleviate nasal congestion. Phenylephrine is less effective than pseudoephedrine for treating rhinitis symptoms, yet it is a common ingredient in many OTC cold preparations. Since pseudoephedrine is currently being used in the illegal manufacturing of methamphetamine, FDA has limited purchases and the availability to behind-the-counter in pharmacies. Topical decongestants should not be used for longer than two to three days, as they can result in rebound rhinitis. Adverse effects associated with these agents include increased blood pressure in those with preexisting hypertension, nosebleeds (topical), agitation, and insomnia. Expectorants are intended to increase mucous production. The most common commercial agent is guaifenesin. Studies show it may have a marginal effect in improving the thickness and quantity of sputum in adults. Sore throat may be treated with aspirin or acetaminophen, while non-steroidal anti-inflammatories (NSAIDs) may be used for headache, ear pain, muscle and
joint pains, malaise, and sneezing associated with the common cold. While their effectiveness is questioned, saline nasal sprays or irrigations and inhaling warm vaporized air may ease some of these symptoms. Treatment in Children. Over the past few years, the use of OTC cough and cold medications for children and infants has been under investigation. Over the past 20 years, 123 deaths involving children younger than six years of age have resulted from the use of OTC cough and cold medications. The adverse events associated with their use, as well as accidental ingestion, are a common cause for emergency department visits. Poor labeling, use of multi-ingredient products, and multiple caregivers administering medications are factors that lead to inadvertent overdosing. In October 2007, the U.S. Food and Drug Administration (FDA) Advisory Committee voted to recommend against the use of OTC cough and cold medications in children younger than two years. Drug manufacturers voluntarily discontinued the marketing of these agents for children less than two years of age. Subsequently, the number of emergency department visits for adverse events involving these medications was cut in half for children in this age group. In 2011, the FDA advisory group voted again to further ban the use of these agents in children less than six years of age. The American Academy of Pediatrics (AAP) recommends against the use of OTC cough and cold medications in children younger than six years, due to safety concerns and the lack of efficacy data surrounding their use. Supportive therapy for children, as well as adults, includes increasing fluid intake to thin secretions; ingesting warm fluids such as tea which may soothe the respiratory mucosa, increase the flow of nasal mucus, and loosen mucus; the use of topical saline and nasal suction to remove nasal secretions; and the use of a humidi-
Table 1 Comparison of the common cold and flu Symptoms
Fever Headache General Aches, Pains Fatigue, Weakness Extreme Exhaustion Stuffy Nose Sneezing Sore Throat Chest Discomfort, Cough
Rare Rare Rare Mild Never Common Usual Usual Mild to moderate hacking cough
Characteristic, high, lasting 3-4 days Prominent Prominent May last 2-3 weeks Early and prominent Sometimes Sometimes Sometimes Common; can become severe
Temporary symptom relief
Antiviral drugs (Relenza® or Tamiflu®) within 24-48 hours
fier which helps loosen nasal secretions. While these interventions are not proven to be effective, they are safe and inexpensive. Symptomatic treatment is suggested only when symptoms are interfering with sleep or causing discomfort. Single ingredient products are recommended to avoid overdosing from multiple medications that contain the same ingredient. Fever and general discomfort from the common cold may be treated with acetaminophen for children older than three months or ibuprofen for children older than six months. The use of aspirin is not recommended in children due to the association with Reye’s Syndrome. Regarding the treatment of nasal congestion and rhinorrhea, ipratropium 0.06 percent nasal spray (Atrovent® Nasal Spray) is indicated for the relief of rhinorrhea due to the common cold for ages five to 11 years. There is no evidence supporting the effectiveness of either oral or topical decongestants in children. Antihistamines or combination antihistamine/decongestants are also not recommended for nasal symptoms. Antitussives are not recommended in children for several reasons. Coughing is a protective action that clears the airway; suppressing it may be harmful to chil-
dren, especially those with asthma. In addition, studies have failed to indicate improvement when dextromethorphan was used. Lastly, accidental overdose of antitussives can cause respiratory depression. One recent study suggested that the bedtime application of vapor rub containing menthol, camphor, and eucalyptus oils to the chest and neck of children aged two to 11 years resulted in relief of night-time cough, congestion, and difficulty in sleep compared to petrolatum or no treatment. It should not be applied to the nasal passages, as it may cause chemical irritation there. Gastrointestinal and central nervous system effects may result from accidental ingestion. Complications of the Common Cold. Wheezing or secondary bacterial infections such as otitis media, sinusitis, or pneumonia may complicate the common cold. Approximately 30 percent of colds in preschool-aged children may be complicated by otitis media, with the risk being highest in children six to 11 months of age. Sinusitis may occur in 5 to 10 percent of children with colds, and is considered when symptoms do not improve after 10 days. Infants and children with reactive airway disease or asthma are at a higher
risk for complications, and may have increased severity and duration of respiratory symptoms. Fifty percent of asthma exacerbations are associated with viral infections, particularly rhinovirus. RSV is also associated with wheezing exacerbations. Table 1 includes comparison of symptoms, prevention and treatment for the common cold and influenza.
Acute rhinosinusitis (ARS) is defined as symptomatic inflammation of the nasal cavity and paranasal sinuses lasting fewer than four weeks. The term rhinosinusitis is used since inflammation of the sinuses is almost always accompanied by inflammation of the nasal cavity, and is more commonly referred to as sinusitis. Viral etiology associated with an upper respiratory infection (URI) or the common cold is the most frequent cause of sinusitis. However, sinusitis can also be caused by allergens, environmental irritants, and bacterial or fungal infections. Acute viral rhinosinusitis (AVRS) is extremely common, while secondary bacterial infections of the paranasal sinuses following a viral URI are estimated to occur in 0.5 to 2 percent of adults and 5 percent of children. Even though viral infections account for 92 to 98 percent of the cases, acute rhinosinusitis is the fifth leading indication for antibiotic prescribing by healthcare professionals. Contrary to common belief, the presence of colored or green nasal discharge alone does not indicate that the infection has been complicated by bacteria. In an uncomplicated case of viral URI, the nasal discharge begins as clear and watery, and becomes thicker and more mucoid throughout the course of the disease. It may become thick, colored, and opaque for several days before reversing to mucoid and clear again or drying. Because differentiating between AVRS and bacterial infection is difficult, it is challenging to determine when antibiotics are indicated.
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Table 2 Outpatient antimicrobial regimens for acute bacterial rhinosinusitis in adults* Indication First-line Initial empiric therapy Amoxicillin-clavulanate (500mg/125mg PO tid or 875mg/125mg PO bid)
Second-line Amoxicillin-clavulanate (2000mg/125mg PO bid) Doxycycline (100mg PO bid or 200mg qd)
Doxycycline (100mg PO bid or 200mg qd) Levofloxacin (500mg PO qd) Moxifloxacin (400mg PO qd)
Risk for antibiotic resistance or failed initial therapy
Amoxicillin-clavulanate (2000mg/125mg PO bid) Levofloxacin (500mg PO qd) Moxifloxacin (400mg PO qd)
*Adapted from IDSA Guidelines for ABRS 2012
Studies indicate that some patients with acute bacterial rhinosinusitis (ABRS) may clear the infection spontaneously without antibiotic treatment. Sinusitis rarely leads to severe complications. Several practice guidelines have been published by various professional organizations to aid practitioners in appropriate antimicrobial prescribing. The treatment recommendations discussed in this lesson are based on the Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults published by the Infectious Disease Society of America (IDSA) in 2012. Since sinus aspirate cultures are not readily available, it is not possible to distinguish between AVRS and ABRS in the first 10 days of illness based on history and examination. Therefore, ABRS should be considered when any of the following are present: (1) persistent signs and symptoms of ARS lasting 10 or more days with no clinical improvement; (2) severe symptoms or signs of high fever (>102°F) and purulent nasal discharge, or facial pain lasting for at least three to four consecutive days at the beginning of the illness; or (3) worsening signs or symptoms characterized by the new onset of fever, headache, or increase in nasal discharge, following a typical upper respiratory
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infection that lasted five to six days and were initially improving. The last symptoms are referred to as double-sickening. Treatment of Sinusitis. The following treatment recommendations are for patients with suspected ABRS. For the relief of pain associated with ARS, analgesics such as NSAIDs and acetaminophen may be used. Intranasal saline irrigation, with either normal saline or hypertonic saline, may be used in adults and children to relieve nasal symptoms. Although saline irrigation is safe and may make the patient more comfortable, it is associated with nasal burning, irritation, and nausea. Saline irrigation is less well tolerated in babies and young children. Intranasal corticosteroids may be used as an adjunct to antibiotics in patients with a history of allergic rhinitis. Neither decongestants (topical or oral) nor antihistamines is recommended for adjunct treatment in patients with ABRS. Empiric antimicrobial therapy should be initiated in patients with signs and symptoms suggestive of ABRS as soon as the clinical diagnosis is made. Based on IDSA’s clinical criteria previously outlined, patients with bacterial infection are more likely to be appropriately identified. The recommendation for “watchful waiting” is gener-
ally no longer necessary. However, “watchful waiting” with follow-up still may be employed in patients where the diagnosis of a bacterial infection is uncertain and milder symptoms are present. Treatment in Adults. Amoxicillin was formerly recommended as a first-line agent due to its narrow spectrum of coverage and low cost. However, the pathogens for ABRS have changed since the introduction of routine conjugated pneumococcal vaccination in children. For both adults and children, the percentage of ABRS due to S. pneumoniae has decreased while the percentage due to H. influenzae has increased. Antimicrobial resistance to both respiratory pathogens continues to rise. Therefore, the IDSA guidelines now recommend amoxicillin-clavulanate (Augmentin®) over amoxicillin as a first-line agent for non-penicillin allergic adults. The dose for most adults is 500mg/125mg orally three times a day, or 875mg/125mg orally twice daily. High dose amoxillin-clavulanate of 2 grams orally twice daily is recommended for geographic regions with high endemic rates (>10 percent) of penicillin-nonsusceptible (PNS) S. pneumoniae, and for patients who are 65 years and older, recently hospitalized, treated with an antibiotic in the previous month, or immunocompromised. For patients who are allergic to penicillin, doxycycline may be used first line, or a respiratory fluoroquinolone such as levofloxacin or moxifloxacin. According to the IDSA, the duration of treatment in adults should be five to seven days. Second-line treatment options include amoxicillin-clavulanate 2000mg/125mg orally twice daily; levofloxacin 500mg orally once daily; or moxifloxacin 400mg orally once daily. (Table 2) Treatment in Children. Again, amoxicillin-clavulanate, rather than amoxicillin alone, is recommended as empiric firstline therapy in children. The addition of clavulanate improves
Table 3 Outpatient antimicrobial regimens for acute bacterial rhinosinusitis in children* Indication First-line Second-line Initial empiric therapy Amoxicillin-clavulanate Amoxicillin-clavulanate (90mg/ (45mg/kg/day PO bid) kg/day PO bid) Beta-lactam allergy Type I hypersensitivity Non-type I hypersensitivity
Risk for antibiotic resistance or failed initial therapy
*Adapted from IDSA Guidelines for ABRS 2012
coverage for ampicillin-resistant H.influenzae and M. catarrhalis in ABRS. However, it also increases the likelihood of diarrhea. If oral antibiotics cannot be given initially due to vomiting, a single dose of ceftriaxone, dosed at 50mg/kg/day, may be administered intramuscularly or intravenously, followed by oral antibiotics 24 hours later (once vomiting has been resolved). High dose amoxicillin-clavulanate, 90mg/kg/day orally twice daily, is recommended for children in geographic areas with PNS S. pneumoniae, as well as those with severe infection, attending daycare, less than 2 years of age, recently hospitalized, having used antibiotics within the past month, or those who are immunocompromised. Combination therapy with a third-generation oral cephalosporin (i.e., cefixime or cefpodoxime) plus clindamycin may be used as second-line therapy for children with non-type I penicillin allergy in regions with high rates of PNS S. pneumoniae. Children with a type I penicillin allergy may be treated with levofloxacin. (Table 3) In children, the recommended duration of antimicrobial therapy
•Levofloxacin (10-20mg/kg/day PO every 12-24 hours) •Clindamycin (30-40mg/kg/day PO tid) plus cefixime (8mg/kg/ day PO bid) or cefpodoxime (10mg/kg/day PO bid) •Amoxicillin-clavulanate (90mg/ kg/day PO bid) •Clindamycin (30-40mg/kg/day PO tid) plus cefixime (8mg/kg/ day PO bid) or cefpodoxime (10mg/kg/day PO bid) •Levofloxacin (10-20mg/kg/day PO every 12-24 hours)
for ABRS is 10 to 14 days. This longer duration, in comparison to adults, is indicated based on the lack of randomized studies in children concluding efficacy in the shorter duration. Macrolides, such as clarithromycin and azithromycin, trimethoprim-sulfamethoxazole (TMP-SMX), and second- or thirdgeneration cephalosporins, are not recommended for empiric therapy due to high rates of resistance with S. pneumoniae. TMP-SMX also has high rates of resistance with H. influenzae. Response to empiric therapy should be seen after three to five days. Altering therapy is suggested for patients who do not show an improvement in that time frame, or when symptoms worsen after two to three days of therapy.
Influenza virus infection is another common viral disease that is highly contagious among children and adults. The annual influenza cycle or season begins as early as October, with a peak in January or February, and ends as late as May. It causes an acute febrile illness and varying other systemic
and upper respiratory symptoms which result in loss of workdays, school absences, as well as morbidity and mortality. Over the past three decades, the estimated annual influenza-related deaths have ranged from 3,000 to 49,000, with approximately 226,000 annual hospitalizations in the U.S. alone. Pediatric mortality from influenza is typically highest in the first year of life. The signs and symptoms of influenza overlap with other viral URIs and include: fever, myalgia, headache, malaise, non-productive cough, sore throat, and rhinitis. Additionally, otitis media, nausea, and vomiting are common in children. A typical uncomplicated course of illness begins after an incubation period of one to two days (up to four), and resolves in three to seven days for most persons, although cough and malaise can persist for greater than two weeks. Fever is the most important clinical finding. It rises rapidly to a peak of 100°F to 104°F (occasionally 106°F), and subsides after three days along with other systemic symptoms. However, the fever may last four to eight days. Complications can occur and lead to primary influenza viral pneumonia; exacerbate underlying medical conditions (i.e,. pulmonary or cardiac disease); lead to secondary bacterial pneumonia, otitis media, or sinusitis; and contribute to co-infections with other viral or bacterial pathogens. Adults shed the virus from the day before symptoms occur, through five to 10 days after illness onset, while the infectivity decreases rapidly by three to five days. Young children may shed the virus several days before illness onset, and can be infectious for 10 or more days after. While limited antivirals are available to treat influenza, vaccine prevention is the most effective strategy. Influenza viruses are encapsulated, single-stranded RNA viruses of the family Orthomyxoviridae. The core nucleotides are used to distinguish between types A, B, and C. In humans, influenza A is
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Continuing Education generally more pathogenic than influenza B. These viruses infect humans and a variety of animals; some of these strains may spread from animal species to humans as well. The influenza viruses are ever changing via antigenic drift and shift. Antigenic drift is a process by which the virus produces ongoing gene mutations resulting in new subtypes and altered virulence. Antigenic shift is less common, but creates virulent strains that are transmissible to a greater population of susceptible individuals which can cause a pandemic. The gene segments between two strains are re-assorted, presumably during a co-infection in a single host. The “Spanish flu” of 1918 was a result of an antigenic shift. This pandemic alone affected 20 to 50 million people globally and was responsible for 549,000 deaths in the U.S. The 2009 H1N1 influenza (also referred to as Swine Flu) pandemic was a recombinant influenza consisting of a mix of swine (pig), avian (bird), and human gene segments. Influenza Diagnosis. Respiratory illnesses caused by influenza virus infection are difficult to differentiate from other illnesses caused by respiratory pathogens based on signs and symptoms alone. Once the presence of influenza virus is confirmed in a region or community, healthy adults with acute influenza-like symptoms most likely have the infection. The accuracy of diagnosis in an influenza outbreak can be as high as 80 to 90 percent. Rapid diagnosis can also be made by testing respiratory secretions from nasopharyngeal samples and/or throat swabs. There are a variety of rapid tests with results available as quickly as 30 minutes. While some are useful in differentiating influenza A and influenza B, none of the current tests can distinguish between influenza A (H1N1) and influenza A (H3N2). The optimal use of rapid diagnostic tests in patient management is not yet defined. Transmission. Influenza viruses are spread primarily
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through large-particle respiratory droplet transmission via coughing or sneezing. Transmission requires close contact with a susceptible individual, since the large droplets do not remain suspended in the air and only travel a short distance. Transmission may also occur via contact with surfaces contaminated with respiratory droplets or through small particles suspended in the air. Influenza Vaccine. Each year in the U.S., a vaccine containing the antigens from the strains most likely to cause infection during the season is produced. At the time of writing this lesson, the vaccine contains three strains, two influenza A strains and one influenza B. The 20122013 vaccine contains the following: A/California/7/2009(H1N1) pdm09-like virus, A/Victoria/361/ 2011(H3N2)-like virus, and B/ Wisconsin/1/2010-like virus. The Centers for Disease Control and Prevention (CDC) recommends that everyone six months of age and older get a flu vaccine each year as soon as it is available. It is especially important for people who are at high risk of developing serious complications such as pneumonia. This includes individuals who have asthma, diabetes, chronic lung disease, are pregnant, or are 65 years of age and older. The vaccine is also important for those who live with, or care for, persons at high risk for developing serious complications. It takes about two weeks for antibodies to develop and provide protection against influenza. Despite the fact that immunity declines over time, most healthy adults and older children will remain protected throughout the season. There are two types of influenza vaccine: inactivated vaccine given by injection and live, attenuated influenza vaccine (LAIV) sprayed into the nostrils. The inactivated vaccine, referred to as the “flu shot,” may or may not contain thimerosal. The flu shot can be given to all persons aged six months and older.
A high-dose inactivated vaccine is also available for persons 65 years of age and older. This product has four times the amount of antigen in the standard formulation, and has been shown to provide higher antibody responses in older adults when compared to the standard dose. Side effects are minor and include soreness, redness, or swelling at the injection site; hoarseness; sore, red, or itchy eyes; cough; fever, aches, headache, itching, and fatigue. Life threatening severe reactions to either vaccine formulation are very rare. LAIV is recommended for healthy persons two through 49 years of age who are not pregnant and do not have chronic health conditions (heart disease, lung disease, asthma, kidney or liver disease, diabetes, anemia, or other blood disorders). The vaccine should not be given if a severe allergy to a component of the vaccine exists or if the patient has an allergy to eggs. It does not contain thimerosal or other preservatives. LAIV is made from a weakened virus and does not cause influenza, but may cause mild symptoms such as runny nose, cough, congestion, fever, headache, muscle aches, cough, chills, tiredness/weakness, sore throat, wheezing, abdominal pain, vomiting, or diarrhea. Specific product labeling and CDC vaccine information statements (http://www.cdc.gov/vaccines/pubs/vis/) should be referred to for complete prescribing instructions and recommendations. Antiviral Treatment/Prophylaxis. Influenza antiviral treatment can shorten the duration of fever, lessen symptoms, reduce the risk of complications from influenza, and shorten hospitalization stays. It is recommended to begin antiviral treatment as soon as possible ― ideally within 48 hours of illness onset, for any patient (1) with confirmed or suspected influenza who is hospitalized; (2) who has severe, complicated, or progressive illness; or (3) at higher risk of complications. Treatment should
Continuing Education not be withheld pending laboratory confirmation of influenza. Antiviral treatment can also be considered in previously healthy outpatients without risk of complications on the basis of clinical judgment, again, if it is begun within 48 hours. Antiviral medications for chemoprophylaxis should not be used indiscriminately as widespread use may lead to resistance. However, they are recommended to control outbreaks among high risk persons in institutional settings. In order to be effective as chemoprophylaxis, the medication must be taken each day for the duration of potential exposure to a person with influenza, and continued for seven days after the last known exposure. For persons taking antiviral medications following immunization, the duration of therapy is until immunity after vaccination develops (generally two weeks, but may be longer in children). It is generally not recommended if more than 48 hours have elapsed since the last exposure to an infectious person. While four antiviral drugs are currently available for the prevention and treatment of influenza, only two of them, oseltamivir (Tamiflu®) and zanamivir (Relenza®), which are neuraminidase inhibitors, are clinically useful against influenza A and B. Amantadine and rimantadine are part of a class of medications called adamantanes which were initially effective against influenza A. However, the current strains of influenza are resistant to both adamantane agents. Resistance to the neuraminidase inhibitors is currently low. Oseltamivir is approved for chemoprophylaxis and treatment in children greater than one year of age and in adults. Pediatric dosing is weight-based until the child reaches 40kg or 12 years of age. Then the child may be administered the adult dose of 75mg orally twice daily for treatment, or 75mg orally once daily for chemoprophylaxis. Oseltamivir is available as 30mg, 45mg, and 75mg capsules 26 and 6mg/mL powder for suspen-
sion. Directions for emergency compounding using the capsules to make a suspension can be found on the manufacturer’s website at: http://www.tamiflu.com/hcp/ resources/hcp_resources_pharmacists.jsp. Zanamivir is approved for chemoprophylaxis in children greater than five years of age, and for treatment in children greater than seven years as well as adults. The dose for both populations is 10mg (two inhalations) twice daily for treatment or 10mg (two inhalations) once daily for chemoprophylaxis. Zanamivir is available as a 5mg powder dose for oral inhalation using the Diskhaler® inhalation device. The recommended duration of therapy for treatment is five days, but can be extended for those who remain severely ill. The recommended duration is seven days for chemoprophylaxis following exposure. However, CDC recommends a minimum duration of two weeks when outbreaks occur in long term facilities and hospitals. Practitioners should consult the Advisory Committee on Immunization Practices’ (ACIP) recommendations for the appropriate use of antivirals for influenza treatment and prophylaxis at: http:// www.cdc.gov/mmwr/pdf/rr/rr6001. pdf.
The author, the Ohio Pharmacists Foundation and the Ohio Pharmacists Association disclaim any liability to you or your patients resulting from reliance solely upon the information contained herein. Bibliography for additional reading and inquiry is available upon request. This lesson is a knowledge-based CE activity and is targeted to pharmacists in all practice settings.
Program 0129-0000-12-011-H01-P Release date: 11-15-12 Expiration date: 11-15-15
CE Hours: 1.5 (0.15 CEU) The Ohio Pharmacists Foundation Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
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continuing education quiz
Program 0129-0000-12-011-H01-P 0.15 CEU
Common Cold, Sinusitis, Influenza: The Diseases, Prevention, Treatment
City, State, Zip______________________________________ Email_______________________________________________
1. The pathogens most commonly associated with symptoms of the common cold are: a. adenoviruses. c. respiratory syncytial virus. b. coronaviruses. d. rhinoviruses. 2. Alcohol-based hand sanitizers have been shown to reduce secondary transmission of colds. a. True b. False 3. The mainstay treatment for the common cold is: a. symptomatic. c. antibacterial agents. b. antiviral agents. d. vaccine prevention. 4. Which of the following common cold treatments in adults should not be used longer than two to three days because they can result in rebound rhinitis? a. First-generation antihistamines b. Non-sedating antihistamines c. Topical decongestants d. Cough suppressants 5. The American Academy of Pediatrics recommends against the use of OTC cough and cold agents in children: a. <6 years. b. <12 years. 6. The most frequent cause of sinusitis is: a. allergens. c. environmental irritants. b. bacterial infection. d. viral URI. 7. The presence of colored or green nasal discharge alone can indicate an acute bacterial rhinosinusitis infection. a. True b. False
Completely fill in the lettered box corresponding to your answer. 1. 2. 3. 4. 5.
[a] [a] [a] [a] [a]
[b] [c] [d] [b] [b] [c] [d] [b] [c] [d] [b]
6. [a] 7. [a] 8. [a] 9. [a] 10. [a]
[b] [b] [b] [b] [b]
[c] [d] [c] [d] [c] [d]
11. [a] 12. [a] 13. [a] 14. [a] 15. [a]
[b] [b] [b] [b] [b]
[c] [d] [c] [d] [c] [d]
I am enclosing $5 for this month’s quiz made payable to: Ohio Pharmacists Association. 1. Rate this lesson: (Excellent) 5 4 3 2 1 (Poor) 2. Did it meet each of its objectives? yes no If no, list any unmet_______________________________ 3. Was the content balanced and without commercial bias? yes no 4. Did the program meet your educational/practice needs? yes no 5. How long did it take you to read this lesson and complete the quiz? ________________ 6. Comments/future topics welcome.
NABP e-Profile ID*__________________________________ *Obtain NABP e-Profile number at www.MyCPEmonitor.net.
Return quiz and payment (check or money order) to Correspondence Course, OPA, 2674 Federated Blvd, Columbus, OH 43235-4990
8. Saline irrigation is less well tolerated in: a. adults. c. babies. b. teenagers. d. elderly. 9. In treating non-penicillin allergic adults with sinusitis, IDSA guidelines recommend the following as a first-line agent. a. Levofloxacin c. Doxycycline b. Amoxicillin d. Amoxicillin-clavulanate 10. In children, the recommended duration of antimicrobial therapy for ABRS is: a. 3 days. c. 10 to 14 days. b. 5 to 7 days. d. 21 days. 11. The most important clinical finding in diagnosing influenza is: a. fatigue. c. headache. b. cough. d. fever. 12. Antigenic drift creates virulent strains that are transmissable to a greater population. a. True b. False 13. CDC recommends flu vaccine administration to all the following persons EXCEPT: a. asthmatics. b. pregnant women. c. children three months of age and older. d. caregivers of persons at high risk. 14. Within what period of time of illness onset should antiviral treatment be started for influenza? a. 24 hours c. Three days b. 48 hours d. One week 15. Which two antiviral drugs are clinically useful against influenza A and B? a. Oseltamivir and zanamivir b. Oseltamivir and amantadine c. Amantadine and rimantidine d. Amantadine and zanamivir To receive CE credit, your quiz must be received no later than November 15, 2015. A passing grade of 80% must be attained. All quizzes received after July 1, 2012 will be uploaded to the CPE Monitor and a statement of credit will not be mailed. Send inquiries to firstname.lastname@example.org.
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Georgia Pharmacy Association
2012-2013 BOARD OF DIRECTORS Name
L. Jack Dunn Chairman of the Board Robert M. Hatton President Pamala S. Marquess President-Elect Robert B. Moody First Vice President Thomas H. Whitworth Second Vice President Hugh M. Chancy State At Large Liza G. Chapman State At Large Keith N. Herist State At Large Joshua D. Kinsey State At Large Tracie D. Lunde State At Large Eddie M. Madden State At Large Jonathan G. Marquess State At Large Christine Somers 1st Region President Ed S. Dozier 2nd Region President Renee D. Adamson 3rd Region President Nicholas O. Bland 4th Region President Julie W. Bierster 5th Region President Sherri S. Moody 6th Region President Amanda McCall 7th Region President Michael Lewis 8th Region President Kristy L. Pucylowski 9th Region President Lance P. Boles 10th Region President Ashley London 11th Region President Ken Von Eiland 12th Region President Thomas R. Jeter ACP Chairman Sharon B. Zerillo AEP Chairman Archie R. Thompson AHP Chairman Drew Miller AIP Chairman Linda Gail Lowney APT Chairman Robert Bentley ASA Chairman John T. Sherrer Foundation Chairman Michael E. Farmer Insurance Trust Chairman Al McConnell Georgia Board of Pharmacy Chairman Kenneth G Jozefcyk Georgia Society of Health Systems Pharmacists Amy C. Grimsley Mercer Faculty Representative Rusty Fetterman South Faculty Representative Sukhmani K. Sarao UGA Faculty Representative Negin Sovaidi Moon ASP, Mercer University Amanda Brown ASP, South University James William Spence ASP President, UGA Jim Bracewell Executive Vice President
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Build Store Traffic, Build Profits March 10, 2013
Save $50 with Early Bird Registration
Crowne Plaza Atlanta Perimeter at Ravinia - Atlanta, GA SPONSORED BY:
(Space Limited to 200)
Build Store Traffic, Build Profits: Front-End Overhaul One Day Intensive Presented by: Gabe Trahan (NCPA) 7.5 hours of CE (with 2 hours of non-CE)
This hands-on, one day seminar is full of walk-away-tools and is specifically designed to capitalize on the strengths of the community pharmacy. Community pharmacies are unparalleled in their customer focus and connection, but without the corporate machine available to the chain competition for merchandising, advertising, store layout, and external curb appeal, a large segment of local pharmacy patients may not know of the superior experience that awaits them in a community pharmacy. This program is designed to deliver the tools and knowledge the pharmacy owner needs to change the picture and create more pharmacy traffic and more profit. Topics: Creating Curb Appeal; OTC Basic to Advanced; Inventory: What, How Many and How Much; Moving Private Label ; Getting the Word Out – Message and Medium; Effective Signage; Trade Secrets: Stores Talking to Stores.
Curb Appeal – Make them want to come inside! Take Home: Detailed checklist that will help the pharmacy staff get and keep the pharmacy looking its best every day. OTC Basic to Advanced – What sells best where lay out your merchandise where it fits best and sells the most. Take Home: Extensive listing of cross merchandising suggestions. Inventory –Tools to keep inventory fresh and best practices on pricing and presentation. Take Home: a hands-on section will focus on building an effective end-cap designed to attract customer attention and make sales. Private Label – A great opportunity for savings to the pharmacy and patient. Lean how to stock, promote, sign and up-sell private label. Take Home: Eye-Catching Sign Samples to use in your store. Marketing – How to effectively advertise to bring customers into your store. Take Home: Advertising check list to express your pharmacy’s value to customers. Selling Cards, Gifts and Seasonal – Stock and merchandise to save the customer a trip to another store and enhance a pharmacy’s image. Take Home: How to calculate investment and create a schedule to order, stock and sell. Stores Talking to Stores – Sharing, networking, and learning from fellow participants. This session focuses on success stories and best practices that will take what you have learned and what you already knew, and build a walk away plan for overhauling your pharmacy’s front-end.
Early Bird - Registration by February 15, 2013
AIP member $295 NCPA member only $350 Non-NCPA member $450
AIP has negotiated an $89 room rate. Please ask for the AIP room block when making reservations. Reserve your room before the block sells out.
Registration after February 15, 2013
AIP member $350 NCPA member only $400 Non-NCPA member $500
Employees can be added for $150 each with your registration
Crown Plaza Atlanta Perimeter at Ravinia Easy access to Marta Across the street from Perimeter Mall Running Trails & gym In-door swimming pool Access to shopping, restaurants and entertainment Shuttle service Free parking
Name:_______________________________________________________________________________ Pharmacy Name:____________________________________________ Phone: (______)_____________ Address:______________________________________________________________________________ E-mail Address (Please Print):_____________________________________________________________ □ AIP Member
□ NCPA Member □ Employee
Amount Paid: _______________________________
□ Check □ Credit Card ______________________________ CVS# ________ Exp. ________ credit card billing address: ________________________________________________________________ Please email Verouschka Betancourt-Whigham at firstname.lastname@example.org if you have any questions. Mailing Address: AIP ● 50 Lenox Pointe NE ● Atlanta, GA 30324
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PLEASE FAX BACK TO
(404) 237-8435 29
Georgia Pharmacy Association
50 Lenox Point NE Atlanta, GA 30324