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Celebrating 30 years of service to the Pharmacists of Georgia!

Let us be Your Insurance Resource Join us in celebrating 30 years of serving the members of the Georgia Pharmacy Association. To learn more visit Call or e-mail TODAY to schedule a time to discuss your health insurance needs.

Trevor Miller – Director of Insurance Services 404.419.8107 or email at Georgia Pharmacy Association Members Take Advantage of Premium Discounts Up to 30% on Individual Disability Insurance Have you protected your most valuable asset? Many people realize the need to insure personal belongings like cars and homes, but often they neglect to insure what provides their lifestyle and financial well-being - their income! The risk of disability exists and the financial impact of a long-term disability (90 days or more) can have a devastating impact on individuals, families and businesses. During the course of your career, you are 3½ times more likely to be injured and need disability coverage than you are to die. (Health Insurance Association of America, 2000) As a member of the Georgia Pharmacy Association, you can help protect your most valuable asset and receive premium discounts up to 30% on high-quality Individual Disability Income Insurance from Principal Life Insurance Company.

For more information visit * Association Program subject to state approval. Policy forms HH 750, HH 702, HH 703. This is a general summary only. Additional guidelines apply. Disability insurance has limitations and exclusions. For costs and details of coverage, contact your Principal Life financial representative.

The Georgia Pharmacy Journal


January 2011



VIP Day Save the Date February 23, 2011

8 Pharm PAC 2010-2011 12 GPhA New Members 31 GPhA Board of Directors


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Welcome New GPhA Staff 2011 Pharmacy Based Immunization Certification Program Save the Date GPhA Member News NASPA 2011-2012 Executive Residency

2 2 7 5 6 9 9 9 10 12 13 14 17 18 20 32

The Insurance Trust Principal Financial Group PharmAssist Recovery Network Display Options, Inc. GPhA Career Center Logix, Inc. Michael T. Tarrant Toliver & Gainer Pharmacists Mutual Companies Melvin Goldstein, P.C. Sparkfly GoToMeeting/GoToWebinar Caribbean CPE Cruise GPhA Workers Compensation AIP The Insurance Trust

Continuing Education for Pharmacists: Management of Pulmonary Artierial Hypertension The 15th SE PRN Conference Held November 2-14, 2010


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President’s Message

For an up-to-date calendar of events, log onto


The Georgia Pharmacy Journal


January 2011

PRESIDENT’S MESSAGE Dale M. Coker, R.Ph., FIACP GPhA President

The Toughest Thing About Success... y the time this publication hits the street, most of us will have had ample time to break our new year’s resolutions. That being out of the way, we can get on to more important business, like planning for the New Year (we can always worry about losing that extra weight another time, anyway, right?) There is always something refreshing about the prospects of what may lie ahead when the calendar rolls over for yet another year. What new challenges will create even greater opportunities? How we view the challenges will determine how we will respond. Irving Berlin said this about challenge: “The toughest thing about success is that you’ve got to keep on being a success.”


of getting started is breaking your complex overwhelming tasks into small manageable tasks, and then starting on the first one.” This quote exemplifies what has occurred since your Board of Directors approved the five year strategic plan last year. We started with a list of directives for membership and advocacy and broke them down into manageable tasks, beginning with redesigning our website, offering more member benefits (starting with free membership to Sparkfly), and personally challenging all board members to recruit at least three new members this year. These tasks will be evaluated each time there is a meeting, and new tasks will be identified and assigned to meet the challenges of our strategic plan.

Before having the privilege of serving on the GPhA Executive Committee, I had always heard it said that GPhA was a leader among state pharmacy associations. Since that time, I have come to understand and appreciate that this not just self-indulgent puffing up by our own, it is true. There are many reasons for the success we have enjoyed over the years, and much of that is owed to the response to challenge. The biggest challenge facing associations today is dwindling membership. This is why our five year strategic plan focuses first on membership.

On the advocacy side of our plan, we have enjoyed some major successes the past two years, but keeping on being a success is not easy. It requires everyone pitching in. This is so critical in meeting the objectives set forth for advocacy for the next five years. Making timely calls to our elected representatives and participating in the political process through the giving of time and resources are crucial to our success. I hope you will participate through giving to Pharm PAC, through being a personal advocate for our profession, through developing relationships with your elected officials, and participating in our political events, such as VIP day on February 23 at the train depot downtown. I hope you will go ahead and mark your calendar to be there. Here’s to our continued success!

So how do you go about increasing your membership in an environment where most associations are going in the opposite direction? I like this quote from Mark Twain, “The secret of getting ahead is getting started. The secret

The secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming tasks into small manageable tasks, and then starting on the first one. The Georgia Pharmacy Journal


January 2011


Welcome New GPhA Staff Members s. Caroline Fields comes to us from Columbia, South Carolina and is a graduate of the University of South Carolina with a B.A. in Journalism & Mass Communications. Prior to relocating to Atlanta, Ms. Fields worked at Capitol Consultants, Inc. (a lobbying and association management firm) where she managed multiple professional/trade associations. She also previously worked at the South Carolina Pharmacy Association in public affairs back in 2007 under the leadership of Jim Bracewell. In addition to her association management experience, Ms. Fields has also worked in sales and marketing. In her free time, she enjoys cooking, reading, spending time with friends and family, and traveling. And as a SC native, she loves to pull for the Carolina Gamecocks!


Caroline Fields GPhA Director of Conferences and Events s. Maggie Patterson is a native Georgian who holds a B.S. in Middle Grades Education and Masters of Education in Leadership and Policy, both from the University of Georgia. Following school Ms. Patterson taught seventh grade science in Gwinnett and Cobb Counties. With a relocation of her family to Memphis, Tennessee she was presented with the opportunity to enter the field of association management and served as the Executive Director of the Apartment Association of Greater Memphis for over four years. Ms. Patterson is thrilled to be back in Georgia and enjoys running, reading, and spending time with her husband and daughter in her spare time.


Maggie Patterson GPhA Director of Continuing Education and Governance r. Andy Freeman joins us as our Director of Government Affairs. Before joining GPhA, Mr. Freeman ran his own successful Governmental Affairs and Political Consulting Company. Although he has represented a diverse group of clients before the Georgia General Assembly, Mr. Freeman began to specialize in health care after his kidneys shut down in 2004 and receiving a transplant in 2006. Andy has been recognized by Georgia Trend Magazine in their Forty Under 40 list of the best and brightest Georgians in politics and business. He lives in Powder Springs with his wife and 2-year-old son.


Andy Freeman GPhA Director of Government Affairs s. Tei Muhammad is a native of Boston, Massachusetts and completed her undergraduate studies here at Clark Atlanta University. Her love for the not-for-profit industry started at the age of 16. Since then, she has played an intricate role in membership development, sustainability and liaises for mission based organizations and trade associations. Ms. Muhammad has joined the GPhA team with a commitment to understand, support, and fulfill the needs of its members in any way she can. She currently resides in Covington, with her most important love her beautiful daughter Giselle.


The Georgia Pharmacy Journal


Tei Muhammad GPhA Member Service Coordinator

January 2011

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

Members Save 20% on Job Postings Use code MEMDIS001

Career Center

EXECUTIVE VICE PRESIDENT’S EDITORIAL Jim Bracewell Executive Vice President / CEO

At the Table There Was an Empty Seat... hose words are perhaps some of the saddest words in Dickens’ “A Christmas Carol.” But, we read that Scrooge asks the Spirit if these things in the future have to be, and the answer is that it will be the future if no one intervened.

Your association has raised the money, reserved the room, paid for breakfast, and saved the morning for a great day for the pharmacy profession in Georgia.


I look forward to seeing you there at the best legislative day ever for pharmacy.

Next month, on Wednesday, February 23, 2010, at the Georgia Freight Depot, across the street from our State Capitol, the GPhA will host our annual VIP Day at the Capitol in a new and improved format.

Register today at Your registration guarantees you food and a name tag at this event.

Your state legislator will be invited to come and enjoy a brief sit down breakfast with you at a reserved table for that legislator and the pharmacists from that House or Senate District.

PharmAssist Recovery Network The PharmAssist Network continues to provide advocacy, intervention and assistance to the impaired practitioners, students and technicians in the state. If you or anyone you know needs assistance, please call the hotline number:

The most important question is, will the seat for the pharmacist from that district be empty or will you be there to cultivate that important relationship between you and your legislator? What you say that morning to your representative will be heard and it will be important to that legislator and to your profession. What you say with your empty seat will overshadow all your GPhA legislative staff can do all year to advocate for your profession.

PharmAssist Hotline Number (24 hours / 7 days a week)

One Day + One Breakfast + One Legislator + Pharmacists = Legislative Success

404-362-8185 (All calls are confidential)

A simple formula for success, but one that only you can compound.

The Georgia Pharmacy Journal


January 2011

Pharm PAC Enrollment Pledge Year 2010-2011

Titanium Level ($2400 minimum pledge)

Patrick Dunham, R.Ph. Michael E. Farmer, R.Ph. David Graves, R.Ph. Ann Hansford, R.Ph. Jeffrey L. Lurey, R.Ph. Robert A. Ledbetter, R.Ph. Marvin O. McCord, III, R.Ph. Judson L. Mullican, R.Ph. W.A. (Bill) Murray, R.Ph. Mark L. Parris, Pharm.D. Fred F. Sharpe, R.Ph. Jeff Sikes, R.Ph.

Platinum Level ($1200 minimum pledge) Robert Bowles, Jr., R.Ph., CDM, Cfts

T.M. Bridges, R.Ph. Bruce L. Broadrick, Sr., R.Ph. Thomas E. Bryan, Jr., B.S. William G. Cagle, Jr., R.Ph. Keith Chapman, R.Ph. Hugh M. Chancy, R.Ph. Dale M. Coker, R.Ph., FIACP J. Ashley Dukes, R.Ph. Stewart Flanagin, Jr., R.Ph. Martin T. Grizzard, R.Ph. Robert M. Hatton, Pharm.D. Alan M. Jones, R.Ph. Ira Katz, R.Ph. Harold M. Kemp, Pharm.D. Brandall S. Lovvorn, Pharm.D. Eddie M. Madden, R.Ph.

Jonathan Marquess, Pharm.D., CDE, CPT

Pam S. Marquess, Pharm.D. Kenneth A McCarthy, R.Ph. Scott Meeks, R.Ph. Drew Miller, R.Ph., CDM Laird Miller, R.Ph. Jay Mosley, R.Ph. Wallace Allen Partridge, Jr. Tim Short, R.Ph. Christopher Thurmond, R.Ph.

Gold Level ($600 minimum pledge) James Bartling, Pharm.D., ADA, CAC II Liza G. Chapman, Pharm.D. Patrick M. Cook, Pharm.D. Mahlon Davidson, R.Ph., CDM Jim Elrod, R.Ph. H. Neal Florence, R.Ph. J.Thomas Lindsey, R.Ph. Robert B. Moody, III, R.Ph. Sherri S. Moody, Pharm.D. Sharon M. Sherrer, Pharm.D. Michael T. Tarrant Jeffrey Richardson, R.Ph. Robert Anderson Rogers, R.Ph. Daniel C. Royal, R.Ph. Dean Stone, R.Ph., CDM Thomas H. Whitworth, R.Ph., CDM

Silver Level

F. Al Dixon, R.Ph. Jack Dunn, R.Ph. Marshall L. Frost, Pharm.D. Michael O. Iteogu, Pharm.D. Willie O. Latch, R.Ph. William J. McLeer, Sr., R.Ph. Kalen Beauchamp Porter, Pharm.D. Edward Franklin Reynolds, R.Ph. Houston L. Rogers, Jr., Pharm.D., CDM

Brandon Ullrich Alan M. Voges, Sr., R.Ph. Flynn W. Warren, M.S., R.Ph. Oliver C. Whipple, R.Ph. Walter Alan White, R.Ph.

Bronze Level ($150 minimum pledge) Monica M. Ali-Warren, R.Ph. James R. Brown, R.Ph. Mark C. Cooper, R.Ph. Michael A. Crooks, Pharm.D. Charles Alan Earnest, R.Ph. Amanda R. Gaddy, R.Ph. Amy S. Galloway, R.Ph. Johnathan Hamrick, R.Ph. William E. Lee, R.Ph. Earl Marbut, R.Ph. Richard Brian Smith, R.Ph. Sharon B. Zerillo, R.Ph.

Members (no minimum pledge) Jill Augustine Claude W. Bates, B.S. Chad J. Brown, R.Ph. Max C. Brown, R.Ph. Lucinda F. Burroughs, R.Ph. Waymon M. Cannon, R.Ph. Walter A. Clark, Jr., R.Ph.

($300 minimum pledge) Renee D. Adamson, Pharm.D. John L. Colvard, J. R.Ph. Chandler Conner, R.Ph. If you made a gift or pledge to Pharm PAC and your name does not appear above please, contact Kelly J. McLendon at or 404-419-8116.. Donations made Pharm PAC are not considered charitable donations and are not tax deductible. The Georgia Pharmacy Journal


January 2011

Pharm PAC Contributors’ List Continued Jean N. Courson, R.Ph. Carleton C. Crabill, R.Ph. Alton D. Greenway, R.Ph. J. Clarence Jackson, Jr., R.Ph. Gina R. Johnson, Pharm.D., BCPS, CDE Ashley S. London Tracie D. Lunde, Pharm.D. Randall Marett, R.Ph. Ralph K. Marett, M.S.

Whitney B. Pickett, Pharm.D. Rose Ann Pinkstaff, R.Ph. Michael Reagan, R.Ph. Leonard Franklin Reynolds, III, R.Ph. James Riggs, R.Ph. Victor Serafy, R.Ph. Harry A. Shurley, Jr., R.Ph. James Strickland, R.Ph. Leonard Templeton, R.Ph.

James. E. Stowe, Jr., R.Ph. William D. Whitaker, R.Ph. Jonathon A. Williams, Pharm.D. Michael R. Williams, R.Ph.

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The Georgia Pharmacy Journal

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Welcome to GPhA! The following is a list of new members who have joined Georgia’s premier professional pharmacy association! Pharmacy School Student Members Retired Members Debbra Bodah, Lawrenceville Robert Boswell, Roswell Linh Cao, Morrow Holly Lynn Dunham, MLT, Atlanta Joshua Ryan Erisman, Lawrenceville Brett Hall, Athens Yannolis Hernandez, Atlanta Michael Kim, Duluth Sy Le, Lawrenceville David Luc, Lilburn Allison Renee’ Roehrs, B.S., Lawrenceville Johnny Sayarath, Jonesboro Kristina Yacob, Marietta

Benjamin W. Knight, R.Ph., Savannah

Joint Membership Meredith C. Peckel, Pharm.D., Evans

Associate Members Melissa Bishop-Murphy, J.D., MBA, Washington, D.C. Jack S. Tonge, O.D., Winder


Individual Pharmacist Members

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Martha M. Cardoso, R.Ph., Cumming Ronald B. Johnson, R.Ph., Lithonia George C. Sanders, R.Ph., Toccoa Nekia L. Austin, J.D., Pharm.D., Fairburn Hugh B. Cromer R.Ph., Forsyth Gary A. Payton, R.Ph., Suwanee Tracey D. Martin, Pharm.D., Trion



First Year Graduate Members Jonathan Hamrick, Pharm.D., Atlanta Amanda McCall, Pharm.D., Jefferson City, TN Adam Schnepp, Pharm.D., Chamblee


The Georgia Pharmacy Journal


January 2011

The Georgia Pharmacy Journal


December 2010

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GPhA Member, Herbert Hatton, R.Ph., Receives Mercer University Dean’s Award ercer University alumnus Herbert W. Hatton, R.Ph., received the Dean’s Award on Oct. 28 from Dr. H.W. “Ted” Matthews, dean of Mercer’s College of Pharmacy and Health Sciences. The award was given during the College’s annual Honors Luncheon held on Mercer’s Cecil B. Day Graduate and Professional Campus in Atlanta. The Dean’s Award annually recognizes an individual who has contributed to the enhancement of the College as well as the pharmacy profession.


Hatton, a 1967 graduate of the College, is a long-time resident of Carrollton and currently serves as pharmacy manager with Publix Super Markets. He is the immediate past president of the College of Pharmacy and Health Sciences Alumni Association and now serves on the board of directors. In 2000, he established the Harriet Jean Hatton Endowed Scholarship in honor of his sister, which is now the eighth-largest scholarship at the College. Additionally, Hatton has been recognized for his mentoring and support of pharmacy students’ organizational and professional efforts. “The dedication he has shown to his profession is paralleled in his commitment to his alma mater,” Dean Matthews said during the ceremony. “He is always on the lookout for young people who would make outstanding pharmacists and is one of the most active and dedicated recruiters for the College.”

GPhA Member, H. Truitt Smith, R.Ph., Passes Away . Truitt Smith, Jr., age 66, of Cornelia, Georgia passed away on Wednesday, December 1, 2010.

deacon and Sunday School Teacher.


Survivors include his wife, Marianne Jackson Smith, Cornelia, GA; daughter and son-in-law, Melissa and Stacy Nichols, Winamac, Indiana; daughter, Jennifer Smith Chastain, Mt. Airy, GA; son and daughter-in-law, James Truitt and Tracey Smith, Woodstock, GA; and 11 grandchildren, Katie, Meredith, Sarah, Susanna, Gabby, Sam, Carrie Jane, and Mary Hannah Nichols, and Bobby, Luke, and Jonathan Powell.

Mr. Smith was born in Newnan, Georgia on March 20, 1944, to the late Henry Truitt, Sr. and Mary Ruby Hicks Smith. He was also preceded in death by his sister, Bebe Thornton. Mr. Smith was a Graduate of UGA receiving his Bachelors Degree in Pharmacy. Mr. Smith was a United States Navy Veteran, serving during the Vietnam Conflict as a hospital corpsman. He owned and operated Arnold Drug Company since 1983. Mr. Smith was an active member of the Georgia Pharmacy Association and had served on the board of directors with the Academy of Independent Pharmacy. He loved people, enjoyed being with his family, and was an avid follower of college football. Mr. Smith was a lifelong stamp collector and a member of the American Philatelic Society. He was a member of First Baptist Church of Dallas, Georgia where he had served as a

The Georgia Pharmacy Journal


January 2011


Augusta Pharmacy is International Model By Erin Zureick Augusta Chronicle on December 7, 2010 arney's Pharmacy in south Augusta prides itself on patient interaction. Its focus on improving patient health through classes and individual attention has helped it expand and attracted national attention.


Chan said those classes resonated with her because 11 percent of her island nation has diabetes and many people don't know how to monitor their blood sugar levels properly.

This week, it also brought in visitors from half a world away to study the pharmacy's operations and programs.

"Diabetes affects such a large part of our population, here and around the world," Bryant said.

A five-member group from Singapore pharmacy chain NTUC Healthcare visited Augusta, meeting with Barney's employees and touring chain pharmacies such as Walgreens, Walmart and Kroger.

Chan also said she liked the Barney's Pharmacy's Champions Club, which recognizes patients who have achieved their diabetes goals, and its weekly bingo games. Pharmacies in Singapore and the U.S. have several key differences, Bryant said. Physicians also dispense medicine in the southeast Asian country, so pharmacies mainly dispense only special medications that doctors don't stock. They also help customers with herbs and vitamin supplements.

"We have always had this dream of building a relationship with customers," said Chan Yiam Moi, NTUC's general manager of the 46-store chain. "Hopefully, we will bring back ideas and put together an action plan." The Singapore group first heard about Barney's Pharmacy from an August New York Times article that highlighted the Augusta business's use of diabetes-management classes to engage patients and improve health.

An independent pharmacy in the U.S. does most of its business dispensing medicine, while a pharmacy in Singapore does most of its business from products in the front of the store. David Pope, a pharmacist and editor-in-chief of Barney's Pharmacy's educational Web site,, said he hopes the Peach Orchard Road business can continue to give feedback to NTUC's pharmacists after they return to Asia.

Those classes and other tools help Barney's Pharmacy reach patients better, said owner Barry Bryant. As part of the diabetes-management classes, known as "The Sweet Spot" courses, patients meet with diabetes educators at the pharmacy who help them improve their diets and monitor blood sugar.

"We like to offer education wherever we can," he said.

UGA College of Pharmacy Team Ranked 4th in National Competition wo fourth-year students from the University of Georgia College of Pharmacy won Fourth Place at the 15th National Clinical Skills Competition held this month during the American Society of Health-System Pharmacist’s 45th Midyear Clinical Meeting. Melissa Mahoney and Jetta Sartwell were able the compete against 108 other teams by winning the preliminary competition held at the College.


their skills by assessing patient information and current therapy, identifying and prioritizing drug therapy problems, identifying treatment goals, and recommending a pharmacist’s care plan. Other activities for pharmacy students included sessions on career planning, pursuing residency training, and opportunities for involvement in ASHP and the ASHP Foundation’s Pharmacy Practice Model Initiative.

During the national competition, which administered by ASHP’s Pharmacy Student Forum and sponsored by the ASHP Research and Education Foundation, students demonstrated

In the College’s Clinical Skills Competition, Casey Allen-Hayes and Kim Ward took Second Place and Jake Galdo and Clark Lee placed Third.

The Georgia Pharmacy Journal


January 2011

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National Alliance of State Pharmacy Associations 20112012 Executive Residency ou are a future leader in pharmacy and understand the contributions pharmacists can make to the future of health care. You want to build a career beyond what is currently available to you. You want a non-traditional, exciting job with a limitless future, but you don’t want to leave pharmacy. Do you want to learn from, and be mentored by leaders in health care? The National Alliance of State Pharmacy Associations (NASPA) Executive Residency in Association Management is the catalyst to jumpstart your career.

Adherence Discovery Projects). • Create and edit a monthly newsletter. • Develop grant concepts and applications. • Network with other state/national executive residents • Be a resource-developer for the nation’s state pharmacy associations. • Have the flexibility to tailor your experience to state association management or public policy. • Work with state pharmacy executives who are knowledgeable, caring, supportive, and fun!


• You will learn first-hand how to lead an association during one of the most tumultuous times in the history of American health care. • You will gain important skills that will help you be successful in any setting. • During your tenure as the NASPA Executive Resident, you will interact with influential leaders from national and state pharmacy associations, other provider and advocacy organizations, government agencies, pharmaceutical manufacturers, and academia. • You will be exposed to and become well-versed in the most pressing health care issues of the day. • You won’t read about it, you’ll be about it!

All applications must include the following: • A cover letter explaining your career goals and reason for interest in the executive residency. • A résumé/curriculum vitae describing your work and professional experience. • Two letters of recommendation from the following: State pharmacy association executive, faculty member, dean, recent employer, or pharmacy mentor, one of which must be a state pharmacy association member. • An official copy of your most recent transcript from your school/college of pharmacy. Mail applications to: National Alliance of State Pharmacy Associations Executive Residency Selection Committee 2530 Professional Road, Suite 202 Richmond, VA 23235

The NASPA Executive Residency offers opportunities unattainable elsewhere: • Launch your association and regulatory/policy career with a solid year of intense, hands-on training from the organization’s top executives. • Get an inside perspective into the mechanics of administering an association. o Budgets, Procedures, Consensus-building, Teamwork • Surround yourself with, and learn from pharmacy’s foremost thought leaders in the nation. • Sharpen your communication and interpersonal skills. • Make valuable contacts that will last a lifetime.

Applications will be reviewed beginning January 15th, 2011. Select candidates will be granted a personal interview, which will be scheduled starting in February of 2011. The position may be filled at any time once the interview process begins. Any interested candidate is encouraged to contact NASPA prior to applying to determine whether the position has been filled. For more information please contact: Jessica Baugh, Pharm. D. NASPA Executive Resident 2530 Professional Road, Suite 202 Richmond, VA 23235 (804) 285-4431 E-mail:

Typical Resident Activities: • Get exposure to national issues as well at state and local issues. • Work on projects that transition the profession to the JCPP 2015 Vision, with a focus on adherence, quality, and outcomes. • Work on safety and quality initiatives with the Alliance for Patient Medication Safety and Pharmacy Quality Alliance • Represent NASPA at various state and national meetings. • Manage ongoing state association projects (such as

The Georgia Pharmacy Journal

Find out more about NASPA at


January 2011


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Continuing Education for Pharmacists Management of Pulmonary Arterial Hypertension Angela O. Shogbon, PharmD, BCPS Clinical Assistant Professor, Mercer University College of Pharmacy and Health Sciences Goals. The goals of this article are to provide an overview of pulmonary arterial hypertension, its pathophysiology, clinical presentation, diagnosis, and management, and to highlight the pharmacist’s role in the management of this disease state. Objectives. At the conclusion of this article, successful participants should be able to: 1) Define pulmonary arterial hypertension (PAH) and describe its pathophysiology. 2) Identify the signs, symptoms and diagnostic tests utilized in the assessment of PAH. 3) Identify and describe the nonpharmacologic and pharmacologic management of PAH. 4) Determine appropriate pharmacotherapy and monitoring parameters for patients with PAH based on WHO functional classification. Introduction

The Georgia Pharmacy Journal

Pulmonary arterial hypertension (PAH) is a disease state with an estimated prevalence of about 15 cases per million based on recent evidence from a French registry.1 With modern therapy, the prognosis of PAH is poor with an approximately 15 percent one year mortality rate.2 PAH is a complex multidisciplinary disorder and recent advances in this field have led to new therapies3 and with these, an increased role for pharmacists to aid in medication therapy management and patient education. Pulmonary hypertension is the presence of abnormally high pressures within the pulmonary vasculature and consists of several subtypes, one of which is PAH.3 Table 1 highlights the World Health Organization (WHO) classification of pulmonary hypertension.4 PAH occurs due to restricted blood flow through the pulmonary arterial circulation which leads to increased pulmonary vascular resistance and eventually right heart


failure.3,5 Hemodynamically, PAH is defined as a mean pulmonary artery pressure (mPAP) of 25 mmHg or greater at rest with a pulmonary capillary wedge pressure (PCWP) of 15 mmHg or less and a pulmonary vascular resistance of greater than 3 Wood units.6 A normal resting mPAP value is between 8 to 20 mmHg.7 The pulmonary capillary wedge pressure (PCWP) is an estimation of the left atrial pressure with a normal value of < 12 mmHg, while the pulmonary vascular resistance (PVR) is the resistance to the flow of blood offered by the pulmonary vessels.8 In a recent French registry, about half of the cases of PAH were either idiopathic PAH (no identifiable cause), heritable PAH (linked to a familial context) or anorexigen associated PAH, while the other half were associated with various disease states such as connective tissue diseases, congenital heart disease, portal hypertension, and HIV-associated PAH.1 Idiopathic pulmonary arterial

January 2011

hypertension (IPAH) is the most common type of PAH and affects more females than males with a ratio of about 1.7:1 and a mean age at diagnosis of about 37 years.9 However, more recent data suggests that the incidence might be increasing in older patients greater than 70 years old.10 Heritable PAH (HPAH) has a hereditary component with about 50 to 90 percent of patients with mutations in the transforming growth factor beta receptor pathway, bone morphogenic protein receptor-2 (BMPR2) which can lead to endothelial dysfunction.3 Drug and toxins have also been associated with PAH with definite associations found with use of toxic rapeseed oil and the appetite suppressants aminorex, fenfluramine and dexfenfluramine.4 These anorexigens are no longer available in the United States.4 Likely associations have been reported with amphetamines, L-tryptophan and methamphetamines and other possible risk factors are cocaine, phenylpropanolamine, St. John’s Wort, chemotherapeutic agents and the selective serotonin reuptake inhibitors.4 Pause and Reflect: What is PAH and describe its pathophysiology? Pathophysiology PAH occurs as a result of changes in the structure and function of the pulmonary vasculature which leads to increased pulmonary vascular resistance and eventually right heart failure.11 The cause of these changes has been proposed to be a multi-hit model such that patients have a predisposing state (e.g. genetic abnormalities) along with other genetic or environmental risk factors or comorbidity that leads to the development of PAH.12 Multiple mechanisms are involved in the pathophysiology of PAH including endothelial cell dysfunction, vascular constriction, loss of relaxing factors, cellular proliferation, procoagulant state and inflammation.13 In PAH levels of endothelin-1 (ET-1), and thromboxane A2 are increased and these substances are vasoconstrictors and promote smooth muscle cell proliferation.14,15 In addition, thromboxane A2 promotes platelet

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activation.3 On the other hand, the levels of vasodilators such as prostacyclin (PGI2) and nitric oxide (NO) are decreased and these agents possess antiproliferative properties and inhibit platelet activation.3,14 The effects of NO are mediated by the production of cyclic guanosine monophosphate (cGMP) whose production is inhibited by phosphodiesterase type 5 enzymes.3 These changes leads to endothelial dysfunction in PAH. There is also a procoagulant state in PAH with elevated levels of fibrinopeptide A, plasminogen activator inhibitor-1, thromboxane A2 and decreased levels of tissue plasminogen activator, NO and PGI2.3,14 Evaluation and Diagnosis of PAH Evaluation for PAH is initiated by obtaining a clinical history including symptoms, risk factors, family history, physical exam, electrocardiogram and chest x-ray.16 If there is a suspicion of PAH based on these findings, an echocardiography with doppler ultrasound would be an appropriate noninvasive screening test to provide estimates of the pulmonary artery pressure and to assess the structure and function of the heart. 16 However, the gold standard test to confirm a diagnosis of PAH is right heart catheterization which involves insertion of a catheter through the right side of the heart and into the pulmonary artery to obtain a more accurate measure of the pulmonary pressures. 16 Other screening tests to identify underlying etiologies of the PAH should also be performed such as HIV serology, pulmonary function tests, and liver function tests, among others.3 Clinical Presentation of PAH The symptoms of PAH are typically due to impaired transport of oxygen and reduction in cardiac output.16 Early stages of PAH may be asymptomatic, however exertional dyspnea is the most frequent presenting symptom. 16 Other symptoms include, fatigue, weakness, anginal chest pain or syncope, and dyspnea at rest with disease progression. 16 Symptoms related


to disease progression leading to right ventricular dysfunction and tricuspid valve regurgitation include: leg swelling, abdominal bloating and distension, anorexia, plethora, profound fatigue. 16 The WHO functional classification of PAH16 is used to classify the severity of patient’s symptoms and is useful in determination of initial treatment options based on disease severity and used to follow up response to therapy (Table 2). Objective signs of PAH include signs of increased pulmonary artery pressure heard by auscultation, signs of advance disease due to right-sided heart failure including hepatojugular reflux, pulsatile liver, right ventricular S3 gallop, jugular venous distension, peripheral edema, low blood pressure, cool extremities.3 Pause and Reflect: Describe some of the symptoms of PAH. List common diagnostic tests used to assess PAH. Goals of Therapy The goals of therapy in the management of PAH are to alleviate symptoms, enhance WHO functional class and exercise capacity which is objectively measured by the 6-minute walk distance test, cardiopulmonary exercise test, to lower mPAP and normalize cardiac output, prevent disease progression and to improve survival.3 Nonpharmacologic Management of PAH The nonpharmacologic management of PAH includes lifestyle modifications which involves low level graded aerobic exercise such as walking as tolerated, and a low Na+ diet of less than 2.4 g/day.3 It is also recommended to avoid pregnancy due to the hemodynamic fluctuations that occur during pregnancy, labor, delivery and postpartum3 which may increase the risk of maternal mortality by 30 – 50 percent.17 Effective methods of birth control are therefore very important in women of child bearing age. Influenza and pneumococcal vaccines are also recommended.3 In addition, supplemental oxygen is recommended in patients with a preflight pulse oximetry saturation of less than 92 percent to prevent hypoxic

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pulmonary vasoconstriction with high altitudes.3 Pharmacologic Management of PAH All patients with PAH should be evaluated for indications for general care interventions which include oral anticoagulants, diuretics, oxygen, and digoxin. Patients with PAH have an increased risk of thrombosis due to a reduction in pulmonary blood flow, dilated right heart chamber, venous stasis and a sedentary lifestyle.18 Studies have evaluated the benefits of oral anticoagulants in patients with IPAH, HPAH and PAH associated with anorexigens.19,20,21 In recent randomized controlled trials, the highest prevalence of use of oral anticoagulants were noted in patients with IPAH and HPAH.22 Currently, oral anticoagulation therapy with warfarin is recommended based on expert consensus for patients with IPAH and HPAH. 22 The INR goal recommended is 1.5-2.5.3 There is not as much data with other types of PAH, but anticoagulation is recommended in these patients with more advanced disease such as those on continuous intravenous prostacyclin therapy.3 Diuretics are utilized in patients with decompensated right heart failure and associated volume overload presenting as abdominal organ congestion, peripheral edema and ascites for symptomatic relief. 22 Oxygen is recommended in appropriate patients to maintain oxygen saturation > 90 percent in order to avoid the pulmonary vasoconstriction associated with

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hypoxemia.3 Use of digoxin is based on clinical judgment22 and can be considered for use in patients with right sided heart failure and a reduced cardiac output, or to slow ventricular rate in patients with concomitant atrial arrhythmias.3 Pause and Reflect: Explain the nonpharmacologic and pharmacologic management of PAH. Specific therapy for PAH includes medications that target the pathways in the pathophysiology of PAH including the prostacyclin pathway, the nitric oxide pathway, and the endothelin pathway with the use of synthetic prostacyclin and prostacyclin analogs, phosphodiesterase type-5 inhibitors and endothelin-1 receptor antagonists respectively.22 Calcium channel blockers are also effective in patients with a positive response to acute vasodilator testing. 22 Acute Vasodilator Testing is utilized to determine patients that will be candidates for use of calcium channel blockers and is usually performed at the time of diagnostic right heart catheterization.3 It involves the use of inhaled nitric oxide (iNO), intravenous epoprostenol, or intravenous adenosine. The use of iNO is preferred and the other two agents are acceptable alternatives.3 Patientâ&#x20AC;&#x2122;s baseline hemodynamics are obtained, then the patient is administer 20 â&#x20AC;&#x201C; 40 ppm of iNO for 5 min and then hemodynamics are repeated while on iNO.3 A positive response is defined as a 10 mmHg or


greater decrease in the mPAP to less than 40 mmHg, without a decrease in cardiac output6. If mPAP is less than 40 mmHg at baseline, then a positive response may be considered if there is a greater than 20 percent decrease in mPAP with a normal cardiac output.3 Acute responsiveness identifies patients with a better prognosis; responders are more likely to have a sustained beneficial response to oral calcium channel blockers than nonresponders and the drug of choice for these patients with a positive response is the calcium channel blockers.3 Calcium Channel Blockers. This class of medications blocks the influx of extracellular Ca+ leading to vasodilation.23 They are indicated only in patients with favorable response to acute vasodilator testing.3 Even though IPAH and anorexigen-induced PAH patients are most likely to respond to acute vasodilators and CCBs, vasoreactivity testing is recommended in all patients with PAH.22 Common agents utilized are long-acting nifedipine, amlodipine or diltiazem.7 Short-acting nifedipine should be avoided due to increased risk for hypotension.18 Nifedipine is initiated at 30 mg/day to a maximum of 240 mg/day24 and diltiazem doses of 120 mg to a maximum of 900 mg/day25 may be utilized. Verapamil should be avoided due to its negative inotropic effects.7 Response to therapy should be assessed after 3 months of therapy with a goal of improvement to WHO Functional Class I or II.7 If not at goal, consider additional or

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alternative PAH therapy.7 Phosphodiesterase-5 (PDE-5) Inhibitors The currently available PDE-5 inhibitors studied and utilized in the management of PAH are sildenafil (Revatio®) and tadalafil (Adcirca®). These agents are potent and highly specific PDE-5 inhibitors that increase cGMP levels leading to vasorelaxation and antiproliferative effects on vascular smooth muscle cells.23 Sildenafil has been shown to improve hemodynamics, WHO functional class and exercise capacity measured by the 6minute walking distance test and hemodynamics.26,27 Tadalafil has also been shown to increase the 6-minute walk distance and the time to clinical worsening in patients with PAH.28 Synthetic Prostacyclin and Prostacyclin Analogs Prostacyclin is produced by endothelial cells and is a potent vasodilator of vascular beds, inhibits platelet activation and possesses cytoprotective and antiproliferative properties,23 however the production of prostacyclin is reduced in patients with PAH.3 Synthetic prostacyclin and prostacyclin analogs available are epoprostenol (Flolan®), treprostinil (Remodulin®, Tyvaso®) and iloprost (Ilomedin®, Ventavis®), and beraprost, non-FDA approved. Epoprostenol and treprostinil can be administered by continuous intravenous infusion via a central venous catheter and use may be complicated by infection.3 Epoprostenol has been shown to improve functional class, exercise tolerance, hemodynamics, and survival in IPAH.3,29 It is administered via continuous intravenous infusion and has a very short half-life of 2.7 min, hence interruptions in the infusion should be avoided to prevent potentially life-threatening rebound PAH symptoms.30 Patients should have an addition infusion pump and IV infusion sets to circumvent this problem.30 Treprostinil has a longer half-life of 4.5 hours and while interruptions in the infusion should also be avoided, it is not

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as life-threatening as with epoprostenol therapy.31 Treprostinil has been shown to improve hemodynamic parameters, symptoms, and exercise capacity in patients with PAH.32,33 Inhaled iloprost has an advantage in targeting the lung vasculature and not requiring intravenous infusion, however, it requires frequent administration of up to 9 times per day.18 Iloprost has been shown to improve WHO functional class and 6-minute walk test in patients with PAH.34 Endothelin Receptor Antagonists This class of medications block endothelin receptors on vascular endothelium and smooth muscle leading to a lowering of systemic vascular resistance, pulmonary vascular resistance & mPAP.23 Medications in this class include: bosentan (Tracleer®), ambrisentan (Letairis®). Bosentan and ambrisentan are only available through access programs which requires that only the pharmacies and prescribers registered through Tracleer Access Program, for bosentan, or LETAIRIS Education and Access Program, for ambrisentan, may prescribe and distribute these medications and they are dispensed only to patients enrolled in and who meet all the requirements of the respective access programs.35,36 Liver enzyme tests should be performed at baseline and monthly in all patients on bosentan and ambrisentan. 35,36 In addition, in women of child bearing age, a pregnancy test should be performed at baseline to exclude pregnancy and then monthly in these patients. 35,36 Women of child bearing age must use two reliable forms of contraception during treatment and for one month after stopping therapy. 35,36 Since bosentan and ambrisentan may reduce the efficacy of hormonal contraceptives, an alternative nonhormonal method must also be used.35,36 In addition to hepatotoxicity and teratogenicity, anemia is another adverse effect that requires routine monitoring with these agents. 35,36 Bosentan is a nonselective endothelin receptor antagonist that has been shown to improve symptoms, the 6-minute walking distance


test and the WHO functional class in patients with PAH.37 Ambrisentan is a selective type-A endothelin-1 receptor antagonists that have been shown to improve exercise tolerance, WHO functional class, hemodynamics and quality of life in patients with PAH.38,39 Sitaxsentan is another medication in this class that was approved in several countries outside of the United States, however, the manufacturer recently announced the voluntary withdrawal of sitaxsentan from countries in which it was marketed due to a potentially fatal idiosyncratic risk of liver injury different from the known risk of heptotoxicity with this class of medication.44 Monitoring Therapy Patients with advanced symptoms, right heart failure, poor hemodynamics, on parenteral or combination therapy should be followed up every 3 months or more frequently as indicated.3 Other patients on oral therapy or less ill can be followed up every 3 to 6 months. Monitoring parameters included assessment of functional class, exercise capacity including the 6 minute walk distance test, and graded treadmill test.3 Combination Therapy Combination therapy is aimed to target the different pathophysiologic pathways involved in PAH and may be considered in patients with inadequate clinical response to monotherapy.3 Inadequate clinical response to medical therapy would warrant consideration of other nonpharmacologic invasive approaches such pulmonary thromboendarterectomy, atrial septostomy, and lung or heart and lung transplantation.3 The treatment algorithm for management of PAH has been provided in Figure 1. For a specific WHO Functional Class, any of the medications listed as a preferred therapy can be used, but drug selection may depend on specific patient factors that may limit use of a specific agent in favor of another.22 For the alternative

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agents, they are listed in order of the strength of the recommendation (e.g. medications under (a) are graded higher than medications under (b). For patients with WHO Functional Class IV PAH without a positive vasodilator test, intravenous epoprostenol is the drug of choice.22 Pharmacistâ&#x20AC;&#x2122;s can play an active role in the management of PAH by counseling patients on appropriate use of

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medications and their adverse effects, evaluate drug therapy for drug interactions and potential contraindications to therapy. Pharmacists should also counsel women of child bearing age on appropriate methods of contraception and can assist with monitoring of appropriate laboratory parameters and tests with use of specific agents. In addition, pharmacists can help with appropriate dose calculations and work with physicians on appropriate drug


selections based on potential contraindications to therapy. Pause and Reflect: Can I determine appropriate pharmacotherapy and monitoring parameters for patients with PAH based on WHO functional classification?

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References 1.Humbert M, Sitbon O, Chaouat A. Pulmonary arterial hypertension in France. Am J Respir Crit Care Med. 2006;173:1023-1030. 2.Thenappan T, Shah SJ, Rich S, et al. A USA-based registry for pulmonary arterial hypertension: 1982-2006. Eur Respir J. 2007;30:1103-10. 3.McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension. J Am Coll Cardiol. 2009;53:1573-619. 4.Simonneau G, Robbins IM, Beghetti M, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2009;54:S43-54. 5.Ghofrani HA, Barst RJ, Benza RL et al. Future perspectives for the treatment of pulmonary arterial hypertension. J Am Coll Cardiol. 2009;54:S108-17. 6.Badesch DB, Abman SH, Simonneau G, et al. Medical therapy for pulmonary arterial hypertension: Updated ACCP evidence-based clinical practice guidelines. Chest 2007;131:1917-1928. 7.Badesch DB, Champion HC, Gomez Sanchez MA et al. Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol. 2009;54:S55-66. 8. Parker Robert B, Rodgers Jo E, Cavallari Larisa H, “Chapter 16. Heart Failure” (Chapter). Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary R. Matzke, Barbara G. Wells, L. Michael Posey: Pharmacotherapy: A Pathophysiologic Approach, 7e: 9.Rich S, Dantzker DR, Ayres SM et a. Primary pulmonary hypertension. A national prospective study. Ann Intern Med. 1987;107:216-23. 10.Yigla M, Kramer MR, Bendayan D, et al. Unexplained severe pulmonary hypertension in the elderly: report on 14 patients. Isr Med Assoc J. 2004;6:7881. 11.Morrell NW, Adnot S, Archer SL. Cellular and molecular basis of pulmonary arterial hypertension. J Am Coll Cardiol. 2009;54:S20-31. 12.Yuan JX, Rubin LJ. Pathogenesis of pulmonary arterial hypertension: the need for multiple hits. Circulation. 2005;111:534-8. 13.Murali S. Pulmonary arterial hypertension. Curr Opin Crit Care. 2006;12:228-234. 14.Christman BW, McPherson CD, Newman JH. An imbalance between the excretion of thromboxane and prostacyclin metabolites in pulmonary hypertension. N Engl J Med 1992;327:70-5. 15.Giad A, Yanagisawa M, Langleben D, et al. Expression of endothelin-1 in the lunds of patients with pulmonary hypertension. N Engl J Med. 1993;328:1732-9. 16.McGoon, M, Gutterman D, Steen V, et al. Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest. 2004;126:14S-34S. 17. Weiss BM, Zemp L, Seifert B, et al. Outcome of pulmonary vascular disease in pregnancy: a systematic overview from 1978 through 1996. J Am Coll Cardiol. 1998;31:1650-7. 18.Hopkins, W and Rubin LJ. Treatment of pulmonary hypertension. Accessed at, April 8, 2010. 19.Rich S, Kaufmann E, Levy P. The effect of high doses of calcium-channel blockers on survival in primary pulmonary hypertension. N Engl J Med. 1992;327:76-81. 20.Fuster V, Steele PM, Edwards WD, et al. Primary pulmonary hypertension: natural history and the importance of thrombosis. Circulation. 1984;70:5807. 21.Frank H, Mlczoch J, Huber K, et al. The effect of anticoagulant therapy in primary and anorectic drug-induced pulmonary hypertension. Chest. 1997;112:714-21. 22.Barst RJ, Gibbs SR, Ghofrani HA et al. Updated evidence-based treatment algorithm in pulmonary arterial hypertension. J Am Coll Cardiol. 2009;54(1):S78-84. 23.Talbert Robert L, Boudreaux Rebecca, Owens Rebecca L, “Chapter 30. Pulmonary Hypertension” (Chapter). Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary R. Matzke, Barbara G. Wells, L. Michael Posey: Pharmacotherapy: A Pathophysiologic Approach, 7e: 24. Lexicomp Online. Accessed at, November 1, 2010. 25.Micromedex Healthcare Series. Accessed at www-thomsonhc-com, September 28, 2010. 26.Prasad S, Wilkinson J, Gatzoulis, MA. Sildenafil in primary pulmonary hypertension. N Engl J Med 2000;343:1342. 27.Galie N, Ghofrani HA, Torbicki et al. Sildenafil citrate therapy for pulmonary arterial hypertension. N Engl J Med 2005;353:2148-57. 28.Galie N, Brundage BH, Ghofrani HA et al. Tadalafil therapy for pulmonary arterial hypertension. Circulation 2009;119:2894-2903. 29.Barst RJ, Rubin LJ, Long WA, et al. A comparison of continuous epoprostenol (Prostacyclin) with conventional therapy for primary pulmonary hypertension. The Primary Pulmonary Hypertension Study Group. N Engl J Med. 1996;334:296-302. 30.GlaxoSmithKline. Flolan (epoprostenol) package insert. Research Triangle Park, NC; 2008. 31.United Therapeutics Corp. Remodulin (treprostinil) package insert. Research Triangle Park, NC; 2010. 32.Tapson VF, Gomberg-Maitland M, McLaughlin VV et al. Safety and efficacy of IV. treprostinil for pulmonary arterial hypertension: a prospective, multicenter,, open-label, 12-week trial. Chest 2006;129-683-688. 33.Simonneau G, Barst RJ, Galie N et al. Continuous subcutaneous infusion of treprostinil, a Prostacyclin analogue, in patients with pulmonary arterial hypertension: a double-blind, randomized, placebo-controlled trial. Am J Respir Crit Care Med. 2002;165:800-4. 34.Olschewski H, Simonneau G, Galie N et al. Inhaled iloprost for severe pulmonary hypertension. N Engl J Med 2002;347:322. 35.Actelion Pharmaceuticals. Tracleer (bosentan) package insert. South San Francisco, CA; 2009. 36.Gilead Sciences. Letairis (ambrisentan) package insert. Foster City, CA; 2010. 37.Rubin LJ, Badesch DB, Barst RJ et al. Bosentan therapy for pulmonary arterial hypertension. N Engl J Med 2002;346:896-903. 38.Galie N, Badesch D, Oudiz R et al. Ambrisentan therapy for pulmonary arterial hypertension. J Am Coll Cardiol 2005;46:529-35. 39.Galie N, Olschewski H, Oudiz RJ et al. Ambrisentan for the treatment of pulmonary arterial hypertension: results of the ambrisentan in pulmonary arterial hypertension, randomized, double-blind, placebo-controlled, multicenter, efficacy (ARIES) study 1 and 2. Circulation 2008;117:3010-3019. 40. United Therapeutics Corp. Tyvaso (treprostinil) package insert. Research Triangle Park, NC; 2009. 41Actelion Pharmaceuticals. Ventavis (iloprost) package insert. South San Francisco, CA; 2010. 42. Pfizer Laboratories. Revatio (sildenafil) package insert. New York, NY; 2009. 43. Eli Lilly and Company. Adcirca (tadalafil) package insert. Indianapolis, IN; 2009. 44. Pfixer. Pfizer stops clinical trials of Thelin and initiates voluntary product withdrawal in the interest of patient safety [press release]. December 10, 2010.

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January 2011



Significant Drug Interactions


Common Adverse Events

Prostanoids 30Epoprostenol, IV (Flolan®)

Continuous IV infusion: Initiate at 2 ng/kg/min, and titrate dose every 15 min or longer by 2 ng/kg/min until dose-limiting effects observed or tolerance limit obtained

All prostanoids: -May cause an additive drop in blood pressure with other antihypertensives and vasodilators; May increase risk of bleeding when used with other antiplatelets or anticoagulants Epoprostenol: May increase levels of digoxin

Contraindicated with significant left ventricular; systolic dysfunction; Avoid abrupt withdrawal; interruptions in drug delivery, or large dose reductions due to risk for rebound symptoms of pulmonary hypertension ; Aseptic technique important to prevent catheter associated infections

Flushing, headache, nausea, vomiting, hypotension, jaw-pain, flu-like symptoms, anxiety/nervousness, diarrhea, pain and infection at injection site

31Treprostinil, SC/IV (Remodulin®)

Continuous infusion: Initiate at 1.25 ng/kg/min (or 0.625 ng/kg/min if not tolerated); dose may be increased by 1.25 ng/kg/min per week for the first 4 weeks of treatment, and later by 2.5 ng/kg/min per week up to 40 ng/kg/min.

All formulations of treprostinil: CYP2C8 substrate; inhibitors (e.g. gemfibrozil) may increase levels and inducers (e.g. rifampin) may reduce levels

Avoid abrupt withdrawal or dose SC – infusion site pain reduction, may result in worsening of PAH and reaction (erythema, symptoms. induration, rash) IV/SC - diarrhea, jaw pain, edema, vasodilatation , nausea, headache

40Treprostinil, oral Oral inhalation: inhalation Initiate with 18 mcg (3 (Tyvaso®) breaths) inhaled 4 times daily while awake Target dose: 54 mcg (9 breaths) inhaled 4 times daily

Safety and efficacy not established in patients with significant underlying lung disease (e.g., asthma or chronic obstructive pulmonary disease [COPD]).

41Iloprost, oral inhalation (Ventavis®)

Oral inhalation: Initiate with 2.5 mcg/dose, if well tolerated, titrate to 5 mcg/dose. Maintenance dose: 5 mcg/dose 6 – 9 times per day while awake with a minimum of 2 hours between doses

May induce bronchospasm especially in Flushing, cough, patients with a history of hyperactive headache, jaw spasm airways. Not evaluated with Ventavis has not been evaluated in patients with COPD, severe asthma or acute pulmonary infections

Endothelin Receptor Antagonists (ERA) 35Bosentan, oral (Tracleer®)

Oral: 62.5 mg po twice daily x 4 weeks, then increase to 125 mg twice daily. Body weight < 40 kg, maintenance dose is 62.5 mg po bid.

All ERA: -Reduces efficacy of hormonal contraceptives Bosentan: -CYP2C9 and CYP3A4 substrate and inducer; Decreases levels of CYP3A4 metabolized statins -Rifampin alters bosentan levels, monitor liver function weekly x 4 weeks, then monthly; Use with ritonavir: discontinue 36 hours prior to initiation of ritonavir and in patients on ritonavir for at least 10 days, initiate bosentan at 62.5 mg once daily or every other day

36Ambrisentan (Letairis®)

Initiate at 5 mg po once daily Dose limited to 5 mg daily when used with and may increase to 10 mg cyclosporine due to up to 2-fold increase in po once daily as tolerated. ambrisentan levels

Phosphodiesterase Type-5 (PDE-5) Inhibitors 42Sildenafil, oral, IV (Revatio®)

Oral: 20 mg three times a day, approximately 4-6 hours apart IV bolus (used temporarily if unable to take oral formulation): 10 mg three times a day

All PDE-5 Inhibitors: Use with caution with alpha-blockers due to potential for additive blood pressure lowering Sildenafil: Major CYP3A4 substrate: Avoid concomitant use with ritonavir and other potent CYP3A4 inhibitors

43Tadalafil (Adcrica®)

Oral: 40 mg once daily

Tadalafil: Major CYP3A4 substrate. Discontinue Tadalafil at least 24 hours prior to initiation of ritonavir and resume at 20 mg once daily after at least one week after initiating ritonavir. May increase doe to 40 mg po daily based on tolerabilit y. Avoid concomitant use with other potent inhibitors of CYP3A4 such as ketoconazole and with chronic use of potent inducers of CYP3A such as rifampin

Inhaled: cough and throat irritation; headache, gastrointestinal effects, muscle, jaw or bone pain, flushing and syncope.

All ERA-Boxed Warnings: Dispensed only Respiratory tract through restricted distribution program: infections, anemia, Tracleer Access Program (T.A.P) for edema, hepatotoxicity bosentan and LEITARIS Education and Access Program (LEAP) for ambrisentan due to risks of liver injury and birth defects. Bosentan: Contraindicated in pregnancy, with cyclosporine (marked increased in bosentan concentrations) and with glyburide (increased risk of liver enzyme elevations) Peripheral edema, nasal congestion, anemia, hepatotoxicity All PDE-5 Inhibitors: -Contraindicated in concomitant use with organic nitrates due to increased hypotensive effects -Seek immediate medical attention if sudden loss of vision occurs or with sudden decrease or loss of hearing

Epistaxis, headache, dyspepsia, flushing, insomnia, erythema, dyspnea, and rhinitis

Headache, myalgia, nasopharyngitis, flushing

Continuing Education for Pharmacists Quiz and Evaluation Management of Pulmonary Arterial Hypertension 1. Which of the following substances involved in the pathophysiology of PAH are increased in patients with this disease? a. Nitric oxide b. Endothelin c. Prostacyclin d. Tissue plasminogen activator

6. Which of the following is drug of choice in a patient with a positive vasodilator test response? a. Sildenafil b. Amlodipine c. Bosentan d. Iloprost 7. Which of the following is the most appropriate drug of choice in a patient with WHO Functional Class IV PAH? a. Bosentan b. Inhaled iloprost c. Intravenous epoprostenol d. Sildenafil

2. Select the agent from the list that has been found to have a definite association with causing PAH. a. Fenfluramine b. Estrogen c. Amitriptylline d.Cigarette smoking

8. How often should liver enzyme tests be monitored in patients on bosentan therapy? a. Weekly b. Monthly c. Every 3 months d. Every 6 months

3. Which of the following is the gold standard test for confirming a diagnosis of PAH? a. Echocardiography b. Electrocardiogram c. Right heart catheterization d. Chest X-ray

9. BJ is a 35 year old female with a recent diagnosis of Class II IPAH with a negative vasodilator test response. The physician has decided to begin medication therapy in BJ. BJ has no significant PMH and only takes loestrin 1 po dialy for contraception. Which of the following would be the most appropriate initial option? a. Diltiazem b. Bosentan c. Sildenafil d. Intravenous epoprostenol

4. All of the following are non-pharmacologic measures recommended in patients with PAH EXCEPT? a. Avoiding pregnancy b. Hepatitis B vaccine c. Low graded aerobic exercise d. Low Na+ diet < 2.4 g/day 5. Which of the following are general measures recommended in appropriate patients with PAH? a. Warfarin anticoagulation b. Oxygen therapy c. Diuretics d. All of the above

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10. Which of the following medications is contraindicated in a patient on tadalafil therapy? a. Doxazosin b. Isosorbide mononitrate c. Epoprostenol d. Bosentan


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Journal CPE Answer Sheet The Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. No financial support was received for this activity.

Management of Pulmonary Arterial Hypertension This lesson is a knowledge-based CPE activity and is targeted to pharmacists. GPhA code: J11-1 ACPE#: 0142-0000-10-0112-H01-P Contact Hours: 1.0 (0.10 CEU) Release Date: 01/01/2011 Expiration Date: 01/01/2013 1. Select one correct answer per question and circle the appropriate letter below using blue or black ink (no red ink or pencil.) 2. Members submit $4.00, Non-members must include $10.00 to cover the cost of grading and issuing statements of credit/ Please send check or money order only. Note: GPhA members will receive priority in processing CE. Statements of credit for GPhA members will be emailed or mailed within four weeks of receipt of the course quiz.

1. 2. 3. 4. 5.





6. A B C D 7. A B C D 8. A B C D 9. A B C D 10. A B C D

Activity Evaluation: must be completed for credit Please rate the following items on a scale from 1 (poor) to 5 (excellent)as to how well the activity: 1. Relates to pharmacy practice: 1 2 3 4 2. Met my educational needs: 1 2 3 4 3. Achieves the stated learning objectives: 1 2 3 4 4. Faculty presented the information: 1 2 3 4 5. Made use of the educational material (article): 1 2 3 4 6. Teaching methods conveyed information (tables, figures, boxes): 1 2 3 4 7. Post-test aided in assessing my grasp of the information: 1 2 3 4 8. Met my expectations: 1 2 3 4 7. Avoided any bias: 1 2 3 4 8. How long did it take to complete this activity? _______________________

5 5 5 5 5 5 5 5 5

A passing grade of 70% is required for each examination. A person who fails the exam may resubmit the quiz only once at no additional charge. Please check here if you are indicating a change of address ___ Phone #: _______________________________ Name: ____________________________________________________________________________ License Number(s) and State(s): ___________________ Email Address: ___________________________ Address: __________________________________________________________________________ City: _________________ State: __________ Zip: __________ Remove this page from the Journal and mail this completed quiz and evaluation to: GPhA, 50 Lenox Pointe NE, Atlanta, GA 30324. The Georgia Pharmacy Journal


January 2011


The 15th Southeastern PRN Conference Held November 12-14, 2010 he Georgia Pharmacy Foundation and Georgia PharmAssist Committee hosted the 15th Annual Southeastern PRN Conference on November 12-14 at the beautiful Simpsonwood Conference Center in Norcross, Georgia, just north of Atlanta. This annual event owes its success to two dedicated GPhA members, Jim Bartling, Pharm.D., ADC, CAC II, Intervention Coordinator, Georgia PharmAssist Program, and Richard B. Smith, R.Ph., Chairman of the Georgia PharmAssist Program.

in consideration for their privacy.) The last speaker of the day was Steve Moore, MSW, LCSW, who is with the Alabama State Board of Pharmacy’s Committee on Rehabilitating Impaired Pharmacists. He gave a very engaging presentation titled “The History of Addiction” and had the attendees laughing and thoroughly enjoying the session.


On Sunday Brian Fingerson delivered the spirituality portion of the meeting covering “12-Steps to Recovery and the Brain – How Spirituality Helps.” One of the Pharmacy Recovery Network’s favorite speakers and a GPhA member, Merrill Norton, Pharm.D., D.Ph., ICCDP-D, and Clinical Associate Professor at UGA, made a presentation on “Beyond Sadness: The Neuroscience of Depression and Addiction.” Steve Moore delivered the closing session with “Understanding Craving and Denial” and once again had the audience engaged.

This “southeastern” meeting attracts individuals from across the country. A large number of the attendees have participated in this conference almost every year, if not in fact every year. They always mention how they look forward to it. This year we heard many comments from these attendees that they thought this was the best conference yet. We are privileged that one of the most well-known PRN websites across the country,, promotes this event.

We sincerely thank all of our speakers for all their hard word and commitment to this program. We couldn’t do it without you.

Student pharmacists are motivated to attend this conference to enhance their knowledge about the disease of addiction. In addition to the pharmacy schools in Georgia participating, each year McWhorter School of Pharmacy has a large contingent of student pharmacists in attendance. All participating students are awarded a certificate acknowledging their participation in this two-day Conference.

The Georgia Pharmacy Foundation and Georgia PharmAssist Committee want to thank the following Exhibitors and Sponsors for their support of this Conference: Academy of Independent Pharmacy (AIP) MARR, Inc. QuestHouse, Inc. Ridgeview Institute Shands Vista – Florida Recovery Center Talbott Recovery Campus

Pharmacy Technicians are also encouraged to attend, and do receive CPE credits for their participation. The conference is open to anyone who wants to learn more about the disease of addiction. Always, there are comments from the participants they had no idea about the extensive information available and how little they really knew about the disease.

Their assistance helped make this Conference possible and is very much appreciated. Each exhibitor provided door prizes that added to the fun of the weekend. We also thank each representative who attended and for their contributions to its success! We look forward to seeing you at next year’s Conference.

Saturday’s program included a presentation by Dr. Paul H. Earley, the Medical Director at Talbott Recovery Campus. His topic covered “The Neurobiology of Addiction and the Hope of New Medications.” Brian Fingerson, R.Ph. and President of Brian Fingerson, Inc. dba KY Professionals Recovery Network KYPRN, and frequent speaker, covered “Risk, Recognize, Resolve: Addiction in the Pharmacy Profession.” Tom House, President of Partnership for Professional Wellness / Professional Monitoring, presented “Drug Testing for Healthcare Professionals: A Positive Recovery Tool!” A popular and emotionally moving portion of the program is when someone gives their “Personal Story” about their recovery. This year was no exception. (Name is not provided

The Georgia Pharmacy Journal

Mark your 2011 Calendar! The 2011 SE PRN Conference will be held at Simpsonwood on November 11-13, 2011 30

January 2011


The Georgia Pharmacy Journal Editor:

Jim Bracewell

Managing Editor & Designer:

Kelly McLendon

The Georgia Pharmacy Journal® (GPJ) is the official publication of the Georgia Pharmacy Association, Inc. (GPhA). Copyright © 2011, 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 who are 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 e-mail the editorial offices as listed above.

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 at upon request. All advertising and production orders should be sent to the GPhA headquarters as listed above.

GPHA HEADQUARTERS 50 Lenox Pointe, NE Atlanta, Georgia 30324 Office: 404.231.5074 Fax: 404.237.8435


Eddie Madden Dale Coker Jack Dunn Robert Hatton Pamala Marquess Jim Bracewell Hugh Chancy Robert Bowles Keith Herist Jonathan Marquess Sharon Sherrer Liza Chapman Mary Meredith Heather DeBellis Fred Sharpe John Drew Amanda Gaddy Shobhna Butler Ashley Faulk Mike Crooks Larry Batten David Gamadanis Chris Thurmond Marshall Frost Ken Eiland Renee Adamson Josh Kinsey Don Davis Ira Katz DeAnna Flores Lance Faglie John T. Sherrer Michael Farmer Steve Wilson

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