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Celebrating 30 years of service to the Pharmacists of Georgia!

2011 OPEN ENROLLMENT! Join us in celebrating 30 years of serving the members of the Georgia Pharmacy Association. To learn more visit www.gpha.org. 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 tmiller@gpha.org 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 www.gpha.org. * 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

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November 2010


17

Departments

Robert C. Bowles, Jr. Receives 2010 NCPA Prescription Drug Safety Award FEATURE ARTICLES

7 Pharm PAC 2010-2011 11 Peer Reviewers Needed 12 GPhA New Members 16 Georgia Pharmacy Foundation Annual Fund 25 New Practitioner Leadership Conference Nomination Form 31 GPhA Board of Directors

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15 Fall 2010 Region Meeting Wrap-up Continuing Education for Pharmacists: 21 Prevalence of Age Associtated Testosterone Deficiency in Males

2 2 5 5 6 9 9 9 10 11 13 14 18 20 30

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 Sparkfly Melvin Goldstein, P.C. GoToMeeting/GoToWebinar GPhA Workers Compensation AIP Southeastern Girls of Pharamcy Leadership Weekend 32 The Insurance Trust

COLUMNS

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President’s Message Editorial

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

www.gpha.org. The Georgia Pharmacy Journal

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November 2010


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

Counting Our Blessings, by Fives

if you do lose a dollar or two, you just smile and say, “it’s just the cost of doing business in today’s economic environment.” I realize that thankfulness in these situations doesn’t come naturally, but with a lot of practice, you too, may be able to join in the chorus, “I’m so happy!”

have heard it said that the hardest arithmetic to master is that which enables us to count our blessings. As pharmacists, arithmetic came pretty easy to most of us and we have mastered the art of counting by fives. It seems that many pharmacists can count the negative aspects of our profession by fives as well, and it is easy to overlook the blessings. The obvious first blessing we can count is that to this point, as bad as the economy has been, it has not affected our profession as it has many others. It is certainly easier to appreciate your job when you begin to imagine yourself without one.

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Seriously, though, I think all of us can make a long list of the things and people we can be thankful for, that we so often take for granted. What doesn’t make sense is that much of the time the people and things we put at the top of the list are sometimes the easiest to ignore. Faith and family would be high on most people’s lists, but are often overshadowed by the demands of work and obligations. We can get so caught up in our destination that we forget to appreciate the journey and those who helped us along the way.

The good book teaches us that we are to be thankful regardless of circumstance. But honest to goodness, it is very difficult to be thankful in certain circumstances. High on the list of a community pharmacist’s list of circumstances for which thankfulness is difficult: dealing with third party issues. It is very hard to conjure up images of thankfulness while dealing with these stressful situations. Perhaps it would be good to think of the movie “Anger Management,” in which Jack Nicholson implored his pupil, Adam Sandler, to sing “I’m so happy, I’m so happy” in such times. It is important to remember that the third party representative you are talking to on the phone is trying to do his/her job as he/she has been instructed to do. Never mind that this is not a peer, or even someone who is necessarily qualified to make decisions regarding patient health and drug selection issues, but that this is a fellow human being. A point to make here is to be thankful that you and the other person both have a job. In what other ways could you display thankfulness? You could be thankful that you are not losing money (if you’re not), and

The Georgia Pharmacy Journal

John Henry Jarrett said, “Gratitude is a vaccine, an antitoxin, and an antiseptic.” What a great quote for pharmacists to heed. We know that a vaccine is a preventative. It stands to reason, then, that if we approach each day with a grateful attitude, we will not be as apt to be critical, judgmental, angry, etc. We also know that an antitoxin counters a poison. A passage from the book of James says that “…no man can tame the tongue. It is a restless evil, full of deadly poison.” A grateful attitude uses the tongue to build up and encourage, not to discourage and tear down. Finally, we know that an antiseptic is used for healing. We are in a healing profession. It would be good to ask in our daily routine if we are using our words and our actions to help heal the hurts and wounds of our patients. 4

November 2010


Thanksgiving is more than just a time to gather with the family to eat turkey and dressing and all the fixins. It is a time to reflect on the things in life for which we are truly thankful, such as faith, family and freedom. As pharmacists we should feel extremely thankful to be in such a respected and trusted profession, and to be represented by a pharmacy association among the country’s finest. We can also be thankful that our profession affords us an opportunity to make a difference in people’s lives each and every day. Most importantly, we can be thankful that we are one country, under God. Thank God! Here’s to an attitude of gratitude and thanksgiving for all our many blessings! Happy Thanksgiving!

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: PharmAssist Hotline Number (24 hours / 7 days a week) 404-362-8185 (All calls are confidential)

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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

www.gpha.org/jobs


Pharm PAC Enrollment Pledge Year 2010-2011

Titanium Level

Gold Level

($2400 minimum pledge)

($600 minimum pledge)

Michael E. Farmer, R.Ph. David Graves, 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 C. Bowles, Jr., R.Ph., CDM, Cfts Taylor 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 Billy Conley J. Ashley Dukes, 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 G. 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.

James W. Bartling, Pharm.D., ADA, CAC II Robert Cecil Liza G. Chapman, Pharm.D. Patrick M. Cook, Pharm.D. Mahlon Davidson, R.Ph., CDM Kevin Florence H. Neal Florence, R.Ph. David Gamadanis Marsha C. Kapiloff, R.Ph. J.Thomas Lindsey, R.Ph. Robert B. Moody, III, R.Ph. Sherri S. Moody, Pharm.D. sharon M. Sherrer, Pharm.D. Jeffrey Richardson, R.Ph. Robert Anderson Rogers, R.Ph. Daniel C. Royal, Jr., R.Ph. Dean Stone, R.Ph., CDM Thomas H. Whitworth, R.Ph., CDM

Silver Level ($300 minimum pledge) Renee D. Adamson, Pharm.D. John L. Colvard, J. R.Ph. F. Al Dixon, R.Ph. Jack Dunn, R.Ph. Marshall L. Frost, Pharm.D. Amy S. Galloway, R.Ph. Michael O. Iteogu, Pharm.D. Willie O. Latch, R.Ph. Kenneth A. McCarthy, R.Ph. Kalen Beauchamp Porter, Pharm.D. Edward Franklin Reynolds, R.Ph. Michael T. Tarrant 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) Mark C. Cooper, R.Ph. Monica M. Ali-Warren, R.Ph. Lance P. Boles, R.Ph., MBA James R. Brown, R.Ph. Michael A. Crooks, Pharm.D. Charles Alan Earnest, R.Ph. Stewart Flanagin, Jr., R.Ph. Amanda R. Gaddy, R.Ph. Fadeke Jafojo Allison Layne William E. Lee, R.Ph. William J. McLeer, Sr., R.Ph. Houston Lee Rogers, Jr., Pharm.D., CDM Richard Brian Smith, R.Ph. Wallace Whiten 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. Jean N. Courson, R.Ph. Carleton C. Crabill, R.Ph. Alton D. Greenway, R.Ph. Martin T. Grizzard, R.Ph. J. Clarence Jackson, Jr., R.Ph. Gina Ryan Johnson, Pharm.D., BCPS, CDE Ashley S. London Tracie D. Lunde, Pharm.D. Ralph K. Marett, M.S. Whitney B. Pickett, Pharm.D. Rose Ann Pinkstaff, R.Ph. Leonard Franklin Reynolds, III, R.Ph. Victor Serafy, R.Ph. Harry A. Shurley, Jr., R.Ph. James. E. Stowe, Jr., R.Ph. William D. Whitaker, R.Ph. Jonathon A. Williams, Pharm.D. Michael R. Williams, R.Ph.

If you made a gift or pledge to Pharm PAC and your name does not appear above please, call Stuart Griffin at 404-4198118 or Ursula Hamilton at 404-419-8115. Donations made the Pharm PAC are not considered charitable donations and are not tax deductible. The Georgia Pharmacy Journal

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November 2010


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

GPhA Second Vice President 2011: Could that pharmacist be you? n the October issue of the GPhA Journal you read about the improved election process that will include online voting for the first time in our Association’s history. Therefore, you could be the first- Second Vice President elected under the new bylaws and your oath office at next years Annual Meeting and Convention June 18-22, 2011.

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5. One day Executive Committee meeting followed by a meeting with the GPhA Standing Committees.

Now is the time you should be giving your candidacy serious consideration if you have not already done so. May I suggest you take time to talk to a current Executive Committee member or a recent former GPhA President and of course as your Executive Vice President I am available to answer any questions you may have about the position?

7. NCPA Annual Meeting – Chair and President attend Saturday through Wednesday- other Executive Committee members at their pleasure but not required

October 6. Four nights on the road presenting Region Meeting programs-rare overnight.

November 8. One day Executive Committee meeting followed by one day meeting with GSHP on legislative agendas.

What are the time commitments is one of the key questions and considerations most candidates have to ponder. I am going to list what are the general time commitments, however events and meetings are determined each year by the Board of Directors and the GPhA Executive Committee. We are moving to more online communications and are even adopting the use of “Go To Meetings” to make more efficient use of our volunteers’ time.

December 9. One night dinner meeting with Executive Committee meeting the next day. January 10. Friday night through Sunday afternoon – Executive Committee meeting and GPhA Board Meeting and Standing Committees meeting.

So what does a GPhA Executive Committee calendar look like following the GPhA Annual Meeting in June 2011?

February 11. One day Executive Committee meeting followed the next day with GPhA VIP Day at the Capitol.

July 1. Two days and two nights Executive Committee planning retreat.

March 12. One day Executive Committee meeting followed the next day with flight to DC and back for Lunch & Lobby with Congress.

August 2. A weekend trip to the Southeastern Pharmacy Officers Conference to a sister southeastern state. 3. Thursday night through Sunday afternoon – Executive Committee Meeting and GPhA Board Orientation and Board meeting.

13. APhA Annual Meeting – President and President Elect attend, Saturday through Tuesday- other Executive Committee members at their pleasure but not required.

September 4. An overnight meeting and next day meeting with GPhA RPh Legislators.

April 14. Four nights on the road presenting Region Meeting programs – rare overnight.

The Georgia Pharmacy Journal

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November 2010


15. One day GPhA Executive Committee meeting

It is a rare privilege to lead a state pharmacy association. To lead the Georgia Pharmacy Association is a special one time opportunity in your career and the reward is priceless. Just ask any former GPhA President.

May 16. Thursday night through Sunday afternoon, Executive Committee meeting and the New Practitioner Leadership Conference.

Is 2011 the year you take a giant step forward in your professional career? If you think it could be then give me a call or contact any GPhA board member and let’s discuss your future as a leader of the pharmacy profession in Georgia.

June 17. One day Executive Committee meeting. 18. Friday night though Wednesday GPhA Annual Meeting and Convention.

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The Georgia Pharmacy Journal

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November 2010


Trust T rust Leader tthe he L eader For the past ce century, entury, Pharmacists Mutual M Insurance Company ompany has been committed c to providing qua lity products and ser rvice with this mission: n: To help our customers mers attain quality service ÀQDQFLDOSHDF  FHRIPLQG2XU    true mutual spirit RISXWWL  LQJSROLF\RZQHUVÀUV   WUHPDLQV   ÀQDQFLDOSHDFHRIPLQG2XUtrue spiritRISXWWLQJSROLF\RZQHUVÀUVWUHPDLQV VWHDGIDVW W GI W 3 KD U PDFL V WV 0X W X DO L V G HG L FDW HG W R VX S S RU WL Q J W K H S KD U PDF\ S U RIHV VL RQ  , Q W K H 3KDUPDFLVWV0XWXDOLVGHGLFDWHGWRVXSSRUWLQJWKHSKDUPDF\SURIHVVLRQ,QWKH llast ast d ecade, w eh ave c on tr i b u te d over over $1 $1 million mi l li o n toward t owar d pharmacy p ha r macy initiatives initiatives decade, we have contributed D Q G VX S S RU W 2X U NQ RZO H GJ H RI W KH L QG X V WU \ D QG RX U FRP PL W PHQ W W R W KH DQGVXSSRUW2XUNQRZOHGJHRIWKHLQGXVWU\DQGRXUFRPPLWPHQWWRWKH SKDUPDF\SURIHVVLRQKDVHDUQHGXVWKHHQGRUVHPHQWRIPDQ\VWDWHDQGQDWLRQDO S KD UP DF\ S URI HV VL RQ KD V HD U QHG X V W KH H QG RU V HPHQ W RI PD Q\ V WD WH DQG Q DW LR Q DO D VVRFLDWLRQV* DVVRFLDWLRQV -RLQWKHWKRXVD -RLQWKHWKRXVDQGVRISROLF\KROGHUVZKRWUXVW3KDUPDFLVWV0XWXDOthe   DQGVRISROLF\KROGH   UVZKRWUXVW3KDUPDF    FLVWV0XWXDO  the lea leader der in SURYLGLQJLQVXUDQFHDQGÀQDQFLDOVHUYLFHVGHVLJQHGVSHFLÀFDOO\IRUWKHSKDUPDF\ SURYLGLQJLQVXU  UDQFHDQGÀQDQFLDO   VHUYLFHVGHVLJQHGV   SHFLÀFDOO\IRUWKHSK    KDUPDF\ SURIHVVLRQ

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Serve Your Profession & Earn FREE CPE Credit!!! ATTENTION GPHA PHARMACISTS – WE NEED YOUR HELP!!! As you may know, GPhA publishes a self-study article in The Journal each month for CPE credit. In order to stay in compliance with ACPE, we are required to have each article reviewed by at least 2 registered pharmacists. Peer Reviewer(s) are asked to consider and respond to questions concerning each article. The following are examples of the questions asked: • Is the content up-to-date and relevant to the practice of medicine • Is the activity appropriate to the stated audience (i.e pharmacists) • Is the activity scientifically rigorous and presented in a manner generally accepted in the medical profession • Does the activity present balanced information, leaving out trade names and including both benefits and limitation of drugs; recommendations are to include entire classes of drugs instead of one product • Amount of time to complete the activity Once you have completed a peer review, you will receive FREE CPE credit for the article you reviewed. If you would like to be considered as a volunteer peer reviewer please contact Caroline Fields at cfields@gpha.org or 404-419-8126. As pharmacists of all practice settings, we need to continually challenge ourselves and sharpen our skills. PLUS it is a nice addition to your professional bio! The Georgia Pharmacy Journal

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November 2010


GPHA MEMBER NEWS

Welcome to GPhA! The following is a list of new members who have joined Georgia’s premier professional pharmacy association! Shola Adewunmi, Savannah Beulah Alioha, Savannah Kristen Alspaugh, Athens Elizabeth Alter, Athens Habeeb Ashiru-Balogun, Atlanta Krystal Avula, LaGrange Brooke Bailey, Savannah Wenda Bailey, Lawrenceville Rachel Barton, Palmetto Christopher James Bass, Cochran Meredith Beker, Roswell Brittany Bennett, Athens Tsedey Kassaye Betre, Atlanta Tejal Bhikha, Atlanta Emily Bigby, Atlanta Kyle Blakely, Acworth Whitney Blan , Lawrenceville Jason Bonner, Hiawassee Cameron Bornholm, Marietta Kimberly Boyle, Atlanta Leigh Bramlett, Trenton Kirk Braun, Duluth David Bray, Eatonton Laura Broadhead, Savannah Amy Brotherton, Atlanta Lucas Brown, Valdosta Meagan Bruni, Atlanta Lauren Buchbinder, Suwanee Kieu Nhi Bui, Stone Mountain Elita Bundrage, Lithonia Olivia Burdine, Dallas Samantha Burke, Athens Victoria Carroll, Sugar Hill Jerrica Dodd Carter, Marietta Lindsey Carter, Atlanta Jeremy Casper, Athens Caroline Champion, Acworth Jessica Chandler, Madison Linda Cheng, Buford Ashley Cobb, Waverly Hall Ashley Cole, Atlanta Lindsay Collins, Atlanta Amanda Conkling, Atlanta Lauren Connelly, Atlanta Keevis Cooper, Union City Dustin Cooper, Tifton Amanda Copeland, Athens

The Georgia Pharmacy Journal

Elizabeth Cordell, Roswell Brian Crogen, Athens Lacey Crook, Lincolnton Willis Curtis, Augusta Annette Daehler, Atlanta Amie Darke, Atlanta Phillip Davis, Atlanta Tyler Davis , Alva FL Adam Decarolis, Athens Marco Delerme, Savannah Emily DePhillips, Savannah Mackenzie DeWitt, Tucker Ed S. Dozier, Albany Robert Joseph Duke, Atlanta Brent M. Dulitz O.D., Avondale Estate Brent Dunn, Jasper Vinh Duong, Morrow Charles Durham, Athens Meghan Elam, Atlanta Monica Elliott, Atlanta Kendra Ellis, Atlanta Susanne Emerich, Duluth Susiana Eng, Sugar Hill Robert English, Woodstock Michelle Eun, Athens Debra Evans, Atlanta Kamika Felder, Athens Tara Fogleman, Snellville Erin Ford, Rocky Ford Brandi Fortner, Loganville Tara Fosnough, Fayetteville James Franken, Athens Mary Franks, Brunswick Monee Geary, Atlanta Sheryle Gillette, Athens Danielle Gordon, Athens Catherine Grady, Cumming Brittany Grant, Monroe Casey Green, Woodstock Ajay Gupta, Atlanta Lindsey Gurley, Athens Annie Hahn, Atlanta Sidney Hall, Alpharetta Afshaun Haniff, Atlanta Sandi Harris, Roswell Ashley Harrison, Roswell Marissa Hatcher, Atlanta

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Cassie Hayes, Athens Susan Elizabeth Haygood R.Ph., East Dublin

Rebecka Hazelwood, Roswell Tammy Hellkamp, Alpharetta Kaylie Henne, Savannah Casey Hentz, Athens Jessica Hicks, Atlanta Christopher T. Hill, Lilburn Ashley Hillman, Savannah Sarah Hinton, Savannah Amber Hodge , Flowery Branch Stephanie Hoge, Lawrenceville Katelyn Hood, Chula Ashley Houser, Montevallo, AL Megan Jacobson, Atlanta Faizan Jhandiya, Atlanta Jessica Johnsa, Cumming Ah Hyun Jun, Athens Rajsi Kale, Alpharetta Meredith Kaywood, Alpharetta Molly Kestranek, Athens Sara Khajehei, Lawrenceville Kelly Kiefer, Atlanta David Kirtland, Stone Mountain Kwasi Kissi, Atlanta Musau Kithome, Atlanta Spencer Knight, Athens Brenton Knowlton, Decatur Charles Kovarik, Savannah Emily Kraus, Atlanta Emily Krix, Norcross Natalie Kurtkaya, Decatur Katherine Kwon, Athens Tanika Lawrence, Lawrenceville Christian Lee, Athens Grace Lee, Athens Rosetta Lee, Cumming Hannah LeGette, Athens Matthew Leigh, Atlanta Trent Leonard, Duluth Xiaofeng Li , Gainesville Wen Liu, Marietta Zijiao Liu, Atlanta Uvette Lou, Roswell Monika Maltese Jordon Mangum, Athens Francisco Marrero , Athens

November 2010


Kelly McAtee, Atlanta Tabitha McWhorter, Atlanta Lauren Minar, Athens Tate Mock, Atlanta Lacey Moody, Clarkston Keri Morgan, Atlanta Jacob Mouchet, Norcross Sarah Myrna, Athens Anh Nguyen, Gainesville Hong An Nguyen, Belden, MS Melanie Nguyen, Duluth Vivi Nguyen, Atlanta Erin Nicholson, Gainesville Jennifer Niemeier, Atlanta Eul Noh, Tucker Magan Ogden, Summerville, SC Hye-won Oh, Atlanta Jocelyn Owusu-yaw , Bostwick Ryan Pate, Atlanta Ami Patel, Lawrenceville Bimal Patel, Marietta Mitansu Patel, Riceville, TN Raj Patel, Norcross Shivani Patel, Atlanta A. Leighann Patterson CPhT, Blairsville Christina Pereira, Atlanta Van Pham, Savannah Megan Phillbeck, Athens Derek Phillips, Atlanta Joel Phillips, Kennesaw Kayla Phillips Monika Pinter, Savannah Marco Alan Ragins Pharm.D., Duluth John Ramble, Fayetteville Lisa Redwine, Lawrenceville Christie Rickabaugh, Athens Kristin Roberts, Villa Rica Melissa Robinson, Lawrenceville Crystal Ruper, Suwanee Brie Rush, St. Petersburg, FL Faga Samdumu, Lawrenceville Reyes Inguez Sanchez, Macon Seyyedeh Saneeymehri, Savannah

James Shumans, Roswell Emily Smith, Brunswick Horace Smith, Macon Laura Smith, Canton Sarah Smith, Athens Suvimol Sonchaiwanich, Atlanta Kevin Sponsel, Atlanta Nicholas Stiles, Alpharetta Jenny Sutherland, Pharm.D., Canton Shad Jason Sutherland, Canton John Sutter, Atlanta Abigail Tate, Atlanta Rozita Tebyanian, Alpharetta Steven Thellman, Athens Krystal Thompson, Athens Marci Thomson, Jenkinsburg Selamawit Tolla, Suwanee Andy Tran, Buford Annie Tran, Savannah Phoung Tran, Morrow Xuan Mai Tran, Atlanta Caroline Traylor, Hahira Richard Tu, Carrollton Liana Tyson-Haynes, Duluth Steven Valdes, Atlanta

Julie Waycaster Pharm.D., North Augusta, SC

Alison S. Weldon Pharm.D. , Albany Jennifer Whitesides, Atlanta Emily Whitney, Alpharetta Lindsey Whitworth, Lawrenceville Kara Williams, Atlanta Lauren Willis, Athens Rebecca Wilson, Atlanta Tiffany Wilson, Statesboro Russell Wise, Atlanta Warner Wolf, Atlanta Jessica Wood, Suwanee John Woods, Atlanta Danielle Word, Athens Joshua Yelverton, Hephzibah Brittany York, Atlanta Amanda Young, Athens Bradley Young, Oxford Chloe Yu, Atlanta Dan Zeitang, Athens

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Catherine Ellen Scanlon, Pharm.D., Atlanta

Lindsay Schaack, Athens Claire Schietinger, Cumming Matthew Schuster, Savannah Ashley Victoria Skipper, R.Ph., Sandersville Marjorie Sen, Stone Mountain Haram Seo, Atlanta Imran Shahbuddin, Atlanta Blake Shay, Atlanta Indu Shekar, Atlanta Whitney Shirley, Athens Brandon Shook, Norcross Khatija Shroff, Lawrenceville

The Georgia Pharmacy Journal

Valana Vannoy, Stone Mountain Thuan Vo, Duluth Jordan Walker, Athens Rachel Wall, Atlanta Alyssa Warren, Kennesaw

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November 2010


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Fall 2010 Region Meeting Wrap-up hanks to the the leadership of the 12 Region Presidents of GPhA. We recently held the Fall 2010 Region Meetings. We had over 300 people attend these events and receive one hour of continuing education credit. At these meetings, the Executive Committee reviewed GPhA membership and benefits that come as a result of GPhA membership. They also discussed the GPhA Government Affairs priorities for the 2011 legislature.

T

In Region 12 Susan Haygood was elected as Secretary/Treasurer for the Region 12.

Jack Dunn, Representative Richard Smith (R-Columbus), Renee Adamson and Robert Bowles attended the Region 3 Region Meeting. The Georgia Pharmacy Journal

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GEORGIA PHARMACY FOUNDATION ANNUAL GIVING CAMPAIGN The Georgia Pharmacy Foundation began its 9th Annual Giving Campaign on September 1st . Since 2002, the Foundation’s Annual Giving Campaigns have raised more than $102,000. Thank you to everyone who has made a difference with their gift. Each year, these resources make it possible for the Foundation to: x x x x

Provide financial aid through scholarships to deserving Georgia student pharmacists Provide training for future pharmacy leaders through our New Practitioner Leadership Conference Help with the funding of the Southeastern PRN Program Provide continuing education programs for pharmacists and pharmacy technicians

By giving to the Annual Campaign you are contributing to the continuity of the pharmacy profession, in turn strengthening the future of pharmacy. These gifts are vitally important to the continued success of the Foundation because they offer the flexibility to support emerging opportunities and unmet needs when often no other source of funding is available. Acknowledging the difference that pharmacy has made in your life will ensure that the profession remains the place where thinkers become leaders. If you have not yet made your tax­deductible* gift for the current campaign, please do so today. Your support, at any level, is important. It will ha ve an impa ct! Remember, many companies will match your contribution, doubling or even tripling the value of your gift! The success of our fundraising depends on donations and grants from foundations, government, corporations, and many generous individuals. Contributions are acknowledged with a Charitable Donation receipt for tax purposes, names will appear on our website and will be listed in the GPhA Journal. Checks should be made payable to the Georgia Pharmacy Foundation. We also welcome Visa, MasterCard, American Express and Discover. Donations can also be made via our website at www.gpha.org. (*As provided by law)

Giving back is the best way to keep our profession going forward! Yes! I want to help support the good work of the Georgia Pharmacy Foundation by contributing to the 9th Annual Giving Campaign with my pledge of: [ ] President’s Circle = $5,000 or more [ ] Gold Partner = $500 ­ $999 [ ] Partner = $____ ­ $99

[ ] Eagle = $2,500 ­ $4,999 [ ] Silver Partner = $250 ­ $499

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Please specify if you would like to make your donation a gift. If so, please provide name and address of where you would like the In Memory/Honor gift card to be sent: (Please Print) [ ] In Memory of _______________________________________________________________________________ [ ] In Honor of _________________________________________________________________________________ Send notification to: __________________________________________________________________________________________ Address: __________________________________________________________________________________________ __________________________________________________________________________________________

* * * * * * * * * * DON’T FORGET, you can make your gift online at WWW.GPHA.ORG ­ click on the Georgia Pharmacy Foundation logo on the front page. [ ] Enclosed is my check payable to Georgia Pharmacy Foundation for $__________ OR [ ] Bill my credit card for $____________ (If you prefer to pay by installments, please indicate which one: [ ] Monthly or [ ] Quarterly. A separate form will be sent to you for completion.) (Please circle one: AmEx Visa M/C Disc.) Card #:_____________________________________________ Security (If name on credit card and the billing address are different from above, please provide that information too)

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MEMBER NEWS

Robert C. Bowles, Jr., Receives 2010 NCPA Prescription Drug Safety Award

he National Community Pharmacists Association (NCPA) announced that Robert C. Bowles, Jr., RPh, owner of Big C. Pharmacy in Thomaston, Ga., has been awarded the 2010 NCPA Prescription Drug Safety Award. The announcement was made at the association's 112th Annual Convention and Trade Exposition held here October 23-27.

disease. Bowles also visits the local senior center on a monthly basis to present educational programs, and consults with each senior to make sure they are adhering to the most effective prescription drug program possible. He also utilizes the "My Dose Alert" technological reminder program to ensure patients are taking their prescription drugs in a timely fashion. Bowles is helping patients safely discard unused prescription drugs through his NCPA "Take Away" disposal program through his pharmacy.

T

The Prescription Drug Safety Award, sponsored by Purdue Pharma, L.P., recognizes pharmacists who have reached out in their communities to provide education on the benefits of the correct use of prescription drug products and the hazards associated with their misuse.

His dedication to helping others extends well beyond Thomaston and the United States. Bowles has made several medical mission trips to Honduras and Panama, and donated medications and supplies for medical mission trips to Africa and Central America. He has held many prominent positions such as president of the Georgia Pharmacy Association from 2008-2009, and received many awards such as the 2009 Outcomes' "Top MTM (Medication Therapy Management) Center" for region eight, which encompasses all of Georgia and South Carolina. He and his wife Judy have three children and five grandchildren.

"We are proud to honor Robert as this year's NCPA Prescription Drug Safety Award winner, because his actions demonstrate a sustained effort for ensuring patients get the maximum health benefit from their prescription drugs," said Joseph H. Harmison, PD, NCPA president and pharmacy owner in Arlington, TX. "He accomplishes those objectives by holding patient education classes, being a leader at medication therapy management services, using technology to make sure patients are adhering to their medication regimens, and providing a drug disposal program for unused and expired medications."

“The Georgia Pharmacy Association is extremely proud of the work of former GPhA President Robert Bowles,” said GPhA Executive Vice President Jim Bracewell, “Robert’s love for his patients and his dedication to his community is what makes the profession of pharmacy as one of the most trusted in healthcare.”

Since graduating with a B.S. in pharmacy from the University of Georgia in 1970, Bowles has been committed to improving the lives of patients. He hosts two to three free patient education classes each month teaching how to properly manage diabetes and heart The Georgia Pharmacy Journal

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November 2010


April 8-10, 2011 Legacy Lodge & Conference Center Lake Lanier Islands Resort Lake Lanier Islands, GA !

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I would like to nominate the following individual to attend the 2011 New Practitioner Leadership Conference: (Please Print) Nominee’s Name: __________________________________________________________ Designation: __________________ (R.Ph., Pharm.D., etc.)

Works For:

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Preferred Mailing Address: ______________________________________________________________________________

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NOMINATED BY: _________________________________________________________________ Designation: _________________ Company: ____________________________________________________________________________________________ Address:

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_________________________________________________________ State: _______ Zip: ___________________ Tel. (____) __________________ E-mail: ___________________________________________________________

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Please return this Nomination Form to: Georgia Pharmacy Foundation Attn: Regena Banks 50 Lenox Pointe, NE Atlanta, GA 30324

Please return by January 24, 2011

Or, you may FAX this Nomination Form to: 404.237.8435 Or, submit online at WWW.GPHA.ORG, If you have questions, please contact Regena Banks at GPhF: Direct # 404.419.8121 • Email: rbanks@gpha.org


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Continuing Education for Pharmacists Prevalence of Age-associated Testosterone Deficiency in Males Bobby Jacob, Pharm.D., Clinical Assistant Professor, Mercer University College of Pharmacy and Health Sciences No disclosures to report

Goal: The goal of this article is to review the published medical literature regarding the appropriate diagnostic criteria for male hypogonadism, also known as testosterone deficiency, while giving the reader an appreciation for the prevalence of male hypogonadism in the general population.

Objectives: After reading this article, the reader should be able to 1) discuss the physiologic regulation and roles of testosterone in the male body 2) explain the appropriate criteria used for diagnosis of clinically relevant hypogonadism or testosterone deficiency in males 3) and summarize the evidence regarding prevalence of male hypogonadism or testosterone deficiency in the general population.

Introduction Over the past several years, pharmacists have witnessed an exponential rise in the number of testosterone prescriptions dispensed. A recent report revealed that prescriptions for testosterone products rose by 1500% from 1994 to 2002.1 Recently, increased media attention has highlighted male hypogonadism, also known as testosterone deficiency, which forms the diagnostic basis for the class of medications known as testosterone replacement therapy (TRT). This condition is increasingly recognized in the medical community for many potentially significant adverse The Georgia Pharmacy Journal

outcomes related to cardiovascular health, diabetes, and obesity. Researchers continue to examine the potential association between testosterone deficiency and aging in males; however, controversy remains regarding the true prevalence of testosterone deficiency given the diversity of definitions used during clinical trials. In 2007, the National Center for Health Statistics estimated there to be almost 16 million men in the United States 65 years of age or older, and the average life expectancy for a man at age 65 years was 17.2 years.2 Age-associated testosterone deficiency presents potentially significant health implications both for individuals and the entire health care system, while representing an opportunity for pharmacists to serve as valuable resources for patient education and advocacy. The following review addresses the appropriate diagnostic criteria for age-associated testosterone deficiency, examines the evidence regarding prevalence rates, and summarizes treatment considerations. Pause and Reflect: Take a moment to consider the roles and synthesis of testosterone in the male body.

Physiology Testosterone is the primary male androgen in the body with synthesis, like many other endogenous hormones, tightly regulated by the hypothalamic-pituitary axis.3 The process begins in the hypothalamus 21

with release of gonadotropinreleasing hormone (GnRH), a 10amino acid peptide found primarily in the arcuate nucleus, which controls sex hormone synthesis and release in both the male and female.4 Pulsatile secretion of GnRH every two hours leads to the rhythmic release of luteinizing hormone (LH) and follicle stimulating hormone (FSH) from the anterior pituitary gland into the systemic circulation.5 Luteinizing hormone then binds to specific receptors on the Leydig cells of the testes, inducing the expression of regulatory enzymes that stimulate androgen synthesis from cholesterol.3 The Leydig cells are responsible for approximately 95% of testosterone production in the male, with the remainder coming from the adrenal glands and peripheral conversion of precursors.3 Testosterone along with FSH regulates spermatogenesis in the interstitial cells, which is critically important for maintaining fertility in the male. In addition, testosterone plays a role in self-regulation by providing negative feedback to the hypothalamus and anterior pituitary gland. In the systemic circulation, approximately 50-70% of testosterone is tightly bound by sex hormone binding globulin (SHBG), while the remainder is either loosely bound to albumin (~30%), or unbound and free (~1-3%).6,7 Biological activity is thought to arise from free, unbound testosterone along with the weakly albumin-bound testosterone. These November 2010


components together compose what is typically referred to as bioavailable testosterone.6 Pause and Reflect: Acknowledge the binding protein and components of bioavailable testosterone. Testosterone has many effects that are clinically important to the male throughout life. Early in life, the most widely recognized effects relate to pubertal development and fertility. There are also possible physiologic roles in older men with respect to sexual health, body composition, bone metabolism, hemostasis, metabolic function, quality of life, and cognition.8,9 Dysfunction at the level of the hypothalamus, pituitary gland, or testes leads to testosterone deficiency. Testicular dysfunction impairs the body’s ability to synthesize testosterone from the Leydig cells. Clinically, this is termed primary hypogonadism and can result from cryptoorchidism, direct trauma, toxic exposure from medications and radiation, infection, or genetic abnormalities such as Klinefelter’s syndrome.8 Men with primary

hypogonadism typically present with reduced levels of serum testosterone due to the testicular impairment, but elevated serum gonadotropin levels (LH, FSH) as a compensatory mechanism by the hypothalamicpituitary axis. Damage to the hypothalamus or pituitary gland results in a condition termed secondary hypogonadism, which arises often from genetic disorders such Kallmann’s syndrome or pituitary tumors.8 In these circumstances, the testes are capable of producing testosterone; however, the absence of the LH and FSH leads to a lack of Leydig cell stimulation. Men with secondary hypogonadism typically have serum testosterone and gonadotropin levels below the normal range. The exact mechanism for ageassociated testosterone deficiency remains to be fully elucidated; however, current evidence suggests contributions from both testicular and hypothalamic-pituitary dysfunction.10 Pause and Reflect: Review the symptoms that present in a patient with primary hypogonadism and resulting causes.

Diagnostic Guidelines Recently published clinical practice guidelines define age-associated testosterone deficiency as a clinical and biochemical syndrome associated with advancing age and characterized by symptoms and serum testosterone levels below the young healthy adult male reference range.9 A clinically relevant diagnosis accounts for both laboratory findings and patient symptoms. Diagnosis is only valid in a consistently symptomatic man with two measurements of morning serum testosterone below the normal reference range separated by at least 24 hours.6 As shown in Table 1, signs and symptoms specifically associated with testosterone deficiency include incomplete or delayed sexual development, reduced libido, decreased spontaneous erections, gynecomastia, loss of body hair, shrinking testes, infertility, height loss, low trauma fracture, or decreased bone mineral density.6 Many other signs and symptoms such as decreased energy or motivation, depressed mood, poor concentration or memory, sleep disturbance, mild anemia, reduced muscle mass, and

Table 1: Specific signs and symptoms in age-associated testosterone deficiency in males (adapted from reference #6) Specific signs and symptoms Reduced libido Decreased spontaneous erections Breast discomfort, gynecomastia Loss of axillary and pubic hair Very small or shrinking testes Inability to father children, low or zero sperm count Height loss, low trauma fractures, low bone mineral density Reduced muscle mass and strength Non-specific signs and symptoms The Georgia Pharmacy Journal

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increased body fat may be attributable to testosterone deficiency or other chronic conditions such as diabetes or depression (Table 2).6 Measurement and interpretation of serum testosterone levels represents a challenge due to the lack of widespread distribution of specific laboratory assays and reference range standardization.11 In addition, testosterone levels are significantly affected by circadian and circannual rhythms, acute or chronic illness, and the chronic use of specific medications, including opioids and glucocorticoids.6 In a male presenting with symptoms specific to testosterone deficiency, serum total testosterone is the most appropriate laboratory parameter to assess.6 However, free testosterone and bioavailable testosterone are reasonable measurements that might provide a more accurate view of biologically active testosterone, particularly when there is discordance between serum total testosterone levels and patient reported symptoms. Given the number of factors that can affect testosterone levels, it is important that clinicians always confirm serum levels with a repeat morning measurement on a

subsequent day. In addition, health care providers must be aware that the normal reference range varies between laboratories depending on the specific assay that is used. Lazarou and colleagues demonstrated the wide variability in reference ranges by asking 25 New England academic medical centers or community laboratories to report the reference range used to define a low serum total testosterone level.12 Laboratory definition of low testosterone occurred anywhere between 101-450 ng/dL with most having the cut-off for low between 251-300 ng/dL (n=10), 201-250 ng/dL (n=6), and 151-200 (n=4). In addition, many of the community laboratories did not have access to assays that are more readily available at academic medical institutions. The Centers for Disease Control and Prevention (CDC) is working on a national initiative aimed at standardizing testosterone measurement across the country.13 Pharmacists encountering patients with questions about laboratory data must emphasize the need for obtaining the normal reference range specific to that laboratory before valid interpretation and conclusions can be made. Pause and Reflect: Contrast the

methodsto measure serum testosterone levels for your patients.

Prevalence Unfortunately, early studies examining prevalence focused solely on the use of serum testosterone levels in establishing the diagnosis of testosterone deficiency. In an openlabel, cross-sectional survey, Mulligan and colleagues estimated the prevalence of hypogonadism among 2,165 men [mean age 60.5 years (4596 years)] seen in United States primary care practices.14 Serum total testosterone, free testosterone, and bioavailable testosterone were measured once in the morning. Hypogonadism was defined as a serum total testosterone level <300 ng/dL or previous diagnosis of hypogonadism with current androgen therapy. The authors reported 38.7% of the men as being hypogonadal; this percentage increased to 40% and 45%, respectively when using criteria specific to free testosterone (<52 pg/mL) or bioavailable testosterone (<95 ng/dL). Hypogonadal men were older than eugonadal men (61.6Âą10.6 vs. 59.9Âą10.1, P=0.0003); however, this difference did not appear to be clinically significant. In addition, each ten-year increase in age

Table 2: Non-specific signs and symptoms in age-associated testosterone deficiency (adapted from reference #6) Non-specific signs and symptoms Decreased energy, motivation, initiative, aggressiveness, self-confidence Feeling sad or blue, depressed mood, dysthymia Poor concentration and memory Sleep disturbance, increased sleepiness Mild anemia Increased body fat, body mass index Diminshed physical or work performance The Georgia Pharmacy Journal

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was associated with a 17% increase in risk for hypogonadism. Hypogonadal men were significantly more likely to have co-morbid conditions such as hypertension, dyslipidemia, diabetes, and obesity. The authors noted that two-thirds of the hypogonadal men reported being symptomatic. In a subsequent cross-sectional survey of similar methodology and design, Schneider and colleagues estimated the prevalence of hypogonadism in a sample of 2,719 men (mean age 58.7±13.4 years) seen at primary care locations in Germany.15 Hypogonadism defined incrementally as serum total testosterone <346 ng/dL, <320 ng/dL, and <300 ng/dL corresponded with prevalence rates of 28.1%, 22.3%, and 19.3%, respectively. The authors did not specifically report on the prevalence of hypogonadism by age; however, total testosterone levels <300 ng/dL were significantly associated with age, along with body mass index, weight to height ratio, type 2 diabetes, dyslipidemia, metabolic syndrome, cancer, acute inflammatory disease, liver disease, and polypharmacy. The publication of the Baltimore Longitudinal Study on Aging (BLSA), a 40-year, open-registration trial, represented an important step forward in male hypogonadism research as the first large-scale, longitudinal prevalence study.16 Prevalence was estimated in a sample of community dwelling men, as opposed to patients in the relatively more ill primary care setting. Men had been seen every two years with blood samples taken in the morning of each visit. During a six month period in 1995 investigators assayed blood samples corresponding to each patient’s three most recent visits, along with those visits that were The Georgia Pharmacy Journal

closest to 10, 15, 20, 25, and 30 years prior to the most recent visit. Hypogonadism was defined as a serum total testosterone level <325 ng/dL or free testosterone index (total testosterone divided by SHBG) of <0.153. Using the criteria for total testosterone, prevalence rates for hypogonadism were 12%, 19%, 28%, and 49% for men in their 50s, 60s, 70s, and 80s, respectively. The trend appears to support an association between increasing age and testosterone deficiency; however, statistical analysis was not conducted. Prevalence based on free testosterone index also appeared to show an association between age and prevalence of hypogonadism. The primary limitations of this study, like earlier research, include the lack of repeat confirmation of testosterone levels, as well as no incorporation of patient symptoms into the definition of hypogonadism. The landmark Massachusetts Male Aging Study (MMAS) was the first large-scale, longitudinal study to estimate the prevalence of hypogonadism among community dwelling males in the general population using a definition that incorporated both laboratory findings and patient symptoms.17 In this observational cohort study, nonfasting, morning serum total testosterone was measured in 1,709 men (ages 40-70 years) from the Boston area at baseline, and then again in 1,156 men subsequently at a follow-up visit. The average time between baseline and the follow-up visit was 8.8 years. Free testosterone levels were calculated at both time points. In addition, men were surveyed regarding the presence of reduced libido, erectile dysfunction, depression, lethargy, inability to 24

concentrate, sleep disturbance, irritability, and depressed mood. Hypogonadism was defined as ≥three signs/symptoms with total testosterone <200 ng/dL, or ≥three signs/symptoms with total testosterone 200-400 ng/dL and free testosterone <89.1 pg/mL. Using these parameters, the crude prevalence of hypogonadism at baseline was 6.0%; after follow-up the prevalence rate doubled to 12.3%. At baseline the prevalence rates were 4.1%, 4.5%, and 9.4% for men in their 40s, 50s, and 60s, respectively, with rates increasing to 7.1%, 11.5%, and 22.8% at follow-up. The trend of increasing prevalence with age was found to be statistically significant both at baseline (P=0.0002) and follow-up (P<0.0001). Use of this stringent definition resulted in decreased prevalence of hypogonadism compared to previous studies; however, it does not diminish the clinical importance of this medical condition given the sizeable percentage of individuals meeting the criteria, particularly at older ages. Subsequent studies in ethnically diverse populations appear to lend further confirmation of the association between aging and increased prevalence of testosterone deficiency. In a population-based, observational study of 1,845 men (mean age 47.3±12.5 years), 8.4% of men over 50 years of age met the criteria for symptomatic androgen deficiency compared to only 4.2% of those men <50 years of age.18 Symptomatic androgen deficiency was defined as total testosterone <300 ng/dL plus free testosterone <50 pg/mL in the presence of at least one specific symptom (decreased libido, erectile dysfunction, or osteoporosis) or ≥two non-specific November 2010


symptoms (sleep disturbance, depressed mood, lethargy, or low physical performance). A similar study done in Taiwan with 734 men (mean age 57.4Âą6.7 years) found 12.0% of the sample met the criteria for symptomatic androgen deficiency, which was defined as total testosterone <300 ng/dL, free testosterone <50 pg/mL, and patient reported symptoms as assessed by the Androgen Deficiency in the Aging Male (ADAM) questionnaire.19 This compares to a prevalence of 24.1% and 29.8%, respectively, when the authors only used criteria for total testosterone (<300 ng/dL) or free

testosterone (<50 pg/mL) without assessing patients for symptoms. Further research is necessary to properly define the relationship between serum testosterone levels and specific symptoms. Zitzmann and colleagues examined 434 men (mean age 57.9Âą6.6 years) and found that decreased libido was associated with total testosterone levels <432.3 ng/dL; however, cognitive changes and erectile dysfunction were associated with levels <288.2 ng/dL and <230.5 ng/dL, respectively.20 Research is also being conducted to examine the question of whether population-wide declines in

testosterone levels relate more closely to factors such as increased obesity or decreased smoking rates, rather than the aging of the general population.21 These non-age factors may account for the increasing prevalence of testosterone deficiency observed as the general population becomes older. Pause and Reflect: Distinguish between the prevalence of hypogonadism in the general population as opposed to the primary care setting.

Testosterone Replacement

Table 3: Testosterone Replacement Therapy Options Available in the United States (adapted from reference #6) Formulation Dosing

Advantages

Testosterone 100 mg per week or enanthate or 200 mg every 2 cypionate weeks intramuscularly

Relatively inexpensive Requires intramuscular injection, peaks and valleys if self-administered, result in serum testosterone levels, which may affect flexible dosing adverse effects of therapy

Non-genital transdermal systems

1 or 2 patches designed to deliver 5-10 mg testostrone over 24 hours applied daily

Ease of application Typically only achieve low to low-normal testosterone mimics normal levels, therefore these men require 2 patches, skin diurnal rhythm of irritation testosterone secretion, lesser increase in hemoglobin compared to injection products

Gel

5-10 g testosterone Flexible dosing, ease gel containing 50of application, good 100 mg testosterone skin tolerability applied once daily

Potential for transfer of testosterone to female partner or children

Buccal tablets

30 mg controlled release twice daily

Gum related adverse events in up to 16% of treated men

Pellets

Four to six 200 mg No specific advantage Requires surgical incision, pellets may extrude, potential infection at site of procedure pellets relative to other subcutaneously every products several months

The Georgia Pharmacy Journal

Disadvantages

Oral administration with absorption at gum

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Therapy Testosterone replacement can be recommended as a treatment option in symptomatic men with low serum testosterone levels after a careful consideration of the risks and benefits for each individual patient (see Table 3). Relatively rapid restoration of normal serum testosterone levels has been demonstrated with TRT.22 Intramuscular administration of testosterone enanthate or cypionate has historically been the mainstay of medical practice. While these products continue to be prescribed, recent innovations have led to commercially available alternatives including gels, patches, and buccal tablets.6 Elderly men are most likely to derive clinical benefit with respect to sexual function, sense of well being, and bone mineral density.9 Patients should be assessed after three to six months of therapy to assess the utility in improving libido, sexual function, muscle mass, and body composition; however longer durations might be required for improvement in bone mineral density.9 Therapeutic goals include symptomatic improvement and restoration of total testosterone levels to the mid-normal range based on the reference range of the laboratory assay being used.6 Annual measurements of total testosterone are warranted in a patient receiving stables doses of TRT.6 When considering TRT, many important safety parameters must be closely monitored at baseline and throughout treatment. Given the potential for thrombotic complications, TRT products should not be used in men with hematocrit levels >54%.6 Prostate cancer, as well as the much more rarely reported male breast cancer, remain absolute contraindications for use.23-27 Current The Georgia Pharmacy Journal

research is challenging many of the long-held views on the relationship between testosterone and prostate cancer; however, clinicians still must be made aware of the contraindication that is listed in the labeling for all TRT products. Specific criteria have been proposed by the Endocrine Society related to prostate health. Discontinuation of testosterone therapy is recommended in a patient if there is an increase in serum PSA >1.4 ng/mL within any 12 month period, PSA velocity >0.4 ng/mL, detection of a prostatic abnormality on digital rectal exam, or American Urological Association IPSS score >19.6 Patients with benign prostatic hyperplasia (BPH) who receive testosterone may also experience significant adverse effects related to reduced urine flow and lower urinary tract symptoms. Testosterone may also lead to complications with obstructive sleep apnea or heart failure; therefore, resolution of these conditions is recommended before initiating therapy.9 Additionally, TRT is associated with acne and inhibition of spermatogenesis, resulting in infertility due to decreased sperm counts.6,8 Product-specific adverse events and monitoring parameters must also be considered when counseling patients. Testosterone gel products are popular agents that allow for direct application to selected areas of skin. In May 2009, the Food and Drug Administration required labeling changes for both gel products resulting from several reports of virilization in children after secondary exposure to testosterone from male users.28 In addition, there have been several reports of virilization in children after transfer of testosterone 26

from males who used pharmacycompounded topical testosterone.29-31 Pharmacists are instructed to warn patients to thoroughly wash hands after topical application of these products, cover the sites of application, and take protective measures to ensure that testosterone is not inadvertently transferred to others.23-24 Skin irritation at the site of application is another adverse event specific to topical agents. Intramuscular injections of testosterone are associated with fluctuations in mood or libido, pain at the injection site, excessive erythrocytosis, and cough.6 Buccal tablets are associated with alterations of taste and irritation to the gum.26 Infection, explusion, and incision pain have been reported in patients using testosterone pellets.6,27 Pause and Reflect: Evaluate your patients for the appropriate method of testosterone replacement therapy including contraindications.

Conclusion The published literature demonstrates a significant association between aging and the prevalence of testosterone deficiency in males. A clinically relevant diagnosis of testosterone deficiency will account for both laboratory findings and patient signs and symptoms. Most data reveal prevalence in the general population of approximately 6-12%; however, men in their 70s and 80s have higher prevalence (20-29%). Several TRT products are currently available on the market. Patient counseling on these various products offer pharmacists an opportunity to provide valuable disease state and pharmacotherapy education.

November 2010


References 1. Travison TG, Araujo AB, Hall SA, et al. Temporal trends in testosterone levels and treatment in older men. Curr Opin Endocrinol Diab Obes 2009;16:211-217 2. National Center for Health Statistics. Older persons’ health. Available at: http://www.cdc.gov/nchs/fastats/older_americans.htm. Accessed on August 17, 2010. 3. Bhasin S and Jameson L. Disorders of the testes and male reproductive system. In: Fauci AS, Braunwald E, Kasper DL, eds. Harrison’s principles of internal medicine. New York, NY: McGraw-Hill;2008. Available from: Access Medicine. Accessed August 17, 2010. 4. Ropper AH and Samuels MA. Adams and Victor’s principles of neurology. New York, NY:McGraw-Hill;2009. Available from: Access Medicine. Accessed August 17, 2010. 5. Snyder PJ. Androgens. In: Brunton LL, Lazo JS, and Parker KL, eds. Goodman and gilman’s the pharmacological basis of therapeutics. New York, NY:McGraw-Hill;2006. 6. Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in men with androgen deficiency syndromes: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2010;95(6):2536-2559. 7. Diver MJ. Laboratory measurement of testosterone. Front Horm Res 2009;37:21-31 8. Petak SM, Nankin HR, Spark RF, et al. American association of clinical endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hygogonadism in adult male patients. Endo Pract 2002;8(6):439-456. 9. Wang C, Nieschlag E, Swerdloff R, et al. ISA, ISSAM, EAU, EAA, and ASA recommendations: investigation, treatment, and monitoring of late-onset hypogonadism in males. Int J Impot Res 2009;21:1-8. 10. Tajar A, Forti G, O’neill TW, et al. Characteristics of secondary, primary, and compensated hypogonadism in aging men: evidence from the European male aging study. J Clin Endocrinol Metab 2010;95:1810-1818. 11. Rosner W, Auchus RJ, Azziz R, et al. Utility, limitations, and pitfalls in measuring testosterone: an endocrine society position statement. J Clin Endocrinol Metab 2007;92:405-413. 12. Lazarou S, Reyes-Vallejo L, and Morgentaler A. Wide variability in laboratory research values for serum testosterone. J Sex Med 2006;3:1085-1089. 13. Vesper HW and Botelho JC. Standardization of testosterone measurements in humans. J Steroid Biochem Mol Biol 2010;121:513519. 14. Mulligan T, Frick MF, Zuraw QC, et al. Prevalence of hypogonadism in males aged at least 45 years: the HIM study. Int J Clin Pract 2006;60(7):762-769. 15. Schneider HJ, Sievers C, Klotsche J, et al. Prevalence of low male testosterone levels in primary care in Germany: cross-sectional results from the DETECT study. Clin Endocrinol 2009;70:446-454. 16. Harman SM, Metter EJ, Tobin JD, et al. Longitudinal effects of aging on serum total and free testosterone levels in healthy men. J Clin Endocrinol Metab 2001;86(2):724-731. 17. Araujo AB, O’Donnell AB, Brambilla DJ, et al. Prevalence and incidence of androgen deficiency in middle aged and older men: estimates from the Massachusetts Male Aging Study. J Clin Endocrinol Metab 2004;89:5920-5926. 18. Araujo AB, Esche GR, Kupelian V, et al. Prevalence of symptomatic androgen deficiency in men. J Clin Endocrinol Metab 2007;92:4241-4247. 19. Liu C, Wu W, Lee Y, et al. The prevalence of and risk factors for androgen deficiency in aging Taiwanese men. J Sex Med 2009;6:936946. 20. Zitzmann M, Faber S, and Nieschlag E. Association of specific symptoms and metabolic risks with serum testosterone in older men. J Clin Endocrinol Metab 2006;91:4335-4343. 21. Travison TG, Araujo AB, Kupelian V, et al. The relative contributions of aging, health, and lifestyle factors to serum testosterone decline in men. J Clin Endocrinol Metab 2007;92:549-555. 22. Wang C, Swerdloff RS, Iranmanesh A, et al. Transdermal testosterone gel improves sexual function, mood, muscle strength, and body composition parameters in hypogonadal men. J Clin Endocrinol Metab 2000;85(8):2839-2853. 23. AndroGel Prescribing Information. Solvay Pharmaceuticals, Inc., Marietta, GA. 2009. 24. Testim Prescribing Information. Auxillium Pharmaceuticals, Inc., Malvern, PA. 2009. 25. Depo-testosterone Prescribing Information. Pharmacia Corporation, Kalamazoo, MI. 2002. 26. Striant Prescribing Information. Columbia Laboratories, Inc. Livingston, NJ. 2003. 27. Testopel Prescribing Information. Slate Pharmaceuticals, Inc. 2009. 28. United States Food and Drug Administration. Testosterone Gel Safety Concerns Prompt FDA to Require Label Changes, Medication Guide. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2009/ucm149580.htm. Updated: May 7, 2009. Accessed: September 1, 2010. 29. Kunz GJ, Klein KO, Clemons RD, et al. Virilization of young children after topical androgen use by their parents. Pediatrics 2004;114(1):282-284. 30. Franklin SL and Geffner ME. Precocious puberty secondary to topical testosterone exposure. J Pediatr Endocrinol Metab 2003;16(1):107-110. 31. Yu YM, Punyasavatsu N, Elder D, et al. Sexual development in a two year old body induced by topical exposure to testos terone. Pediatrics 1999;104(2):e23

The Georgia Pharmacy Journal

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November 2010


Continuing Education for Pharmacists Quiz and Evaluation Prevalence of Age Associated Testosterone Deficiency in Males 1.

What is the primary androgen in the male? a. Estradiol b. DHEA c. Testosterone d. Luteinizing hormone

6. Which of the following symptoms is NOT specific for testosterone deficiency? a. Decreased libido b. Erectile dysfunction c. Decreased post-prandial blood glucose d. Decreased bone mineral density

2. Where is the majority of endogenous testosterone synthesized in the male? a. Hypothalamus b. Anterior pituitary c. Adrenal gland d. Leydig cells

7. Which of the following should be considered in making a clinically relevant diagnosis of hypogonadism? a. Post-prandial blood glucose AND serum testosterone levels b. Cortisol and serum testosterone levels c. Symptoms and serum testosterone levels d. Symptoms and post-prandial blood glucose

3. What protein binds the majority of endogenous testosterone? a. Angiotensin converting enzyme b. Thyroid stimulating hormone c. Sex hormone binding globulin d. None of the above

8.

4. Which of the following would be expected in the laboratory evaluation of primary hypogonadism? a. Elevated testosterone and gonadotropins b. Elevated testosterone and decreased gonadotropins c. Decreased testosterone and gonadotropins d. Decreased testosterone and elevated gonadotropins

9. What is the best time to measure serum testosterone levels? a. Morning b. Afternoon c. Evening d. Midnight

5. Which of the following is TRUE regarding secondary hypogonadism? a. Severity of disease is inferior to primary hypogonadism b. Severity of disease is superior to primary hypogonadism c. Results from damage to hypothalamus or pituitary gland d. Results from direct damage to the testes

The Georgia Pharmacy Journal

Which of the following statements in TRUE? a. Measurement of testosterone levels is standardized across the country b. Testosterone levels can be affected by opioids and glucocorticoids c. Measurement of free testosterone levels serves no useful clinical purpose d. Testosterone measurements do not require confirmation with a repeat measurement

10. Which of the following must be monitored in a patient receiving testosterone replacement therapy? a. Blood glucose b. Heart rate c. Hematocrit d. Serum creatinine

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November 2010


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 was received for this activity.

Prevalence of Age Associated Testosterone Deficiency in Males This lesson is a knowledge-based CPE activity and is targeted to pharmacists. GPhA code: J10-11 ACPE#: 0142-0000-10-010-H01-P Contact Hours: 1.0 (0.10 CEU) Release Date: 11/15/2010 Expiration Date: 11/15/2012 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.

A A A A A

B B B B B

C C C C C

D D D D D

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

29

November 2010


Gi lsl off Pharmac G Girls Ph Pharmacy P cy SSoutheastern South th h t heastern

Leadership Weekend Leade ership p Week kend 2011

-DQXDU\Ĺ&#x201A;*URYH3DUN,QQ$VKHYLOOH1& -DQXDU\  Ĺ&#x201A;*URY    YH3DUN,QQ$VK    KHYLOOH1&  Gather your girlfrie girlfriends ends for a weekend of fun fun, n, facts, and facials! Register ster today to ensure your spot at the 201 2011 1 Southe Southeastern eastern â&#x20AC;&#x153;Girls of Pharmac Pharmacyâ&#x20AC;? cyâ&#x20AC;? Leadership W Weekend. eekend. Full registration includes: CE programming eve programming, event ent materials, materials two breakfas breakfasts, sts and one dinner reception sts, reception with included drink dr ticket. tickets separately. You Extra reception tic ckets can be purchased se eparately. (Men - Donâ&#x20AC;&#x2122;t be e shy! Y ou can attend atten too!) Rooms are availab available ble at the Grove Park Inn for $140 per night. Call (800) 800) 438-5800 to book your room today today.. You Spa appointments s are available for reservation tion through the Grove Park ark Inn. Y ou must be registered make SCPhAâ&#x20AC;&#x2122;s appointment for the event to ma ake reservations through SCPhA â&#x20AC;&#x2122;s reserved appoin ntment times. New this year! Attendees are ent entitled itled to a 15% treatment discount d on services booked ked before noon on Friday Friday, Sunday,, Ja January discountt is not valid on manicures or January 14th and after noon on Sunday nuary 16th. This discoun cannot packages. directly at pedicures and can nnot be combined with any y other discounts or packa ages. Call the spa d today. 828-253-0299 to make m your reservations to day. For questions, ple please ase call 803.354.9977. South Carolina Pharmac Pharmacy cy Association is accredited by the Accreditation A Council for Pharmacy Education as a provider of continuing SKDUPDF\HGXFDWLRQ7KLVDFWLYLW\LVHOLJLEOHIRU$&3(FUHGLWVHHÂżQDO&3(DFWLYLW\DQQRXQFHPHQWIRUVSHFLÂżFGHWDLOV SKDUPDF\HGXFDWLRQ 7K KLVDFWLYLW\LVHOLJLEOHIRU     $&3(FUHGL  WVHHÂżQDO&3(DFWLYLW\DQQRXQFHP      PHQWIRUVSHFLÂżFGHWDLOV    

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2010 - 2011 GPhA BOARD OF DIRECTORS

The Georgia Pharmacy Journal Editor:

Jim Bracewell jbracewell@gpha.org

Managing Editor & Designer:

Kelly McLendon kmclendon@gpha.org

The Georgia Pharmacy Journal® (GPJ) is the official publication of the Georgia Pharmacy Association, Inc. (GPhA). Copyright © 2010, 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 www.gpha.org 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

Position

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Chairman of the Board President President-Elect First Vice President Second Vice President Executive Vice President/CEO State-at-Large State-at-Large State-at-Large State-at-Large State-at-Large State-at-Large State-at-Large Region One President Region Two President Region Three President Region Four President Region Five President Region Six President Region Seven President Region Eight President Region Nine President Region Ten President Region Eleven President Region Twelve President ACP Chairman AEP Chairman AHP Chairman AIP Chairman APT Chairman ASA Chairman Foundation Chairman Insurance Trust Chairman Ex Officio - President, GA Board of Pharmacy Ex Officio - Chairman, GSHP Ex Officio Mercer Ex Officio Mercer ASP Ex Officio South Ex Officio South ASP Ex Officio UGA Ex Officio UGA ASP

Sonny Rader Gina Ryan Johnson Jill Augustine Rusty Fetterman Olivia Santoso Sukh Sarao David Bray

www.gpha.org

Print: Star Printing - 770.974.6195

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31

November 2010


The The GPhA GPhA Journal Journal 50 Lenox Lenox Pointe, Pointe, N.E. N.E. Atlanta, Atlanta, Georgia Georgia 30324

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The Georgia Pharmacy Journal: November 2010  

Join us in celebrating 30 years of serving the members of the Georgia Pharmacy Association. Celebrating 30 years of service to the Pharmacis...

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