The Kentucky Pharmacist - July/August 2020

Vol. 15 No. 4 July/August 2020

THE KENTUCKY

PHARMACIST Official Journal of the Kentucky Pharmacists Association

PharmD student and Miss America Camille Schrier will appear at the KPhA VIRTUAL Annual Meeting & Convention November 13-14, 2020.

The Voice of Pharmacy in Kentucky

TABLE OF CONTENTS FEATURES 

KPhA Annual Meeting & Convention goes virtual |23|

On the Cover Mission Statement: The mission of KPhA is to advocate for and advance the profession through an engaged membership.

Editorial Office: ©Copyright 2020 to the Kentucky Pharmacists Association. The Kentucky Pharmacist is the official journal of the Kentucky Pharmacists Association published bi-monthly. The Kentucky Pharmacist is distributed to KPhA members, paid through allocations of membership dues. All views expressed in articles are those of the writer, and not necessarily the official position of the Kentucky Pharmacists Association.

PharmD student and Miss America Camille Schrier will appear at the KPhA VIRTUAL Annual Meeting & Convention November 13-14, 2020.

IN EVERY ISSUE President’s Perspective |3| My KPhA Rx |6| July CE Article |8| July Quiz |13| July CE Answer Sheet |14| August CE Article |16| August Quiz |21| August Answer Sheet |22| Pharmacy Policy Issues |24| New KPhA Members |25| Pharmacy Law Brief |26|

Publisher: Mark Glasper Managing Editor: Sarah Franklin Editorial, advertising and executive offices at 96 C Michael Davenport Blvd., Frankfort, KY 40601.

Phone: 502.227.2303 Fax: 502.227.2258.

Email: info@kphanet.org.

Website: www.kphanet.org.

ADVERTISERS APSC|5| PTCB |15| EPIC |25| APMS |27| Pharmacists Mutual |28| Cardinal |29| CMP Pharma |Back Cover|

|2| Kentucky Pharmacists Association | July/August 2020

PRESIDENT’S PERSPECTIVE Over the next few months, you will get a chance to read the feelings and dealings of myself as they relate to Our Association and Profession. I want to preface these articles with a few ground rules.

First and foremost, if you don’t know me, I am on almost every social media platJoel Thornbury form and am pretty much an open book, especially when it President, KPhA comes to our Profession. I’m proud of it, and it resonates and connects with so many of us.

I will be one of your loudest supporters (GO YOU!!!), but that also means I reserve the right to ask questions. Hopefully, my questions will spur thought and perspective. One of the things you need to know about me is my mind is always going on ways to improve our Association and our Profession, especially as it relates to you applying your skills toward improved patient care.

“Our Association is here to represent ALL our colleagues. I will try my best to make it that way also.”

Second, if you are mad or upset with what I write, that’s perfectly OK! I’m not asking you to agree with everything I say.

Please note, all the writings are my own opinion and may not correlate with the view of The Association. However, I will ask you to ask yourself, are you angry at my words or at the situation that we have allowed occurring? Are you upset because I will ask you to do something different or not in your usual manner? Or are you upset because my words challenge your current thinking or belief?

Third, I will push you to get Outside of Your Box (OYB) or comfort zone. My mother and father always taught my siblings and me to be as prepared as possible, try not to panic if you aren’t, and to deal with the new adventure in the best way. Admittedly, there were times in life when our nerves were stressed, but we always put our faith in God and each other, and things seemed to work out in the end. I can remember my mom saying, “Keep the Faith!” and that motto stays

with me today when I face tough challenges.

Fourth, my columns will generally all be in the digital media format, but I do believe in “Letters to the President or Executive Director.” If you have a feeling one way or another, write that puppy down and send it in! We traditionally aren’t a very vocal profession, so I’m trying to nudge everyone to become a smidge more vocal. I need your thoughts, ideas, and opinions.

I need your voices. We need voices.

Finally, I will mention my primary practice area (Community Retail) occasionally, but only out of convenience. I have experience in many areas of our Profession and have no allegiance to one while I’m sitting in this position. Our Association is here to represent ALL our colleagues. I will try my best to make it that way also. So here we go.

TOGETHER, Pharmacy Wins!

TOGETHER! Yes, TOGETHER is the catch phrase of today.

If you haven’t heard it yet from an advertisement, just step back a moment. You will realize all the new ads use it as their core. Everywhere I turn, tune, and look, there seems to be this word: TOGETHER. I heard another new advertisement today from a local hospital system out of southern West Virginia.

Advertisers, especially in health care, seem to have fallen head over heels in love with the word. Well, I’m not a marketer, and since the professionals seem to find it the word that can get their idea and message across, then who am I to not take it out for a trot.

Merriam-Webster Dictionary defines TOGETHER as: Adverb: in or into one place, mass, collection, or group; in or into contact, connection, collision, or union; at one time; by combined action; with each other (as a unit: in the aggregate, considered as a whole).

Adjective: (Slang) Mentally and emotionally stable and well organized (Merriam-Webster).

Does anyone see the similarities of the definition and a profession? Who doesn’t feel some comradery with your colleague, no matter the practice site? Do we not come together respectfully at meetings to learn as one? Have you ever tried to fill a glass of water one drop at a time? Isn’t it easier and quicker when you have a stream of those drops flowing together? Why should we continue to fight for recognition of what we are and

KPhA sends email announcements weekly. If you aren’t receiving: eNews, Legislative Updates and other important announcements, send your email address to info@kphanet.org to get on the list. |3| www.KPHANET.org

what we can do singularly? Why should you or your colleague that refuses to join an association scream, ‘Hey, This is what I was trained for and can do!” Shouldn’t someone or something attempt to bring us in as ONE? TOGETHER is much better than APART. Our beloved State’s Motto is “United We Stand! Divided We Fall”. Then why do we seem to fight more against and not support one another? At the core of every druggist are education and an oath committing them to science and improvements to the health of humankind while holding themselves to the highest professional moral, ethical, and legal conduct.

I see things through rose-colored glasses and say, “Maybe.”

They did pass OBRA’90—the requirement to offer counseling upon the dispensing of a prescription. Oh, wait, we fought that tooth and nail because it did not mention being paid.

How about Medicare Part D? Where they began paying for CMRs and TIPS interactions? Oh wait, we initially fought that one too because we don’t get paid enough for those to deal with them.

We have to start to change our game before they are going to stop recognizing us any more than we are now. I say we have to learn a more efficient way to deal with patients because we have traditionally treated them more like customers than patients. We stand back and allow more and more medications to freely move Over-the-Counter even though we quiver with the knowledge that interactions are occurring left and right without adequate education on their proper use and dangers.

It will take an open mind, getting outside your comfort zone, and beginning back down a path that exists but has overgrown. STOP ASKING WHAT YOU GET BEFORE YOU GIVE and STOP SITTING QUIETLY UNTIL IT IS TOO LATE! We are ALL part of a TOGETHER when we mention pharmacists. We have to start getting others to donate their time, money, or resources toward the Profession or Association if they choose not to roll up their sleeves. Do you want to make a change? Do you want to get to a better place?

You have to join others’ voices, or no one will hear you.

Yes, I am full of questions, but at this point in my professional career as a druggist, this “junk” we deal with on recognition and respect (and lack thereof) is frustrating! I am Joel Thornbury, third generation pharmacist with many years of practice and professional experience, stepping in as President of this beloved Association for the second time because our Profession burns in my belly and soul. Doesn’t it in yours or at least didn’t it one day in your past? I mean, who didn’t use the “I’m called to be a pharmacist because of a childhood experience or witness” as one of the reasons you were applying? So, why are so many of our colleagues so upset with either the Association or the Profession? If it is your calling, then it can’t be considered a job. Don’t like your job? LEAVE! Don’t like your Profession? QUIT! Don’t like either of the previous two statements? Then let’s roll up our sleeves TOGETHER and do something about it! Remember, UNITED WE STAND!!!

There are a few things that I want you to gather from this DIVIDED WE FALL!!! month’s article. First, I’m super pumped and honored to be back as President of OUR Association. I know, and it burns Our KPhA is Your KPhA Too! my soul that we aren’t exactly where we should be as a profesI get frustrated at our present situation because too many sion or Association. There is a lot of work to be done to get us times, I sit in silence respectfully and listen to other colleagues moving in the direction of increased relevance. Please feel beat and bash our Association for not doing anything for welcome to become more vocal and involved. TOGETHER, them. Is it my fault, The Association’s, or just maybe their with open minds and a willingness to think more creatively, fault? Perhaps this is just what they learned, to point the finare the only ways WE can get to where we know we can be. ger. There might be some reasoning here because society Finally, I hurt when you hurt, not feeling that OUR Profesdoesn’t think we, for the most part, do anything at work exsion is the Greatest out there! Until next time, Stay Positive, cept put pills in a bottle, ring them out while taking a power Keep the Faith, and Keep Your Patient in the Center of your bill, or bother them about getting a vaccination they should care! GO FUN!!!! GO PHARMACISTS!!!! have gotten somewhere else. Doesn’t the back of the box have References all they need to know about OTC medications and their usage? Maybe we are all simply taught to quietly do our jobs to Merriam-Webster. (n.d.). Together. In Merriam-Webster.com the best of our abilities and not ring our bells, thus, allowing dictionary. Retrieved others to misperceive or describe what is going on.

August 19, 2020, from https://www.merriamSo how do you think we can fix this injustice or misunderwebster.com/dictionary/together. standing? I’d be lying if I said it was going to be easier than United We Stand, Divided We Fall. (n.d.). Retrieved August going through pharmacy school again. I have no new secret formula. I don’t have any black magic. However, experience 20, 2020, from has shown me that it will take all of us TOGETHER to make https://statesymbolsusa.org/symbol-officialit happen. Do we even think the Government over the past item/kentucky/state-motto/united-we-stand-divided-we-fall.

20-plus years has been helping us? Some would say “No,” but |4| Kentucky Pharmacists Association | July/August 2020

|5| www.KPHANET.org

MY KPhA Rx KPhA Annual Meeting & Convention Goes Virtual – Don’t Miss It!

ent. But I’ve been pleasantly surprised “attending” virtual events arranged by other associations. They’ve been down right fascinating to follow. True, I have an ulterior motive when viewing these events because I want to learn as much as possible for our event. However, I still find the combination of technology and human creativity can create a useful and entertaining product.

I’m sure you’ve heard KPhA leadership decided to move the Annual Meeting & Convention to a completely virtual format November 1314, 2020 out of an abundance of care Mark Glasper, for our attendees, speakers, exhibiKPhA Executive tors & sponsors, special guests and Director/CEO staff. We continually monitored the evolving factors related to the Coronavirus (COVID-19) outbreak to arrive at this difficult, but correct, decision. However, we still look forward to having you join us for this fully online event complete with quality continuing education, great networking opportunities and our annual exhibition – all virtual!

I like to say that every problem creates an opportunity. And, that’s exactly what’s happened with COVID-19 and the meeting and event community. Yes, the pandemic has forced us to move away from the norm and our in-person events. However, we’re able to create new opportunities to enjoy by attending these new online forums.

Re-imagine Our Event KPhA staff members are busy now finding the right virtual event vendor to offer the most flexibility for our needs. You would think there wouldn’t be too many of these companies available given the recency of the COVID-19 pandemic – but there are! In actuality, virtual event companies have been around a long time, offering many of the features we need.

And, virtual meeting products such as Zoom have existed in the marketplace as well. However, now you see a marrying of the two concepts to bring about the current array of virtual and hybrid events.

I know this Annual Meeting & Convention will seem differ-

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“We will appreciate not only your participation in this year’s Annual Meeting & Convention but also your feedback after the event.”

CE, Networking & Exhibits Oh My! You’ve probably already taken online CE, so offering CE during our virtual Annual Meeting may not seem so unusual.

We will offer the same number of CE hours as we always do through the use of concurrent sessions. You will also have on-demand access to all of the offerings through November 30, 2020, so you don’t have to be concerned about missing a valuable session. And, you can even chat with other participants during the “live” versions.

But, how on earth do you network online? This isn’t Facebook or LinkedIn after all. That’s where the technology and human ingenuity come in. You can look forward to attending a coffee hour each morning where you can interact with your friends and colleagues. Just grab a cup of coffee and enjoy good conversation. The same goes for a happy hour on the first day of the event. Pour yourself your favorite beverage and share stories of how you’re enjoying the event.

Ok, so now you understand the networking component of a virtual meeting. But, you’re still having problems grasping how we’re going to achieve an online exhibition. Not to worry. We’ve got that covered as well. You’ll have plenty of opportunity to interact with exhibitors through prearranged meetings or chats. And, you’ll also be able to view videos and download their product brochures.

But, what about the Ray Wirth Awards Ceremony & Banquet you ask? Well, the banquet is a casualty of moving our event to a virtual format. However, we will still have an awards ceremony and I hope you tune in to watch this year’s worthy nominees receive their awards.

Miss America Camille Schrier to Appear One thing for sure hasn’t changed about the Annual Meeting & Convention. PharmD student, Miss America Camille Schrier, is still planning to make an appearance at our event!

You won’t be able to meet her up close and personal as we had planned but she will still grace our event with her virtual presence. Stay tuned as we finalize her schedule.

As I mentioned, we’re working hard to deliver a quality program for your CE and networking needs. It’s definitely a challenge but your KPhA staff is up to it. We will appreciate not only your participation in this year’s Annual Meeting & Convention but also your feedback after the event. Virtual and hybrid meetings are going to be a part of our future and your input will be valuable to us.

I look forward to “seeing” you at the KPhA Annual Meeting & Convention November 13-14, 2020!

PharmD student and Miss America Camille Schrier will appear at the KPhA VIRTUAL Annual Meeting & Convention November 13-14, 2020. Save the Date now!

Register for the KPERF Golf Scramble at kphanet.org

|7| www.KPHANET.org

July CPE Article 2019 American Geriatrics Society Beers Criteria® Update Authors: Mark Huffmyer, PharmD, BCGP, BCACP, CACP; Ana Vo, PharmD Candidate; Mary Sau, PharmD Candidate; Bao-Han Nguyen, MS, PharmD Candidate; Lynne Eckmann, PharmD, BCGP; Daniela C. Moga, MD, PhD The authors declare that there are no financial relationships that could be perceived as real or apparent conflicts of interest.

Universal Activity # 0143-0000-20-007-H01-P &T 1.0 Contact Hours (0.1 CEU) Expires 8/31/23

KPERF offers all CE articles to members online at www.kphanet.org

Learning Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: Define Beers Criteria® and its application.

Identify common medications to avoid or flagged with caution based on the 2019 American Geriatrics Society Beers Criteria®.

Evaluate updates from the 2015 American Geriatrics Society Beers Criteria®.

Illustrate Beers Criteria® to optimize medication regimens in older adults by evaluating risks and benefits of medications and reducing adverse drug events.

Set (HEDIS), National Committee for Quality Assurance (NCQA), and Pharmacy Quality Alliance (PQA) have From 2010 to 2050, it is projected that the older adult populaadapted Beers Criteria® with the same goal to improve pation (i.e., 65 years and older) will grow from 8% to 21% of the tient outcomes. world population. With an increasingly aging population, clinical consequences arise as a result of the prevalence of After Beers’ death, the Beers Criteria® was adopted by the comorbidities and decreased functional ability of the populaAGS, who published the first update in 2012. Since then, the tion. Older adults are more likely to experience polypharmaAGS has updated Beers Criteria® every three years under the cy and associated inappropriate prescribing of medications. consideration of an interdisciplinary expert panel, including Drug utilization reviews are tools that pharmacists can utilize representatives from CMS, NCQA and PQA; the latest such to identify potentially inappropriate medications (PIMs) and update was published in 2019.6 Beers Criteria® compiles a list their adverse drug reactions. Although PIMs are not a definiof PIMs including (1) PIMs in older adults, (2) drug-disease tive contraindication for medication use in older adults, they or drug-syndrome interactions, (3) drugs to be used with caumay worsen a patient’s existing disease and require individution in older adults, (4) drug-drug interactions that should be alized evaluation of risks and benefits for decision-making. avoided in older adults, (5) medications that should be avoidInappropriate medications causing adverse drug reactions can ed or dose-adjusted with varying levels of kidney function in have significant clinical consequences; adverse drug reactions older adults, (6) drugs with harmful adverse effects, and (7) are among the most common causes of iatrogenic harm and medications with strong anticholinergic properties. Rationale, mortality. recommendation, quality of evidence, and strength of recommendation are included. Quality of evidence is evaluated on In order to identify harmful medications and standardize pre- an ACP- and GRADE-based approach and rated as low, scribing guidelines for older populations over 65 years of age, moderate, or high. Strength of evidence is rated as strong or Mark H. Beers, MD, developed the Beers Criteria® in 1991. weak based on whether risk “clearly” or “may not” outweigh 6 It has become the most widely used and longest-standing re- benefits. source by clinicians in the United States of America to identi- How to Utilize the Beers Criteria® fy PIMs in older adults. As drug experts and liaisons, pharmacists and pharmacy technicians in clinical and community In 2015, AGS released a set of principles to guide the application of the Beers Criteria® and optimize its implementation settings have the most important role in drug utilization reby clinicians. The first principle states that medications inview. Beers Criteria® can serve as a useful tool in helping pharmacists and pharmacy technicians be actively involved in cluded in the Beers Criteria® should be considered potentialthe healthcare team to help identify medication-related prob- ly inappropriate, not definitely inappropriate.9 Drugs should lems and optimize treatment to improve outcomes. Regulato- be evaluated to ensure benefit over harm, but they are not ry bodies such as the Center for Medicaid and Medicare Ser- contraindicated in the elderly population. Furthermore, to vices (CMS), Healthcare Effectiveness Data and Information help with clinical decision-making, each criterion has a raBackground

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tionale and recommendation that should be used to explain why and when a drug is potentially inappropriate. Because patients vary widely, understanding why a drug is included in the Beers Criteria® will help clinicians make the best decisions about which medications are inappropriate for an individual and provide safer, alternative therapies. Moreover, assessment of medication regimens should not end with Beers Criteria®. These criteria should be used as a starting point for a complete medication review, which involves evaluating each drug’s indication, adverse effects, effectiveness, and several patient factors including adherence, ability to pay, and goals of care.9 While a useful tool in the medication management of patients 65 and older, the AGS Beers Criteria® cannot be used as a universal set of rules. Clinicians should ultimately rely on their common sense and clinical judgment.9

bleed. The AGS presented this as a strong recommendation with moderate quality of evidence. Alternatives to oral NSAIDs include acetaminophen, nonacetylated salicylate, or SNRIs (i.e., duloxetine, venlafaxine); topical use of NSAIDs, capsaicin, or lidocaine may also be preferred.12 Aspirin for Primary Prevention

The Beers Criteria ® recommends using aspirin for primary prevention of cardiovascular disease or colorectal cancer with caution in adults aged 70 years or older. The risk of bleeding increases with age, and several studies have shown this risk outweighs the benefits in older adults. Furthermore, the ASPREE (Aspirin in Reducing Events in the Elderly) trial showed that among healthy adults who were predominantly 70 years of age or older and without an indication for aspirin, all-cause mortality was higher among patients receiving lowThis article will highlight some of the most frequently encoundose aspirin compared to placebo.13 Aspirin is still generally tered and clinically relevant findings from the 2019 American indicated for secondary prevention in patients with established Geriatrics Society Beers Criteria®. Recommendations are cardiovascular disease. 6 discussed for specific medication classes: drugs with strong anticholinergic properties, nonsteroidal anti-inflammatory Proton Pump Inhibitors (PPIs) drugs, aspirin, and proton pump inhibitors. These are folHigh quality of evidence supports the advisory that PPIs such lowed by recommendations regarding PIM use and specific as omeprazole increase risk of Clostridium difficile infection medical conditions: falls/syncope, delirium and dementia, urinary incontinence, and syndrome of inappropriate antidiu- and bone loss along with fractures. The AGS strongly recommends limited duration of therapy for PPIs (less than eight retic hormone secretion. The final two sections discuss drugweeks) unless patients have high-risk conditions such as erodrug interactions and medications that should be avoided or have dosage reduced based on kidney function. A summary of sive esophagitis, Barrett esophagitis, pathological hypersecretory condition, have failed other alternatives, or are under changes to the 2015 update follows these sections. concurrent chronic NSAID or corticosteroid therapy.6 Drugs with Strong Anticholinergic Properties Though less potent, an H2 receptor antagonists (H2RA) may be considered as an alternative.14 Medications with anticholinergic properties cause effects such as dry mouth, dry eyes, urinary retention, and constipation. In Falls and Syncope the older adult population with reduced renal and liver clearance capabilities and increased permeability of the blood-brain Falls are a major concern among older patients due to prevabarrier, anticholinergic agents may lead to falls and cognitive lence of concurrent bone disorders and increased risk of fracimpairment.6,10,11 There is increased risk of tolerance devel- tures. Broken bones, hip fractures, and head injury are among serious concerns associated with falls. Three million older opment when anticholinergics are used as hypnotics in older populations.6 Some commonly prescribed drugs with anticho- adults will be treated in emergency departments, and 800,000 linergic properties include select antidepressants, antiemetics, patients are hospitalized for fall injuries annually15. Many antihistamines, antiparkinsonian agents, antimuscarinics, and drugs may cause bradycardia and orthostatic hypotension, leading to risk of syncope. The AGS strongly recommends skeletal muscle relaxants. Beers Criteria® strongly recommend avoiding use of anticholinergic agents in older patients avoiding acetylcholinesterase inhibitors (AChEIs) in patients who experience syncope due to bradycardia with high quality with moderate quality of evidence. One notable exception is evidence.6 Tertiary tricyclic antidepressants (TCAs) (i.e., amithe use of diphenhydramine for acute treatment of severe altriptyline, imipramine), nonselective peripheral alpha-1 blocklergic reactions when the immediate benefits outweigh the ers (i.e., doxazosin, prazosin), and some antipsychotics (i.e., potential risks.6 olanzapine, chlorpromazine) may cause bradycardia or orNonsteroidal Anti-Inflammatory Drugs (NSAIDs) thostatic hypotension. It is strongly recommended these select TCAs be avoided in older adults with syncope due to orthosNon–cyclooxygenase-selective NSAIDs such as ibuprofen, tatic hypotension, while nonselective peripheral alpha-1 blockdiclofenac, meloxicam, nabumetone, and others, increase risk ers and antipsychotics are graded as weak recommendations; of gastrointestinal (GI) bleeding, peptic ulcer disease, high high quality evidence is used to make these recommendablood pressure, and kidney injury. Risk of bleeding increases tions.6 with age and patients over 75 years old are considered to be in a high risk bleeding group. Furthermore, the risk is amplified Patients with a history of falls or fractures should avoid anin those concurrently taking corticosteroids, anticoagulants, or tiepileptics, antipsychotics, benzodiazepines, ‘Z’-drugs (i.e., antiplatelets. Risk is dose- and duration-related. Bleeding or eszopiclone, zolpidem), antidepressants, and opioids unless perforation of the GI tract occurs in ~1% of patients treated safer alternatives are not an option. These drugs may cause for three to six months and up to 4% in those in treatment for ataxia, impaired psychomotor function, syncope, and addione year. If chronic use of NSAID is indicated, consideration tional falls. Consider reducing other CNS-active medications should be given to a gastroprotective agent such as a proton or implementing strategies to reduce falls if one of these drugs pump inhibitor (PPI) or misoprostol to reduce risk of GI |9| www.KPHANET.org

must be used. Some antidepressants have higher risk than others, including TCAs, selective serotonin reuptake inhibitors (SSRIs), and SNRIs. The AGS conferred strong recommendations with high quality of evidence. Moderate quality of evidence suggests opioids may be considered to manage pain in acute situations but otherwise avoided.6 Fall prevention should be enforced by managing conditions such as cardiac arrhythmias, hemodynamic balance, orthostatic hypotension, and autonomic disorders. Balance exercises are also recommended if the patient is mobile.16 Alternative use for anticonvulsants for new-onset epilepsy should favor newer agents with more favorable side effect profiles (i.e., lamotrigine, levetiracetam). Neuropathic pain can be treated with SNRIs, gabapentinoids, topical capsaicin, or lidocaine patch.12 Alternatives to benzodiazepines and Z-drugs include buspirone and SNRIs for anxiety. Nonpharmacologic options should be considered prior to the use of hypnotics for sleep; these include practicing good sleep hygiene (i.e., avoiding stimulants prior to bedtime, limiting light exposure). To decrease risk of falls, SNRIs and bupropion are preferred over TCAs and SSRIs for depression.12

in overweight patients, treating constipation, and maintaining fluid intake. Pelvic exercises that strengthen the pelvic floor muscle may be recommended. Surgical intervention may be indicated if pharmacologic options fail.19 Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) A number of drug classes may exacerbate or potentiate SIADH and hyponatremia; these include antipsychotics, diuretics, SNRIs, SSRIs, and TCAs. Usage of carbamazepine, mirtazapine, oxcarbazepine, or tramadol may also be a risk.

The AGS strongly cautions against use of these medications, but if they must be started, stopped, or dose-adjusted, monitoring sodium level is recommended. Moderate quality of evidence supports these recommendations.6 Drug-drug Interactions to Avoid

Several key drug-drug interactions are noted in older adults.

Beers Criteria® strongly recommends avoiding concurrent use of opioids and benzodiazepines due to increased risk of overdose. Usage of opioids and gabapentin or pregabalin together is linked with increased risk of sedation, leading to respiratory Delirium and Dementia depression and mortality. It is generally recommended to avoid this combination unless gabapentinoids are being used While delirium and dementia often manifest similarly with to reduce chronic opioid dose or during the period of transipatients exhibiting confusion and cognitive impairment, the tion from opioids to gabapentinoids for pain management.6 characteristics of the symptoms and etiologies are different.

Any combination of three or more CNS-active drugs should Delirium is often due to an acute, reversible cause and is tranbe avoided due to increased risk of falls and fractures; these sient. On the other hand, dementia is a chronic, progressive, include TCAs, SSRIs, SNRIs, antipsychotics, antiepileptics, and acquired impairment of executive function that is often benzodiazepines, Z-drugs, and opioids. Moderate quality of insidious in onset.17 Drugs that may enhance these effects evidence supports these recommendations.6 include anticholinergics, benzodiazepines (i.e., alprazolam, diazepam), Z-drugs, and antipsychotics. Delirium can also be Medications That Should be Avoided or Have Dosage Reinduced or worsened by corticosteroids and H2RAs. Avoiding duction by Kidney Function these drugs is strongly recommended due to their effects on Many drugs are cleared renally. In the older population, imthe central nervous system (CNS). Antipsychotics should be avoided for delirium/dementia treatment unless nonpharma- paired renal function is more likely; thus, it is important to take note of renally-eliminated medications and adjust the cologic options (i.e., behavioral interventions) have failed or are not possible and the patient threatens harm to self or oth- dose or avoid them altogether in these patients.6. Medications ers; a short course of therapy may be considered if unavoida- are listed below according to the creatinine clearance (CrCl) at which the dosage should be reduced or the drug should be ble.6,12 Moderate quality of evidence supports these recomavoided, followed by the rationale. Drugs are provided for mendations, with the exception of low-quality evidence betwo categories, anti-infectives and cardiovascular or hemostahind claims against H2RAs.6 If nonpharmacologic options sis. have failed, a low-dose anticholinergic agent such as risperidone or quetiapine may be used for the shortest duration pos- Anti-infectives: sible for dementia.12 Drugs that should be dose-reduced with: Urinary Incontinence  CrCl <30 mL/min: ciprofloxacin due to increased risk of Urinary incontinence, especially in women, increases with age CNS effects and tendon rupture.6 and affects quality of life. Over 200 million people are affected  CrCl <30 mL/min: SMZ-TMP due to worsening renal by incontinence globally.18 There is a lack of efficacy in the function and hyperkalemia with SMZ-TMP.6 usage of oral estrogen replacement therapies. Therefore, it is strongly recommended that oral estrogen be avoided in older Drugs that should be avoided with: female patients. High quality of evidence supports this claim.  CrCl <15 mL/min: SMZ-TMP due to worsening renal Peripheral alpha-1 blockers may aggravate incontinence in function and hyperkalemia with SMZ-TMP.6 women. There is a strong recommendation to avoid this class as well with moderate quality of evidence.6 Alternatives for Cardiovascular or hemostasis: oral estrogen may include topical or vaginal options. Escitalopram, venlafaxine, and gabapentin may also be recommend- Drugs that should be dose-reduced with: ed for symptoms of vasomotor instability (i.e., hot flashes).12  CrCl >30 mL/min: dabigatran in the presence of drugLifestyle modifications should be implemented in patients drug interactions due to lack of evidence for safety and presenting with urinary incontinence including losing weight |10| Kentucky Pharmacists Association | July/August 2020

efficacy.6

overdose6.

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CrCl <30 mL/min: enoxaparin due to increased risk of bleeding.6

Other Resources

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CrCl between 15 to 50 mL/min: rivaroxaban (if being used for nonvalvular atrial fibrillation) and edoxaban due to lack of evidence for safety and efficacy.6

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CrCl between 20 to 59 mL/min: dofetilide due to increased risk of QTc interval prolongation and torsade de pointes.6

Drugs that should be avoided with:

In addition to the Beers Criteria®, several resources are available to help in the medication review of older patients. GeriatricsCareOnline.org and AmericanGeriatrics.org are popular websites with additional tools, publications, and programs dedicated to the geriatric population. Additionally, AGS has an app available on Apple and Android devices called iGeriatrics. It has been updated with the latest Beers Criteria® and is a reference tool that can be kept in one’s pocket. Aside from PIMs, vaccination guidelines and fall prevention guidelines may also be useful for pharmacists.

CrCl <15 mL/min: rivaroxaban (if being used for nonvalvular atrial fibrillation) due to lack of evidence for safety Summary and efficacy.6 This CE aims to highlight the most clinically relevant findings  CrCl <20 mL/min: dofetilide due to increased risk of presented in the 2019 American Geriatrics Society Beers CriQTc interval prolongation and torsade de pointes.6 teria® update. Further investigation and a more thorough assessment can be done by reviewing the tables attached to the  CrCl <25 mL/min: apixaban due to lack of evidence for appendix directly from Beers Criteria®. safety and efficacy.6 The Beers Criteria® is a unique and useful tool that can help  CrCl <30 mL/min: fondaparinux due to increased risk of identify potentially inappropriate medication in older adults to bleeding.6 guide drug therapy optimization including deprescribing, im CrCl <30 mL/min: amiloride, spironolactone, and triam- prove medication selection to avoid adverse drug events, and improve patient care and health-related outcomes. terene due to increased potassium levels as well as decreased sodium levels when using triamterene.6 References  CrCl <30 mL/min: rivaroxaban (if being used for venous 1. Lunenfeld B, Stratton P. The clinical consequences of an thromboembolism treatment or prophylaxis during hip or ageing world and preventive strategies. Best Pract Res Clin Obknee replacement) and dabigatran due to lack of evidence stet Gynaecol. 2013;27(5):643-659. doi:10.1016/ for safety and efficacy.6 j.bpobgyn.2013.02.005 2. Rambhade S, Chakarborty A, Shrivastava A, Patil UK,  CrCl <15 or >95 mL/min: edoxaban due to lack of eviRambhade A. A survey on polypharmacy and use of inapprodence for safety and efficacy.6 priate medications. Toxicol Int. 2012;19(1):68‐73.

Summary Changes from the 2015 AGS Beers Criteria® Up- doi:10.4103/0971-6580.94506 date 3. Peer RF, Shabir N. Iatrogenesis: A review of nature, exUpdating the criteria every three years allows the AGS to add tent, and distribution of healthcare hazards. J Family Med Prim new evidence-based guidelines and remove any non-pertinent Care. 2018;7(2):309-314. doi:10.4103/jfmpc.jfmpc_329_17 information.6 From the 2015 reiteration of Beers Criteria®, 4. Marcum ZA, Hanlon JT. Commentary on the new Amerthe AGS removed drugs that have been discontinued from the ican Geriatric Society Beers Criteria for Potentially InapproUnited States market, recommendations with weak evident priate Medication Use in Older Adults. The American Journal of findings, and drugs that were no longer specific to the scope or Geriatric Pharmacotherapy. 2012;10(2):151-159. doi:10.1016/ target patient population. Of note, drug interactions with j.amjopharm.2012.03.002 chronic seizures, epilepsy, insomnia, and vasodilator risk of 5. Curtin D, Gallagher PF, O’Mahony D. Explicit criteria as syncope have been removed from recommendations due to clinical tools to minimize inappropriate medication use and its broader recommendations that are no longer unique to elderly consequences. Therapeutic Advances in Drug Safety. 2019;10:1patients.6 10 doi:10.1177/2042098619829431 Several drugs have also been added to the criteria.

6. 2019 American Geriatrics Society Beers Criteria® Update Glimepiride and serotonin-norepinephrine reuptake inhibitors Expert Panel. American Geriatrics Society 2019 Updated (SNRIs) were added to the list of drugs to be avoided.

AGS Beers Criteria® for Potentially Inappropriate MedicaGlimepiride has an increased risk of severe, prolonged hypotion Use in Older Adults. J Am Geriatr Soc. 2019;67:674-694. glycemia, and SNRIs should be specifically avoided in those doi:10.1111/jgs.15767 with a history of falls or fractures. Additionally, ciprofloxacin 7. Jano E, Aparasu RR. Healthcare outcomes associated and SMZ-TMP were added to the list of medications that with Beers’ Criteria: a systematic review. Annals of Pharmashould be avoided or have dosage reduced based on kidney cotherapy. 2007;41(3):438-448. doi:10.1345/aph.1H473 function. Drug-drug interactions were also added including 8. American Geriatrics Society 2012 Beers Criteria Update ciprofloxacin, macrolides (except azithromycin), and SMZExpert Panel. American Geriatrics Society updated Beers CriTMP causing increased risk of bleeding with warfarin. Additeria for potentially inappropriate medication use in older tionally, opioids should not be used concurrently with either adults. J Am Geriatr Soc. 2012;60(4):616‐631. doi:10.1111/ benzodiazepines or gabapentinoids due to increased risk of 

|11| www.KPHANET.org

j.1532-5415.2012.03923 9. Steinman MA, Beizer JL, DuBeau CE, Laird RD, Lundebjerg NE, Mulhausen P. How to Use the American Geriatrics Society 2015 Beers Criteria-A Guide for Patients, Clinicians, Health Systems, and Payors. J Am Geriatr Soc. 2015;63 (12):e1‐e7. doi:10.1111/jgs.13701 10. Rudolph JL, Salow MJ, Angelini MC. The Anticholinergic Risk Scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168(5):508-513. doi:10.1001/ archinternmed.2007.106 11. Staskin DR, Zoltan E. Anticholinergics and central nervous system effects: are we confused?. Rev Urol. 2007;9(4):191‐ 196.

12. Hanlon JT, Semla TP, Schmader KE. Alternative medications for medications included in the use of high-risk medications in the elderly and potentially harmful drug-disease interactions in the elderly quality measures. J Am Geriatr Soc. 2015;63(12):e8-e18. doi:10.1111/jgs.13807 13. McNeil JJ, Nelson MR, Woods RL, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med. 2018;379:1519-1528. doi:10.1056/NEJMoa1803955 14. Maes ML, Fixen DR, Linnebur SA. Adverse effects of proton-pump inhibitor use in older adults: a review of the evidence. Ther Adv Drug Saf. 2017;8(9):273‐297. doi:10.1177/2042098617715381 15. Centers for Disease Control and Prevention. Important Facts about Falls. https://www.cdc.gov/ homeandrecreationalsafety/falls/adultfalls.html. Accessed May 8, 2020.

16. Ungar A, Rafanelli M, Iacomelli I, et al. Fall prevention in the elderly. Clin Cases Miner Bone Metab. 2013;10(2):91‐95.

17. Lippmann S, Perugula ML. Delirium or Dementia?. Innov Clin Neurosci. 2016;13(9-10):56‐57. Published 2016 Oct 1.

18. Norton P, Brubaker L. Urinary incontinence in women.

The Lancet. 2006;367(9504):57-67. doi:10.1016/S0140-6736 (06)67925-7 Thirugnanasothy S. Managing urinary incontinence in older people. Bmj. 2010;341:339-343. doi:10.1136/bmj.c3835

|12| Kentucky Pharmacists Association | July/August 2020

Kentucky Professionals Recovery Network (KYPRN) is a free-standing organization that provides confidential monitoring of licensed professionals struggling with the disease of addiction.

www.kyprn.com

July 2020 — 2019 American Geriatrics Society Beers Criteria® Update 1. As of 2020, who publishes the Beers Criteria® and how often is it updated?

A. American Geriatrics Society, every year B.

American Geriatrics Society, every 3 years

C. National Academy of Medicine, every 3 years D. National Academy of Medicine, every 5 years

6. Some drugs should be used cautiously in older adults with certain medical conditions. Which of these drug - medical condition pairings fits this description?

A. Diazepam – bleeding B.

Carbamazepine - delirium and dementia

C. Ibuprofen – SIADH D. Oral estrogen - urinary incontinence

2. Which of the following is true about PIMs (potentially inappropriate medications)?

7. Which of the following is NOT an alternative drug for NSAIDs?

A. PIMs are a definitive contraindication in older adults,

A. Acetaminophen

B.

B.

PIMs may worsen a patient’s existing disease.

Buspirone

C. PIMs never require dose adjustment

C. Topical capsaicin

D. PIMs are associated with better outcomes.

D. Duloxetine

3. Which is included in the set of key principles AGS has published for how best to utilize Beers Criteria®?

8. Enoxaparin and fondaparinux are associated with an increased risk of bleeding in patients with a creatinine clearance less than what?

A. AGS Beers Criteria® is a starting point for a complete medication review.

A. 15 mL/min

B.

AGS Beers Criteria® can be used as a universal set of rules for all older patients.

C. Medications in AGS Beers Criteria® are definitely inappropriate.

D. Rationale and recommendation statements are included for some criterion.

4. Which of the following is true about anticholinergics?

A. They increase the risk of diarrhea.

B.

Like NSAIDs, they are considered to be safe in the use of older adults.

C. They can include antidepressants, antipsychotics, and antihistamines.

B.

30 mL/min

C. 60 mL/min D. 90 mL/min 9. What was Dr. Mark H. Beers’s goal when he created the Beers Criteria® in 1991?

A. To standardize medications to be avoided in nursing home populations B.

To standardize medications to be avoided in patients with reduced kidney function

C. To standardize medications to be avoided in pediatric populations D. To standardize medications to be avoided in patients with impaired lung function

D. They should be used for patients with dementia.

5. Which combination of drugs is NOT noted in Beers Criteria® as an important drug-drug interaction in older populations?

10. Which of the following changes was made to the 2015 AGS Beers Criteria® and appear in the latest update?

A. Concomitant use of benzodiazepines with opioids

A. Drug interactions with opioids that increase risk of overdose were added.

B.

B.

Concomitant use of opioids with gabapentin

Glimepiride was added and should be avoided in those with a history of falls.

C. Combined use of three or more CNS-active medications such as antidepressants, antipsychotics, antiepileptics, and benzodiazepines

C. SNRIs were added due to effects on kidney function as well as risk of bleeding with warfarin.

D. Concomitant use of opioids with Sulfamethoxazoletrimethoprim (SMZ-TMP)

D. Drug interactions with chronic seizures and epilepsy were added due to new evidence showing an increased risk to elderly patients.

|13| www.KPHANET.org

This activity is a FREE service to members of the Kentucky Pharmacists Association.

The fee for non-members is $30. Mail completed forms to: KPERF, 96 C Michael Davenport Blvd., Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile.

Expiration Date: 8/31/23 Successful Completion: Score of 80% will result in 1.0 contact hour or .1 CEUs. TECHNICIANS ANSWER SHEET July 2020 — 2019 American Geriatrics Society Beers Criteria® Update Universal Activity #0143-0000-20-007-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 7. A B C D 9. A B C D 2. A B C D 4. A B C D 6. A B C D 8. A B C D 10. A B C D Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieved the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet.

Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party.

Signature ____________________________________________Completion Date___________________________ Personal NABP eProfile ID #__________________________ Birthdate _______ (MM)_______(DD)

PHARMACISTS ANSWER SHEET

July 2020 — 2019 American Geriatrics Society Beers Criteria® Update

Universal Activity #0143-0000-20-007-H01-P Name _______________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C 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

Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieved the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet.

Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party.

Signature ____________________________________________Completion Date___________________________ Personal NABP eProfile ID #_____________________________ Birthdate _______ (MM)_______(DD)

The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy |14| Kentucky Pharmacists Association | July/August 2020

Quizzes submitted without NABP eProfile ID # and Birthdate cannot be accepted.

Have an idea for a continuing education article? WRITE IT! Continuing Education Article Guidelines The following broad guidelines should guide an author to  completing a continuing education article for publication in The Kentucky Pharmacist.  



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

Articles are generally written so that they are pertinent to both pharmacists and pharmacy technicians. If the subject matter absolutely is not  pertinent to technicians, that needs to be stated clearly at the beginning of the article.

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|15| www.KPHANET.org

August CPE Article Community-Acquired Pneumonia 2019 Guidelines: Outpatient Therapeutic Updates Authors: Taylor Hawkins, PharmD, Julie Harting, PharmD, BCIDP, and Julie Burris, PharmD

The authors declares that there are no financial relationships that could be perceived as real or apparent conflicts of interest.

Universal Activity # 0143-0000-20-008-H01-P &T 1.0 Contact Hour (0.10 CEU) Expires 8/31/23

KPERF offers all CE articles to members online at www.kphanet.org

Learning Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: 1.

Identify community-acquired pneumonia pathogens and limitations in the laboratory

2.

Define literature and guideline updates related to community-acquired pneumonia

3.

Compare differences between the 2007 and 2019 Infectious Diseases Society of America guidelines.

vention (CDC), and pneumonia, along with influenza, is considered the 9th leading cause of death in the United States. 5 Pneumonia is a lower respiratory tract infection that can lead After twelve years, the Infectious Disease Society of America to severe illness in all ages. Milder cases can be treated in the (IDSA and American Thoracic Society ATS) issued a CAP outpatient setting, however severe cases require hospitalizaguideline update in Fall 2019. In this time gap, the term tion. The lungs are exposed to gases, particles, and microbes health care-associated pneumonia (HCAP) was removed due in the air continuously.1 Pneumonia occurs when a large to over-utilization of broad-spectrum antimicrobial therapy in amount of an organism is present in the lower respiratory that patient population, antimicrobial resistance for common tract, or when the natural defense mechanisms are overCAP pathogens changed, and evidence regarding corticosterwhelmed.1 Pneumonia typically presents with a fever and oid treatments became available. This article will summarize respiratory symptoms consisting of cough, sputum producchanges to management of outpatient CAP. tion, chest pain, shortness of air and tachypnea. 2 Upon physDiagnosis and limitations: ical examination, the patient may present with crackles or rales.3 These signs and symptoms may also be accompanied The updated guidelines highlight that the majority of patients with laboratory and vital abnormalities such as leukocytosis will not have the etiology of CAP identified. In a multicenter, (increased white blood cells), tachycardia, low oxygen level, prospective study titled Etiology of Pneumonia in the Comand a difference in procalcitonin level.3 Pneumonia is usually munity (EPIC), Jain S, et al evaluated 2,320 hospitalized paconfirmed by visualizing infiltrates on a chest radiographic tients with CAP. Radiographic evidence and diagnostic imaging, which is a crucial part of diagnosis. methods were required to participate in the study. Sixty-two Community-acquired pneumonia (CAP) occurs in patients percent of the patients had no pathogen detected. Of those who have not resided in a hospital, long-term care facility, or with an identified pathogen, 24% were viral, 11% bacterial, nursing home 14 days prior to illness onset.1 In comparison, 1% fungal, and 3% co-infection.6 Due to the low yield of patients who are exposed to the above healthcare settings, or pathogen identification, in an outpatient setting, neither have been hospitalized or mechanically ventilated for > 48 blood cultures nor sputum gram stain or culture should be hours are categorized differently as hospital-acquired (HAP) routinely performed. Both types of cultures (blood or respiraor ventilator-associated pneumonia (VAP).4 In 2017, there tory) are only recommended in the setting of severe, inpatient were approximately 50,000 deaths due to all types of pneuCAP.2 monia according to the Centers for Disease Control and PreAs supported by the EPIC study, respiratory viruses are more Introduction:

|16| Kentucky Pharmacists Association | July/August 2020

Table 1: Outpatient Community Acquired Pneumonia Treatment Regimens Comorbidities (heart, lung, liver, renal disease, diabetes, alcocommonly associated No comorbidities or risk factors holism, malignancy, and asplenia) with CAP than previSingle agent therapy options Combination therapy options ously thought.  Amoxicillin 1 gram PO TID (preferred)  Amoxicillin/clavulanate (500 mg/125 mg PO TID or When influenza is OR 875/125 mg PO BID or 2000 mg/125 mg po BID) OR a currently occurring in cephalosporin (cefpodoxime 200 mg PO BID or cefurox Doxycycline 100 mg PO BID OR the community, it is ime 500 mg PO BID) recommended to test  A macrolide (if local resistance <25%)  AND a macrolide or doxycycline for influenza A and B.  Azithromycin 500 mg PO on day 1 and Nasal swabs are prethen 250 mg PO daily Single agent therapy option ferred, and a sputum  Clarithromycin 500 mg PO BID or culture has a lower  Respiratory fluoroquinolone Clarithromycin ER 1000 mg PO daily yield for detection.  levofloxacin 750 mg PO daily The CDC notes that  moxifloxacin 400 mg PO daily rapid influenza testing has a sensitivity ranging from 50-70%. This means, almost half of the time there is outpatient setting is minimal. a false negative for influenza. Sensitivity to detect influenza B Clinical updates in new guidelines:2 is lower than for detection of influenza A. For other viral speThe 2019 guidelines recommend the use of the pneumonia cies, since viral culture results and serial antigen testing may severity index (PSI) over the CURB-65 score to determine not be available until weeks after an acute illness and can involve invasive techniques for sampling, polymerase chain re- need for hospitalization. The CURB-65 score is simpler and action (PCR) technology has replaced these techniques due to based on five criteria; urea, confusion, respiratory rate, blood pressure, and age ≥ 65 years old. The PSI score is much more increase sensitivity and specificity.7 The rate of detection increases by 50% compared to other methods. The sensitivity of detailed containing 20 variables including comorbidities, laboratory values, imaging results, and clinical presentation.

PCR for the eight most common respiratory viruses ranges The PSI scores patients as one of five mortality classes and, is from 95-100% with a 99-100% specificity. Mixed viral infecconsidered better for predicting mortality, and identifies more tions are detected in up to 30% of specimens. The assay detects and differentiates between influenza A and B, respiratory patients as low risk. The PSI score determines overall mortality risk and breaks the patients into groups. Risk groups II, III, syncytial virus (RSV), parainfluenza, human metapneumovirus, rhinovirus, coronavirus, and adenovirus. The sample and I are determined to be low risk and can be treated in the is of the nasopharyngeal and the turnaround time is six and a outpatient setting. Risk groups IV and V correlate with moderate and high risk and require hospitalization. However, the half hours.8 PSI score is an unrealistic index in the outpatient setting due The most common bacterial causes of CAP are Streptococcus to the many of the laboratory and radiographic findings needpneumoniae followed by Haemophilus influenzae, Mycoplased. Severe CAP classification has not changed since the 2007 ma pneumoniae, Staphylococcus aureus, Legionella species, IDSA/ATS guidelines, which includes criteria of respiratory Chlamydia pneumoniae, and Moraxella catarrhalis.2 As statrate, confusion, uremia, leukopenia, thrombocytopenia, hypoed above, blood and sputum cultures should only be obtained thermia, and hypotension. in hospitalized patients who have severe CAP, are intubated, who are receiving empiric coverage for methicillin-resistant S. The 2019 guidelines also recommend against the use of IV aureus (MRSA) or P. aeruginosa, or who have been hospital- corticosteroids except in circumstances of septic shock. This ized and/or received IV antibiotics in the past 90 days.2 Other may come as change of practice, but the authors of the guidelines cite evidence for their lack of support. Corticosteroids are non-respiratory diagnostic testing such as pneumococcal urinary antigen or Legionella urinary antigen should also not be not recommended for outpatient community-acquired pneumonia. performed in an outpatient setting unless recent travel or se-

vere CAP. A prospective, multicenter study including 1,941 patients evaluated the sensitivity and specificity of these urine antigen tests. Of the 64% of patients who received a Legionella urinary antigen test, only 1.6% (32 patients) were positive.

Similarly, of the 61% of patients receiving a pneumococcal urinary antigen test, only 4.2% (81 patients) were positive.9 Therefore, the clinical utility of these tests, particularly in the

Treatment for outpatient setting: Drug-resistant Streptococcus pneumoniae is a nationwide problem. The CDC 2019 Antibiotic Resistance Threats in the United States report mentioned there were twice as many deaths from antibiotic resistance than previously reported in a similar 2013 report.10 Overall, rates of drug-resistant pneumo|17| www.KPHANET.org

Table 2: Antimicrobial Spectrum Comparison

Bug

Amoxicillin

Streptococcus pneumoniae

✓

Atypical bacteria (Chlamydia sp., Legionella sp, Mycoplasma sp)

✗

Doxycycline

Macrolides

Respiratory flouroquinolone

Cephalosporin

+/-

+/-

✓

✓

✓

✓

✓

✗

✓

✓

✓

✓

✓

✓

✓

✓

Haemophilus influenzae Non-betalactamase producing Betalactamase producing

✓ ✗

Staphylococcus aureus MSSA

✗

✓

+/-

+/-

✓

MRSA

✗

✓

✗

+/-

✗

✓

✓

✓

✓

✗

✗

✗

✗

Moraxella catarrhalis Respiratory Viruses

✗ ✗

Footnote: Amoxicillin. In: Sanford Guide [online database]. Sperryville, VA. Accessed on 2020 Apr 19. Doxycline. In: Sanford Guide [online database].

Sperryville, VA. Accessed on 2020 Apr 19. Erythromycin. In: Sanford Guide [online database]. Sperryville, VA. Accessed on 2020 Apr 19. Levofloxacin. In: Sanford Guide [online database]. Sperryville, VA. Accessed on 2020 Apr 19. Cephalosporins. In: Sanford Guide [online database]. Sperryville, VA. Accessed on 2020 Apr 19.

Amoxicillin-Clavulanate does cover for Moraxella catarrhalis.

coccal infections have decreased from 2005 to 2017 as a result of vaccination. However, macrolide resistant among Streptococcus pneumoniae has increased since the 2013 report.10 Based on several large healthcare institution antibiograms in the greater Louisville area, macrolide resistance in Kentucky is on average 50%. Macrolide monotherapy was previously recommended as first-line outpatient therapy in the 2007 guidelines, but is now only recommended when local resistance is less than 25%. Therefore, the majority of Kentuckians should no longer be prescribed macrolide monotherapy for outpatient CAP. Instead, high-dose amoxicillin is now recommended as the preferred CAP outpatient treatment regimen for patients without comorbidities or risk factors (Table 1). High doses of amoxicillin help combat resistance of Streptococcus pneumoniae. The mechanism of resistance to penicillin is through alteration in the molecular cell wall targets, also called penicillin-binding proteins.11 Mutations that alter the binding proteins result in decreased affinity of agents, causing them to be less effective.11 This resistance can be overcome if the concentration of the agent exceeds a MIC for 40-50% of the dosing interval.11 Therefore, with higher dose of amoxicillin, the resistance is combated. When prescribing amoxicillin for CAP, there is a loss of coverage for other common CAP pathogens. Amoxicillin adds more robust coverage for drug-resistant Streptococcus pneumoniae, but lacks coverage for other common pathogens for CAP (Table 2). Guide|18| Kentucky Pharmacists Association | July/August 2020

line authors supported this switch since Streptococcus pneumoniae is the most prevalent CAP pathogen.

Doxycycline or macrolide monotherapy can be used if there is a contraindication to amoxicillin, including a serious hypersensitivity to penicillin. A serious hypersensitivity includes a reaction of anaphylaxis, Stevens-Johnson syndrome and hives. It is important to clarify penicillin allergies and determine if it was a childhood or adult reaction. While doxycycline resistance has also been increasing worldwide. 12 In the Louisville metro area, Streptococcus pneumoniae is susceptible on average 80% of the time per the antibiograms mentioned above. Therefore, doxycycline has better coverage against Streptococcus pneumoniae compared to a macrolide.

Table 2 compares coverage of these two agents for common CAP pathogens. Even though doxycycline has better coverage, it also has a more broad-spectrum therapy. Antimicrobial stewardship strategies promote use of narrow spectrum agents when possible. It would not be appropriate to use doxycycline in a patient with no contraindication for amoxicillin for antimicrobial stewardship purposes. Doxycycline has drug interactions with warfarin, iron or calcium supplements, bile acid sequestrants, carbamazepine, proton pump inhibitors and more agents. Doxycycline can cause photosensitivity, discoloration of teeth (especially in children), and gastrointestinal intolerance.

In outpatients with comorbidities of heart, lung, liver, renal disease, diabetes, alcoholism, malignancy, or asplenia, combination therapy is recommended. Combination therapy should include amoxicillin-clavulanate or an oral cephalosporin with a macrolide or doxycycline. Patients with comorbidities can also be treated with monotherapy using an oral respiratory fluoroquinolone (Table 1). In the Louisville metro area, Streptococcus pneumoniae is susceptible on average 100% of the time per the antibiograms mentioned above. Fluoroquinolones have an increased risk of QTc prolongation, hepatotoxicity, phototoxicity, a black box warning of tendon rupture, increased risk of seizures. Fluoroquinolones have interactions with antidepressants, antiarrhythmics, antipsychotics, warfarin, antacids, calcium, and multivitamins. Risk factors for MRSA and Pseudomonas should also be a factor for determining treatment in the outpatient setting. Risk factors for MRSA include a positive culture in the past year, recurrent skin infections, severe pneumonia, and IV antibiotic use or hospitalization in the past 90 days. Pseudomonas risk factors include a positive culture in the past year, severe COPD, invasive respiratory procedures or support, and IV antibiotic use or hospitalization in the past 90 days. Treatment for patients with risk factors for MRSA should include a combination therapy of a beta lactam and a macrolide (Table 1).2 Oseltamivir is indicated in patients that test positive for influenza in the inpatient and outpatient setting regardless of duration of illness prior to diagnosis. Benefit has been seen up to 45 days after onset of influenza symptoms, however 48 hours after symptom onset shows the most benefit. This recommendation is consistent with the 2009 IDSA Influenza guidelines.13 However, the CDC also lists inhaled zanamivir, intravenous peramivir, and oral baloxavir as viable treatment options. The CDC recommends in the setting of severe or complicated illness defined as pneumonia or a chronic medical condition, oseltamivir should be started as soon as possible if not hospitalized. If no evidence of a bacterial infection, antibacterial therapy should be stopped in 48-72 hours as an antimicrobial stewardship initiative. However, empiric antimicrobial therapy should not be held in a positive influenza setting with pneumonia.

Duration of treatment for CAP should be guided by clinical stability and normal mentation. The duration of therapy should be no less than 5 days. Follow up imaging should not be obtained.

tients age 19-64 years with medical conditions including heart, lung, or liver disease, alcoholism, or a smoker should receive 1 dose of the PPSV23. Once this group turns 65 years and older, they should receive another dose of PPSV23 5 years after the first dose.

For patients 19 and older with immunocompromising conditions should receive 1 dose of PCV13 followed by 1 dose of PPSV23 8 weeks later, then another dose of PPSV23 5 years later. At the age of 65, should receive PPSV23 5 years after the most recent PPSV23 dose.

The patient should also receive the influenza vaccine yearly as the flu commonly presents with pneumonia. Patients 65 and older should receive a high dose influenza vaccine (Fluzone high dose or Fluad). Smoking cessation can also be discussed with the patient and pharmacists can recommend appropriate nicotine replacement therapies. Counseling from the pharmacist can help with overall compliance of antibiotic therapy from the patient and help with antibiotic stewardship.

Over the counter medications can help some of the symptoms for pneumonia. Fever reducers/ pain relievers included acetaminophen, ibuprofen, naproxen, or aspirin can help. Cough symptoms of pneumonia can also be treated with expectorant cough medicines like Mucinex or Robitussin decongestants.

Conclusion: Overall, the recommendations for the 2019 guidelines included more information on diagnosis and routine labs. The overall empiric therapy has not been changed much from the 2007 guidelines. However, increased macrolide resistance has made macrolide monotherapy less favored. For outpatient community-acquired pneumonia the following changes have been made: beta lactam therapy preference over macrolide monotherapy and cultures should not be routinely taken. For inpatient or severe CAP, many more changes occurred such as corticosteroid use for patients with sepsis, sputum and blood cultures in severe disease and patients empirically receiving treatment for MRSA or Pseudomonas aeruginosa, and procalcitonin therapy is not recommended to determine etiology.

References: 1.

Hawbolt J. Community-acquired pneumonia. US Pharm.

2007; 32(10):44-50.

2.

Metlay JP, Waterer GW, Long AC, et al. American Thoracic Society and Infectious Diseases Society of America diagnosis and treatment of adults with communityacquired pneumonia. American Journal of Respiratory and Critical Care Medicine. Published online October 1 2019.

3.

Sattar SBA, Sharma S. Bacterial Pneumonia. [Updated 2020 Mar 6]. In: StatPearls [Internet]. Treasure Island

Role of the pharmacist: Pharmacists can recommend pneumococcal vaccination to protect against Streptococcus pneumoniae, especially for patients who are at high risk of developing pneumonia. The CDC recommends to all patients 65 and older to receive the pneumococcal polysaccharide vaccine (PPSV23). For pa-

|19| www.KPHANET.org

(FL): StatPearls Publishing; 2020 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/ NBK513321/ 4.

Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-assocaited pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the America Thoracic Society. Published online July 14 2016.

5.

Kochanek KD, Murphy SL, Xu JQ, Arias E. Deaths: Final data for 2017. National Vital Statistics. 2017;68(9).

6.

Jain S, Self WH, Wunderink RG, et al. Communityacquired pneumonia requiring hospitalization around U.S. adults. N Eng J Med. 2015 Jul 30; 373: 415-427.

7.

Freeman AM, Leigh, Jr TR. Viral Pneumonia. [Updated 2019 Dec 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513286/

8.

Respiratory virus detection by PCR. ClinLab Navigator. http://www.clinlabnavigator.com/respiratory-virusdetection-by-pcr.html. Published: unknown; updated 2011 Sept; accessed 2020 May 11.

9.

Bellew S, Grijalva CG, Williams DJ, et al. Pneumococcal and legionella urinary antigen tests in communityacquired pneumonia: prospective evaluation of indications for testing. Clin Infect Dis. 2018 Sep 28; 68(12): 2026-2033.

10. CDC. Antibiotic Resistance Threats in the United States, 2019. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2019.

11. Prado C, Perlof S, Talavero F, et al. Pneumococcal infections (streptococcus pneumoniae) medication. Drugs & Diseases. 2018; 348: 1-17.

12. Chenoweth C, Saint S, Martinez F, Lynch JP, Fendrick M. Antimicrobial resistance in Streptococcus pneumonia: implication for patients with community-acquired pneumonia. Mayo Clin Proc. 2000 Nov; 75:1151-1168.

13. Harper SA, Bradley JS, Englund JA, et al. Seasonal influenza in adults and children-diagnosis, treatment, chemoprophylaxis, and institutional outbreak management. Infectious Diseases Society of America. Published online April 15 2009.

14. Uyeki TM. Preventing and controlling influenza with available interventions. N Eng J Med. 2014 Feb 27; 370: 789-791 15. Ezeanolue E, Harriman K, Hunter P, Kroger A, Pellegrini C. General best practice guidelines for immuniza|20| Kentucky Pharmacists Association | July/August 2020

tion. Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP). Accessed on 2020 March 4.

jobs.kphanet.org THE location for pharmacy job seekers + employers for targeted positions.

August 2020â&#x20AC;&#x201D;Community-Acquired Pneumonia 2019 Guidelines: Outpatient Therapeutic Updates

1. Which pathogen is the most common cause of communityacquired pneumonia?

A. Respiratory viruses B. Atypical bacteria C. Haemophilus influenzae D. Staphylococcus aureus E. Streptococcus pneumoniae F. Moraxella catarrhalis

7. Which of the following is the reason why tetracyclines should not be used in pregnant women?

A. Discoloration of teeth and long tubular bones B. Increased risk of birth defects C. Increased risk of premature birth D. Increased risk of low birth weight

8. A patient is currently taking lisinopril, metformin, TUMS, and Tylenol. The patient is currently being prescribed 2. According to the ACIP, a 65-year-old male with no immun- levofloxacin for community acquired pneumonia. Which of the following is a counseling point for the patient? ocompromising condition, CSF leak, or cochlear should receive which vaccine?

A. Separate levofloxacin by 2 hours before or 6 hours after metformin A. PCV13 B. Separate levofloxacin by 2 hours before or 6 hours after TyB. PPSV23 lenol C. Influenza C. Separate levofloxacin by 2 hours before or 6 hours after lisD. PCV13 + influenza inopril E. PPSV23 + Influenza D. Separate levofloxacin by 2 hours before or 6 hours after cal3. Amoxicillin has coverage against which of the following? cium supplement A. Atypical bacteria 9. According to the 2019 CAP guidelines, what is the miniB. Haemophilus influenzae mum recommended duration of therapy?

C. Moraxella Catarrhalis A. A minimum of 5 days D. Streptococcus pneumoniae B. A minimum of 10 days E. Staphylococcus aureus C. Independent of clinical stability 4. A 25-year-old female presents to clinic with communityD. Should be guided by procalcitonin acquired pneumonia. The patient has a past medical history of COPD, type 2 diabetes, and hyperlipidemia. Which of the 10. What is the correct follow up for a patient post treatment following medication regimens should the patient receive? of community acquired pneumonia?

A. Amoxicillin 1 gram by mouth three times a day A. Chest X-ray B. Cefpodoxime 200 mg by mouth twice daily B. Independent of symptoms C. Doxycycline 100 mg by mouth twice daily+ Amoxicillin 1 C. Should be guided by clinical stability gram by mouth three times a day D. Should be guided by white blood cell count D. Azithromycin 500 mg by mouth on day 1 + 250 mg by mouth on following days + amoxicillin-clavulante 875 mg/125 mg by mouth twice daily 5. A 32-year-old male presents to clinic with communityacquired pneumonia. Patient has no significant past medical history. Which of he following medication regimens should the patient receive?

A. Amoxicillin 1 gram by mouth three times a day B. Cefpodoxime 200 mg by mouth twice daily C. Doxycycline 100 mg by mouth twice daily+ Amoxicillin 1 gram by mouth three times a day D. Levofloxacin 750 mg by mouth once daily 6. A 78-year-old male presents to clinic with sputum production, cough, and fever. The patient has a past medical history of COPD, heart failure, and CKD. The patient has a penicillin allergy of hives/rash. The patient is diagnosed with community-acquired pneumonia. Which of the following regimens should the patient receive?

A. Doxycycline 100 mg by mouth twice daily B. Levofloxacin 750 mg by mouth once daily C. Amoxicillin 1 gram by mouth three times a day D. Cefpodoxime 200 mg by mouth twice daily

|21| www.KPHANET.org

This activity is a FREE service to members of the Kentucky Pharmacists Association.

The fee for non-members is $30. Mail completed forms to: KPERF, 96 C Michael Davenport Blvd., Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile.

Expiration Date: 8/31/23 Successful Completion: Score of 80% will result in 1.0 contact hours TECHNICIANS ANSWER SHEET. August 2020â&#x20AC;&#x201D;Community-Acquired Pneumonia 2019 Guidelines: Outpatient Therapeutic Updates Universal Activity # 0143-0000-20-008-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D E F 2. A B C D E

3. A B C D E 4. A B C D

5. A B C 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

Information presented in the activity:

Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieved the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet.

Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party.

Signature ____________________________________________Completion Date___________________________ Personal NABP eProfile ID #_____________________________ Birthdate _______ (MM)_______(DD)

PHARMACISTS ANSWER SHEET August 2020â&#x20AC;&#x201D;Community-Acquired Pneumonia 2019 Guidelines: Outpatient Therapeutic Updates Universal Activity # 0143-0000-20-008-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________

PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D E F 2. A B C D E

3. A B C D E 4. A B C D

5. A B C 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

Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieved the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet.

Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party.

Signature ____________________________________________Completion Date___________________________

Personal NABP eProfile ID #_____________________________ Birthdate _______ (MM)_______(DD)

The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy Education as a provider of continuing Pharmacy education. |22| Kentucky Pharmacists Association | July/August 2020

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Pharmacy Policy Issues Board Specialty Certification in Pharmacy Author: Kyle D. Bryan, Pharm.D. Issue: The Board of Pharmacy Specialtiesâ offers numerous certifications in different areas of pharmacy. What is the history of this program? What areas of pharmacy can a pharmacist get a specialty certificate in? What are the requirements?

also provide opportunities for career advancement and to maintain competitiveness in their specific field. Most importantly perhaps, board certification allows pharmacists to become true experts in their field in a time when pharmacotherapy regimens are becoming increasingly complex and require highly detailed knowledge for optimal outcomes. As Discussion: The Board of Pharmacy Specialtiesâ was found- pharmacists continue throughout their career and consider ed in 1976 as a division of the American Pharmacists Associ- how to advance their practice or stay knowledgeable in their field, certifications should be considered to help the pharmaation based on the recommendations of the Task Force on cist practice as an expert in their field and to help optimize Specialties in Pharmacy established by that organization in 1 patient care.

1973. The first specialty approved was nuclear pharmacy practice in 1978. Since 1978 a total of twelve specialties have been approved as of the time of this writing. These include: References: nutrition support and pharmacotherapy (1988), psychiatry (1994), oncology (1996), ambulatory care (2009), critical care Board of Pharmacy Specialties website. March 2019. and pediatrics (2013), cardiology, infectious disease, and geriAvailable at: https://www.bpsweb.org/ atrics (2017), and most recently compounded sterile preparations in 2018.1 Two other specialty certifications are currently Ogurchak, C. We Don’t Need No Education: Postin development -- solid organ transplantation and emergency Pharmacy School Options, Pharmacy Careers, (June) medicine -- and are scheduled to be available during 2019Spring 2018. Available at 2020.1 Over the past fifteen years the number of active certifihttps://www.pharmacytimes. cations issued by the Board of Pharmacy Specialtiesâ has com/publications/career/2018/careersspring2018/ grown exponentially with a total of 41,640 certificants as of we-dont-need-no-education-postpharmacy-schoolJanuary 2019.1 The most common certification, with 23,700 options/. specialists, is the pharmacotherapy specialty.1 The requirements for board certification are different for each specialty but in general one must possess a PharmD or BS in Pharmacy degree, have a current active license to practice pharmacy in the U.S., demonstrate practice experience, and sit for the specialty certification exam and achieve a passing score.2 The demonstration of practice experience varies by specialty but usually includes 3-4 years of practice experience with 50% or greater of practice time spent in the area of the specialty, completion of a Postgraduate Year 1 residency program plus 1-2 years of practice experience, or completion of a specialty Postgraduate Year 2 residency.1 The specialties for compounded sterile preparations and nuclear pharmacy are unique in that they require 4,000 hours of post-licensure practice to meet the practice experience requirement.1 The board certifications in the twelve specialty areas offered by the Board of Pharmacy Specialtiesâ provide an opportunity for pharmacists to advance their clinical pharmacy knowledge and help ensure that they are providing the best possible care for patients. Certification allows pharmacists who have been out of school for an extended period of time to refresh their knowledge of the content area and stay on top of the ever-changing fields in pharmacy. Certification could |24| Kentucky Pharmacists Association | July/August 2020

Welcome to KPhA! We’re so happy to have you!

The list reflects new memberships received from May 1, 2020— June 30, 2020.

Timothy Bailey, London New Practitioner 1st Year Thomas Parker, Pikeville Pharmacist Benjamin Rush, London Technician Rikki Shimfessel, Frankfort Technician Christopher Whitman, Louisville New Practitioner 1st Year Jarrod Williams, Lexington Pharmacist

|25| www.KPHANET.org

Pharmacy Law Brief Courts Cannot Decide Everything Author: Joseph L. Fink III, BSPharm., JD, DSc (Hon), FAPhA, Professor of Pharmacy Law and Policy and Kentucky Pharmacists Association Professor of Leadership, Department of Pharmacy Practice and Science, UK College of Pharmacy

Question: I continue to see reports in various media outlets about court decisions of interest on a wide variety of issues and topics. That got me wondering whether courts can take on for decision any and all topics that come their way or are there limitations?

Response: The authority of a court to decide cases is referred to as the “jurisdiction” of the court. Breaking down that term to its Latin origins, that word means the authority to say (“dict”) what the law (“juris”) is.

Certain courts have more expansive jurisdiction than others. Some courts have a predetermined focus; an example from the state court system would be small claims court. In Kentucky, a small claims court is limited to handling matters where the amount in controversy is $2,500 or less. Examples from the system of federal courts would include the U.S. Tax Court which is authorized to handle resolution of disputes between taxpayers and the Internal Revenue Service.

A second federal example would be the U.S. Court of Appeals for the Armed Forces, known for quite a few years as the U.S. Court of Military Appeals.

Other courts have more expansive jurisdiction. The “standard” federal courts, i.e., U.S. District Court, or U.S. Court of Appeals, follow some basic rules of access. For a matter to be taken up by the federal court system it must fall into one of two categories of jurisdiction: [1] “Federal question”, meaning that a key issue in the matter arises under or involves federal law such as the U.S. Constitution or a federal statute or regulation; or [2] Diversity of citizenship, which exists when the parties to the legal proceeding are residents of different states. However, there is an additional requirement to gain access to the federal courts under this category – the amount at issue must exceed $75,000.

Disclaimer: The information in this column is intended for educational use and to stimulate professional discussion among colleagues. It should not be construed as legal advice. There is no way such a brief discussion of an issue or topic for educational or discussion purposes can adequately and fully address the multifaceted and often complex issues that arise in the course of professional practice. It is always the best advice for a pharmacist to seek counsel from an attorney who can become thoroughly familiar with the intricacies of a specific situation, and render advice in accordance with the full information.

rum. Those would be referred to as matters presenting “concurrent jurisdiction.” If the matter does not fit within one of the two specified categories then it must go to state court.

Another way to slice and dice this is that a court which is the first to take up a dispute would be referred to as having “original jurisdiction”. That is in contrast to a court exercising “appellate jurisdiction” when hearing an appeal for review of a decision reached by a lower court.

When a legal matter is capable of being decided by a court the issue is said to be “justiciable” If the opposite is true, i.e., the court cannot decide the matter, it is said to be nonjusticiable. If the controversy is not capable of being decided by legal principles or through the jurisdiction of a lawful court it falls in this letter classification. In other words, this is one of a type of matter that a court cannot decide.

For example, the judiciary may refuse to adjudicate claims challenging action by the executive branch of government. The court may rule that it cannot decide a matter if it decides the relevant issues are politically charged. This is because the courts are typically viewed as the apolitical, or less political, branch of government.

All this information about courts having authority to decide cases is relevant because of a ruling on a case made by the Kentucky Court of Appeals during 2019 – Seum v. Bevin, 584 S.W.3d 711 (Ky. App. 2019).

The subject matter of the case may be of interest to If a matter falls into one of those two categories, the pharmacists so a very brief review is included here. federal courts are said to have “exclusive jurisdiction”. That is in contrast to matters where the issue Three Kentuckians filed a lawsuit against the Govercould be taken to either a federal court or a state fo- nor and Attorney General challenging a state statute |26| Kentucky Pharmacists Association | July/August 2020

that classified marijuana as an illegal substance. The three plaintiffs suffered various maladies that they thought would receive beneficial treatment with medicinal marijuana but were challenging the role of the two public officials in enforcing state statutes enacted by the legislature. Their arguments boiled down to an argument that failing to create an exemption for medicinal use was unconstitutionally arbitrary and also violated their right to privacy.

At the trial court level the judge ruled that the matter had been settled by the Kentucky Supreme Court with principles addressed in Commonwealth v. Harrelson, 14 S.W.3d 541 (Ky. 2000). He ruled in favor of the positions of the governmental officials. The plaintiffs appealed to the Kentucky Court of Appeals. That tribunal ruled that the statutes are not impermissibly arbitrary because they serve a valid public interest in controlling marijuana for reasons related to health, safety and criminal activity. The appellate court further ruled that the restrictions on marijuana do not violate the right to privacy because they don’t stem from efforts to interfere in morality or private conduct.

Of more direct interest here, the appellate court ruled that the plaintiff’s claims were nonjusticiable because “they raise a political question within the exclusive purview of the legislature.” The judges acknowledged the importance of the basic concept of our governmental structure designated as “separation of powers.”

Courts and judges may appear to have broad latitude in taking up and deciding cases but if one were to examine legal filings it would quickly become clear that the initial point of departure in nearly all arguments directed to the court will related to the authority of the tribunal to take up the matter, it’s jurisdiction.

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|28| Kentucky Pharmacists Association | July/August 2020

|29| www.KPHANET.org

KPhA BOARD OF DIRECTORS

KPERF BOARD OF DIRECTORS

Don Kupper, Louisville donku.ulh@gmail.com

Chair

Bob Oakley, Louisville rsoakley21@gmail.com

Chair

Joel Thornbury, Pikeville jthorn6@gmail.com

President

Secretary

Cathy Hanna, Lexington channa@apscnet.com

President-Elect

Clark Kebodeaux, Lexington clark.kebodeaux@uky.edu

Treasurer

Brooke Hudspeth, Lexington brooke.hudspeth@uky.edu

Secretary

Chris Killmeier, Louisville cdkillmeier@hotmail.com

Chris Killmeier, Louisville cdkillmeier@hotmail.com

Treasurer

Joel Thornbury, Pikeville jthorn6@gmail.com

President, KPhA

Lewis Wilkerson, Frankfort rphs2@aol.com

Past President Representative

Kevin Lamping, Lexington kevin.lamping@twc.com Paul Easley, Louisville rpeasley@bellsouth.net

Directors Ronnah Alexander, Providence ralexander@hfchc.net

Sarah Lawrence, Louisville slawrence@sullivan.edu

Jessika Chilton, Beaver Dam jessikachilton@ymail.com

Pat Mattingly, Lebanon pat@patspharmacy.com

Kyle Harris, London kyleharrispharmd@yahoo.com Jacob Barnett, Lexington jacobbarnett15@gmail.com

University of Kentucky Student Representative

Chad Corum, Manchester pharmdky21@gmail.com

Mark Glasper Executive Director mglasper@kphanet.org Sarah Franklin Director of Communications & Continuing Education sarah@kphanet.org

Cassy Hobbs, Louisville cbeyerle01@gmail.com Thao Le Batovsky, Louisville tle3380@my.sullivan.edu

KPhA Staff

Sullivan University Student Representative

Jeff Mills, Louisville jeff.mills@nortonhealthcare.org Martika Martin, Somerset Speaker of the House 12marmar@gmail.com Nathan Hughes, Louisville Vice Speaker of the House njhughes1980@gmail.com Trevor Ray, Caneyville trevor@midwaypharmacy.com Cory Smith, Barbourville corysmith6155@gmail.com Misty Stutz, Crestwood mstutz@sullivan.edu |30| Kentucky Pharmacists Association | July/August 2020

Angela Gibson Director of Finance & Administrative Services agibson@kphanet.org Jody Jaggers, PharmD Director of Public Health jjaggers@kphanet.org Kristen Blankenbecler, PharmD Director of Clinical Outreach kristen@kphanet.org Michele Pinkston, PharmD, BCGP Director of Emergency Preparedness michele@kphanet.org Lisa Atha Office Assistant/Member Services Coordinator latha@kphanet.org

“An analysis of the data indicate that Kentucky pharmacists support and participate in professional organizations to a better extent than pharmacists in other areas. They have, in large measure, overcome much of the professional isolation which has generally existed in the profession, and persist in some areas of the nation.” (Kentucky Pharmacists Membership in Professional Organizations) - From The Kentucky Pharmacist, July 1970 Volume XXXIII, Number 7

Frequently Called and Contacted Kentucky Board of Pharmacy

Kentucky Regional Poison Center

State Office Building Annex, Ste. 300

(800) 222-1222

125 Holmes Street

American Pharmacists Association (APhA)

Frankfort, KY 40601

2215 Constitution Avenue NW

(502) 564-7910

Washington, DC 20037-2985

www.pharmacy.ky.gov

(800) 237-2742

Pharmacy Technician Certification Board (PTCB)

www.aphanet.org

2215 Constitution Avenue

National Community Pharmacists Association (NCPA)

Washington, DC 20037-2985

100 Daingerfield Road

(800) 363-8012

Alexandria, VA 22314

www.ptcb.org

(703) 683-8200 www.ncpanet.org

Kentucky Society of Health-System Pharmacists

National Association of Chain Drug Stores (NACDS) 1776 Wilson Blvd., Suite 200 Arlington, VA 22209 www.nacds.org 703-549-3001

info@ncpanet.org

P.O. Box 4961 Louisville, KY 40204 (502) 456-1851 x2 www.kshp.org info@kshp.org

KPhA/KPERF HEADQUARTERS 96 C Michael Davenport Blvd.

Frankfort, KY 40601 502.227.2303 (Phone) 502.227.2258 (Fax) info@kphanet.org www.kphanet.org www.facebook.com/KyPharmAssoc www.twitter.com/KyPharmAssoc www.youtube.com/KyPharmAssoc |31| www.KPHANET.org

THE

Kentucky PHARMACIST 96 C Michael Davenport Blvd.

Frankfort, KY 40601

https://cmppharma.com/