The Kentucky Pharmacist Vol. 11, No. 6

THE KENTUCKY PHARMACIST Vol. 11, No. 6 November/December 2016 News & Informat ion for Members of the Kentucky Pharmacists Ass ociation

INSIDE: Scenes from the 2016 KPhA Legislative Conference

Guardian of the Profession in Frankfort

Table of Contents

November/December 2016 2016 KPhA Legislative Conference Sponsors Dec. 2016 CE — Dec. 2016 CE — Post-Surgical Bariatric Patient Issues December Pharmacist/Pharmacy Tech Quiz Answer Sheet Kentucky Renaissance Pharmacy Museum KPhA New and Returning Members Pharmacy Time Capsules Pharmacy Law Brief Pharmacy Policy Issues Naloxone Training Pharmacists Mutual Cardinal Health KPhA Board of Directors 50 Years Ago/Frequently Called and Contacted

Table of Contents Table of Contents— Oath— Mission Statement 2 President’s Perspective 3 2016 KPhA Legislative Conference 4 Congratulations to Dr. Danny Bentley 5 From your Executive Director 6 Campaign for Kentucky’s Pharmacy Future 7 APSC 8 KPhA Emergency Preparedness 9 KPhA Strategic Plan 10 Nov. 2016 CE — National Diabetes Prevention Program 11 Nov. Pharmacist/Pharmacy Tech Quiz Answer Sheet 16 Campaign for Kentucky’s Pharmacy Future: Committee of 100 17

18 19 30 31 32 35 36 38 39 40 41 42 43

Oath of a Pharmacist At this time, I vow to devote my professional life to the service of all humankind through the profession of pharmacy.

I will consider the welfare of humanity and relief of human suffering my primary concerns.

I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy outcomes for the patients I serve.

I will keep abreast of developments and maintain professional competency in my profession of pharmacy.

I will embrace and advocate change in the profession of pharmacy that improves patient care.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.

Kentucky Pharmacists Association The mission of the Kentucky Pharmacists Association is to promote the profession of pharmacy, enhance the practice standards of the profession, and demonstrate the value of pharmacist services within the health care system.

Editorial Office: © Copyright 2016 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.

Editor-in-Chief: Robert McFalls Managing Editor: Scott Sisco Editorial, advertising and executive offices at 96 C Michael Davenport Blvd., Frankfort, KY 40601.

Phone 502.227.2303 Fax 502.227.2258.

Email ssisco@kphanet.org.

Website http://www.kphanet.org.

The Kentucky Pharmacy Education and Research Foundation (KPERF), established in 1980 as a non-profit subsidiary corporation of the Kentucky Pharmacists Association (KPhA), fosters educational activities and research projects in the field of pharmacy including career counseling, student assistance, post-graduate education, continuing and professional development and public health education and assistance.

It is the goal of KPERF to ensure that pharmacy in Kentucky and throughout the nation may sustain the continuing need for sufficient and adequately trained pharmacists. KPERF will provide a minimum of 15 continuing pharmacy education hours. In addition, KPERF will provide at least three educational interventions through other mediums — such as webinars — to continuously improve healthcare for all.

Programming will be determined by assessing the gaps between actual practice and ideal practice, with activities designed to narrow those gaps using interaction, learning assessment, and evaluation. Additionally, feedback from learners will be used to improve the overall programming designed by KPERF.

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President’s Perspective

November/December 2016

PRESIDENT’S PERSPECTIVE

Once our vision and mission were established, our second task was to identify strategic areas of focus for the next five years that will advance our ability to fulfill our mission and make our vision a reality. We identified four Strategic Focus Areas in which we will concentrate our efforts through 2020: Engage, Support, Advance and Advocate.

Trish Freeman

Engage: Recruit, involve and empower pharmacists, student pharmacists and technicians to be active members of KPhA.

KPhA President 2016-2017

Support: Position KPhA to be the destination for all professional-related needs including continuous professional development, networking and innovative practice guidance.

In the spirit of embracing and advocating change, the KPhA Board of Directors developed a bold strategic plan to advance both our association and our profession over the next five years. The strategic planning process, facilitated by Interim Dean Kelly Smith of the UK College of Pharmacy and Dean Cindy Stowe from Sullivan University College of Pharmacy, was conducted at a Board retreat in July. Since that time, the KPhA Board has worked diligently to finalize the 2016-2020 Strategic Plan, and we are excited to share key aspects of the approved plan with KPhA pharmacists, student pharmacists and technician members, as well as other professional stakeholders in this issue of The Kentucky Pharmacist.

Advance: Advance pharmacy practice to improve patient and public health.

Advocate: Promote the pharmacist as an essential member of the healthcare team through a singular voice.

After identifying these strategic focus areas, we were challenged by our facilitators to clearly articulate three to five main goals for each area and to identify the specific objectives we hoped to accomplish under each goal. While we were unable to fully complete this process during our strategic planning retreat, Chair Chris Clifton, President-Elect Chris Harlow, Executive Director Robert McFalls and I formed a workgroup and met to hammer out the proposed The first task in our strategic planning was to seriously details. Subsequently, much discussion occurred over contemplate who we are and who we want to be as an email with follow up at the next KPhA Board Meeting in organization. The outcome of this process is a revised vision and mission statement for KPhA and the delineation August. The strategic plan goals for each focus area are provided in the one-page summary on page 10. The full of the core values we hold individually and as an organistrategic plan can be viewed and downloaded at the KPhA zation, represented by the acronym – I VALUE. website at the following link: Our Vision http://kphanet.org/page/2016StratPlan.

We are a unified pharmacy profession empowered to maximize patient and public health as Since approving our strategic plan, we have accomplished one specific goal – to map our strategic objectives to spefully integrated members of the healthcare team. cific committees for review and action. We have provided Our Mission each committee chair with committee charges for the year based on the strategic plan. In addition to our standing The mission of KPhA is to advocate for and committees as outlined in the KPhA By-Laws – Organizaadvance the profession through an engaged memtional Affairs, Public Affairs and Professional Affairs – we bership. continue to have an active Government Affairs and New Our Core Values Practitioner Committee and several workgroups including the Health Information Technology Workgroup, Provider I3: Integrity, Innovation and Inclusiveness Status Workgroup and Emergency Preparedness V: Vision A: Accountability Workgroup. Additionally, we have expanded our commitL: Leadership tees this year to include a Student Engagement CommitU: Unity tee and a Leadership Development Committee to assist E: Excellence

Continued on Page 10

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2016 KPhA Legislative Conference

November/December 2016

More than 320 pharmacists, student pharmacists and technicians came together November 11 to discuss issues the pharmacy profession could advance in the upcoming 2017 Kentucky Legislative Session. The Conference included panel discussions with pharmacists and legislators, small group discussions of the issues and CE presentations focused on opportunities for pharmacists to get involved in public health initiatives and legislative and regulatory changes.

Save the Date 139th KPhA Annual Meeting and Convention June 22-25, 2017 Griffin Gate Marriott Resort Lexington, KY 4

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Congratulations Dr. Danny Bentley

November/December 2016

Dr. Bentley was elected to represent the 98th District in the Kentucky House of Representatives on November 7th.

OUR KPhA looks forward to working with Dr. Bentley as the only pharmacist in the Kentucky Legislature!

Congratulations to Dr. Danny Bentley on his election to the KY House of Representatives!

Paid for by Joel Thornbury for House of Representatives

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From Your Executive Director

November/December 2016 MESSAGE FROM YOUR

EXECUTIVE DIRECTOR Robert “Bob” McFalls As Albert Einstein once observed, “No problem can be solved from the same level of consciousness that created it.”

With that in mind, I want to share how excited I am, along with OUR KPhA staff team, about the Association’s new strategic plan and the thought leadership that went into its development. OUR KPhA’s new Strategic Plan will guide our collective efforts in the coming months by providing opportunities for each and every one of us to ENGAGE, to SUPPORT, to ADVANCE and to ADVOCATE. Let’s explore.

focus on improvements in patient care and to address current and emerging public health issues.

ADVOCATE Since our beginnings, OUR KPhA has been leading the profession’s efforts to shape public policy, to legislate in ways that advance pharmacy’s priorities and to stand firm against potential harm — especially at the state level where the rubber meets the road in so many ways. Our strategic direction now is to unite — to join as one profession — again, in partnership with our stakeholders in promoting the pharmacist as an essential member of the healthcare team.

ENGAGE OUR KPhA is engaged by its members to unite the profession in advancing our vision and mission at multiple touch points. Engagement means that we are committed to work, then to stretch and ultimately to translate our vision into reality. We are engaged in a fight, so to speak, in terms of binding ourselves together with our colleagues to obtain provider status, to improve health outcomes through patient care interventions and to ensure that pharmacy is recognized as an integral partner and treated equitably. We are stronger when we are united as fully engaged members of OUR KPhA.

Those of you who know me well realize what a huge fan I am of Jim Collins and his treatise, Good to Great (2001). The book is built on the research of the top leaders of hundreds of companies, from which 11 companies emerge over time to demonstrate how they transformed from good to great. In a later work, Built to Last: Successful Habits of Visionary Companies, Collins and Jerry Porras introduce us to the concept of a “Big Hairy Audacious Goal” (BHAG), a concept that is easy for us to embrace wholeheartedly. A BHAG encourages us to define visionary goals that are strategic in nature and SUPPORT that are emotionally compelling. I think OUR KPhA’s newly OUR KPhA seeks to be the destination of choice by pharma- adopted Strategic Plan offers us this opportunity and more. It cists for all professional-related needs, including but not lim- is both tactical in approach, guiding us to focus on what we ited to continuous professional development, networking and need to be doing now, and while serving as a new “BHAG” of innovative practice guidance. To advance this strategic aim, sorts that we can and must use to advance the profession of members must guide the Association in its efforts to be in pharmacy. close alignment with our pharmacy partners and stakeholdFor the power of the BHAG, according to Collins and Porras, ers. As the profession has evolved, so has the need to adis to get us out of thinking too small. It challenges US to look vance our continuous learning opportunities to stay abreast toward our envisioned future. Since it is so “big” and so as well as ahead of the curve in providing patient care and “audacious” and so “hairy,” it calls us to collective action. In service. OUR KPhA can be the lead vehicle to coordinate essence, a great BHAG charges us to focus on the strategic this partnership effort. timeline while simultaneously creating a sense of urgency.

Or, to look at it another way, it calls us to focus on the here ADVANCE and now while challenging us to envision and enact a broadA mentor from Memphis taught me the importance of the er and more perfect profession for the future. military term, “advance” in direct comparison to “retreat.” I am pleased to note that this tactic is exactly what emanated Along with President Trish Freeman and our entire Board of Directors, the staff and I look forward to hearing from you from our 2016 Board Retreat. OUR KPhA is positioned, and to your engagement, support, advancement and advothrough the strategic thinking and involvement of our Members, Directors and Officers to advance pharmacy practice to cacy of OUR new strategic direction.

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Campaign For Kentucky’s Pharmacy Future

November/December 2016

The Campaign for Kentucky’s Pharmacy Future: The Next 50 Years

END OF YEAR TAX BENEFIT ALERT! Donations to the KPERF/KPhA Building Fund are tax deductible!

Leave a legacy by participating in the campaign to replace OUR KPERF/KPhA Headquarters! Learn more about options for payment and levels of recognition at http://www.kphanet.org/?page=buildingcampaign or call 502-227-2303.

KPhA sends email announcements weekly.

If you aren’t receiving: eNews, Legislative Updates, Grassroots Alerts and other important announcements, send your email address to ssisco@kphanet.org to get on the list.

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APSC

November/December 2016

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KPhA Emergency Preparedness

November/December 2016

Volunteer Volunteer Volunteer It’s 2016 and pharmacist, pharmacy technician and student pharmacist recruitment is underway for the Kentucky Pharmacists Association emergency preparedness program! Pharmacy professionals play a critical part in responding to emergency events such as a natural disaster or infectious disease outbreak.

You may sign up as a volunteer on the KPhA website, completing a volunteer form below or simply sending an email directly to Leah Tolliver at ltolliver@kphanet.org.

Please join the emergency preparedness program and help to recruit other volunteers! We need all of you!

For more information on how you can be involved in the KPhA Pharmacy Emergency Preparedness Initiative, contact Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness at 502-227-2303 or by email at ltolliver@kphanet.org.

For more resources, visit YOUR www.kphanet.org and click on Resources—Emergency Preparedness.

KPhA Pharmacy Emergency Preparedness Volunteer Form

Name: __________________

____

Status (Pharmacist, Technician, Student): ___________________

Email: ______________________________ Phone: ________________________ County: Interest in serving as a volunteer: Yes____ No ____ Interest in serving as a Volunteer District Coordinator: Yes____ No _____ You also may join the Medical Reserve Corps by following the KHELPS link on KPhA Website to register (www.kphanet.org under Resources) Please send this information to Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness via email at ltolliver@kphanet.org, fax to 502-227-2258 or mail at KPhA, 96 C Michael Davenport Blvd., Frankfort, KY 40601.

Donate online to the Kentucky Pharmacists Political Advocacy Council!

Go to www.kphanet.org and click on the Advocacy tab for more information about KPPAC and the donation form.

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KPhA Strategic Plan

November/December 2016

Please take a few minutes to review our bold new strategic plan and consider how you might participate in advancing OUR Association and professional goals. I look forward to hearing your thoughts as we work toward our vision of being a unified pharmacy profession, empowered to maximize patient and public health as fully integrated members of the healthcare team.

Continued from Page 3 us in meeting specific strategic plan goals. We are confident that through an active and engaged committee structure, we can achieve many of our strategic priorities in the coming year.

The Campaign for Kentucky’s Pharmacy Future: The Next 50 Years http://www.kphanet.org/?page=buildingcampaign

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Nov. 2016 CE — NDPP

November/December 2016

National Diabetes Prevention Program Paves New Paths for Enhancing Pharmacy Practice By: Urvi J. Patel, PharmD/MPH Candidate 2017, University of Kentucky College of Pharmacy; Lori E. Hall, PharmD, Centers for Disease Control and Prevention, Division of Diabetes Translation The authors declare no financial relationships that could be perceived as real or apparent conflicts of interest.

Universal Activity # 0143-0000-16-011-H01-P&T 1.5 Contact Hours (0.15 CEUs) Expires 10/22/2019 Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: 1.

2.

3.

4.

5.

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

Define the National Diabetes Prevention Program; State the specific requirements of the National Diabetes Prevention Program; Propose how the National Diabetes Prevention Program can serve as a mechanism to enhance collaborative care; Identify the lack of pharmacy involvement within the National Diabetes Prevention Program; and Describe the role pharmacy can play within the National Diabetes Prevention Program.

Fact: Pharmacy practice as we know it is evolving to include more prevention based initiatives.

look for models that show how they offer services beyond medication dispensing.1,2,3,4

This is evident not only by the enhancement of the pharmacy practice model, wherein pharmacists take a more active role in patient care, but also in recent legislative proposals at state and national levels that support this notion. As more team based care initiatives are implemented, much interest has been generated with regard to the integration of pharmacists into that team. Research shows that pharmacists can be utilized to extend the healthcare team into the community by taking advantage of their accessibility and favorable reputation. The collaboration of pharmacists with healthcare providers and extenders (such as community health workers) helps to greatly improve chronic disease prevention and control.1,2,3,4 Connecting pharmacists with community-based programs allows them to serve as a true component of community-clinical linkages.

One innovative approach to enhancing the pharmacy practice model includes pharmacist involvement in public health initiatives such as the National Diabetes Prevention Program (National DPP). This is a lifestyle change program (LCP) aimed at the prevention of type 2 diabetes in patients who meet certain criteria. The program is based on a multicenter clinical research study published in 2002 that found that LCPs that provide the needed infrastructure for a patient to reduce his/her body weight by 5-7 percent will minimize the risk of developing type 2 diabetes by 58 percent in adults.5,6

The National DPP lifestyle change program utilizes a curriculum approved by the Centers for Disease Control and Prevention (CDC) that is divided into two six month blocks.

The first half of the year focuses on healthy eating, physical activity, stress and challenge management and commitConversations about collaborative practices and their conment (getting back on track if a participant falters). The secnection to improved patient outcomes are becoming comond half of the year focuses on enhancing the skills learned monplace in today’s healthcare. Kentucky’s own legislative in the first half, tracking progress of dietary and physical efforts have awarded our pharmacists with the opportunity activity modifications, overcoming barriers and receiving to broaden collaborative care agreements to include physisupport. Each of the objectives is achieved through lessons cian, pharmacist and patient groups over the traditional on specific topics laid out in the curriculum. These topics singular link model (i.e. one physician, one pharmacist, one include Healthy Eating, Take Charge of What’s Around patient). Unfortunately, implementation of collaborative efYou, The Slippery Slope of Lifestyle Change, Heart Health forts has proven to be the most significant barrier to the and much more.7 adoption of team-based care practices. A growing amount of evidence supports that team-based care approaches The organization delivering the National DPP is asked to benefit patient outcomes, therefore pharmacists are now provide at least 16 sessions, usually held weekly, during poised to drive the conversation around collaboration and the first six months. Organizations are allowed up to six 11

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Nov. 2016 CE — NDPP months to complete these sessions to allow for flexibility for things like holidays, vacations, etc. In the last six months, the delivering organization is asked to provide at least one session per month on a topic chosen from 15 topic choices. The program can be offered in a variety of settings and can be delivered through in-person or online means. Certain components of the program can be modified to meet the needs of the community. These modifications include the promotion of local activities that align with the mission of the program, providing strategies that will help participants with upcoming community challenges and healthy food demonstrations that appeal to the group.7

November/December 2016 where from health systems linked to colleges of pharmacy to independent pharmacies. The pharmacies also vary in their levels of CDC recognition status. Currently there is one pharmacy (in Gainesville, Texas) that has achieved full CDC recognition, meaning it demonstrated program effectiveness by meeting the standards set by the DPRP following at least 24 months of participant data submission.11

Pharmacists have consistently earned top rankings as one of the most trusted professionals which offers them the opportunity to serve as the bridge linking the community and healthcare systems.12 Their unique placement allows them to have close ties with the patient base from which Organizations that choose to offer this program can apply they operate and have the potential to build strong connecfor recognition through the CDC’s Diabetes Prevention tions with provider groups in their area. Utilization of this Recognition Program (DPRP). The DPRP serves as a link to engage patients and providers in preventive health technical resource and quality assurance arm for the Naprograms, such as the National DPP, could reduce the burtional DPP as it provides technical assistance to impleden of chronic diseases and greatly improve patient health menting organizations, builds the standards that an organi- outcomes.2 As mentioned earlier, the pharmacy practice zation is to adhere to and formulates a registry of organiza- model is encouraging pharmacists to take on a more pations that have applied for and received full CDC recognitient-centered role. Programs such as the National DPP tion. In order for an organization to be deemed as a CDC- allow pharmacists to do that by providing a pre-packaged recognized National DPP, certain criteria have to be met. curriculum that is rooted in health education and lifestyle An organization must: designate an individual to serve as modification. When considering that pharmacists have the program coordinator, employ a trained lifestyle coach been providing chronic disease management strategies, to deliver the program, follow a CDC-approved curriculum such as Diabetes Self-Management Education (DSME), for in delivering the program, provide a minimum number of quite some time now, it becomes evident that this profesrequired sessions and submit participant data every 12 sion could be the driving force for this nationally recogmonths. In addition, the participants of the program have to nized prevention program. be eligible based upon specific criteria that includes adults Another factor to be considered when implementing the 18 years of age or older with a body mass index of greater National DPP within pharmacies is that pharmacy technithan or equal to 24 (greater than or equal to 22 if Asian) cians also can deliver the program. The National DPP was with a minimum of 50 percent of the cohort having had a developed to be administered by lay-individuals who are recent blood test or claim code indicating they have prediafamiliar with the community. Even though pharmacists are betes or gestational diabetes mellitus (GDM). A maximum trusted healthcare professionals and active components of of 50 percent of a program’s participants may be considthe community, pharmacy technicians provide a level of ered eligible without a blood test or history of GDM only if relatability that goes beyond that professional relationship. they screen positive for prediabetes based upon the CDC The connection that they will have with the participants of Prediabetes Screening test (or other CDC approved risk the program will serve as an invaluable anchor that allows test).8,9 Although application for recognition status is a volthose participants to successfully complete the lifestyle untary process for any National DPP, a recent Centers of change program.13 Another positive component of the Medicare and Medicaid Services (CMS) ruling has deemed pharmacy technician delivering the National DPP is the that only those organizations that have applied for CDC potential to decrease the cost of the program and enhance recognition will be eligible to receive reimbursement for its sustainability. Costs are accumulated through a variety providing the program to Medicare patients. The CMS reof mechanisms such as materials and location rental, but imbursement mechanism is set to start in January 2018.10 the most significant and most easily modifiable cost surCurrently there are 1,296 organizations across the nation rounds compensation for the individuals that coordinate that have applied for recognition, of which only 17 are and deliver the program. If the pharmacy technician were based in pharmacies. These pharmacy settings represent to deliver the program, as opposed to a pharmacist, the the first ones in the country to seek recognition as a CDC- compensation cost would be greatly reduced.14, 15 recognized National DPP and their settings range any-

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Nov. 2016 CE — NDPP In Kentucky, a group of five Kroger pharmacies have utilized their existing American Diabetes Association (ADA) recognized DSME program to implement the National DPP within their communities. Initially the program was delivered by one pharmacist and one dietician, but due to the expansion of the program they now have 12 pharmacists who work with dieticians to serve as lifestyle coaches. The program is currently delivered to state employees, out of pocket customers and American Association of Diabetes Educators (AADE) scholarship recipients. Throughout the program, the pharmacists follow the CDC-approved National DPP curriculum to provide weekly and monthly programming that is modified to meet the needs of their participants. Outcomes and biometric measures from the program’s participants are then communicated with each physician to ensure the continuity of care.

This program has earned much success for many reasons.

One of the primary successes is centered upon their utilization of the National DPP to enhance an existing diabetes education infrastructure. Pharmacists within this group already are recognized as experts on diabetes education and are thus well-accepted as lifestyle change coaches in this diabetes prevention program. Another success is due to their efforts to expand their patient base. These pharmacists leveraged the State Employee Benefit to cover the National DPP for the participants, provide reimbursement to the deliverers and serve as a basis of referrals for the program. The group also obtained buy-in from Kroger to pilot the National DPP among store employees. They have used the momentum provided by these collaborations to actively expand their relationships with other employers and insurers to offer the LCP as a reimbursed health benefit. An additional success resonates upon the accessibility and integrative nature of Kroger itself. The grocery store setting allows for the pharmacists to enhance the National DPP by providing lessons on healthy food options to complement the baseline curriculum. Funding and technical assistance for the program are provided by the AADE with additional support provided by the Kentucky Department for Public Health.

November/December 2016 vices such as the National DPP in pharmacies enhances pharmacist outreach, fills a gap within the healthcare system and allows for pharmacists to advance their profession beyond traditional roles.

Citations: 1. Fielding JE, Johnson RL, Calonge BN, et al. TeamBased Care to Improve Blood Pressure Control. American Journal of Preventive Medicine. 2014;47(1):100102. doi:10.1016/j.amepre.2014.03.003.

2. Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General.

Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011.

3. Cranor CW, Christensen DB. The Asheville Project: Short-term Outcomes of a Community Pharmacy Diabetes Care Program. Journal of the American Pharmaceutical Association. 2003; 43(2): 149-159. doi: 10.1331/108658003321480696.

4. Machado M, Nassor N, Bajacar, JM. Sensitivity of Patient Outcomes to Pharmacist Interventions. Part III: Systematic Review and Meta-Analysis in Hyperlipidemia Management. Annals of Pharmacotherapy. 2008; 42 (9): 1195-1207. doi: 10.1345/aph.1K618.

5. National Diabetes Prevention Program: The Research Behind the Program. Centers for Disease Control and Prevention Website.https://www.cdc.gov/diabetes/ prevention/prediabetes-type2/preventing.html Updated: Jan. 14, 2016. Accessed Aug. 27, 2016.

6. Diabetes Prevention Program Research Group. Reduction in the Incidence of Type 2 Diabetes Intervention or Metformin. The New England Journal of Medicine. 2002; 346:393-403. doi: 10.1056/ NEJMoa012512.

7. National Diabetes Prevention Program: Lifestyle Change Program Details. Centers for Disease Control and Prevention Website. https://www.cdc.gov/diabetes/ prevention/lifestyle-program/experience/index.html Updated: Jan. 14, 2016. Accessed Aug. 27, 2016.

Pharmacists are an excellent avenue for the development of community-clinical linkages, but they often are overlooked. On that same note, preventive health services are the most cost effective and burden reducing health tactics, 8. National Diabetes Prevention Program: Requirements for CDC Recognition. Centers for Disease Control and but they are significantly underutilized.14 Marrying the pharPrevention Website. https://www.cdc.gov/diabetes/ macy and public health practice models enhances the prevention/lifestyle-program/requirements.html Updatpharmacists’ ability to impact the community which they so ed: Jan. 14, 2016. Accessed Aug. 31, 2016. loyally serve. Through this collaboration, pharmacists are able to increase access to care and reduce the burden of 9. National Diabetes Prevention Program: CDC Prediabechronic disease within their community. Implementing sertes Screening Test. Centers for Disease Control and 13

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Nov. 2016 CE — NDPP

November/December 2016

Prevention Website. http://www.cdc.gov/diabetes/ prevention/pdf/prediabetestest.pdf. Accessed Sept. 9, 2016.

13. Centers for Disease Control and Prevention Diabetes Prevention Recognition Program: Standards and Operating Procedures. Centers for Disease Control and Prevention Website. http://www.cdc.gov/diabetes/ prevention/pdf/dprp-standards.pdf. Published Jan. 1, 2015. Accessed Sept. 27, 2016.

10. Medicare Diabetes Prevention Program Expansion.

Centers for Medicare and Medicaid Services Website. https://www.cms.gov/Newsroom/ MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets 14. Pharmacist: Salary Details. U.S. News and World Re-items/2016-07-07.html. Published July 7, 2016. Acport Website. http://money.usnews.com/careers/bestcessed Sept. 5, 2016. jobs/pharmacist/salary. Accessed Sept. 27, 2016.

11. National Diabetes Prevention Program: Registry of 15. Pharmacy Technician: Salary Details. U.S. News and recognized Organizations. Centers for Disease Control World Report Website. http://money.usnews.com/ and Prevention Website. https://nccd.cdc.gov/ careers/best-jobs/pharmacy-technician/salary.

DDT_DPRP/Registry.aspx Accessed Aug. 31, 2016.

Accessed Sept. 27, 2016.

12. National Association of Boards of Pharmacy: Pharmacists Ranked as Second Most Trusted Profession in Annual Gallup Poll https://www.nabp.net/news/ pharmacists-ranked-as-second-most-trustedprofession-in-annual-gallup-poll Published: Dec. 31, 2014. Accessed Sept. 6, 2016.

16. National Prevention Strategy: Economic Benefits or Preventing Disease. United States Surgeon General Website. http://www.surgeongeneral.gov/priorities/ prevention/strategy/appendix1/pdf. Accessed Aug. 30, 2016.

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.   

 

Average length is 4-10 typed pages in a word processing document (Microsoft Word is preferred).

Articles are reviewed for commercial bias, etc. by at least one (normally two) pharmacist reviewers.

When submitting the article, you also will be asked to fill out a financial disclosure statement to identify any financial considerations connected to your article.

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 Articles should address topics designed to narrow at the beginning of the article. gaps between actual practice and ideal practice in Article should begin with the goal or goals of the pharmacy. Please see the KPhA website overall program – usually a few sentences. (www.kphanet.org) under the Education link to see Include 3 to 5 objectives using SMART and meas- previously published articles. urable verbs.





Include a quiz over the material. Usually between 10 to 12 multiple choice questions.

Feel free to include graphs or charts, but please submit them separately, not embedded in the text of the article.

Articles must be submitted electronically to the KPhA director of communications and continuing education (ssisco@kphanet.org) by the first of the month preceding publication.

KPhA Remembers KPhA desires to honor members who are no longer with us. Please keep KPhA informed by sending this information to eramey@kphanet.org . Deceased members for each year will be honored permanently at the KPhA office.

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Nov. 2016 CE — NDPP

November/December 2016

November 2016 — NDPP Paves New Paths for Enhancing Pharmacy Practice 1. Collaborative care practices have been effortlessly implemented throughout Kentucky.

A. True B. False 2. The National Diabetes Prevention Program is a: A. Lifestyle change program for patients with diabetes.

B. Lifestyle change program aimed at the prevention of type 2 diabetes.

C. Lifestyle change program that is linked to no clinical research.

D. Lifestyle change program based on a multicenter clinical research study.

E. Both B and D

6. Which of the following is not a criterion an organization delivering the National Diabetes Prevention Program must meet to earn CDC-recognition?

A. Utilization of a CDC-approved curriculum B. Delivery of the program by a trained lifestyle coach C. Participants that are adults 21 years or older D. Submission of participant data every 12 months

7. How many pharmacies are currently enrolled as organizations that offer the National Diabetes Prevention Program?

A. 17 B. 1,296 C. 12 3. What government agency’s work is closely linked to D. 18 the National Diabetes Prevention Program?

A. United States Public Health Service 8. Which other health professional are the Kroger B. Centers for Disease Control and Prevention pharmacists in Kentucky working with to deliver the C. Food and Drug Administration National Diabetes Prevention Program?

D. Drug Enforcement Agency A. Primary Care Providers B. Physical Therapists 4. What is the minimum number of sessions that an C. Dieticians organization delivering the National Diabetes D. Nurses Prevention Program is required to offer within the first six months delivery?

9. Which organizations are the Kroger pharmacists in A. Six Kentucky working with to receive reimbursement for B. 15 providing the National Diabetes Prevention Program?

C. 16 A. Kentucky State Employee Benefit D. None of the above B. Kroger Company C. Centers for Disease Control and Prevention 5. Which of the following is not an objective focus of D. Both A and B the National Diabetes Prevention Program?

A. Healthy eating 10. Pharmacy can merge with public health to fill a B. Challenge management preventive health gap within the healthcare system.

C. Medication management A. True D. Commitment B. False

CE Reminder: A pharmacist shall complete a minimum of one and five-tenths (1.5) continuing education units (15 contact hours) annually between January 1 through December 31, pursuant to 201 KAR 2:015, Section 5(1). A pharmacist first licensed by the Board within 12 months immediately preceding the annual renewal date shall be exempt from the continuing pharmacy education provisions.

Still need hours? KPERF CE articles are available to members online at www.kphanet.org under the Education Tab. 15

THE KENTUCKY PHARMACIST

Nov. 2016 CE — NDPP

November/December 2016

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: October 22, 2019 Successful Completion: Score of 80% will result in 1.5 contact hours or .15 CEUs. Participants who score less than 80% will be notified and permitted one re-examination.

TECHNICIANS ANSWER SHEET. November 2016 — NDPP Paves New Paths for Enhancing Pharmacy Practice (1.5 contact hours) Universal Activity # 0143-0000-16-011-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B 3. A B C D 5. A B C D 2. A B C D E 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

Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve 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 November 2016 — NDPP Paves New Paths for Enhancing Pharmacy Practice (1.5 contact hours) Universal Activity # 0143-0000-16-011-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B 3. A B C D 5. A B C D 2. A B C D E 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

Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve 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.

16

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

THE KENTUCKY PHARMACIST

Campaign For Kentucky’s Pharmacy Future

November/December 2016

Join the Committee of 100!

Each contributor who pledges at least $5,000 over the next 5 years will be counted among the Committee of 100.

Add your name to the list today by calling 502-227-2303 or log on to http://www.kphanet.org/?page=buildingcampaign

Contributions are tax deductible.

The Campaign for Kentucky’s Pharmacy Future: The Next 50 Years Donation Levels for KPhA and KPERF Building Fund Campaign Diamond Bowl of Hygeia Platinum Bowl of Hygeia Gold Bowl of Hygeia Silver Bowl of Hygeia Bronze Bowl of Hygeia E.M. Josey Memorial Cornerstones Builders Brick Layers

$100,000+ $75,000-$99,999 $50,000-$74,999 $25,000-$49,999 $10,000-$24,999 $5,000-$9,999 $2,500-$4,999 $1,000-$2,499 $1-$999

Pledges can be paid over 5 years. Gifts made to KPERF are tax deductible to the extent allowable by law. http://www.kphanet.org/?page=buildingcampaign or call 502-227-2303.

17

THE KENTUCKY PHARMACIST

2016 KPhA Legislative Conference

November/December 2016

KPhA Thanks our 2016 Legislative Conference Sponsors Unanimous Consent Sponsors $2,000 and above

American Pharmacy Cooperative Inc. American Pharmacy Services Corp.

Kentucky Customers of Cardinal Health Humana, Inc. McKesson Corporation Recovery AS Sullivan University College of Pharmacy

Majority Vote Sponsors Anonymous Donor CareSource Kentucky Department for Public Health Immunization Program Kroger Cincinnati Division National Association of Chain Drug Stores Passport Health Plan Pharmacists Mutual WellCare of Kentucky 18

THE KENTUCKY PHARMACIST

Dec. 2016 CE — Post-Surgical Bariatric Patient Issues

November/December 2016

Long-term Nutrient and Medication Related Issues in the Post-Surgical Bariatric Patient By: Christopher Miller, PharmD, MS, MBA, BCNSP, Clinical Assistant Professor, Department of Pharmacy Practice & Science, University of Kentucky College of Pharmacy There are no financial relationships that could be perceived as real or apparent conflicts of interest.

Universal Activity # 0143-0000-16-012-H01-P&T 2.0 Contact Hour (0.2 CEUs) Expires 11/17/2016

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

Goals: To raise the level of pharmacist awareness and understanding of this rapidly increasing chronic condition and to enable the practitioner to become increasingly involved as a valuable participant in the post-surgical management of these patients.

Pharmacist Objectives At the conclusion of this Knowledge-based article, the reader should be able to: 1. Describe the potential for specific nutrient deficiencies and supplements that are necessary for patients who have undergone bariatric surgeries; 2. Provide ongoing monitoring and management of the post-surgical bariatric patient; and 3. Implement health and medication counseling strategies for patients who have undergone bariatric surgery.

Technician Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: 1. Understand the appropriate dosage forms for drugs, nutrients, and minerals that should be used, especially in the early post-surgical period to improve outcomes; 2. Become familiar with the most common symptoms of vitamin and nutrient deficiencies; and 3. Understand what vitamins and nutrients are required to be supplemented in the bariatric surgery patient and what surgeries are associated with the most risk for nutrient deficiencies.

Introduction/Background:

The definition of obesity according to ASMBS and CDC: 4,5

Obesity continues to be a major public health problem in the United States and worldwide, with approximately 38 percent of the U.S. population affected based on current data from the American Society of Metabolic and Bariatric Surgery (ASMBS).1,2 Of the 38 percent, nearly 8 percent had severe obesity, including 5.5 percent in men and approximately 10 percent in women.1 The data show that between 2013 and 2014 a record number of women had obesity at an estimated 40 percent, while men remained somewhat stable at approximately 35 percent.1 One study found the prevalence of the disease among teens has doubled in just one generation. Additionally, among children and adolescents, 17 percent had obesity in 2011-2014, while 5.8 percent had severe obesity.1 The Centers for Disease Control (CDC) reports that Kentucky was ranked as one of the higher states in the prevalence of obesity, so this should be a major healthcare priority in this state.3

Category

BMI Range

Normal Size

18.9 to 24.9

Overweight

25 to 29.9

Class I, Obesity

30 to 34.9

Class II, Serious Obesity

35 to 39.9

Class III, Severe Obesity

40 and greater

Obesity has been associated with an increase hazard ratio for all-cause mortality as well as a significant medical and

psychological co-morbidity.2 Per the ASMBS, obesity is not only a chronic medical condition, but also should be considered a bona fide disease state.2 Obesity-related conditions include heart disease, stroke, type 2 diabetes (T2D) and certain types of cancer, some of the leading causes of preventable death.6 According to ASMBS, approximately 193,000 bariatric surgeries were performed in 2014 and this trend is increasing.

There has been a significant emergence in the sleeve gastrectomy (SG) procedure surging to more than 50 percent 19

THE KENTUCKY PHARMACIST

Dec. 2016 CE — Post-Surgical Bariatric Patient Issues of all weight-loss surgeries. Based on most current data, the SG procedure was performed 51.7 percent of the time; this was followed by Roux-en-Y gastric bypass (RYGB) at 26.8 percent; the gastric banding (GB) procedure 9.5 percent; and, biliopancreatic diversion with duodenal switch (BPD/DS) representing only 0.4 percent. This data showed that RYGB is the most popular operation for those with T2D rising to 33.3 percent from 30.4 percent from the previous report.7 The emergence of these surgeries has been based on evidence that demonstrated long-term benefits in the treatment of chronic diseases such as T2D, hypertension and obstructive sleep apnea. For the first time, metabolic surgery is included as a standard treatment option for people with diabetes, even those who have mild obesity.8 These evidence based guidelines were recently published in the 2016 issue of Diabetes Care.9 According to the guidelines, metabolic surgery should be recommended to treat T2D in patients with Class III obesity as well as those with Class II if hyperglycemia is not adequately controlled.8 There are basically two broad classifications of bariatric surgery and include those that are restrictive versus those that are considered more malabsorptive. The restrictive procedures decrease food intake and promote a feeling of fullness after meals to promote weight loss (GB, SG). Gastric banding is considered purely restrictive, whereas the SG procedure is considered primarily restrictive with some malabsorption since a portion of the hormone secreting stomach is resected. The RYGB procedure is considered to be both restrictive and malabsorptive. The most extensive malabsorptive procedure is BPD/DS which places the patient at significantly more risk for protein calorie malnutrition and nutrient deficiencies, including the fat soluble vitamins.

This procedure has significantly decreased in popularity due to the potential for nutrition related complications.2,10-12 Primary Nutrient related issues associated with Bariatric Surgery Thiamine (B1):2,10-13 The recommended post-surgical preventive supplementation, risk factors for deficiency with treatment recommendations and follow-up schedule are documented in Table 1. Recommended supplementation dosing by ASMBS to maintain normal thiamine levels is 3mg daily which should be included in the prescribed daily multivitamin supplement. Thiamine is primarily absorbed in the duodenum and proximal jejunum by an active carriermediated process where it is phosphorylated to the active form thiamine pyrophosphate (TPP). This active form plays a key role in in the metabolism of carbohydrates, (i.e. Glycolysis and oxidative decarboxylation) lipids and branch chain amino acids (BCAA). Preoperative thiamine deficiencies have been identified in up to 29 percent of the candi20

November/December 2016

dates for bariatric surgery, whereas thiamine deficiency after surgery has been reported to occur in up to 49 percent of RYGB surgery patients. Thiamine deficiency can lead to a condition known as beriberi, Wernicke’s encephalopathy (WE) or Wernike-Korsakoff syndrome (WKS). One of the most common early symptoms of thiamine depletion is nausea and vomiting and can lead to deficiency as early as two weeks. Clinical symptoms are highly variable and may involve the central and peripheral nervous system (e.g. “dry” beriberi), the cardiovascular system (e.g. “wet” beriberi) and the metabolic system (e.g. metabolic acidosis). The classical symptoms of WE involve ocular abnormalities, gait ataxia and mental status changes. Symptoms of WKS can include confusion, loss of mental activity with permanent memory loss and if left untreated can progress to coma and death. “Wet” beriberi is characterized by cardiovascular disorders, especially cardiomyopathy with right ventricular enlargement leading to cardiac insufficiency and edema. In severe cases, lactic acidosis may occur which is potentially lethal. Laboratory monitoring to screen for deficiency is serum thiamine (10-64 ng/ml); however, this is a poor indicator of total body stores. Symptom assessment and other lab data checks should be performed if deficiency is suspected, such as thiamine pyrophosphate (TPP) and erythrocyte transketolase activity.

Calcium/Vitamin D: (2,10-13) The recommended postsurgical preventive supplementation, risk factors for deficiency with treatment recommendations and follow-up schedule is documented in Table 1. Vitamin D is a key regulator of calcium and bone metabolism modulating intestinal absorption and renal excretion of calcium and phosphate. Pre-surgical calcium deficiency has been reported to be approximately the same as what is reported in the postsurgical period of around 10 percent. Vitamin D deficiency is much more common and has been reported to occur in 25-68 percent of the patients prior to surgery and 25-80 percent post-surgical. In order to support optimal bone health, calcium supplementation should be given at 12002000 mg/day of elemental calcium in divided doses to optimize absorption. Calcium is mostly absorbed in the duodenum and proximal jejunum. In gastric bypass patients, reduction of the stomach into a small pouch results in substantial decrease in acid production, impairing solubility and absorption. Since the acid secreting parietal cells can no longer be stimulated to produce acid by the presence of food, absorption of the carbonate salt is impaired. The duodenum is typically bypassed in the RYGB procedure, and the recommendation is to use the more inherently soluble calcium citrate salt. In non-bypass patients, the carbonate form of calcium salt can be used which is less expensive and does have a high degree of elemental calcium. When

THE KENTUCKY PHARMACIST

Dec. 2016 CE — Post-Surgical Bariatric Patient Issues

November/December 2016

the carbonate salt is used, it is recommended that it is taken with food to stimulate acid production to enhance absorption. It also is important to note that oral calcium can alter intestinal absorption of cationic trace elements such as iron, zinc and copper, and they should be separated by at least two hours. This becomes most crucial with the iron supplement in these patients.

considered insufficient, with a target of > 30 ng/ml. The other laboratory markers are the same as with calcium and include alkaline phosphatase, intact PTH and the DEXA (bone density) assessment. It is recommended that a bone density assessment be done at baseline and then at approximately two year intervals for high risk patients (malabsorptive surgeries).

Monitoring for signs and symptoms of calcium deficiency include low bone density, osteoporosis, muscle contractions, pain, spasms and paresthesia. The most appropriate screen tool for monitoring calcium status is ionized calcium with a goal range of 4.5-5.6 mg/dl (total serum calcium normal range 9-10.5 mg/dl). Also, it is important to note that serum calcium is not reflective of calcium status since slight decreases in calcium are compensated and normalized by parathyroid hormone (PTH), Vitamin D controlled increase in intestinal absorption, reduction in renal elimination and osteolysis. Other laboratory tests to support calcium status would include alkaline phosphatase, intact PTH (goal < 65 pg/ml) and dual-energy X-ray absorptiometry (DEXA) bone density assessment. The T-score on a bone density scan of -2.5 or lower qualifies as osteoporosis, whereas a Tscore of -1.0 to -2.5 signifies osteopenia, meaning belownormal bone density without full osteoporosis.

Anemia related nutrient deficiencies: (2,10-13) The recommended post-surgical preventive supplementation, risk factors for deficiency with treatment recommendations and follow-up schedule are documented in Table 1 for iron, cyanocobalamin (B12) and folic acid. Poor absorption of these nutrients after bariatric surgery has been associated with anemia in this patient population. Iron deficiency anemia (IDA), along with vitamin B12 deficiency are by far the most common anemias occurring after bariatric surgery. These have been reported to occur on average in 15 percent of the patients after two years and 31 percent after five years in malabsorptive surgeries.

IDA is seen in many morbidly obese patients even prior to surgery and can be as high as 18 percent. The average prevalence of IDA is 17 percent (SG) to 30 percent (BDP/ DS, RYGB) after two years and 45 percent after five years (BDP/DS, RYGB). Iron is absorbed throughout the small Vitamin D absorption occurs primarily in the distal small intestine but more efficiently absorbed in the duodenum intestine and is involved in many roles within the body sup- and proximal jejunum. The poor absorption of iron after porting neuromuscular function, bone calcification and seRYGB surgery occurs since the primary absorption sites rum calcium levels. Patients are at risk for secondary hyare bypassed. However, it is reported to be multifactorial perparathyroidism after malabsorptive surgeries due to re- given that red meat is poorly tolerated after surgery (high duced absorption of calcium and vitamin D. Vitamin D source of iron) and avoided early after surgery. Secondly, should be given in a dose of at least 3000 IU daily to susthere is reduced acid exposure due to the surgery along tain a serum 25-hyrdroxyvitamin D (25(OH) D level of > 30 with a high use of acid reducing medications. Thirdly, there ng/ml. In a study by Goldner et al. (14) patients (n=45) were is an increase in hepcidin synthesis associated with obesity supplemented with 5000 IU daily and this dose was found -related inflammation that interferes with iron availability. to be an effective and safe dose to establish normal PTH Furthermore, the decreased acid production in the stomach levels. However, 30 percent of the patients still had insuffi- after RYGB can affect the reduction of iron from the ferric cient levels of vitamin D after surgery suggesting that there (F3+) to ferrous state (F2+), thus reducing absorption. Theremay be a benefit from higher doses. BPD/DS surgery pafore, giving iron in a combination with ascorbic acid tients are at higher risk of vitamin D deficiency compared to (Vitamin C) to increase acidity and enhance absorption of other surgeries due to malabsorption and limited availability non-heme iron would be a good recommendation. Finally, of bile salts required for absorption. Vitamin D malabsorpanother factor to consider is that iron is associated with tion also can lead to hypophosphatemia which is best cor- significant gastrointestinal side effects such as nausea, rected through increased vitamin D supplementation. How- abdominal pain and diarrhea. Therefore, poor medication ever, phosphate supplementation, preferably in powder adherence because of the side effects can be a major conform, should be considered for cases of mild to moderate tributing factor in IDA. Monitoring for signs and symptoms hypophosphatemia (1.5 â&#x20AC;&#x201C; 2.5 mg/dl). Monitoring for signs of IDA would include fatigue, impaired work performance and symptoms of deficiency of vitamin D include osteoma- and productivity, anemia, inability to regulate body temperlacia in adults, arthralgia, depression and myalgia. Labora- ature and white finger nail beds. The primary laboratory tory monitoring is performed using serum 25(OH) D as the screening tool to monitor for IDA is ferritin; however, this marker and < 20 ng/ml is considered deficient; 20-30 ng/ml may need to be evaluated in conjunction with C-reactive 21

THE KENTUCKY PHARMACIST

Dec. 2016 CE — Post-Surgical Bariatric Patient Issues

November/December 2016

TABLE 1: Managing Critical Vitamins/Nutrients Post Surgery (2,10-13) Nutrient

Prevention

Risk Factors

Treatment/ Deficiency

Monitoring/Follow-up

Thiamine

2 multivitamins daily each containing 100 percent RDA; ASMBS recommends 3mg daily

recurrent vomiting

severe deficiencies (WE) require parenteral therapy; 500mg i.v. daily for 3-5 days; then 250 mg i.v. daily for 3-5 days, then 100 mg per day orally indefinitely

patients should be monitored after surgery at 3, 6-9, and 12 months, and then yearly intervals

If 25(OH)D < 20 ng/ ml, 50,000 units per week orally x 8 weeks along with 3000 IU daily for maintenance

patients should be monitored after surgery at 3, 6-9, and 12 months, and then yearly intervals

1000 – 2000 µg/day orally or 1000 µg/week IM

patients should be monitored after surgery at 3, 6-9, and 12 months, and then yearly intervals

for episodes of vomiting oral thiamine should be provided at 100mg/day x 7-14 days Calcium / Vitamin D

Vitamin B12

Iron

intravenous glucose infusions alcohol abuse

1200 – 2000 mg / day calcium citrate

pre-existing vitamin D deficiency

ASMBS has recommended vitamin D supplemented with at least 3000 IU daily initially and titrated to 25(OH)D to > 30 ng/ml

malabsorption after SG, RYGB, BPD/DS surgeries

1000 µg daily (except GB) if adequate oral absorption can be confirmed

Decreased meat and dairy intakes

alternatively, 500 µg/week intranasal or 1000 µg intramuscular monthly

malabsorptive procedures

45–60 mg of elemental iron provided as multivitamins and supplements

Pre-existing deficiency

menstruating women may require 50-100 mg elemental iron daily

Insufficient supplements

extreme weight loss

menstruation, GI bleeding insufficient supplementation; poor adherence avoidance of meat

Up to 150-200 mg / day of elemental iron until levels normalize IV iron per the institutions replacement protocol in severe cases

copper deficiency Folate

a minimum of 400 – 800 µg/ day in the form of multivitamin supplements suggest 800-1000 µg/day for women of child bearing age to reduce the risk of neonatal neural tubular defects

low consumption of folate rich foods

1 mg daily for about 1-3 months

low adherence with prescribed supplements

If serum levels are low 5 mg/day possibly needed if severe malabsorption

22

DEXA scan at baseline, then at 2 yr. intervals after surgery; bisphosphonates considered if T-score < 2.5

Optional MMA & HCy levels annually patients should be monitored after surgery at 3, 6-9, and 12 months, and then yearly intervals oral iron preparations in combination with vitamin C help decrease pH and enhance iron absorption patients should be monitored after surgery at 3, 6-9, and 12 months, and then yearly intervals RBC folate is more sensitive than serum folate

THE KENTUCKY PHARMACIST

Dec. 2016 CE — Post-Surgical Bariatric Patient Issues Zinc

multivitamins containing zinc 200 % RDA (RDA=11 mg males, 8 mg females) for malabsorption surgeries

Copper

multivitamin that provides 2mg/day of elemental copper for malabsorption surgeries

pre-existing deficiency Malabsorption surgeries (SG, RYGB, BPD/DS) avoidance of meat high use of antacids

malabsorption surgeries (BPD/DS> RYGB> SG) high use of antacids high zinc supplementation

November/December 2016 variable recommendations

ASMBS recommends 60 mg elemental twice daily

patients should be monitored after surgery at 3, 6-9, and 12 months, and then yearly intervals for malabsorptive surgeries

In severe cases of copper deficiency dose of 2-4 mg elemental copper infused i.v. x 6 days; followed by oral of 3-8 mg/day until levels normalize

patients should be monitored after surgery at 3, 6-9, and 12 months, and then yearly intervals for malabsorptive surgeries

Provide 50 mg elemental zinc daily

When zinc deficiency is being treated give 1mg elemental copper for each 8-15 mg of zinc Vitamin A

Vitamin K

multivitamins containing RDA of Vitamin A; 10,000 IU daily orally for malabsorption surgeries has been recommended

Multivitamins containing vitamin K supplement BPD/DS may require additional 300 µg/daily

malabsorption procedures (BPD-DS>RYGB) extreme weight loss (low food intake)

no corneal changes: 10,000 – 25,000 IU/day orally x 1-2 weeks corneal changes: 50,000-100,000 IU i.m. followed by 50,000 IU i.m. daily x 2 weeks

malabsorption procedures (primarily BPD-DS) antibiotic use may decrease bacteria producing vitamin K in the intestine

deficiency initially treated with 10mg i.m. or subcutaneously; then 1-2 mg/week orally for BPD/DS and RYGB

patients should be monitored at yearly intervals after BPD/DS surgery and optional for RYGB

patients should be monitored at yearly intervals for BPD/ DS surgery

Note: This table is primarily for SG, RYGB, and BPD/SD surgeries as gastric banding does not require aggressive nutrient supplementation and monitoring. One multivitamin per day is required for GB surgeries, and frequent monitoring is not as critical. protein (CRP) since it is acute-phase reactant and can be depressed in an inflammatory state. The goal value is 15200 ng/ml for males and 12-150 ng/ml for females (critical range < 20 ng/ml). Additional labs for monitoring iron include serum iron and total iron binding capacity (TIBC).

Vitamin B12 (cobalamin) absorption is impaired primarily due to changes in hydrochloric acid (HCl) production with reduced availability of intrinsic factor. B12 and folic acid are both involved with the maturation of red blood cells (RBC) and over time a deficiency of either can lead to macrocytic

anemia, a condition characterized by the production of fewer and larger RBCs with decreased ability to carry oxygen.

Manifestations of B12 deficiency may not develop until years after surgery due to the body reserve capacity. Pre-surgical deficiency for B12 has been reported to be up to 18 percent and this may be higher in those taking metformin and proton pump inhibitors because these medications have been shown to reduce absorption of nutrient and trace elements that require an acidic pH. The post-surgical deficiency has been reported up to 35 percent by most investigators for

23

THE KENTUCKY PHARMACIST

Dec. 2016 CE — Post-Surgical Bariatric Patient Issues recipients of RYGB surgery. A significant decrease in HCl results in pepsinogen not being converted to pepsin which is necessary for release of B12 from food protein. This can be profound with RYGB surgery because of a significant reduction in stomach capacity. Furthermore, Intrinsic Factor (IF) is produced by the parietal cells in the stomach, which can be impaired with bariatric surgery causing B 12 deficiency (pernicious anemia). Without IF production, B12 can’t be taken up and absorbed in the terminal ileum, which is the primary site of absorption. Signs and symptoms of B12 deficiency (pernicious anemia) include tingling in fingers and toes, depression, dementia and ataxia. The primary screening tool for B12 deficiency is serum level of B12 with a goal range of 200-1000 pg/ml. However, serum B12 is not sensitive and may miss 25-30 percent of the deficiency cases. Other useful screening tests include serum and urine methylmalonic acid (MMA) and serum homocysteine (HCy) levels. MMA testing is a highly sensitive marker for B12 deficiency and provides a useful diagnostic tool.

Folic acid absorption occurs primarily in the proximal portion of the small intestine; however, absorption is active throughout the small bowel. Pre-surgical deficiencies have been reported in the range of 0-24 percent. The prevalence of postoperative deficiency has ranged from 0-40 percent in patients. In one study, Gehrer et al. (15) reported 22 percent of SG and 12 percent RYGB patients that were deficient after surgery. It is recommended that patients be supplemented with 200 percent of the RDA on a daily basis which is 800 µg (RDA=400 µg), and this can be accomplished through the routine multivitamin supplement. Supplementation of > 1000 µg/day has not been recommended as it may mask vitamin B12 deficiency. It is important to note that folate does not affect the myelin of nerves, and neurological damage is not common as is the case with vitamin B12 deficiency. Many times these deficiency states are not easily identifiable. It is especially important to make sure that women of child bearing age are supplemented with folic acid to minimize the risk of neural tube defects.

Signs and symptoms of deficiency for folic acid include macrocytic anemia, palpitations, fatigue and neural tube defects. The primary laboratory screening tool for folate status is serum folate and red blood cell (RBC) folate (more sensitive marker). The most sensitive marker for deficiency is homocysteine in conjunction with erythrocyte folate.

Trace Element related nutrient issues: (2,10-13) The recommended post-surgical preventive supplementation, risk factors for deficiency with treatment recommendations and follow-up schedule are documented in Table 1 for zinc and copper. Zinc is a major co-factor for more than 300 en-

November/December 2016

zymes and plays a key role in cell growth, wound healing and immunity. Zinc is primarily absorbed to some extent in the duodenum and the proximal jejunum. Zinc has been shown to upregulate metallothionein which can bind and trap copper in the small intestine, thus reducing absorption.

An acidic pH is required for zinc absorption and can be significantly reduced by some of the bariatric procedures.

Additionally, there is malabsorption from the bypass of the duodenum and proximal jejunum which contributes to potential deficiency. Zinc deficiency has been reported to be up to 30 percent pre-surgery and post-surgical prevalence is reported to be BPD/DS (74-91 percent), RYGB (21-33 percent) and SG (12-13 percent). The main signs and symptoms of zinc deficiency are alopecia, glossitis, nail dystrophy and in some cases acrodermatitis enteropathica.

Serum plasma zinc is used as the screening tool for zinc deficiency assessment although this is not well established. The goal range is 60-130 µg/dl and should be monitored in conjunction with albumin levels since albumin is the primary binding protein.

Copper is a key component of many enzymes involved in the synthesis of neurotransmitters as well as intestinal iron absorption and is primarily absorbed in the stomach and duodenum. In the small intestine, copper is bound to metallothionein with a greater affinity than zinc or other metals.

This binding causes copper to be trapped in the enterocyte and sloughed off and excreted thus causing reduced copper absorption. Gastric acid is involved in freeing up copper from food and the risk for copper deficiency increased when stomach and duodenum are bypassed. Also, the diarrhea caused by the BPD/DS surgery can result in excess copper loss. To prevent deficiency post-surgery, 2mg of elemental copper is recommended and should be given as part of the routine multivitamin and mineral supplement.

Approximately 51-68 percent of BPD/DS patients demonstrate low copper levels up to four years post-operatively which contrasts to 4 percent for RYGB up to five years.

Signs and symptoms of copper deficiency include myeloneuropathy, anemias and paresthesias. The anemia is often misinterpreted as iron or vitamin B12 deficiency. The current method for interpreting copper deficiency is based on blood copper and ceruloplasmin which can give false results in the presence of obesity-induced inflammation.

The goal copper serum level is reported to be 0.75–1.45 µg/ml.

Fat soluble Vitamins A & K:(2,10-13) The recommended post-surgical preventive supplementation, risk factors for deficiency with treatment recommendations and follow-up schedule are documented in Table 1 for fat soluble vitamins A & K. Bariatric patients at the highest risk for these

24

THE KENTUCKY PHARMACIST

Dec. 2016 CE — Post-Surgical Bariatric Patient Issues

November/December 2016 (2,10-13,17-22)

Table 2: Counseling Tips in Managing the post-surgical Bariatric Patient Medication/ Patient Education Points to Improve Outcomes Health Related Issue Alcohol Use  Avoid alcohol use due to further impairment of nutrient absorption and metabolism.  Accelerated alcohol absorption reported and increased risk for development of alcohol use disorder (AUD).

Tobacco Use



NSAID Use

  

Hypertensive Medication Medication Adherence/ Optimal dosage forms

       

Contraception

   

Potential drug nutrient interactions

           

Avoided due to increased risk for poor wound healing, anastomotic ulcer and overall impaired health.

Avoid non-steroidal anti-inflammatory drugs because they have been implicated in anastomotic ulcerations/perforations; other pain meds need to be utilized such as acetaminophen.

Salicylates also should be avoided due to potential similar complications.

Transdermal pain relievers should be considered.

Monitor blood pressure as medication requirements may need to be reduced as weight loss occurs.

Continually monitor adherence to nutrient supplements and stress importance.

Use liquid or chewable dosage forms for enhanced bioavailability and tolerance, especially early after surgery.

Avoid extended release, film coated and enteric coated medications due to potential for reduced bioavailability.

Recommend citrate salt of calcium for enhanced absorption and space calcium dosing in 500600mg increments; chose a brand that contains vitamin D3.

Recommend iron be given in combination with ascorbic acid to enhance absorption.

In patients with insufficient IF and achlorhydria recommend other forms of B12 such as sublingual, intranasal, or IM to prevent deficiency.

Consider recommendation of an oral vitamin B liquid complex to provide additional prophylaxis.

Weight loss after surgery improves fertility which increases risk for unplanned pregnancy.

Guidelines recommend against pregnancy for 12-18 month to prevent fetal harm due to potential nutrient deficiencies.

Malabsorptive surgeries have potential to reduce absorption of oral contraceptives.

The use of copper or levonorgestrel intrauterine device (IUD) remains the recommended method due to avoiding weight gain and issues with decreased oral absorption of tablets.

Calcium & iron supplements need to be separated by at least two hours.

Iron supplements should be taken on an empty stomach to enhance bioavailability.

Folate metabolism can be altered by several anti-seizure drugs (e.g. phenytoin) so the patient needs to be monitored.

Caution with giving zinc in 50mg elemental supplements for extended period of time due to potential copper deficiency.

Metformin impairs vitamin B12 absorption; monitor for B12 deficiency.

Avoid excessive use of tea products that are high in tannins due to interaction with iron supplement.

Avoid > 1000 µg of folic acid supplementation for an extended period of time as this could mask B12 deficiency.

Cations in the vitamin and mineral supplements can interfere with fluoroquinolone absorption and counseling is required on timing of medication.

Acid reducing (e.g. proton pump inhibitors) therapy is common in this patient population and the patient need to be monitored for reduced bioavailability of the nutrients and trace elements requiring an acid environment such as thiamine, iron, B12, zinc and copper.

Patients on vitamin K antagonists should have their INR monitored closely during the early post-operative period due to potentially reduced warfarin absorption, reduced absorption of fat soluble vitamins, or reduced vitamin K intake when patients are on a liquid diet.

Dabigatran may cause a high frequency of adverse GI effects, including dyspepsia and esophagitis and may not be an ideal agent for anticoagulation.

Apixiban is potentially a good alternate anticoagulant since it is absorbed in the colon and theoretically should not be affected by malabsorptive surgeries.

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THE KENTUCKY PHARMACIST

Dec. 2016 CE — Post-Surgical Bariatric Patient Issues T2D Medication Management

    

Patient experiencing nausea/vomiting & GI symptoms

  

November/December 2016

Medications used for T2D may need to be modified due to better glycemic control post metabolic surgery.

Consider discontinuing sulfonylureas due to risk of hypoglycemia after surgery.

Insulin doses generally need to be decreased to prevent hypoglycemia after surgery.

Thiazolidinedione’s should be avoided due to weight gain..

Metformin is the best option due to lack of hypoglycemia and neutral weight gain; drawback potential diarrhea.

Assess for dumping syndrome common is these patients.

Assess for potential thiamine deficiency and recommend additional supplementation (Table 1).

Assess for Iron intolerance.

vitamins are those that have undergone malabsorptive surgeries, especially BDP/DS. Vitamin A requires micelle formation with conjugated bile acids and is mainly absorbed in the proximal jejunum. Vitamin A has been reported to be inadequate in approximately 14-17 percent of the presurgical patients and reported prevalence of deficiencies are 61-69 percent after BDP/DS and 8-11 percent after RYGB. Clinical symptoms of Vitamin A deficiency (VAD) include decreased vision, night blindness, exophthalmia, pruritus and dry hair. Night blindness is reported to be one of the earliest clinical signs of VAD. Current guidelines do not specify the dosage for post-surgical prophylaxis; however, Pereira et al. (16) has demonstrated that 10,000 IU to be optimal for malabsorptive surgeries. Plasma retinol has been deemed to be the best tool for diagnosing VAD with a reference range of 20-80 µg/dl. Additionally, retinol binding protein also can be used to help verify VAD along with symptoms of ocular changes.

medications versus the RYGB and BPD/DS. Malabsorptive procedures bypass portions of the small intestine where many drugs are absorbed and metabolized by intestinal enzyme systems. CYP3A4 which is responsible for the metabolism of the majority drugs, is the most abundant enzyme in the gut. Also, CYP2C9, CYP2C19, CYP3A5 and Pglycoprotein are present in the small intestine. Additionally, the rerouting of the GI tract decreases drug exposure to the normal acidic environment, and medications that require acid exposure for optimal absorption are likely to be affected. Medications that require longer absorption times (e.g. extended release products) are impacted by these surgeries. The most appropriate initial dosage forms recommended in the initial period after these surgeries are immediate release products that are easily absorbed such as the chewable and liquid dosage form. These are better tolerated and better absorbed as they do not require long dissolution times. Distribution of drugs also can be altered in this patient population due to the decrease in adipose tissue (reduced Vitamin K absorption occurs primarily in the distal jejunum volume of distribution) from these weight loss therapies and and ileum and similar to other fat soluble vitamins requires should be considered in the medication management of the formation of micelles. Vitamin K has a rapid turnover and these patients. Table 2 provides some counseling tips for minimal body stores and it is primarily supplied by dietary pharmacists as they relate to potential medication, drug nuphylloquinones; however, another source is colonic bacteria. trient interactions (DNIs), and health related issues with bariThere are very limited reports for vitamin K deficiency in baratric surgeries. iatric surgery population both prior to and after surgery. To Conclusion assess vitamin K status prothrombin time (PT) should be evaluated although this is not a very sensitive measure.

Pharmacists are optimally positioned because of their expertise to counsel and assist these patients with the long-term management of their chronic nutrient supplementation needs. These patients are at high risk for nutrient deficienPharmacokinetic & Pharmacological Implications: (2,10,13) cies and many potential drug nutrient interactions. One of Due to surgical alterations of the GI tract, the pharmacokithe major ongoing issues with this patient population is drug netic parameters can be significantly altered and the potenadherence as studies have demonstrated that this remains tial exists for many medication and drug-nutrient related isseriously problematic in this patient population at a low comsues and interactions. This review is primarily focused on pliance rate of approximately 30 percent. (23,24) These issues vitamin and nutrient issues so this will not be discussed in provide both a difficult challenge and great opportunity for detail. However, these surgeries, especially those more malpharmacists to expand their role in helping to manage postabsorptive have the potential to significantly alter absorption surgical bariatric patients in the ambulatory care setting. and intestinal metabolism of many medications. Restrictive procedures such as GB and SG would be expected to have References less of an impact on absorption and intestinal metabolism of 1. American Society for Metabolic and Bariatric Surgery.

Pharmacological Implications and Education Counseling

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THE KENTUCKY PHARMACIST

Dec. 2016 CE — Post-Surgical Bariatric Patient Issues

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

November/December 2016

Obesity in America reaches new highs more women -81. than ever have obesity, rates increased slightly among 14. Goldner W, Stoner JA, Lyden E, et al. Finding the optiteens. http://connect.asmbs.org/june-2016-cdc-obesitymal dose of vitamin D following Roux-en-Y gastric bynumbers.html#. pass: a prospective, randomized prospective pilot clinMechanick JI, Youdin A, Jones DB, et al. Clinical pracical trial. Obes Surg. 2009;19:173-179. tice guidelines for the perioperative nutritional, meta15. Gehrer S, Kern B, Peters T, et al. Fewer nutrient after bolic, and nonsurgical support of the bariatric surgery laparoscopic sleeve gastrectomy (LSG) than after patient—2013 update: cosponsored by American AsRoux-en-Y gastric bypass (LRYGB) a prospective sociation of Clinical Endocrinologists, The Obesity Sostudy. Obes Surg. 2010;20:447-453. ciety, and American Society for Metabolic and Bariatric 16. Pereira SE, Saboya CJ, Saunders C, Ramalho A. SeSurgery. Surg Obes Rel Dis. 2013; 9: 159-91. rum levels and liver store of retinol and their associaAdult obesity prevalence maps. (2016, Sept. 1). tion with night blindness in individuals with class III Retrieved from https://www.cdc.gov/obesity/data/ obesity. Obes Surg 2012; 2: 602-8. prevalence-maps.html.

17. Parikh, M, Johnson JM, Ballem, N. ASMBS position Defining adult overweight and obesity (2016, June 16). statement on alcohol use before and after bariatric surRetrieved from gery. Surg Obes Related Dis. 2016; 12: 225-230. http://www.cdc.gov/obesity/adult/defining.html.

18. Aills, L, et al. ASMBS bariatric nutrition guidelines.

Disease of obesity. Retrieved from Surg Obes Rel Dis. 2008. https://asmbs.org/patients/disease-of-obesity.

19. Miller, AD, Smith, KM. Medication and nutrient adminAdult obesity facts (2016, Sept. 1). Retrieved from istration considerations after bariatric surgery. Am J http://www.cdc.gov/obesity/data/adult.html.

Health Syst Pharm. 2006;63(19):1852-1857.

American Society for Metabolic and Bariatric Surgery.

20. Timpe Behnen, EM, Patula, R. Ask the expert: NSAIDS Sleeve gastrectomy surges to nearly half of all weightafter bariatric surgery. loss surgeries in America, new study finds. http:// http://www.practicalpainmanagement.com 2014 PPM. connect.asmbs.org/december-2015-sleeve-study.html.

21. Hamad, G. Bariatric surgery: postoperative and longAmerican Society for Metabolic and Bariatric Surgery. term management of the uncomplicated patient.

New guidelines call for metabolic surgery as treatment http://www.uptodate.com ©2016 UpToDate®. for diabetes. http://connect.asmbs.org/june-201622. Kushner, RF, Cummings, S, Herron, DM. Bariatric surdiabetes-recos.html. gery: Postoperative nutritional management.

Rubino, F, Nathan, DM, Eckel, RH, et al. Metabolic http://www.uptodate.com ©2016 UpToDate®. surgery in the treatment algorithm for type 2 diabetes: 23. Modi AC, Zeller MH, Xanthakos SA, Jenkins TM, Inge a joint statement by international diabetes organizaTh. Adherence to vitamin supplementation following tions. Diabetes Care. 2016 Jun; 39(6):861-877. adolescent bariatric surgery. Obesity (Silver Spring) Stein J, Stier, C, Raab, H, Weiner. Review article: the 2013; 21: E190-5. nutritional and pharmacological consequences of obe24. Brolin RE, Leung M. Survey of vitamin and mineral sity surgery. Aliment Pharmacol Ther 2014; 40: 582supplementation after gastric bypass and biliopancre609. atic diversion for morbid obesity. Obes Surg 1999; 9 Isom, KA, Andromalos, L, Ariagno, M, et al. Nutrition 150-4. and metabolic support recommendations for the bariatric patient. Nutr Clin Pract. 2014; 29(6):718-739.

Send potential continuing education topics to Scott Sisco at ssisco@kphanet.org

12. Aills, L, Blankenship, J, Buffington, C, et al. ASMBS allied health guidelines for the surgical weight loss patient. Surg Obes Related Dis. 2008;4: S73-S108.

13. Bland CM, Miller Quidley A, Love BL, et al. Long-term pharmacotherapy considerations in the bariatric surgery patient. Am J Health-Syst Pharm. 2016; 73: e469 27

THE KENTUCKY PHARMACIST

Dec. 2016 CE â&#x20AC;&#x201D; Post-Surgical Bariatric Patient Issues

November/December 2016

December 2016 â&#x20AC;&#x201D; Long-term Nutrient and Medication Related Issues in the Post-Surgical Bariatric Patient

TECHNICIAN ONLY QUIZ 1. Which vitamin deficiency has been associated with night blindness; and certain bariatric surgeries place a patient at increased risk for this potential problem?

A. Vitamin D B. Thiamine C. Vitamin A D. Vitamin E 2. Which dosage forms for nutrient supplementation should be initiated in the early post-surgical period because of improved tolerance and absorption?

A. Liquid formulations B. Extended release formulations C. Enteric coated dosage forms D. Film coated tablets 3. Which of the following nutrients/vitamins deficiencies does not involve neurological disorders?

A. Folic acid B. Thiamine C. Vitamin B12 D. Copper 4. Which vitamin should be given with the calcium supplement to enhance absorption of calcium and improve bone health for the bariatric patient?

A. Vitamin E B. Vitamin K C. Vitamin A D. Vitamin D 5. Which bariatric surgery would cause the most concern with the absorption of fat soluble vitamins?

A. Gastric banding (GB) B. Roux-en-Y gastric bypass (RYGB) C. Sleeve gastrectomy (SG) D. Biliopancreatic diversion with duodenal switch (BPD/ DS)

6. What vitamin may need to be given sublingual, intranasal or intramuscularly if adequate oral absorption cannot be maintained because of reduced gastric acid exposure after bariatric surgery?

A. Folic acid B. Thiamine C. Vitamin A D. Vitamin B12 7. Which vitamin is not part of a routine supplementation care plan in the post-surgical period due to lack of evidence for deficiency?

A. Thiamine B. Folic acid C. Vitamin D D. Biotin (B7) 8. Which vitamin or trace element nutrient, when given orally, may cause GI upset and contribute to potential patient issues with compliance?

A. Copper B. Zinc C. Iron D. Selenium 9. This vitamin or nutrient deficiency could lead to a condition known as beriberi and may cause potential neurological and cardiovascular complications?

A. Zinc B. Copper C. Folic acid D. Thiamine 10. Which nutrients or vitamins routinely given to bariatric patients should not be given in close proximity to one another or in combination to reduce the potential for a nutrient interaction reducing absorption?

A. Calcium and iron supplements B. Vitamin D and calcium supplements C. Iron and vitamin C supplements D. Zinc and selenium supplements

Are you connected to YOUR KPhA? Join us online!

Facebook.com/KyPharmAssoc Facebook.com/KPhANewPractitioners @KyPharmAssoc @KPhAGrassroots

KPhA Company Page

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THE KENTUCKY PHARMACIST

Dec. 2016 CE â&#x20AC;&#x201D; Post-Surgical Bariatric Patient Issues

November/December 2016

December 2016 â&#x20AC;&#x201D; Long-term Nutrient and Medication Related Issues in the Post-Surgical Bariatric Patient

PHARMACIST ONLYQUIZ 1. Methylmalonic acid is a highly sensitive screening tool to evaluate the nutritional status of which of the following nutrients?

A. Folic acid B. Ascorbic acid C. Vitamin A D. Vitamin B12

7. Metformin may decrease the absorption of which of the following vitamins and requires monitoring to prevent a potential deficiency?

A. Folic acid B. Thiamine C. Vitamin D D. Vitamin B12

2. Which trace element or vitamin would need to be supplemented when giving zinc in fairly high doses to prevent a potential deficiency?

A. Copper B. Selenium C. Vitamin D D. Calcium

8. Which vitamin deficiency is associated with night blindness and this symptom should be routinely monitored in post-surgical bariatric patients?

A. Vitamin A B. Vitamin D C. Vitamin K D. Vitamin E

3. Which of the following bariatric surgeries is the most malabsorptive and places the patient at the greatest risk for nutrient deficiencies?

A. Gastric Banding (GB) B. Biliopancreatic diversion with duodenal switch (BPD/ DS) C. Roux-en-Y gastric bypass (RYGB) D. Sleeve Gastrectomy (SG)

9. What is the minimum daily maintenance supplementation of Vitamin D according to ASMBS that is recommended for patients who have undergone bariatric surgeries in the early post-surgical period and titrated to 25(0H) D > 30 ng/dl?

A. 3000 IU B. 2000 IU C. 5000 IU D. 10,000 IU

4. When a patient experiences episodes of vomiting after bariatric surgery what vitamin deficiency might be expected and would require supplementation?

A. Thiamine (B1) B. Cyanocobalamin (B12) C. Vitamin D D. Folic acid

10. Which vitamin or nutrient, when supplemented, can mask the deficiency of another vitamin or nutrient with similar deficiencies and if left untreated may result in serious neurological complications?

A. Thiamine can mask the deficiency of copper which can result in this complication.

B. Copper can mask the deficiency of thiamine which can result in this complication.

C. Vitamin B12 can mask the deficiency of folic acid which can result in this complication.

D. Folic acid can mask the deficiency of vitamin B12 which can result in this complication.

5. Which of the following medications should be avoided in a patient who has undergone bariatric surgery due to potential serious complications?

A. Proton pump inhibitors (PPIs) B. Nonsteroidal anti-inflammatory drugs (NSAIDS) C. Anticoagulant agents D. Fat soluble vitamins 6. Benefits of metabolic surgery have been well established in which of the following chronic disease states?

A. Hypertension B. Type 2 Diabetes C. Hyperlipidemia D. Cancer

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THE KENTUCKY PHARMACIST

Dec. 2016 CE — Post-Surgical Bariatric Patient Issues

November/December 2016

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: November 17, 2019 Successful Completion: Score of 80% will result in 2.0 contact hours or .2 CEUs. Participants who score less than 80% will be notified and permitted one re-examination.

TECHNICIANS ANSWER SHEET. December 2016 — Long-term Nutrient and Medication Related Issues in the Post-Surgical Bariatric Patient (2.0 contact hours) Universal Activity # 0143-0000-16-012-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 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

Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve 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 December 2016 — Long-term Nutrient and Medication Related Issues in the Post-Surgical Bariatric Patient (2.0 contact hours) Universal Activity # 0143-0000-16-012-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 Achieve 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.

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

THE KENTUCKY PHARMACIST

Kentucky Renaissance Pharmacy Museum

November/December 2016

The Kentucky Renaissance Pharmacy Museum offers several ways way to show support of the Museum, our state's leading preservation organization for pharmacy.

While contributions of any size are greatly appreciated, the following levels of annual giving have been established for your consideration.

Friend of the Museum $100  Proctor Society $250 Damien Society $500 Galen Society $1,000 Name______________________________________ Specify gift amount________________________ Address ____________________________________ City____________________Zip______________ Phone H____________________W________________ Email___________________________________ Employer name_____________________________________________________for possible matching gift.

Tributes in honor or memory of_____________________________________________________ Mail to: Kentucky Renaissance Pharmacy Museum, P.O.Box 910502, Lexington, KY 40591-0502 The Kentucky Renaissance Pharmacy Museum is a non-profit 501(c)(3) business entity and as such donations are tax deductible. A notice of your tax deductible contributions will be mailed to you annually.

For more information on the Kentucky Renaissance Pharmacy Museum, see www.pharmacymuseumky.org or contact Gloria Doughty at g.doughty@twc.com.

Kentucky Pharmacists Political Advocacy Contribution Form Name: _________________________________ Pharmacy: ___________________________ Address: _______________________ City: ________________ State: _____ Zip: ________ Phone: ________________ Fax: __--_______________ E-Mail: __________________________________ Contribution Amount: $_________ Check ____ (make checks payable to KPPAC)

Mail to: Kentucky Pharmacists Political Advocacy Council, 96 C Michael Davenport Blvd., Frankfort, KY 40601

CONTRIBUTION LIMITS The primary, runoff primary and general elections are separate elections. The maximum contribution from a PAC to a candidate or slate of candidates is $1,000 per election.

Individuals may contribute no more than $1,500 per year to all PACs in the aggregate.

In-kind contributions are subject to the same limits as monetary contributions.

Cash Contributions: $50 per contributor, per election.

Contributions by cashier’s check or money order are limited to $50 per election unless the instrument identifies the payor and payee. KRS 121.150(4) Anonymous Contributions: $50 per contributor, per election, maximum total of $1,000 per election.

(This information is in accordance with KRS 121. 150)

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THE KENTUCKY PHARMACIST

KPhA New and Returning Members

November/December 2016

KPhA Welcomes New and Renewing Members Sept. â&#x20AC;&#x201D; Oct. 2016 Michael Scott Akers Grayson

Candace Bryant Nashville, Tenn.

Sarah Durham Amherst, N.Y.

Cynthia Akers Grayson

Melissa Burgess Paducah

Bruce T Eckerle Louisville

Jennifer Anderson Morehead

Johnny Walker Burke Prestonsburg

Mark S Edwards Richmond

Robin Applegate Nicholasville

Kenneth D Calvert Glasgow

Cathy Edwards Richmond

Charla Ann Applegate Nicholasville

Marietta L Campoy Pikeville

Joseph Max Eiler Louisville

Thomas L Arnold Nicholasville

Vickie Chaudry Corbin

Rita Etter Williamson, W.Virg.

Deronda Kay Back Jackson

Donald Dale Clark Rockfield

Brian E Fingerson Louisville

Nancy Horn Barker Winchester

William Scott Clark Louisville

Jennifer L Fitch Lexington

Amy Gordon Louisville

Kerri L Barman Scottsville

Charles R. Clifton Fort Thomas

Laura H Fleener Leitchfield

Linda L Gormley Villa Hills

Ronald E Barned Glasgow

Rhonda Cochran Liberty

William K Fleming Prospect

Daniel K Gray London

Keith Barnes Elizabethtown

Elizabeth Cole Louisville

Charles R Fletcher Monticello

Scott A Greenwell Prospect

Walter Michael Bauman Danville

Samuel Joseph Coletta Covington

Jane J Fletcher Leitchfield

Marsha Greer-Arnold Louisville

Justin Bell Georgetown

Kimberly Lynn Corley Owensboro

Shane Fogle Central City

Jack B Gross Louisville

Jim R Bell Sebree

Ann Rehm Cowden Lexington

Timothy L Ford Campbellsville

R. Kip Guy Lexington

Lauren Nicole Belt Lexington

Randy D Crawford Franklin

Andy France Covington

Pamela Haeberlin Louisville

Robert Michael Bero New Bern, N.C.

Carmen Maria Cress Stanton

Virginia France Covington

Rhonda A Hamilton Owensboro

Joseph A Bickett Louisville

Melvin R Croley Park City

Julian Simms Frank Paris

Gary Hamm Elizabethtown

John Russell Biddle Louisville

Marcelle R Curtis Shelbyville

Tom Roe Frazer Sturgis

Kimberly Renee Hardeman Morehead

James C Brown Bowling Green

Kimberly Daugherty Louisville

Milton Dale Frizzell Murray

Jeffrey Harrison Tompkinsville

William Brown Wingo

Marshall Davis Paducah

Barry Frost Columbia

Lisa Hart Frankfort

Charles L Bryant Cave City

David Dubrock Arlington

Peggy Gibson Elkton

Steve Hart Frankfort

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MEMBERSHIP MATTERS: To YOU, To YOUR Patients To YOUR Profession!

THE KENTUCKY PHARMACIST

KPhA New and Returning Members

November/December 2016

Amanda Helton Pathfork

Courtney Ashley Kleppinger Berea

Aleshea Martin Crestwood

Clarinda Newell Greenup

Emily C. Henderson Shelbyville

Jerry Knifley Columbia

William Pat Mattingly Lebanon

Johnny P Nixon Tompkinsville

Mike Paul Herald Hazard

Kerry Knochenmus Louisville

Charlene McCown Grayson

Jamie Norman Russellville

Tiffany Herald Hazard

Robert Knott Paducah

Sheldon M. McCreary Louisa

Freddie M. Norris Glasgow

Kashiwa Dionna Hereford Newburgh, Ind.

Molly H Kulp Louisville

John J. McDaniel Lexington

Kenneth Norwood Louisville

Linette Hieneman Flatwoods

Michael Kupper Louisville

William I. McMakin La Grange

Fred Nowak Independence

Michael D Horne Georgetown

Richard S. Lacefield Bowling Green

John McMeans Ashland

Robert S Oakley Louisville

Jerry J Horwitz Cincinnati, Ohio

Kymberli A Lander-Douglas Frankfort

Nicole Maroudas McNamee Forest Hills

Jeff O'Connor Frankfort

Celina Howell Pikeville

Judith B Lawson Monticello

Janet Mills Louisville

Jennifer A O'Hearn Louisville

Bryan Howze St. Augustine, Fla.

Jill E Lee Frankfort

Jeffry D Mills Louisville

Samantha Orth Gainesville, Fla.

James Howze St. Augustine, Fla.

Robert Lester Elkhorn City

Jesica Mills Owensboro

Dennis Parker Glasgow

Gerard M. Hyland London

Paul K Lewis Louisville

Boyd Roger Minnich Mount Sterling

Jennifer D Parker Florence

Patrick James Louisville

Douglas Linger Georgetown

Emily Gale Morton Hardinsburg

Vincent Peak Louisville

Phillip Johnson Georgetown

Leslie Little Richmond

Steven J Mueller Petersburg

Charles W. Peal Lexington

Ella L Johnson Hazard

Aaron Lohnes Stanville

Shelia Mullins Richmond

Michael Perdue Catlettsburg

Karen Knight Jones Gilbertsville

Robert Long Louisville

Lance Murphy Clarksville, Tenn.

Robert Perkins Clinton

Megan Kappes Fort Mitchell

Terry Manley Mount Sterling

David Nation Owensboro

Walter William Powell Louisville

David E Kemplin Lexington

Ashley Nicole Marlin Louisville

Troy Neagle Glasgow

Roger Powers Williamsburg

Melissa Brewer Kennon Lexington

John Marshall Henderson

James Rodney Neat Louisville

Gary Preece Prestonsburg

Ethan Klein Louisville

Charles Matt Martin Crestwood

William Nebel Eddyville

Kris Preston Pikeville

KPhA Honorary Life Members Ralph Bouvette, Leon Claywell, R. David Cobb, Gloria Doughty, Ann Amerson Mazone, Kenneth Roberts

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John Russell Prine Bowling Green Meghann Randolph Somerset Amanda Rapson-McCoy Hebron

THE KENTUCKY PHARMACIST

KPhA New and Returning Members

November/December 2016

Nicholas Rawe WIlder

Mary Roberts Scott Robinson Creek

Cindy D Stowe Louisville

Julie Warren Gamaliel

James Ray Hopkinsville

Michael C. Sheets Fisherville

David Riley Stultz Greenup

L Dwayne Watson Paducah

Wendy Renfrow Barlow

Kelli Shirley Glasgow

Tracy Sullivan Paducah

Stacy Wedeking Metropolis, Ill.

C. Levi Rice Beaver Dam

Jarrod Shirley Glasgow

Richard Sutton LaCenter

Kim Wheatley Bardstown

Patsy Richards Hustonville

Sherri M. Short Richmond

Carolyn Taylor Crestwood

McKay Whiting Reeseda, Calif.

Jerry Rickard Madisonville

JD Shoulders Bowling Green

David Taylor Crestwood

David Whitley Russellville

Eugene Carroll Riley Russellville

Angela Shoulders Bowling Green

Brittany N. Taylor Lancaster

Ronald E Whitmore Alvaton

Stewart Riley Elkton

Joe Simmons Glasgow

Gloria J Taylor Louisville

Kim Wilkerson Frankfort

Elizabeth Anne Riner Louisville

Brent Allen Simpkins Lexington

Paul A. Thompson Harrodsburg

Lewis Wilkerson Frankfort

Kristie Michelle Roark-Hampton Angela Rose Slaughter Whitesburg Covington

Deborah B Thorn Bowling Green

Eric Willis Lexington

Pheli Roberts Louisville, KY

Tina Annie Slider Louisville

Joel Thornbury Pikeville

Bruce Allan Wilson Radcliff

Brandy Marie Robertson Barlow

Evelyn Cole Smith Campbellsville

Sandy Thornbury Pikeville

Carol Wishnia Louisville

James Robinette London

Linda F Soper Carlisle

Patricia Thornbury Lexington

Jacob Wishnia Louisville

Lynda Romeo Louisville

Andrea Spaulding Burlington

Brenda Turner Jackson

Simon Wolf Louisville

Morgan Rothbauer Hopkins, S.C.

Chelsea Stamper Harrodsburg

G Steven Underwood Louisville

William D Wooden Leitchfield

Elizabeth Routh Louisville

Glenn W Stark Frankfort

Benjamin Vice London

Grady A Wright Georgetown

Ashley Nicole Saling Mammoth Cave

Doris Stone Kevil

Kelly Jo Walker Philpot

Arnold Zegart Prospect

Ryan M. Sawyer Lexington

Jack Stone Mayfield

Robert Wallace Dry Ridge

Ellen Louise Schueler Franklin

Larry Stovall Scottsville

Todd Walters Pineville

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Ask them to join YOU in supporting OUR KPhA!

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Email ssisco@kphanet.org to be placed on the Green list for electronic delivery.

Once the journal is published, you will receive an email with a link to the online version.

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THE KENTUCKY PHARMACIST

Pharmacy Time Capsules

November/December 2016

Pharmacy Time Capsules 2016 (Fourth Quarter) 1991  The first attempt to cure cancer by gene therapy takes place at the National Cancer Institute in Bethesda, Md. 1966  All US cigarette packs begin carrying the warning: “Caution!

Cigarette smoking may be hazardous to your health.”  In 1966, Medicare’s coverage took effect, as Americans age 65 and older were enrolled in Part A and millions of other seniors signed up for Part B.  The first pancreas transplantation was performed.

1941  On Dec. 7, 1941 the US was attacked by the Japanese at Pearl Harbor in Hawaii. More than 2,400 American servicemen were killed that day, and America entered the war.

1916  The unique contour bottle design of Coca-Cola is introduced.

By: Dennis B. Worthen, PhD, Cincinnati, OH One of a series contributed by the American Institute of the History of Pharmacy, a unique non-profit society dedicated to assuring that the contributions of your profession endure as a part of America's history. Membership offers the satisfaction of helping continue this work on behalf of pharmacy, and brings five or more historical publications to your door each year. To learn more, check out: www.aihp.org

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THE KENTUCKY PHARMACIST

Pharmacy Law Brief

November/December 2016

Pharmacy Law Brief: Legal Research Topics of Interest

Author: Joseph L. Fink III, B.S. Pharm., J.D., Professor of Pharmacy Law and Policy and KPhA Professor of Leadership, Department of Pharmacy Practice and Science, UK College of Pharmacy Question: I know that faculty members are expected to conduct research as part of their position responsibilities.

What are some contemporary research issues of interest to pharmacy law faculty? I remember from pharmacy school some of the pharmaceutical science and clinical practice faculty discussing their research topics. What legal topics are at the forefront where pharmacy intersects with the law?

Response: The answer to this question is indeed a moving target as new topics of interest and importance come and go. At the outset, however, it may be helpful or instructive to provide a definition of legal research. Pharmacists are familiar with research involving test tubes, white mice or clinical study volunteers or they may recall from a college course on statistics the important role of hypothesis testing in scientific research; they’re less familiar with legal research. The scope and methods of legal research have changed over the years as electronic databases of legal decisions and other legal resources have been created to replace the row upon row of law books that often provide the backdrop for television shows or movies involving the law. In fact, a July 2016 article in the journal of the Kentucky Bar Association addressed the changing role of the law library, traditionally the hub of legal research.1 There are many definitions of legal research. Here is one from a textbook on that topic: “Legal research is the process of identifying and retrieving information necessary to support legal decision-making. In its broadest sense, legal research includes each step of a course of action that begins with an analysis of the facts of a problem and concludes with the application and communication of the results of the investigation.”2 The multi-step process involved identifying sources of information relevant to the legal issue being explored, retrieving that from appropriate sources, evaluating that for relevance, either positive or negative, to the issue or topic being investigated, marshalling that information in an organized and understandable discussion of the matter and presenting that clearly to advance or refute a point.

This list represents an attempt to set forth some contemporary issues with the list presented in no particular order of importance or interest.

Submit Questions: jfink@uky.edu 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.



Legal issues surrounding stocking and dispensing of Plan B

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Death with Dignity statutes

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Prescribing by pharmacists as in Oregon and California



Legal framework for expanded availability of naloxone

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Continuing issues with OBRA ’90

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Evolving legal duties of the pharmacist

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Legal issues with marijuana for medicinal or recreational use

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Categories of classification of medication

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Legal issues with biosimilars

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Prescription drug monitoring programs and privacy issues

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Interplay of U.S. regulation of pharmaceuticals with such regulatory schemes in place in other parts of the world



Right to Try legislation



Regulation of telehealth activities

Scholarly discussions of recent court decisions and trends in litigation are always appropriate to enable professionals to keep up with how courts, judges and juries are viewing the field. And just as students can participate in scholarly activities in a structured research group or laboratory, this also may occur with legal topics or issues.

Readers may note that the list of topics above does not match to any great extent the issues covered in their required course covering the laws applicable to pharmacy practice they took while in pharmacy school. Just as what

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EPIC Pharmacies

November/December 2016 APhA MRM Region 4 2016

a, say, pharmacologist covers in lecture differs from what he or she is currently studying in the lab, the same may well be true for a faculty member whose scholarly focus is the law.

Finally, conducting the scholarly research does no one much good unless it is effectively communicated to others. Presenting the findings of the research is essential. One may have heard the admonition directed at faculty members to “Publish or perish!” Publications are the “coin of the realm” in academe and play a large role in performance evaluations, both those done annually and others conducted less frequently for consideration of making promotion or tenure decisions.

Thanks to KPhA Student Directors Katherine Keeney and Kevin Chen for coordination of KPhA’s Expo booth at this year’s APhA MRM Region 4 meeting in October in Cincinnati. Roamey enjoyed the ride and meeting lots of new friends.

References: 1. Brooks TN, Runge FL, Steenken B. The Future of Law Libraries. Kentucky Bench & Bar 2016(July);80:18-23.

2. Jacobstein JM, Mersky RM. Fundamentals of Legal Research (8th ed.) St. Paul, MN: Foundation Press (2002), p. 1.

Join us for the 139th KPhA Annual Meeting & Convention!

June 22-25, 2017 Griffin Gate Marriott Resort, Lexington

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Pharmacy Policy Issues

November/December 2016

PHARMACY POLICY ISSUES:

OTC Medication Education for Children Author: Erika Darnell Young is a PY2 student at the University of Kentucky College of Pharmacy. A native of Benton, Ky., she completed her pre-professional education at UK with a major in Chemistry.

Issue: Children are beginning to self-medicate at younger ages, leading to increased incidence of overdoses and medication misuse. This leads to an increased burden on emergency departments and poison control centers, as well as causing trauma to the children and their families. How should policy be changed to prevent this from occurring? public school curriculum at any age Discussion: Children are beginning Have an Idea? to self-medicate with OTC medicalevel.4 Students in areas without a This column is designed to tions at younger ages. A recent study local college of pharmacy with an acaddress timely and practical has shown that a majority of children tive APhA student chapter are mississues of interest to pharmacists, start self-medicating at 11-12 years ing out on this vital education that pharmacy interns and pharmacy old, and 90 percent of 16-year-old could prevent over-dosages, emertechnicians with the goal being to adolescents report self-medicating.1 gency room visits and perhaps even encourage thought, reflection and This increase in self-administration of deaths. Students older than 5th-6th exchange among practitioners. medications can become dangerous, grade also are missing out on this Suggestions regarding topics for leading to accidentally overdosing on education. In classrooms across the consideration are welcome. Please medications that children do not know US, health education is mandatory at send them to jfink@uky.edu. how to use properly, or that they think all levels of education. In these clasare safer than other drugs because ses, students learn about Sexually they can be purchased without a preTransmitted Infections and what comscription. It has been estimated that 71,224 emergency ponents make up a healthy meal. In such classes, OTC room visits were made by children 18 years old and young- medication education would be a natural addition to teach er for unintentional medication overdoses2 and in 2013 the students how to read and interpret labels in order to more US poison control centers handled 250,000 exposure cases safely use these medications. involving children ages 6 to 19, with half of those being due Adding OTC medication safety to state curriculum requireto medication errors or misuse.3 How do we prevent these ments would help teach all students how to understand laemergency room visits and poison control calls in our pabels on medications and the importance of using medicines tients? correctly, not just those students lucky enough to be in the Many people have turned to patient education. In a study same community as a college of pharmacy. Educating stuamong 8th graders in New Hampshire, before an OTCdents will prevent unintentional overdoses and decrease education presentation was given, only two-thirds of the the burden of overdose on emergency departments and participants were able to read and interpret OTC drug prod- families alike. uct labels correctly.1 Following a presentation on how to References: understand and correctly use OTC medications, the number 1. Abel C, Johnson K, Waller D, Abdalla M, and Goldsmith of students who could accurately interpret the label infor1 CW. Nonprescription Medication Use and Literacy mation increased to almost 90 percent. The American among New Hampshire Eighth Graders. J Am Pharm Pharmacists Association, in collaboration with Scholastic, Assoc. 2012:777-787. began an initiative to promote OTC education among 5th and 6th grade students after seeing the previous statistics 2. Schillie, SF. et al. Medication Overdoses Leading to and the positive impact of education. Many student chapEmergency Department Visits Among Children. Am J ters of APhA, such as the one at the University of Kentucky, Prevent Med. 2009;37:181â&#x20AC;&#x201C;187. are involved in educating this age group in schools in the 3. Mowry JB, Spyker DA, Cantilena LR Jr, Bailey JE, Ford local vicinity to their college.

M. 2012 Annual Report of the American Association of However, many elementary and middle school students Poison Control Centersâ&#x20AC;&#x2122; National Poison Data System who need this information are not being reached. Currently, (NPDS): 30th Annual Report. Clin Toxicol (Phila). states do not require coverage of medication safety in their 2013;51(10):949-1229.

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THE KENTUCKY PHARMACIST

November/December 2016

KPERF Naloxone Certification Training 4. US Department of Health and Human Services, Centers for Disease Control and Prevention. (n.d.). StateLevel School Health Policies and Practices Study: 2014

Overview (pp. 2-4). https://www.cdc.gov/healthyyouth/ data/shpps/ pdf/2014factsheets/2014_overview_fact_sheet.pdf.

KPERF Naloxone Certification Training The online training program can be found at the following link on the KPhA website: http://www.kphanet.org/?page=NaloxoneCert2015 The cost of the training is $5 for KPhA members, and $10 for non-KPhA members. After successfully completing the course, credit will be applied to your CPE Monitor Profile and you will be emailed a certificate of completion.

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November/December 2016

Pharmacists Mutual

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Cardinal Health

November/December 2016

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KPhA Board of Directors/Staff

November/December 2016

KPhA BOARD OF DIRECTORS

HOUSE OF DELEGATES

Chris Clifton, Villa Hills chrisclifton@hotmail.com

Chair

Lance Murphy, Louisville lancemurphy84@gmail.com

Trish Freeman, Lexington trish.freeman@uky.edu

President

Amanda Jett, Louisville ajett@sullivan.edu

Chris Harlow, Louisville cpharlow@gmail.com

President-Elect

KPERF ADVISORY COUNCIL

Brooke Hudspeth, Lexington brooke.hudspeth@kroger.com

Secretary

Christen S Bruening, Cincinnati, Ohio cmschenkenfelder@gmail.com

Chris Palutis, Lexington chris@candcrx.com

Treasurer

Matt Carrico, Louisville matt@boonevilledrugs.com

Jessika Chinn, Beaver Dam jessikachilton@ymail.com

Past President Representative

Vice Speaker of the House

Kim Croley, Corbin kscroley@yahoo.com Kimberly Daugherty, Louisville kdaugherty@sullivan.edu

Directors Matt Carrico, Louisville* matt@boonevilledrugs.com Kevin Chen, Lexington kevin.chen@uky.edu

Speaker of the House

Mary Thacker, Louisville mary.thacker@att.net University of Kentucky Student Representative

Chad Corum, Manchester pharmdky21@gmail.com Matt Foltz, Villa Hills mfoltz@gomedcare.com Cathy Hance, Louisville cathy@compoundcarerx.com Cassy Hobbs, Louisville cbeyerle01@gmail.com Katherine Keeney, Louisville Sullivan University KKEENE6675@my.sullivan.edu Student Representative Chris Killmeier, Louisville cdkillmeier@hotmail.com Jeff Mills, Louisville jeff.mills@nortonhealthcare.org Richard Slone, Hindman richardkslone@msn.com Sam Willett, Mayfield duncancenter@bellsouth.net * At-Large Member to Executive Committee

KPhA/KPERF HEADQUARTERS 96 C Michael Davenport Blvd., Frankfort, KY 40601 502.227.2303 (Phone) 502.227.2258 (Fax) www.kphanet.org www.facebook.com/KyPharmAssoc www.twitter.com/KyPharmAssoc www.twitter.com/KPhAGrassroots www.youtube.com/KyPharmAssoc Robert McFalls, M.Div. Executive Director rmcfalls@kphanet.org Scott Sisco, MA Director of Communications & Continuing Education ssisco@kphanet.org Angela Gibson Director of Membership & Administrative Services agibson@kphanet.org Leah Tolliver, PharmD Director of Pharmacy Emergency Preparedness ltolliver@kphanet.org Elizabeth Ramey Receptionist/Office Assistant eramey@kphanet.org

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THE KENTUCKY PHARMACIST

50 Years Ago/Frequently Called and Contacted

November/December 2016

50 Years Ago at KPhA SWINTOSKY NAMED DEAN Dr. Joseph V. Swintosky, Head, Pharmaceutical Research Section at Smith Kline & French Laboratories, Philadelphia, Pennsylvania, has been named Dean of the University of Kentucky College of Pharmacy, ending a two year search for a replacement for Dean Earl P. Slone, who, during much of that period was abroad with UKâ&#x20AC;&#x2122;s technical assistance program in Indonesia.

Dr. Arthur C. Glasser has been serving as acting Dean of the College of Pharmacy.

- From The Kentucky Pharmacist, December 1966, Volume XXIX, Number 12.

Frequently Called and Contacted Kentucky Pharmacists Association 96 C Michael Davenport Blvd.

Frankfort, KY 40601 (502) 227-2303 www.kphanet.org Kentucky Board of Pharmacy State Office Building Annex, Ste. 300 125 Holmes Street Frankfort, KY 40601 (502) 564-7910 www.pharmacy.ky.gov Pharmacy Technician Certification Board (PTCB) 2215 Constitution Avenue Washington, DC 20037-2985 (800) 363-8012 www.ptcb.org

Kentucky Society of Health-System Pharmacists P.O. Box 4961 Louisville, KY 40204 (502) 456-1851 x2 (502) 456-1821 (fax) www.kshp.org info@kshp.org American Pharmacists Association (APhA) 2215 Constitution Avenue NW Washington, DC 20037-2985 (800) 237-2742 www.aphanet.org

National Community Pharmacists Association (NCPA) 100 Daingerfield Road Alexandria, VA 22314 (703) 683-8200 info@ncpanet.org Drug Information Center Sullivan University College of Pharmacy 2100 Gardiner Lane Louisville, KY 40205 (502) 413-8638 www.sullivan.edu Kentucky Regional Poison Center (800) 222-1222

KPhA Government Affairs Contribution Name: _______________________________Pharmacy: _____________________________

Email: ______________________________________________________________ Address: _____________________________________________________________ City: ___________________________________________ State: _________ Zip: ____________ Phone: ________________ Fax: __--_______________ E-Mail: _____________________________ Contribution Amount: $_________ Check ____ (make checks payable to KPhA Government Affairs)

Mail to: Kentucky Pharmacists Association, 96 C Michael Davenport Blvd., Frankfort, KY 40601

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November/December 2016

THE

Kentucky PHARMACIST 96 C Michael Davenport Blvd.

Frankfort, KY 40601

SAVE THE DATE

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