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Palmetto Pharmacist

The Official TheJournal Officialof Journal the South of the Carolina South Carolina Pharmacy Pharmacy Association Association• Vol. Vol.58,53, Num. Num. 4 5

Creating Convention Memories With SCPhA Megan Montgomery

2018-2019 SCPhA President and Board Chair

PRSRT STD US POSTAGE PAID COLUMBIA, SC PERMIT 1353 Palmetto Pharmacist • Volume 58, Number 4

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Palmetto Pharmacist • Volume 58 Number 4


Volume 58, Issue 4

July/August 2018

The Palmetto Pharmacist, the official publication of the South Carolina Pharmacy Association, is distributed to association members as a membership service. Statements of fact and opinion are made by the authors alone and do no imply an opinion on the part of the officers or members of SCPhA. For advertising rates and other information, contact SCPhA. 2018-2019 Board of Directors President/Board Chair Megan Montgomery Immediate Past President Kayce Shealy

What’s Inside...

Treasurer Pamela Whitmire Director-At-Large Will Brumfield Midlands Region Director Jennifer Baker

Pee Dee Region Director Jarrod Tippins Upstate Region Director Ron Guida Speaker, House of Delegates Elliot Turner Speaker-Elect, House of Delegates Brian Clark CEO Craig Burridge General Counsel Jon Wallace Midlands Delegates Kelly Clark Taylor Evans Carmen Monts Alyssa Norwood

Low Country Delegates Cynthia Feldman

Pee Dee Delegates John Carmichael Kelly Jones Jillian Wilkes

Upstate Delegates Maggie Blauret Deborah Bowers Linda Reid Tiffaney Threatt SCPhA Staff Craig Burridge Chief Executive Officer

Cassandra-Hicks Brown COO/CEA

Lauren Palkowski Director of Communications & Conferences

Katharine Stafford Keller Director of Membership & Special Events Santana Goodwin Administrative Assistant

Jon Wallace General Counsel Cecily DiPiro PPN Network Coordinator Journal CE Review Chair Sarah Braga

Journal Peer Review Committee Sarah Braga Amber Giles Briana Murray Kelly Winters

5 President’s Platform “Did You Miss It?”, SCPhA President Megan Montgomery 8 SCPhA Annual Convention Wrap-Up

President-Elect David Shirley

Low Country Region Director Justin Davis

16 Student Perspective: Global Awareness Institute- Natural Medicines Rotation in Peru Nicolle Dambly, PharmD Candidate Class of 2018, SCCP-USC and Nikita Morse, PharmD Candidate Class of 2018, SCCP-USC 25 Journal CE: Pharmacogenomics: Proof That One Size Does Not Fit All Erika E. Tillery, PharmD, BCPP, BCGP, Melanie Routhieaux, PharmD Candidate Class of 2018, Presbyterian College School of Pharmacy, and Jessica Keels, PharmD Candidate Class of 2018 Presbyterian College School of Pharmacy

Regular Columns 19 Financial Forum 20 South Carolina College of Pharmacy 21 Presbyterian College School of Pharmacy 23 Rx and the Law 35 Classifieds Advertisers 2 Smith 4 Pharmacists Mutual 6 McKesson 6 Bayer Healthcare 7 Epic Pharmacies 18 Epic Pharmacies 22 Rx Planning Solutions 22 Mutual Drug 24 Health Mart 34 Pharmacy Quality Commitment 34 Laurel Road 35 Jon Wallace, Attorney at Law Events At-A-Glance NACDS Pharmacy-Based Point of Care- August 17, 2018 CE Escape- December 1-2, 2018 SE Girls of Pharmacy Leadership Weekend- January 18-20, 2019

Palmetto Pharmacist • Volume 58, Number 4

CE at Sea Cruise- May 18-23, 2019

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Palmetto Pharmacist • Volume 58 Number 4


PRESIDENT’S PLATFORM

Did You Miss It? If you did not attend our 142nd Annual Convention...the answer is Yes. Yes, you did miss it! Spending a weekend indoors at a beachfront resort listening to educational programming may not look exciting on paper…and there were times I caught my mind wandering to the long list of to-dos I could be crossing off had I stayed home, but every minute spent at convention was completely worth it. Convention Kick-Off Thursday’s programming started off with a presentation about CPESN (Community Pharmacy Enhanced Services Networks) and its patient focused model for improving outcomes while decreasing overall healthcare costs. After a fun hour of socializing, the discussion shifted to the role of pharmacists in a team based healthcare model utilizing collaborative practice agreements. Day 1 ended just in time to dine at one of Hilton Head Island’s many wonderful restaurants. Day of Education Friday was THE day to rack up many CE credits. We hit the ground running with a controlled substance update, and the financial management CE included practical information for everyone. Dr. Tracy Foo, MD (a renowned advocate for pharmacist immunization) presented a thorough review of the HPV virus, ACIP guidelines, and how to approach the topic with patients. We ended our afternoon discussing the biological and socioeconomic factors affecting the aging baby boomers. Sandwiched between the educational programming was a hopping exhibit hall complete with good food, great door prizes, and more time to mingle with peers. The evening culminated in games and costumes, some quite unforgettable! *I may or may not have snuck into the student trivia. Apparently I am behind in my knowledge of comic books. Day of Fun Saturday started with a little business at the House of Delegates. This meeting is open to all and is a great review of the previous year’s goals and projects as well as a time to acknowledge those who served in varying capacities. Election results were announced, and we welcomed Justin Davis and Will Brumfield to the Board. If any attendees were not yet awake by the start of programming, the Immunization Update was surely their morning cup o’ joe! Dr. Carrie Smoak’s convention speaking debut was full of energy, and her practical approach to increasing vaccination rates in the community setting was well received. The Self-Care trivia bowl was one to remember! We witnessed President Kayce Shealy channel her alter ego of DJ Prezzy K as this nail biting competition came down to the Palmetto Pharmacist • Volume 58, Number 4

Megan Montgomery

2018-2019 SCPhA President and Board Chair

final question! This fierce showdown relied heavily on judgment calls and tested the OTC skills of the several spectators chosen as lifelines. In the end, USC got the W! The students from MUSC, PC, USC, and South did a fantastic job. In addition to introducing speakers and playing DJ, President Shealy was Master of Ceremonies at the Awards and Installation Dinner and seemed all too eager to hand me the reigns as President and Board Chair. We honored our Awards recipients, gave thanks to our sponsors, spotlighted former presidents, and debuted our new Board of Directors. And no Awards Dinner is complete without the Smith Drug Icebox Raid! Sunday It only seemed appropriate the convention ended with the show stopping New Drug Update with Dr. Wayne Weart. Enough said. Mic drop. Walk off stage. Normally I’d bask in the glory of having attended an event others missed, as if it gave me a one up on everybody else. Although, I would argue attending convention does give me an edge of sorts, my memories are usually contingent on the presence of others. For me, convention is where I: …met Julian Reynolds, with whom I worked for 3 years before moving back home and joining John Pugh at Prosperity Drug; …participated in my first (and only) flash mob that marked the commencement of Terry Blackmon’s leadership; …listened to the heartfelt speeches of our members receiving the prestigious Bowl of Hygeia. This year’s winner, Ron Hubbard, was no exception; …shared my vision of SCPhA’s role in taking pharmacy to new heights. 5


Convention is the time I designate each year to: • Receive all my live and required CE credits • Catch up with classmates • Network with colleagues in different sectors • Receive school updates while rubbing elbows with deans and professors • Network. Network. Network. • Acknowledge those having served our association • Induct those continuing or taking on new responsibilities • Award trailblazers and leaders of our profession • Get goofy with my theme wear • Get dressy for awards dinner • Catch some rays • Reenergize my mind and body to initiate and/or be receptive to changes as we advance pharmacy in SC What will be the memories of next year’s Annual Convention? The answers depend on a several factors... 1. Your presence 2. The education requested by our members (so fill out those surveys!) 3. The theme and your willingness to dress the part ;) 4. Our membership continuing to move and shake our profession 5. Actually marking your calendar, so… **Mark your calendars*** SCPhA’s 143rd Annual Convention- June 13-16th, 2019 at Marriott Resort, Hilton Head Island In the mean time – reach out to your Region Director with questions or concerns to bring to our Board meetings. Also, share your exciting projects and initiatives happening at your workplace or in your community. Take advantage of member benefits such as discounts to educational offerings, professional and legislative updates through our weekly Small Doses and bi-monthly Palmetto Pharmacist publications. Ask our legal counsel about situations needing clarification or guidance. Come to a House of Delegates meeting to network and advocate for our profession. Let SCPhA help keep you in the know! I ask again, did you miss it? If the answer is yes…I look forward to seeing you next year!

Fascinated

by thinking ahead

At Bayer you’re expected to be. Innovation is part of our DNA. But its not something that happens exclusively in laboratories. We see it as being open to new and unconventional approaches and perspectives. Our working culture is driven by our passion and the fascination to think ahead. That is why we encourage you to question the status quo and constantly think beyond the obvious. It takes imagination, ambition and courage to find answers to society’s most pressing questions. Passion to innovate. Power to change.

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Palmetto Pharmacist • Volume 58 Number 4


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New Law Regarding Tamper-Resistant Prescription Paper for Controlled Substances - Effective July 16, 2018 Information from SC DHEC H.3826 requires written prescriptions for controlled substances to be written on tamper-resistant prescription pads, with exceptions. Prescription orders transmitted by facsimile, orally, or electronically are exempt from the tamper-resistant prescription pad requirements. This act is effective July 16, 2018. SECTION

1.

Section 44-53-360 of the 1976 Code is amended by adding an appropriately lettered subsection at the end to read:

“( )(1) A written prescription for any Schedule II, III, IV, and V controlled substance must be written on tamper-resistant prescription pads which contain one or more industry-recognized features designed to prevent all of the following: (A) unauthorized copying of a completed or blank prescription form; (B) erasure or modification of information written on the prescription by the prescriber; and (C) use of counterfeit prescription forms. (2) Prescription orders transmitted by facsimile, orally, or electronically are exempt from the tamper-resistant prescription pad requirements of this section. (3) The tamper-resistant prescription pad requirements do not apply to refill prescriptions of an original written prescription that was presented to a pharmacy before the effective date of this act. (4) The exceptions set forth in Section 1927(k)(3) of the Social Security Act, 42 U.S.C. Section 1396r-8(k)(3), concerning nursing facilities, hospitals, and other institutional and clinical settings, are exempt from the tamper-resistant prescription pad requirements of this section. (5) If a written prescription is not submitted on a tamper-resistant prescription form meeting the requirements of this section, a pharmacy may fill the prescription in full as written on an emergency basis as long as the pharmacy receives a verbal, facsimile, electronic, or compliant written prescription from the prescriber within seventy-two hours after the date on which the prescription was filled. Palmetto Pharmacist • Volume 58, Number 4

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SCPhA Annual Convention Snapshots

June 14-17, 2018

Hilton Head Island, SC

A special thanks to all of our sponsors, exhibitors, speakers and attendees for participating in this year’s Annual Convention. Attendees learned about CPESN, Collaborating with Physicians and Patients, Financial Management, HPV Vaccination, participated in Self-Care Bowl amongst the pharmacy schools and received updates on controlled substances, pharmacy immunization as well as new drug information. We look forward to hearing about how these CE programs impact your work as pharmacy professionals! 8

Palmetto Pharmacist • Volume 58 Number 4


SCPHA 2018 Best of the Best

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Annual Convention • June 14-17, 2018

A Special Thank You to This Year's Sponsors: Platinum Sponsors

GOLD SPONSOR

Silver Sponsors

Additional Event Sponsors

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Thank You to Our Exhibitors for your Support! Abbvie Hepatology Abbvie Metabolics Adapt Pharma American Pharmacy Cooperative (APCI) Amerisource Bergen AstraZeneca Bayer Healthcare Cardinal Health CarePoint Christian Pharmacists Fellowship Int’l (CPFI) Compliant Pharmacy Alliance Display Options- Rx Planning Solutions Drug Enforcement Administration Epic Pharmacies GlaxoSmithKline Heron Therapeutics Independent Pharmacy Cooperative/PACE Integral Rx JH Batten- TN Kelestan Packaging Lilly

Magellan Rx Management McKesson Merck Molina Healthcare of SC MUSC College of Pharmacy Mutual Wholesale Drug Co Nephron Pharmaceuticals Novo Nordisk Pfizer Vaccines Pharmaceutical Dimensions Pharmacist Mutual Presbyterian College School of Pharmacy QS/1 Real Value Rx SC Board of Pharmacy SC Cancer Alliance SC DHHS-Healthy Connections SC Pharmacy Association Smith Drug Company South University School of Pharmacy USC College of Pharmacy Veletek Asscociates

Congratulations to This Year's Self-Care Bowl Winner, University of South Carolina College of Pharmacy

Congratulations to This Year's Winners of Our Contests

Social Media Post Nikki Cross $50 SCPhA Bucks for future event or SCPhA Gear

50/50 Raffle

Benifitting SCPhA Pharmacy Foundation to promote and preserve the Profession Linda Reid $627.00 10

Costume Contest

At Friday Night Event Will Brumfield, Megan Montgomery and Elliot Turner Palmetto Pharmacist • Volume 58 Number 4


SCPhA Awards 2018 Each year, the members of the South Carolina Pharmacy Association celebrate outstanding members of the profession. These men and women have displayed a great passion for pharmacy and are the recipients of SCPhA’s Annual Awards, embodying the best in pharmacy. Award recipients were nominated and chosen by their peers, the highest compliment that any professional can receive. We honor these outstanding pharmacy professionals for their contributions to their profession, their colleagues, their communities and their State Association. May these award recipients continue to bring a new dimension of honor to the profession of pharmacy and inspire others to follow in their footsteps.

Outgoing President Award

Sponsored by Smith Drug Company Each year, Smith Drug Company proudly recognizes the Outgoing President of the South Carolina Pharmacy Association. This award recognizes the Outgoing President and Board Chair for leadership, sacrifices and contributions to the association. This year’s recipient, Kayce Shealy more than demonstrated the skills of an outstanding leader. “It has been my great honor and privilege to serve as President of the South Carolina Pharmacy Association this past year. Today’s healthcare system presents so much opportunity for pharmacists, and we have been working hard to move our profession forward. This year has gone by really fast, and we still have a lot of work to do. I look forward to our leadership continuing to progress our profession.”—Kayce Shealy

Bowl of Hygeia

Sponsored by Boehringer-Ingelheim The Association is pleased to announce that Robert Hubbard was awarded SCPhA’s 2018 Bowl of Hygeia Award. “Being selected as the 2018 Bowl of Hygeia recipient is truly the pinnacle of my career as a pharmacist. I am honored to be joining such a distinguished and impressive group of past recipients, many of whom have encouraged, mentored and enriched my professional life. I am humbled by what the Bowl of Hygeia embodies and I am grateful to receive this prestigious award. Thank you for nominating me for this award and to NASPA and Boehringer Ingelheim for sponsoring the Bowl of Hygeia." - Robert Hubbard

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SCPhA Awards 2018 Pharmacist of the Year SCPhA is pleased to name Kelly Jones as 2018 Pharmacist of the Year. “What an honor to be chosen as Pharmacist of the Year. I am so grateful to SCPhA. I recently made the shift from academic to retail pharmacy. One thing I have noticed - potential. I have always said that pharmacy has not seen it’s best days. I believe that now more than ever.”- Kelly Jones

Kenneth R. Couch Distinguished Mentor Award

The Kenneth R. Couch Distinguished Mentor Award was created to recognize individuals who promote and encourage students or pharmacists to attain leadership positions and excellence in the practice of pharmacy through example as a role model and mentor. This year’s recipient is William Wynn. “I am humbled to have my name in the same sentence as Ken Couch when it comes to mentoring others on leadership. In fact, it is a good day just to stand in Ken’s shadow. I want to lead, I want to see others learn to lead, and I want to spread the message that you can succeed without others having to fail. In short, I don’t know if I deserve this recognition, but I will spend my career trying to earn it. It is truly an honor to receive the Ken Couch Distinguished Mentor Award. Thank you for your confidence.” - William Wynn

Excellence in Innovation

Sponsored by Upsher-Smith Laboratories and NASPA The Excellence in Innovation award is a national award coordinated by the National Alliance of State Pharmacy Associations, and generously sponsored by Upsher-Smith Laboratories, Inc. to recognize and honor a qualified pharmacist who has demonstrated significant innovation in their respective practice, method or service directly or indirectly resulting in improved patient care and/or advancement of the profession of pharmacy. Congratulations goes to this year’s recipient, Carmen Monts. “I am truly honored to receive this award. I am so fortunate to work with a fantastic group of pharmacists, technicians, clerks, and delivery drivers at Prosperity Drug. The work that we do at Prosperity Drug is made better by the community of providers that we work with who share the vision of collaboration in the health care team in order to improve patient care. I look forward to future opportunities for pharmacists as part of an integrated health care model.” -Carmen Monts 12

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SCPhA Awards 2018 Student Pharmacist of the Year

SCPhA would like to congratulate Bailey Newman, 2018 Student Pharmacists of the Year. Bailey has performed on an extremely high level. During her tenure, she has performed on an academically high level and has been engaged in a lot of service activities. She is involved with several professional organizations including the South Carolina Pharmacy Association, the American Pharmacists Association, the American Society of Health System Pharmacists, the Kappa Epsilon Professional Fraternity, and Phi Lambda Sigma, among others. “The last two years working with leaders, pharmacists, and peers as a member of the Junior Board have been both rewarding and challenging as a student. I have learned it takes a village of dedicated advocates to continue to better our profession for ourselves, and more importantly - our patients. I am looking forward to this last year of education and my future as a pharmacist with an open mind. It is with a humble heart that I accept this award and thank all of those at the USC College of Pharmacy and SCPhA who have helped me reach this point.” - Bailey Newman

Distinguished Young Pharmacist Award

Sponsored by Pharmacist Mutual The Distinguished Young Pharmacist award was created in 1987 to encourage newer pharmacists to become involved in association activities and civic projects, and to recognize one such pharmacist in each state for individual excellence and outstanding contributions. We’d like to congratulate Erin Blackmon-Stelling on being this year’s recipient of this award. “When I look at the list of pharmacists that have won this award before me I feel honored and can only hope that I am able to live up to those standards! I truly have a passion for the profession of pharmacy (in particular independent pharmacy) and caring for the patients in our community. Thank you to the people who nominated and voted for me to receive this award. I am shocked and so thankful!!” - Erin BlackmonStelling

Generation Rx Award

Sponsored by Cardinal Health SCPhA is pleased to annouce that Cheryl Anderson received the Cardinal Health Generation Rx Champions Award at SCPhA’s Annual Convention. This award recognizes professionals who have demonstrated excellence in community-based prescription drug abuse prevention, as well as outstanding efforts within the pharmacy community to raise awareness of this serious public health problem. “I am honored to be nominated by my peers and humbled to be chosen by the South Carolina Pharmacy Association to be this year’s recipient of the GenerationRX Award of Excellence. I share this award with my exceptional state and community pharmacy partners who share my passion, innovation and commitment to develop prescription medication safety and opioid interventions. We, as partners are making a difference by sharing evidence-based best practices and inspiring solutions to increase awareness of prescription drug abuse and misuse. ” - Cheryl Anderson Palmetto Pharmacist • Volume 58, Number 4

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SCPhA Awards 2018 Technician of the Year SCPhA is pleased to name Jameika Williams as 2018 Technician of the Year for her outstanding work. “I am so honored to be recognized by SCPhA as technician of the year. It is my privilege to be able to represent the profession of pharmacy through serving the people within my community. My goal is to bring a dose of comfort to their lives in their time of need.” - Jameika Williams

Congratulations to this year’s scholarship recipients: Ashley Chase, Rebekah Crandall, Marty Faile, Cassidy Hall, Courtney Jackson-Jones, Ashley Prentice, Maraya Ramdhani, Irene Ruiz, Coretta Sime-Toundji, Christi Smith and Sara Tavares.

Save the Date! SCPHA’s 2019 Annual Convention June 13-16, 2019 Marriott Resort Hilton Head Island, SC 14

Palmetto Pharmacist • Volume 58 Number 4


CE Escape December 1-2, 2018 Omni Resort Hilton Head Island, SC Registration Opening Soon!

A BIG Thank You to SCPhA Members for Your Generous Contributions! Visionary Level $1,200 John Pugh

Leader Level $600

recoveryAS.com (Addiction Services) William Lee Amy Hibbitts Frank Holmes

Friend Level $300

Betsy Blake Deborah Tapley Janet Thames Patti Fabel Tonya Jones Emily Thompson James Mathis Joanna Catravas

Make more of your membership! Contact SCPhA at 803.354.9977 or email at info@scrx.org.

Pamela Hourihan

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OPIOID MISUSE

STUDENT PERSPECTIVE

Student Perspective: Global Awareness Institute- Natural Medicines Rotation in Peru By: Nicolle Dambly, PharmD Candidate Class of 2018, SCCP-USC and Nikita Morse, PharmD Candidate Class of 2018, SCCP-USC In July 2017, two students from Columbia, South Carolina embarked on a once in a lifetime rotation experience in Iquitos, Peru. This rotation was an elective, academic experience studying natural medicines derived from the plethora of medicinal plants native to the Amazon as well as how they are being used for treatment in the indigent patient populations of Iquitos and the surrounding areas. The following is the story of our journey. We drove from Columbia to Miami, FL to catch our first flight to start our adventure. From Miami we flew to Lima, Peru where we met up with 9 other students who would spend the next two weeks with us. After a twelve and a half hour layover in Lima we finally got on the flight that would take us to Iquitos. Iquitos is a unique city because there are no roads to get there. The only way in and out of the city is via air-travel. When we arrived in Iquitos, we disembarked the plane onto the tarmac and walked towards the only building in site. There were no employees directing us where to go, so we followed the flow of people who theoretically knew where they were going. There was one conveyor belt for the luggage and no actual roof to cover the building - only beams that seemed to act for structural purposes and nothing else. Only one of the four toilets in the airport ladies room had a seat on it and there were wild animals climbing on the beams above our heads. We were definitely not in the States anymore! While we waited for our bags, we met the two people who were running the rotation, Dr. Barbara Brodman and her assistant and our guide/ translator Chachi. From the airport, we got on a bus with our belongings and went into the heart of the city. We stayed for the first night at a hotel before we forged into the jungle for the rest of our trip. We had no idea that in a few days we would miss the limited air conditioning we had in the room we slept in that night. Peru has the same heat and humidity of a Carolina summer without the luxury of air conditioning. Humid, sticky, wet, filthy, disgusting - these were all words used on a day-to-day basis to describe ourselves while we were on the reserve, so that first night with air conditioning, in hindsight, was a treat! During the first week, we were given a quick, 30-minute lesson, on how to row a canoe. Then we set off for our first full day in Iquitos. The row from the reserve to town was about 45 minutes each day. We did this every day in preparation for a one-hundred mile, five hour row we were to complete on Friday. We pulled our canoes up onto the shore of a lumber yard, then climbed a seemingly endless mountain of sawdust to reach the road. We were then shuttled to nearby classrooms in moto-taxis. Because of its inaccessibility by road, Iquitos has very few cars and the majority of the vehicles are motorcycles or moto-taxis: motorcycles with covered benches on the back that can fit two to three people. very day for the first week we would arrive in town and go to class at one of two locations: El Instituto de InvestigaE ciones de la Amazonia Peruana (The Research Institute of the Peruvian Amazon or IIAP), or El Instituto de Medicina Tradicional (The Institute of Traditional Medicine or IMET), where we were lectured by experts on natural medicines and their importance. IMET is also home to a large garden of medicinal plants where we were given a tour and were allowed to smell, touch and sometimes taste plants. It was from this garden that we took most of the pictures we used for our plant portfolios. Each student had to complete a portfolio which consisted of a picture of the plant being discussed, the scientific name, common name (sometimes in Spanish and English), medicinal uses, preparation techniques and any other pertinent information. We were graded on these portfolios at the end of the trip. Clean water was provided to us on the reserve and we filled up our reusable water bottles each day. Lunches were provided to us in town at a reputable establishment where we did not need to worry about food borne illnesses or dirty water. After lessons each day we were allowed to explore Iquitos in groups of 16

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(Student Perspective, Continued)

STUDENT PERSPECTIVE

3 or more. We used this time to buy snacks at the grocery store, take our laundry to the nearby laundry service, and relax. t night on the reserve we bathed in the river. There were three small indoor showers at the reserve, but they A used non-heated water that was pumped directly from the river, so the only advantage they offered was privacy. Each night two to three students would give their presentation on assigned topics, then we would have free time to write in our journals or work on our plant portfolios. On Friday, we packed up our tents and enough clothes and supplies for a weekend away, and then we went on a five-hour row down the Amazon River. By the end of our row we reached a sugarcane farm run by a man called Pollacco and his wife. They graciously let us set up our tents in their front yard. We were given a tour of the farm and then Pollacco opened up his small store where we could purchase his products including his handmade molasses, sugar cane alcohol, and Coca Cola. He explained to us the medicinal benefits of certain types of sugar cane alcohols and we were allowed to sample his molasses. he next morning, we thanked our hosts and headed on speedboats towards a lodge that we had passed the T day before: the Heliconia. Throughout the day we were given the option to participate in several different activities at the lodge. Some students went dolphin watching, some went fishing, and some went on a nighttime jungle-walk. The following day, we visited the local Yagua tribe in their village. We were given a tour, greeted by the chief, participated in a ceremonial dance, had our faces painted to symbolize that we were welcome guests, and shot arrows through a blow-gun. After we returned to the lodge we all went on a two-hour jungle walk where we were introduced to more medicinal plants. Some were the same as the ones grown at the IMET garden, but others were unique, not able to be grown at IMET. We also encountered many unique creatures such as tarantulas, poison dart frogs, snakes, monkeys, birds, butterflies, and insects. It was a very hands-on experience. The next day, we headed back to the reserve on a speedboat. uring the second week of the trip, we visited a natural reserve where we went on a hike and learned about D different plants and animals native to the area. We also visited the local zoo, and a butterfly farm. We also had the opportunity to visit the Belen Market where they sell many of the natural medicines we learned about as well as handmade goods and food. We had more lessons at IMET and finished up our plant portfolios. Although there were many challenges, we had a great time, we made some lifelong friends, and we gained invaluable knowledge on natural medicines. This rotation provided the opportunity for us to learn about alternative options for patients who may not believe in or are not willing to try the standard medicine we are so used to. There are patients who want natural options to treat their cholesterol or diabetes and this rotation afforded us the knowledge to be able to make such recommendations. Albeit, they most likely will not be able to purchase the supplements in the pharmacy and may have to go to a specialty food store or otherwise that sells the natural remedy, but it is valuable for us to be able to give them an answer to their questions. In reality, this rotation does not offer much truly practical knowledge that will be implemented into everyday practice. But it opens your eyes to cultural diversity and gives you a better awareness of the differences in medicinal thinking. We would recommend this rotation to students looking to expand their cultural understanding and are also up for an adventure! The rotation is offered by the Global Awareness Institute (GAI) to P4 students during July. Students must submit an application by mid-January during their P3 year. Along with the application, a $500 deposit is required. The total price for the trip is $3,150 which includes a round trip plane ticket from Lima to Iquitos and then back to Lima, most meals while in Iquitos, as well as lodging and transportation while in Iquitos. Students are responsible for their own transportation from their home to Lima, and back from Lima at the end of the two weeks. Students must have a passport and complete the physician verification form provided by GAI. It is highly recommended that students acquire certain vaccines including yellow fever, typhoid, hepatitis A, hepatitis B, and a tetanus booster. Students should also obtain a prescription for a malaria prophylaxis treatment such as doxycycline or atovaquoneproguanil. Finally, students are expected to prepare a presentation on an assigned topic,before the trip, so that it can be presented to the group during the first week. Palmetto Pharmacist • Volume 58, Number 4

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Palmetto Pharmacist • Volume 58 Number 4


FINANCIAL FORUM

Financial Forum This series, Financial Forum, is presented by PRISM Wealth Advisors, LLC and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

GETTING (MENTALLY) READY TO RETIRE

Even those who have saved millions must prepare for a lifestyle adjustment. A successful retirement is not merely measured in financial terms. Even those who retire with small fortunes can face boredom or depression and the fear of drawing down their savings too fast. How can new retirees try to calm these worries? Two factors may help: a gradual retirement transition and some guidance from a financial professional. An abrupt break from the workplace may be unsettling. As a hypothetical example, imagine a well-paid finance manager at an auto dealership whose personal identity is closely tied to his job. His best friends are all at the dealership. He retires, and suddenly his friends and sense of purpose are absent. He finds that he has no compelling reason to leave the house, nothing to look forward to when he gets up in the morning. Guess what? He hates being retired. On the other hand, if he prepares for retirement years in advance of his farewell party by exploring an encore career, engaging in varieties of self-employment, or volunteering, he can retire with something promising ahead of him. If he broadens the scope of his social life, so that he can see friends and family regularly and interact with both older and younger people in different settings, his retirement may also become more enjoyable. The interests and needs of a retiree can change with age or as he or she disengages from the working world. Retired households may need to adjust their lifestyles in response to this evolution. Practically all retirees have some financial anxiety. It relates to the fact of no longer earning a conventional paycheck. You see it in couples who have $60,000 saved for retirement; you see it in couples who have $6 million saved for retirement. Their retirement strategies are about to be tested, in real time. All that careful planning is ready to come to fruition, but there are always unknowns. Some retirees are afraid to spend. They fear spending too much too soon. With help from a financial professional, they can thoughtfully plan a withdrawal rate. While no retiree wants to squander money, all retirees should realize that their retirement savings were accumulated to be spent. Being miserly with retirement money contradicts its purpose. The average 65-year-old who retires in 2017 will have a retirement lasting approximately 20 years, by the estimation of the Social Security Administration. So, why not spend some money now and enjoy retired life?1 Broadly speaking, our spending declines as we age. The average U.S. household headed by an 80-year-old spends 43% less money than one headed by a 50-year-old. (1) Retirement challenges people in two ways. The obvious challenge is financial; the less obvious challenge is mental. Both tests may be met with sufficient foresight and dedication. References 1 - tinyurl.com/ydedsyl5 [4/24/17]

Pat Reding and Bo Schnurr may be reached toll-free at 800-288-6669 or pbh@berthelrep.com.Registered Representative of and securities and investment advisory services offered through Berthel Fisher & Company Financial Services, Inc. Member FINRA/SIPC. PRISM Wealth Advisors LLC is independent of Berthel Fisher & Company Financial Services Inc.

Palmetto Pharmacist • Volume 58, Number 4

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SCCP

South Carolina College of Pharmacy Update by Phillip Hall, Professor and Campus Dean, SCCP and Stephen J. Cutler, Ph.D., Dean & Professor, USC College of Pharmacy

The Class of 2018 Pharmacy educators get the pleasure each year of injecting the fresh tonic of new perspectives and new ideas that members of the graduating class bring to the profession. These men and women, who came to us from many backgrounds and experiences and with whom we’ve shared the last four years, are brimming with eagerness and vitality. At the University of South Carolina (USC) and the Medical University of South Carolina (MUSC), we go through each hooding ceremony with conflicting emotions: - pride in the achievement of the graduates - gratitude towards the faculty and staff who provided the education - kinship with the parents and family members - sorrow we’re losing daily interaction with those graduating - nostalgia for our own first steps into pharmacy careers - satisfaction we are providing value to the profession that has meant so much to us What we don’t feel is fear. At MUSC and USC, we have absolute confidence that, like so many before them, the men and women of the Class of 2018 are prepared, motivated and capable of doing great things in pharmacy. The following examples illustrate the kinds of interesting, inspirational stories you can find when you pick any member of the Class of 2018. At USC, Taylor Barnes ’18 and Laura Straw ’18 are both Walker Leadership Scholars who also graduated with the USC Leadership Distinction designation. Among other achievements, the two were selected as the inaugural co-presidents of the Walker Leadership Scholars Alumni Foundation and both went on to pursue post-graduate year one residencies (PGY1). The Walker Leadership Scholars Endowment Fund was created in 2013 by USC alumna Donna J. Walker ’79, an entrepreneur whose career path has included independent pharmacy, advocacy, pharmaceutical sales and marketing, and international pharmaceutical marketing management. Barnes and Straw were selected as Walker scholars for their high capacity for leadership; the fund provides the opportunity to accelerate leadership development through experiential learning and mentorship. They went on to earn Graduation with Leadership Distinction, showing their ability to demonstrate extensive, purposeful engagement beyond the classroom; understand course concepts in “real world” settings; and apply learning to make decisions and solve problems. As students, they were both bright and driven and made the most of the opportunities brought by their selection as Walker scholars. Barnes is currently a PGY1 resident at Children’s National Medical Center in Washington, D.C. and Straw is a PGY1 resident in ambulatory care at Palmetto Health Richland. “My primary career goal is to end up on faculty at a College of Pharmacy following residency, but I am also interested in policy, advocacy, and the outside perception of the pharmacy profession,” Barnes said. “My favorite part about the Walker Leadership Scholars program has been all the people I have met and learning about the different opportunities that a degree in pharmacy can offer me!” At MUSC, Staci Jones ’18 is one of the students profiled in our “18 from ‘18” campaign, a newly-launched initiative to give people a closer look at some of the backgrounds, motivations, experiences and/or career expectations of our students. You can see more on the MUSC pharmacy web site and social media with the hashtag #18from18. Jones has been on active duty in the U.S. Navy for 10 years and operated and maintained a nuclear reactor onboard the USS John C. Stennis aircraft carrier for four-and-a-half years, supporting both the Irag and Afghanistan wars. She has traveled to Dubai, Singapore, Hong Kong, Thailand, Japan and South Korea. She also taught nuclear power fundamentals to junior sailors for three-and-a-half years at the Naval Weapons Station in Goose Creek. A native of Nashua, New Hampshire, she earned her bachelor of science in liberal studies from Excelsior College. When she decided to go to pharmacy school, she was accepted into a New Hampshire program and was inclined to go there, where the mother of two might have some family support. But once she approached MUSC, she found a program that was personal and flexible enough to accommodate her application to the Navy’s scholarship program. As a graduate, she is going to continue in the Navy as a pharmacist. “Since I have completed my degree requirements, I have been promoted from an enlisted E-7 to and officer 0-3, which is a huge jump in rank and responsibility,” she said. “My plans are to spend the next 10 years in the Navy, until I am eligible for retirement. Every 3-4 years the Navy will station me at a new hospital or clinic. I would love to be stationed overseas somewhere in the Mediterranean, like Rota, Spain or Sicily for a few years. After I retire from the Navy, I would love to work as a pharmacist in the VA.” These are just a few examples of the outstanding students we have the privilege to work with at the College of Pharmacy, and they are good illustrations of why each graduation brings both pride and a touch of nostalgia as we watch the members of the graduating class leave our halls and join you in this great profession.

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Palmetto Pharmacist • Volume 58 Number 4


Presbyterian College School of Pharmacy Update

PCSP

by Cliff Fuhrman, PhD, RPh, Dean, PCSP

Presbyterian College Presents the Class of 2018 Presbyterian College School of Pharmacy held its fifth Hooding and Graduation Ceremony on Friday, May 11, 2018, and 69 graduates were honored in front of their families, faculty, and college officials. Dr. Stuart Haines, the keynote speaker, spoke to the graduates about covenant, trust, and integrity with patients. He also told the inspiring story of Vivien Thomas, an African-American surgical technician who developed procedures to treat cyanotic heart disease in pediatric patients. Don Viets, chosen by his classmates to give the Distinguished Graduating Student Speaker Address, told his classmates a touching story about a successful businessman who missed important family moments. He charged his classmates to focus on what is most important as they begin their careers. The new graduates received the characteristic olive green hoods by Dean Cliff Fuhrman and Dr. Nancy Goodbar and recited the Oath of a Pharmacist. Sun, bagpipes, and happy smiles filled the morning as the Class of 2018 begins their new journey as pharmacists. Dr. Stuart T. Haines, PharmD, BCPS, BCACP, BC-ADM is Professor of Pharmacy Practice and Director of the Division of Pharmacy Professional Development at the University of Mississippi School of Pharmacy. He is the editorin-chief of iForumRx.org, an online journal club for ambulatory care pharmacy specialists, a scientific editor for the journal Pharmacotherapy, and an editor for the textbook Pharmacotherapy: A Pathophysiologic Approach. He has served on numerous editorial boards and authored more than 100 scholarly papers and book chapters regarding diabetes, cardiovascular disease, ambulatory care pharmacy practice models, and instructional methods. Awards presented during Hooding Ceremony: Lilly Achievement Award: Morgan Enlow Merck Manuals Award for Academic Excellence: Brad Leonard & Victoria Paradiso Mylan Excellence in Pharmacy Award: Evan Bryson Presbyterian College Mortar and Pestle Award: Jessica Keels United States Public Health Service Excellence in Public Health Pharmacy Award: Sarabeth Herring Wolters Kluwer Health Award of Excellence in Clinical Communication: Josh Stamps Spring Awards Day The 8th annual Awards Day was held on April 23rd and offered an opportunity for the pharmacy school to recognize students, faculty, and staff members who have provided exceptional service during the school year. Preceptor of the Year- Dr. Lee Dailey, Laurens County Memorial Hospital Faculty Preceptor of the Year- Dr. Erika Tillery, G. Werber Bryan Psychiatric Hospital Student Advocate of the Year- Mrs. Deanie Kane Faculty Researcher of the Year, Dr. Jennifer Clements Teacher of the Year- Dr. Eileen Ward Additional Awards: Pharmacy Student Ambassadors Extra Mile Award – Jackie Klenotiz Exemplary Service to Admissions Faculty Award – Dr. Katherine Hanlon Outstanding Student Service Award – Anderson Isaac Outstanding Student Leadership Award – Courtney King Outstanding Student Research Award – Darshana Rana Outstanding Student Professionalism Award – Katelyn Thomasson

Palmetto Pharmacist • Volume 58, Number 4

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Palmetto Pharmacist • Volume 58 Number 4


PHARMACY LAW

Rx and the Law By Don R. McGuire Jr., RPh, JD

This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

ANIMAL PATIENTS The pharmacist at Anytown Pharmacy had prepared prescriptions for two pets and placed them in the refrigerator awaiting pickup. When Butch’s owner came in to pick up his prescription, the owner was given another dog’s prescription. Upon administration, the dog became lethargic and Butch’s owner took him to the vet. Unfortunately, Butch’s symptoms couldn’t be reversed and he died as a result of the incorrect drug’s effects. Butch’s owner subsequently made a claim for damages against the pharmacy. What damages is Butch’s owner entitled to recover? In the majority of states, pets and other animals are considered personal property. As such, the owner is not entitled to recover damages for emotional pain and suffering or mental anguish, no matter how close the owner is to the pet or how much a part of their family they consider the pet to be. This can make these types of claims difficult to settle because the owner feels that the bond with their pet is not being considered. Under the law, they are correct. The bond with their pet is not compensable. What is compensable is the market value of the animal and other costs resulting from the incident. These other costs could be the cost of treatment by a vet or in extreme cases, the cost of burial or cremation of the animal. The market value of an animal includes a number of factors, such as the original purchase price, the cost of replacement, and other elements that can enhance the animal’s value. For example, if the animal patient is a prize-winning race horse, the owner would be entitled to recover lost stud fees and other income derived from the horse’s performances. The cost to replace a winning race horse can also be substantial. The potential vet bills for an injured pet could also be substantial. Because of the bond with their pet, the distraught owner might be willing to try any treatment, even those with only a small chance of success. It would not be unusual for vet bills to exceed the market value of an animal. Because animals are considered property under the law, some states may have different procedures for these types of claims. States that have damage caps in medical negligence cases may not apply them here. These caps are generally applied to the injured patient’s damages for pain and suffering. Because animal claims are property claims and there are no emotional damages, these caps do not apply. Also, because these claims are property claims, they may not be eligible for the Medical Review Panel process if that is in place in your state. In the Medical Review Panel process, the negligence claim is reviewed and evaluated by a panel of practitioners before the case can go to court. The case then only goes to court if one of the parties disagrees with the panel’s decision. Pharmacists may not think much about the financial risks from an animal claim because there are no damages for emotional distress. While this is true, the other exposures can still be significant. Market values for race horses that have died as the result of prescription errors can reach six figure settlements. This can be multiplied if more than one animal is killed or injured. A case in Florida in 2009 resulted in the deaths of 21 polo ponies from a compounded nutritional supplement. A jury awarded the owners of the horses $2.5 million. Pharmacists are health care providers because they want to help their patients. This is true whether the patient is human or an animal. The differences in the law for damages as the result of an error should not influence the way that a pharmacist approaches the care that they provide. There are groups advocating in several states for changes in these laws to allow for the owner to recover emotional damages. Pharmacists will need to verify the law in their state. All patients deserve the same processes and safeguards. As with any aspect of their practices, pharmacists should be well informed of the standards and risks for any activity undertaken. © Don R. McGuire Jr., R.Ph., J.D., is General Counsel, Senior Vice President, Risk Management & Compliance at Pharmacists Mutual Insurance Company. This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly. Palmetto Pharmacist • Volume 58, Number 4

23


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Palmetto Pharmacist • Volume 58 Number 4


JOURNAL CE Pharmacogenomics: Proof That One Size Does Not Fit All ACPE UAN: 0171-9999-18-035-H01-P Initial Release 6/15/18 Expiration Date 6/15/21 Erika E. Tillery, PharmD, BCPP, BCGP Associate Professor of Pharmacy Practice, Presbyterian College School of Pharmacy Clinical Pharmacist Specialist – Psychiatry, Division of Inpatient Services, G. Werber Bryan Psychiatric Hospital Melanie Routhieaux, PharmD Candidate Class of 2018 Presbyterian College School of Pharmacy Jessica Keels, PharmD Candidate Class of 2018 Presbyterian College School of Pharmacy

Learning Objectives: Upon completion of this knowledge-based activity, the pharmacist will be able to: 1. Review the history of pharmacogenomics and discuss potential benefits of genetic testing. 2. Evaluate the clinical utility of pharmacogenomics and pharmacogenetics in cardiovascular disease, infectious diseases, oncology, pain, psychiatry, and respiratory disorders. 3. Discuss the future of pharmacogenomics and pharmacogenetics in the field of pharmacy. 4. Identify the role of the pharmacist in interpreting pharmacogenetic results. Conflict of Interest Statement The authors certify that they have no affiliations or involvement with any financial or non-financial interest in the subject matter or materials discussed in this manuscript. Abstract Objective: To review pharmacogenomics and the place in therapy for pharmacogenetics as well as the pharmacist’s role in utilizing pharmacogenomics in practice. Summary: Medications are selected based on population averages, but this mean distribution has contributed to adverse drug events and increased healthcare costs, because all individuals are unique and respond differently to therapies.  Pharmacogenetic testing provides individualized treatment, and may reduce the incidence of negative patient-centered outcomes. Pharmacists receive more pharmacotherapy training in their pharmacy degree than other healthcare professions. Incorporating pharmacogenetic interventions into the management of patients receiving pharmacotherapy may lead to improved outcomes by mitigating adverse effects and optimizing Palmetto Pharmacist • Volume 58, Number 4

current therapies. Current use of pharmacogenetic testing targets cardiovascular diseases, infectious diseases, oncology, pain, psychiatry, and respiratory disease states. The ultimate goal of pharmacogenomics is to implement pharmacogenetic testing in all eligible patients receiving pharmacotherapy for acute and chronic disease states where substantial variations in one’s genetic profile may lead to adverse drug events or contribute to non-response. Conclusion: By incorporating pharmacogenomic knowledge in therapeutic care plans, the pharmacist may provide optimal treatment recommendations to patients and providers; potentially reducing healthcare costs and limiting the “trial-and-error” implementation of medications that frequently occurs. Keywords: pharmacy, pharmacogenomics, pharmacogenetics, cardiovascular, pain, psychiatry, infectious diseases, oncology, respiratory Key Terminology1,2 • Pharmacodynamics: the study of how a drug exerts its effects in the body (what the drug does to the body) • Pharmacogenomics: the study of the role of inheritance in individual variation in drug response. The general study of all of the many different genes that determine drug behavior • Pharmacogenetics: the study of inherited differences or variations in drug metabolism and response • Pharmacokinetics: the study of absorption, distribution, metabolism, and excretion of drugs (what the body does to drugs) 25


JOURNAL CE • • • • •

Poor Metabolizer (PM): markedly reduced or absent enzyme activity Intermediate Metabolizer (IM):  reduced enzyme activity Extensive metabolizer (EM): also known as “normal” metabolizers; most common type Ultra-rapid Metabolizer (UM): also known as rapid or ultra-rapid metabolizers; have high enzyme activity Wild-type: a normal version of the gene that is not mutated; most common form

Most pharmacologic agents are administered based on the average population benefit; many of which are dosed based on actual body weights in adult and pediatric patients.3 Healthcare professionals, including pharmacists, are trained to select, administer, and dispense medications based on pharmacokinetic properties. Unfortunately, the efficacy of drugs is highly variable (25-60%), and each year over 2 million patients experience adverse drug reactions that result in increased hospitalizations and mortality.4 Furthermore, the vast majority of efficacy reports are based on surrogate outcomes of the average population, such as blood pressure, and omit patient-oriented outcomes such as stroke and death.3,5 Pharmacogenomics, also referred to as “personalized” or “tailored medicine”, analyzes the genetic makeup of individuals and incorporates the pharmacokinetic and pharmacodynamic properties of the medications to provide an optimal treatment for the unique patient.3 Pharmacogenomic studies and pharmacogenetic testing may streamline therapies; resulting in fewer adverse drug reactions and fatalities, as well as reduce healthcare costs.3 It is important to note that pharmacogenomics is not as “new” of a discovery as one would think. The first recognized impact of genetics on pharmacokinetics occurred in the 1950s, and involved succinylcholine, where several patients exhibited an abnormal response to succinylcholine due to a genetic variation in their plasma cholinesterase enzymes.6,7 The second recognized impact of pharmacogenetics occurred with the discovery of glucose-6 phosphate dehydrogenase enzyme deficiency that results in excess hemolysis in the presence of primaquine-sensitive individuals.8 Years later, the genetic differences in metabolizing enzymes involved with isoniazid resulted in the discovery of “slow” and “rapid” metabolizers.9 Throughout the years genetic discoveries have expanded, including the significant effects of drug metabolizing enzymes, such as the hepatic Cytochrome P-450 enzymes.9 Perhaps the expansion of pharmacogenomics would not have occurred without the development of new biotechnology and The Human Genome Project. The Project, jointly managed by the National Institutes of Health (NIH) and the Department of Energy, was created to sequence the entire human genome.10,11 This resulted in the discovery of over 30,000 genes that code for over 100,000 proteins.10,11 Once the project was completed, 26

large pharmaceutical companies formed the Single Nucleotide Polymorphism (SNP) Consortium with a goal to find and map common single nucleotide polymorphisms distributed throughout the human genome.12 As a result, over three billion base pairs and 1.4 billion SNPs have been discovered.12 It was not until the 2000s, however, that scientists collaborated to form the Pharmacogenomics Research Network (PGRN) leading to the widespread utilization of genetic testing. Their goal was to 1) research and examine the correlation between genetic variation and drug response, 2) become a valuable resource with reliable information that links phenotypes to genotypes and 3) create a publicly available and interactive data base through which investigators could freely access pharmacogenetic information regarding knowledge, tools, and resources.13 Thanks to the Human Genome Project, SNP Consortium, and PGRN, pharmacogenetic testing has been widely used and shown benefit in cardiovascular disease, pain management, psychiatry, infectious diseases, respiratory diseases, and oncology. Genetic testing has continued to develop throughout the years and may be the future of pharmacy where all medication therapies are based on individual needs, not the population average. This “tailored approach” to managing medications could increase the safety of drugs as well as their efficacy. Pharmacists have the most expertise in drug therapy, receive extensive training in pharmacodynamics and pharmacokinetics, and may have a significant role in interpreting pharmacogenetic results and developing individualized treatment plans because of their knowledge. Current Use of Pharmacogenetics Cardiovascular Disease Pharmacists throughout the United States can attest to the prevalence of cardiovascular disease and the amount of prescription medications that are filled on a daily basis for individuals suffering from disease states such as heart failure, hypertension, and hyperlipidemia. Although guidelines do exist for treating these disease states with pharmacotherapy, some individuals do not respond to the “one size fits all” approach. A prime example of genetic variation with cardiovascular medications is warfarin. Current research has shown genetic polymorphisms exist with CYP2C9, VKORC1, and CYP4F2 in relation to warfarin.14 CYP2C9 is the primary enzyme that metabolizes warfarin to its active metabolite, 3’-Hydroxywarfarin.15 Individuals who are heterozygous carriers of the 2C9*2 or 2C9*3 allele require an approximate 19% and 33% dose reduction, respectively. Homozygous carriers require an approximate 36% and 78% reduction in warfarin dose due to the increased risk of bleeding.16 VKORC1 converts warfarin’s target, vitamin K, to its active form. Multiple variants in VKORC1, including 1173C/T, may predict dosing in Caucasians and African Americans.16 Some studies have also showed an association with variants of CYP4F2 and a need for higher warfarin dosing, but the findings have not been consistent.16 The antiplatelet clopidogrel (Plavix®) is another widely studied medication, mainly in terms of Cytochrome Palmetto Pharmacist • Volume 58 Number 4


JOURNAL CE P450 enzymes. The loss-of-function CYP2C19*2 is shown to increase the risk of cardiovascular events, including an increased risk of stent thrombosis. The opposite effect has been observed in individuals with the gain-of-function of the CYP2C19*17 allele, as it may increase one’s response to clopidogrel and cause an increased risk of bleeding.16 Outside of anticoagulant therapies, many other cardiovascular medications have been studied for genetic variants, including HMG-CoA reductase inhibitors (eg, statins). Most notably the anion transporter SLCO1B1 gene, which helps transport statins into the liver, has been studied for its association with statin-induced myopathy. Individuals who are heterozygous for the CT genotype are at a 4.5-fold increased risk of myopathy.15 However, those who are homozygous for the CC genotype (compared to the TT genotype) are at a 17-fold increased risk for developing myopathy. Therefore, dosing statins may vary based upon the person’s genotype. For instance, any individual who exhibits a C allele upon genetic testing should not exceed 20 mg/day of simvastatin.14 The final group of medications that have been studied in cardiovascular disease states are antihypertensives. The most reliable studies currently available have looked at beta blockers (propranolol, timolol, and metoprolol), and their primary metabolizing enzyme, CYP2D6. Loss-of-function variants are extremely common with this enzyme, and poor metabolizers (510% of Caucasian and African subjects) will exhibit two loss-of-function variants. In these individuals, beta blocker concentrations are extremely high, and they may exhibit signs of hypotension and bradycardia.16 It may be beneficial to determine one’s carrier status in order to decrease the frequency of these side effects, since the variations are so common. Infectious Disease There are a plethora of diseases and medications that fall under the umbrella of infectious disease. The one that has been most studied in pharmacogenetics is HIV and AIDS and the antiretroviral medications associated with these two disease states. There are quite a few genetic polymorphisms that have been discovered in association with susceptibility to the virus itself. The CC chemokine receptor (CCR5) is a coreceptor for certain HIV strains, including HIV-1. The most frequent polymorphism in CCR5 is most commonly seen in Caucasians and is a 32 base pair deletion. With this polymorphism, individuals are less susceptible to getting the virus, and if they are diagnosed with HIV their disease is less likely to be severe.17 If an individual is homozygous for the deletion, they will not express the CCR5 coreceptor at all, which will prevent the virus from entering their cells and infecting them in any way.18 Another important genetic component that is linked to disease susceptibility and severity is human leukocyte antigen (HLA), specifically HLA-B. Individuals who are homozygous for the HLA-B*35 allele have a faster rate of disease progression to AIDS (generally Palmetto Pharmacist • Volume 58, Number 4

occurs in half the time compared to those without the polymorphism).18 HLA-B is also associated with a major hypersensitivity reaction to abacavir, a nucleoside reverse transcriptase inhibitor (NRTI) used to treat HIV. Current studies have established a strong association between the overexpression of the HLA-B*5701 allele among those exhibiting a hypersensitivity reaction while receiving abacavir.17 A double-blind, prospective, randomized study of approximately 2000 individuals from 19 countries sought to determine if it would be beneficial to provide pre-therapy screening for the HLA-B*5701 allele in order to reduce the risk of these reactions. Following 6 weeks of therapy with abacavir, those who received screenings (prospective screening group) versus those who did not (control group) had a reduced risk of hypersensitivity reactions.19 For this reason, the FDA has issued a black box warning for abacavir in relation to the HLA-B*5701 allele and strongly recommends pharmacogenetic testing prior to implementing pharmacotherapy. Oncology It is well known that oncologic medications are already created for specific cancer types, and they are tailored to each individual. However, the utilization of pharmacogenomics prior to initiating therapy may identify potential non-responders to certain medications as well as optimal dosing. The medication 6-mercaptopurine is used in individuals with acute lymphoblastic leukemia (ALL), and its function is based on the enzyme thiopurine methyltransferase (TPMT).20 Currently, research has found over 20 variations in TPMT, with the majority of polymorphisms resulting in decreased activity of the enzyme. When the enzyme is not as effective, there are higher levels of 6-mercatopurine in the body, leading to a higher risk of toxicity.21 The majority of these variations are related to TPMT*2, *3A, and *3C, and individuals with these polymorphisms require a lower dose of medication than those without these variants. Since 2004, the FDA has recommended pre-therapy genetic testing for TPMT variants in children diagnosed with ALL.22 Irinotecan is a chemotherapy currently used to treat colorectal cancer.20 Uridine diphosphate glucuronosyl transferase (UGT1) is the primary enzyme that helps convert irinotecan to the active form in the body. The most common variants result in an inefficient enzyme, leading to a decrease in irinotecan metabolism. UGT1A1*28 homozygous individuals have a 70% decrease in UGT1 enzymatic activity.23 This polymorphism is most common in Caucasians with Gilbert syndrome (familial hyperbilirubinemia) and in African populations.22,23 Capecitabine, a prodrug of 5-fluorouracil (5FU), is utilized as the backbone for many types of cancer treatments such as colorectal, breast, and pancreatic.20 Dihydropyrimidine dehydrogenase (DPD or DYPD) is the rate-limiting enzyme in 5-FU inactivation.21 Over 30 single nucleic polymorphisms (SNPs) have been found in association with DYPD, but few are related to the function on the enzyme. A common SNP that has been 27


JOURNAL CE identified is DYPD*2A, which leads to a deficient enzyme and a higher risk of developing neutropenia. Studies have shown that 55% of individuals with a deficient DYPD enzyme had grade 4 neutropenia, defined as having a neutrophil count less than 500 cells/mm3, after treatment with 5-FU.23,24 In population subgroups, African Americans tend to have lower DYPD activity, while Koreans have higher enzyme activity.22 Because it is a prodrug of 5-FU, abnormal enzyme activity would affect capecitabine in a similar manner. Pain

Pain management has become increasingly more prominent in the world of healthcare, and researchers are studying genetic variations that may lead to more customized treatment plans for persons suffering from chronic pain. Some of the most studied polymorphisms are those associated with CYP2D6, which is the enzyme responsible for converting the prodrugs codeine, dihydrocodeine, oxycodone, and hydrocodone to their active metabolites (morphine, dihydromorphine, oxymorphone, and hydromorphone). However, there are multiple variations for this enzyme that have been discovered that lead to varying responses to these opioids. For example, individuals with 2D6*3, *4, or *8 polymorphisms have nonfunctional enzymes and are considered poor metabolizers. Those with 2D6*9, *10, or *41 polymorphisms have reduced function enzymes and are considered intermediate metabolizers. Finally, individuals with 2D6*1, *2, or *35 polymorphisms may express an increased amount of functional enzymes and make one an ultra-rapid metabolizer.25 Another Cytochrome P450 enzyme that has been studied in pain is CYP2C9, which metabolizes many nonsteroidal anti-inflammatory drugs (NSAIDs). Most commonly, individuals who exhibit CYP2C9*2 or *3 variants are poor metabolizers. Poor metabolizers have an increased concentration of the medication in their system, as they have lower clearance than those with the wildtype. This may also mean that poor metabolizers have a higher risk of side effects while taking NSAIDs, although a direct correlation has yet to be proven.26 Additionally, pain medications that are substrates of P-glycoprotein mediated transport may be influenced by genetic variants. The ABCB1 efflux transporter is the target of genetic polymorphisms that can influence levels of medications such as morphine and fentanyl. Those exhibiting the ABCB1 3435 C>T variant would be more sensitive to opioids such as morphine, and therefore would need lower doses to reach a therapeutic response.25,26 Studies have also shown that Korean individuals who are homozygous for the T allele are at a higher risk of respiratory depression with fentanyl, which is important for monitoring in clinical settings and counseling in outpatient settings.27 Psychiatry Research of personalized medicine via 28

pharmacogenetics is becoming more prevalent in the field of psychiatry. Because medications within the same drug class can produce a variety of responses from person to person, utilizing pharmacogenetics prior to therapy initiation may reduce the amount of unsuccessful pharmacotherapy treatment attempts as well as adverse effects in individuals suffering from mental health disorders.28 Two of the more common genetic variants that have been studied to date relate to the major neurotransmitters that are associated with psychiatric disorders: serotonin and dopamine. The SLC6A serotonin transporter gene has been studied in regards to its association with an individual’s response to Selective Serotonin Reuptake Inhibitors (SSRIs). Those who are homozygous for the s-short allele are less responsive to SSRIs and do not achieve remission as often. However, Asian individuals who are homozygous for the s-short allele actually have been found to have the opposite response to SSRIs and will respond better and achieve remission more often.29 Additionally, the s-short allele is associated with a higher rate of severe adverse effects, which include gastrointestinal effects, fatigue, dizziness, drowsiness, and anxiety.29 The DRD2 and DRD3 dopamine receptor genes have been studied in relation to antipsychotic efficacy and adverse effects. The DRD2 gene has three major polymorphisms which include: the Taq1A polymorphism, the −141-C Ins/ Del, and Ser311Cys.  The Taq1A variant has been shown to affect response to first and second generation antipsychotics (FGAs and SGAs), and a meta-analysis showed an association between Taq1A and an increased risk of tardive dyskinesia. 30,31 The −141-C Ins/Del polymorphism in the promoter region has been associated with lower expression of the D2 receptor and an increase in adverse effects of antipsychotics. Ser311Cys is a coding polymorphism that has been shown to reduce signal transduction through the receptor and may decrease the efficacy of antipsychotic medications.30 The DRD3 gene has a Ser9Gly polymorphism that may influence dopamine binding affinity and increase the risk of tardive dyskinesia.32 Cytochrome P450 enzyme variants have also been studied for their effect on psychiatric medications. CYP2D6 was the first enzyme that was found to be associated with response to psychiatric medications.33 Individuals with one or two inactive 2D6 alleles are considered poor metabolizers (PM) and have an increased risk for toxicity and side effects while taking medications metabolized by this enzyme. Those with three or more copies of 2D6 are considered ultra-rapid metabolizers and have a decreased response to the medications since they have a faster rate of metabolism. Psychiatric medications that are metabolized by CYP2D6 include fluoxetine, paroxetine, venlafaxine, amitriptyline, risperidone, aripiprazole, haloperidol, as well as others in similar classes.33 Other important Cytochrome P450 enzymes include 2C19, 2C9, and 1A2. The common variant of CYP2C19 is *17. Individuals who are homozygous for the CYP2C19*17 allele are considered ultra-rapid metabolizers and may not respond to antidepressants such as citalopram, sertraline, clozapine, and diazepam.34 Fluoxetine is a major substrate for CYP2D6 and 2C9 enzymes. If an individual expresses Palmetto Pharmacist • Volume 58 Number 4


variants for both of the enzymes that cause them to be a PM, treatment with fluoxetine may lead to severe adverse effects.33 Finally, CYP1A2 has been studied in its response to medications such as olanzapine and clozapine while smoking. Many variants of the 1A2 gene are induced by smoking tobacco, and those who have two 1A2 alleles and smoke cigarettes are at high risk of treatment failure. Institutionalized persons who cannot smoke often see a relapse in psychosis following discharge from the hospital due to an increase in their enzyme function while smoking.33 Another prevalent genetic variant involves carbamazepine and the HLA-B*1502 allele. Carbamazepine is a widely used medication for the treatment of bipolar disorder, epilepsy, trigeminal neuralgia, and chronic pain.35 This medication has been associated with major adverse effects, including the lifethreatening hypersensitivity reactions Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrosis (TEN).35 Studies have demonstrated a strong association between carbamazepine-induced SJS/TEN and HLA-B*1502, which is found primarily in the Han Chinese population.36 The risk of this reaction has been associated at such a high extent that the FDA added a black box warning to the package insert strongly recommending genetic testing prior to therapy. If an individual is HLA-B*1502 positive, the use of carbamazepine should be avoided.37 Additionally, the presence of HLA-A*3101 confers a moderate risk of developing hypersensitivity reactions such as SJS/TEN and is a common variant globally.38 Although genetic testing is available for this genotype, no clear recommendations for HLA-A*3101 screening are provided at this time.38 Respiratory Disease Respiratory diseases are becoming more relevant in pharmacogenetics, namely cystic fibrosis and asthma. Genetic testing may be beneficial for individuals with asthma, but it can be extremely important for children with cystic fibrosis – a disease state with a genetic predisposition. Asthma has typically been defined as airway remodeling that occurs due to uncontrolled inflammatory/ repair processes.39 However, recent studies have shown that inflammation may not be the sole cause, but rather genetics may play a key role in the development of asthma. A disintegrin and matric mealloprotease-33 (ADAM33) has multiple functional roles intracellularly, including cell signaling, cell adhesion, inflammatory response, and apoptosis and is the major gene that has been associated with asthma development.40 Expression of ADAM33 has been observed in fetal development as early as 8 weeks after gestation, and it is postulated that this protein is important in lung development during pregnancy.39 There is a soluble form of the gene that can develop from environmental factors leading to a gain-offunction allele where the airways become thicker, airway obstruction occurs, and lung function begins to rapidly Palmetto Pharmacist • Volume 58, Number 4

JOURNAL CE decline. Individuals with moderate and severe asthma have demonstrated a greater expression of ADAM33 than those with mild asthma or healthy individuals.40 Cystic fibrosis is caused by genetic mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) which aids in the transport of chloride ions into organs such as the lungs. Individuals who have cystic fibrosis have complications with this transport system, leading to excess mucus in these organs.41 In order for a child to be affected by cystic fibrosis, they must have inherited CFTR mutation copies from both the mother and the father. The two most common mutations found are DF508 and W1282X. Both of these mutations are deletions in the gene that cause the individual to not produce enough transporters to allow chloride into organs like the gut, pancreas, and lungs.41 Table 1 provides a summary of the aforementioned genetic variations and their corresponding medications and/or disease states. The Future of Pharmacogenetics Although progress has occurred with pharmacogenetic testing over the past 15 years, there is still much to be researched and discovered. Research is ongoing to further investigate correlations between genes and medications/disease states. Many of the studies involve a very small population. In order for the findings to be more widely accepted larger studies need to be conducted. It is important that researchers increase the sample size of studies and include individuals with diverse ethnicities in order to expand the knowledge of pharmacogenetics in people of all backgrounds.42 There are several black box warnings for medications with genetic polymorphisms that lead to severe adverse reactions. For example, abacavir, clopidogrel, and carbamazepine have FDA approved black box warnings for pre-therapy genetic testing in order to avoid major adverse events due to potential polymorphisms. In the coming years, it can be speculated that more medications with gene-related adverse events will be discovered where the FDA will require pretherapy genetic testing. Finally, the ultimate goal is to implement routine genetic testing in all individuals in order to reduce healthcare costs and limit the trial-and-error pharmacotherapy treatment approach. In order for this to occur, better technology will need to be developed in order to decrease the amount of time required to process results, as it may take several days to weeks to submit DNA samples and have them returned to the provider.43 With increased interest in genetic testing, and a resultant increase in the number of genetic testing companies, the cost of pharmacogenetic testing has declined in recent years. Table 2 provides a summary of genetic testing companies in and around South Carolina and includes contact information and cost. Support from medical professionals is needed 29


JOURNAL CE Table 1. Genetic Variations Associated with Common Medications/Disease States* Medication/ Disease State

Gene

Warfarin

CYP2C9

Clopidogrel

Variant

Effects

2C9*2/*3

Increased risk of bleeding, decreased dose needed

VKORC1

1173C/T

Determines dose increase or decrease

CYP4F2

Unknown

Potentially increased dose

CYP2C19

2C19*2

Decreased response, increased risk of CV events

Company

Location(s)

Contact Information

Testing Price Range ($)

Arcpoint labs

(Multiple Locations) 355 Woodruff Rd Suite 403 Greenville, SC 29607

Tel: 864-326-2221

300-400

AlphaGenomix

1130 Hurricane Shoals Road NE Suite 1800 Lawrenceville, Georgia, 30043

Tel: 678-250-9222 Toll Free: 1-888-250-6228

399 (psych) 499 (comprehensive)

2C19*17

Increased response, increased risk of bleeding

Cohesion Phenomics

230 Spindale St. Suite B, Spindale, NC 28160

Tel: 828-375-0145 Email: cohesionphenomics.com

unavailable

CT

4.5-fold increased risk of myopathy

eLab Solutions Corporation

5009 Roswell Road Sandy Springs, GA 30342

Tel: 866-990-3522 (ELAB) Email: info@elabsolutions.com

200-400

Statins

SLCO1B1

CC

17-fold increased risk for myopathy

Beta Blockers (propranolol, timolol, metoprolol)

CYP2D6

Loss-of-function variants

High concentrations, high risk of hypotension and bradycardia

SSRIs

SLCA6

ss (short allele)

Asians: better response, higher remission rate Other populations: less responsive, low remission rate, higher rate of ADEs

Antipsychotics (first and second generation)

DRD2/DRD3

Taq1A/Ser9Gly

Increased risk of tardive dyskinesia

DRD2

−141-C Ins/Del

Increased risk of ADEs

DRD2

Ser311Cys

Decreased response to medication

Amitriptyline Aripiprazole Fluoxetine Paroxetine Risperidone Venlafaxine

CYP2D6

1-2 inactive 2D6 alleles

PM: increased risk of toxicity/ADEs

3 or more 2D6 copies

UM: decreased response to medication

Citalopram Clozapine

CYP2C19

2C19*17

UM: decreased response

610 Airport Road Suite 200 Huntsville, AL 35802 GeneAlign

PO Box 601689 Dallas, TX 75360

214-444-9555 Email: genealignnotify@genealign.com

unavailable

Pro-Genex

The Advanced Technology Development Center at Georgia Tech 75 5th Street Suite 200 Atlanta, GA 30308

Toll Free: 844-794-3637 ext 800

unavailable

LabCorp

Multiple Locations throughout SC

1-800-735-4087 contact specific location

420-1045

**This is not a complete list of every company in SC and surrounding areas that conducts pharmacogenetic testing.

Fluoxetine

CYP2C9

PM to 2C9 and 2D6

Severe adverse effects

Clozapine Olanzapine

CYP1A2

2 1A2 alleles

Interacts with tobacco smoke and may lead to high risk of treatment failure and relapse in psychosis

Codeine Hydrocodone Oxycodone

CYP2D6

2D6*3/*4/*8

PM: nonfunctional enzymes; poor pain control

2D6*9/*10/*41

IM: reduced function enzymes

2D6*1/*2/*35

UM: increased number of enzymes; increased risk of respiratory depression

NSAIDS

CYP2C9

2C9*2/*3

PM: decreased dose, higher risk of ADEs

Opioids

ABCB1

3435 C>T

Decreased dose

HIV/AIDS

CCR5

32 bp deletion

Decreased risk of acquiring HIV, decreased risk of severe disease development

HLA-B

HLA-B*35

Higher rate of disease progression

Abacavir

HLA-B

HLA-B*5701

Severe hypersensitivity reaction

6-mercaptopurine

TPMT

TPMT*2/*3A/*3C

Decreased dose

Irinotecan

UGT1

UGT1A1*28

Decreased dose

Capecitabine/5-FU

DPD or DYPD

DYPD*2A

Increased risk of neutropenia

Carbamazepine

HLA

HLA-B*1502

Increased risk of SJS/TEN

Asthma

ADAM33

sADAM33 (soluble)

Increased risk of moderate to severe asthma development

Cystic Fibrosis

CFTR

DF508 and W1282X

Increased risk of cystic fibrosis development

Abbreviations: ADEs = adverse drug events; CV = cardiovascular; CYP = cytochrome; PM = poor metabolizer; UM = ultra-rapid metabolizer; SSRIs = selective serotonin reuptake inhibitors; NSAIDs = non-steroidal antiinflammatory drugs; HIV/AIDS = human immunodeficiency virus/acquired immunodeficiency syndrome; SJS/TEN=Stevens-Johnson Syndrome/Toxic Epidermal Necrosis

*This list is not comprehensive and includes only the most common polymorphisms with the best available evidence. There are a number of genes that have been studied for these and other disease states. 30

Table 2: Companies with Pharmacogenetic Testing Capabilities in South Carolina and Surrounding Areas**

These company results are based on alist general, nonspecific web searchin completed in July 2017. The prices listed are ** This is not a complete of every company SC and surrounding areas a rough cash estimate, do not include processing fees, and depend on the specific test being conducted as well as that conducts pharmacogenetic testing. These company results are based on a sample size. Health insurance may cover all or part of the total cost. general, nonspecific web search completed in July 2017. The prices listed are a rough cash estimate, do not include processing fees, and depend on the specific test being conducted as well as sample size. Health insurance may cover all or part of the total cost.

in order to implement genetic testing on a larger scale, with further education and/or specialized training recommended for pharmacists, prescribing providers, and nurses to properly interpret results. Genetic test results could be implemented into pharmacy computer systems in order to aid in the order verification process. Pharmacists should intervene when they know that an individual is a poor or ultra-rapid metabolizer of a medication by counseling them about potential side effects and/or consulting the prescribing provider for therapeutic alternatives. Conclusion Since the initiation of the Human Genome Project, pharmacogenomics has become a new idea in the world of medicine and is continuously expanding. As experts in medicine, pharmacists are at the forefront of research, utilization, and interpretation of pharmacogenetic test results. Although many genetic variants have already been discovered, further studies are needed to better understand the idea of personalized medicine. In order to reduce healthcare costs and adverse drug events, it is important to learn more about the genetic polymorphisms that exist. Pharmacists are uniquely positioned to educate consumers about how one’s genetic makeup may affect his/her response to medicine. As research progresses, more technology and evidence will become available to guide decision-making. Pharmacists may contribute to the personalized medicine approach to patient care by understanding pharmacogenomics and interpreting pharmacogenetic test results for patients and providers, potentially creating a niche market for the profession of pharmacy. Palmetto Pharmacist • Volume 58 Number 4


JOURNAL CE References

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The Active Metabolite of Warfarin (3’-Hydroxywarfarin) and Correlation with INR, Warfarin and Drug Weekly Dosage in Patients under Oral Anticoagulant Therapy: A Pharmacogenetics Study. PLoS ONE. 2016;11(9):1-16. DOI:10.1371/journal.pone.0162084 16. Weeke P and Roden DM. Pharmacogenomics and Cardiovascular Disease. Curr Cardiol Rep. 2013 Jul;15(7):376. PubMed Central PMCID: PMC3941471 17. Quirk E, McLeod H, and Powderly W. The Pharmacogenetics of Antiretroviral Therapy: A Review of Studies to Date. Clin Infect Dis. 2004;39(1):98-106. DOI: https://DOI.org/10.1086/421557 18. Knight JC. Genetics and the general physician: insights, applications, and future challenges. QJM. 2009 Nov;102(11):757-72. PubMed Central PMCID: PMC2766102 DOI: 10.1093/qjmed/hcp115 19. Mallal S, Phillips E, Carosi G, et al. HLA-B*5701 screening for hypersensitivity to abacavir. N Engl J Med. 2008 Feb;358(6):568-79. DOI: 10.1056/NEJMoa0706135 20. Cancer.net [Internet]. American Society of Clinical Oncology (ASCO); c2005-2017 [cited 2017 Jul 15]. Understanding Pharmacogenomics; [about 1 screen]. Available from: http://www.cancer.net/navigating-cancer-care/how-cancer-treated/personalized-and-targeted-therapies/understanding-pharmacogenomics 21. Weng L, Zhang L, Peng Y, Huang RS. Pharmacogenetics and Pharmacogenomics: A Bridge to Individualized Cancer Therapy. Pharmacogenomics. 2013;14(3):15-24. 22. Huang RS and Ratain MJ. Pharmacogenetics and Pharmacogenomics of Anticancer Agents. CA Cancer J Clin. 2009;59(1):42-55. PubMed Clinical PMCID: PMC3109906 DOI:10.3322/caac.20002. 23. Houtsma D, Guchelaar HJ, and Gelderblom H. Pharmacogenetics in Oncology: A Promising Field. Curr Pharm Des. 2010;16(2):155-63. PubMed PMID: 20205661 24. Common Terminology Criteria for Adverse Events v4.0 (CTCAE). US Department of Health and Human Services. Published May 28, 2009. Updated June 14, 2010. Accessed July 23, 2017. https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf 25. Ingleman-Sundberg M. Genetic polymorphisms of cytochrome P450 2D6 (CYP2D6): clinical consequences, evolutionary aspects and functional diversity. Pharmacogenomics Journal. 2005. 5;6-13. DOI: 10.1038/sj.tpj.6500285 26. Ting S and Schug S. The pharmacogenomics of pain management: prospects for personalized medicine. Journal of Pain Research. 2016;9:49-56. PubMed Central PMCID: PMC4755469. DOI:10.2147/JPR.S55595. 27. Park HJ, Shinn HK, Ryu SH, Lee HS, Park CS, Kang JH. Genetic polymorphisms in the ABCB1 gene and the effects of fentanyl in Koreans. Clin Pharmacol Ther. 2007;81:539–46. 28. Kaplan A. Psychiatric Pharmacogenomics. Psychiatric Times [Internet]. 2011 Dec 12. [cited 2017 Jul 16] [about 1 p.]. Available from: http://www.psychiatrictimes.com/articles/psychiatric-pharmacogenomics 29. Narang P, Johnson A, Enja M, and Lippmann S. Pharmacogenomics can enhance prescribing of psychiatric medications. South Med J. 2016;109(10):628-30. 30. Zandi PP and Judy JT. The promise and reality of pharmacogenetics in psychiatry. Psychiatr Clin North Am. 2010 Mar;33(1):181-224. PubMed Central PMCID: PMC3178049 DOI: 10.1016/j.psc.2009.12.001 31. Bakker PR, van Harten PN, van OJ. Antipsychotic-induced tardive dyskinesia and polymorphic variations in COMT, DRD2, CYP1A2 and MnSOD genes: a metaanalysis of pharmacogenetic interactions. Mol Psychiatry. 2008;13(5):544–556. DOI: 10.1038/sj.mp.4002142. 32. Lerer B, Segman RH, Fangerau H, Daly AK, Basile VS, Cavallaro R, et al. Pharmacogenetics of tardive dyskinesia: combined analysis of 780 patients supports association with dopamine D3 receptor gene Ser9Gly polymorphism. Neuropsychopharmacology. 2002;27(1):105-19. PMID: 12062911. DOI: 10.1016/S0893133X(02)00293-2 33. Mrazek DA. Psychiatric pharmacogenomic testing in clinical practice. Dialogues Clin Neurosci. 2010 Mar;12(1):69-76. PubMed Central PMCID: PMC3181940 34. Sim SC, Risinger C, Dahl ML, et al. A common novel CYP2C19 gene variant causes ultrarapid drug metabolism relevant for the drug response to proton pump inhibitors and antidepressants. Clin Pharmacol Ther. 2006 Jan;79(1):103-13. PubMed PMID: 16413245 DOI: 10.1016/j.clpt.2005.10.002 35. Tegretol® (carbamazepine) [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2015. 36. Clinical Pharmacogenetics Implementation Consortium Guideline for HLA Genotype and Use of Carbamazepine and Oxcarbazepine: 2017 Update. Clin Pharmacol Ther. 2018 Apr; 103(4): 574-581. DOI: 10.1002/cpt.1004.Epub 2018 Feb 2 37. US Food and Drug Administration [Website]. Information for healthcare professionals: dangerous or even fatal skin reactions – carbamazepine (marketed as Carbatrol, Equetro, Tegretol, and generics). Updated August 14, 2013. Accessed July 23, 2017. 38. Amstutz U., Shear N.H., Rieder M.J., Hwang S., et al. Recommendations for HLAB*15:02 and HLA-A*31:01 genetic testing to reduce the risk of carbamazepine induced hypersensitivity reactions. Epilepsia. 2014;55(4):496–506. PubMed PMID: 24597466. 39. Sharma N, Tripathi P, and Awasthi S. Role of ADAM33 gene and associated single nucleotide polymorphisms in asthma. Allergy Rhinol. 2011 Apr-Jun; 2(2):e6370. PubMed Central ID: PMC3390120 DOI: 10.2500/ar.2011.2.0018 40. Mahesh PA. Unravelling the role of ADAM33 in asthma. Indian J Med Res. 2013 Mar; 137(3):447-50. PubMed Central ID: PMC 3705653 41. Brice P, Jarrett J, and Mugford M. Genetic screening for cystic fibrosis: An overview of the science and the economics. Journal of Cystic Fibrosis. 2007 Jul; 6(4):255-61. DOI: https://DOI.org/10.1016/j.jcf.2007.02.002 42. Xie H and Frueh FW. Pharmacogenomics steps toward personalized medicine. Personalized Medicine. 2005;2(4):325-37. 43. Vaiopoulou A, Gazouli M, and Karikas GA. Pharmacogenomics: Current applications and future prospects towards personalized therapeutics. JBOUN. 2013;18(3):570-78.

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JOURNAL CE Pharmacogenomics: Proof That One Size Does Not Fit All Corresponding Course Program Number: 0171-9999-18-035-H01-P 1. Complete and mail entire page. SCPhA members can take journal CE for free; $15 for non-members. Check must accompany test. You may also complete the test and submit payment online at www.scrx.org. 2. Mail to: Palmetto Pharmacist CE, 1350 Browning Road, Columbia, SC 29210-6309. 3. Continuing Education statements of credit will be issued within six weeks from the date of the quiz, evaluation form and payment are recieved. Notification will be sent via eamil if you have not successfully completed the quiz. 4. Participants scoring 70% or greater and completing the program evaluation form will be issued CE credit. Participants recieving a failing grade on any examination will have the examination returned. The participant will be permitted to retake the examination one time at no extra charge. South Carolina Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as providers for continuing education. This article is approved for 1 contact hour of contiuning education credit (ACPE: UAN: 0171-9999-18-035-H01-P). This CE credit begins 6/15/18 and expires 6/15/21. CE credit will be uploaded to the CPE Monitor System. Name _______________________________ License # _________________ Birth Month/Day (MM/DD)___________ Address _________________________________________________________________________________________ NABP eID ______________ Phone _______________ Email ______________________________________________ EVALUATION (circle the appropriate response) 1. Did the article achieve the stated objects? (Not at all) 1 2 3 4 5 (Completely) 2. Overall evaluation of the article? 3. Was the information relevent to your practice?

(Poor) 1

2

3

4

5 (Excellent)

(No) 1

2

3

4

5 (Yes)

4. How long did it take you to read the article and complete the exam? _______________

CE credit will ONLY be awarded when a submitted test is accompanied by completing the evaluation above or online at www.scrx.org.

Self-Assessment Questions: 1. Potential benefits of incorporating pharmacogenomics in medication management include which of the following? a. Generalized treatment approach based on population averages b. Increased propensity for adverse effects c. Providing individualized treatment recommendations d. Selling more medicine to patients 2. The Human Genome Project identified how many genes? a. 3,000 b. 30,000 c. 100,000 d. 1,000,000 3. Which of the following Cytochrome P-450 genetic variants does not correspond to an increased risk of bleeding? a. 2C19*2 b. 2C19*17 c. 2C9*2 d. 2C9*3 (Continued on next page)

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Palmetto Pharmacist • Volume 58 Number 4


JOURNAL CE 4. Pre-therapy screening for HLA-B*5701 should be implemented before dispensing which of the following medications? a. Abacavir b. Carbamazepine c. Simvastatin d. Warfarin 5. A 56 year old female with breast cancer is found to have the DYPD*2A SNP on pharmacogenetic analysis. What is a consequence of this genetic polymorphism? a. Anemia b. Leukocytosis c. Neutropenia d. Thrombocytopenia 6. A 21 year old male with schizophrenia was discharged from an inpatient psychiatric hospital on clozapine 7 days ago. He is brought to the pharmacy by his mother who insists on a medication refill even though he has 7 days remaining because he has resumed his psychotic behaviors. He smells of cigarette smoke and is also wearing a nicotine patch. Which of the following is the most likely explanation of this individual’s psychiatric decompensation? a. CYP1A2 and nicotine led to increased clozapine concentrations b. CYP1A2 and smoking led to decreased clozapine concentrations c. CYP3A4 and nicotine led to increased clozapine concentrations d. CYP3A4 and smoking led to decreased clozapine concentrations 7. Pharmacists may begin incorporating pharmacogenomics into practice. Which of the following recommendations is the most appropriate for a pharmacist after viewing a patient’s pharmacogenetic results? a. CYP2D6*3 and hydrocodone: decrease the dose of hydrocodone b. CYP2D6*9 and hydrocodone: increase the dose of hydrocodone c. CYP2D6*1 and oxycodone: increase the dose of oxycodone d. CYP2D6*35 and oxycodone: decrease the dose of oxycodone 8. Which of the following is a limitation of pharmacogenetic testing? a. Length of time needed to receive test results b. High cost; ineligible for insurance reimbursement c. Few testing centers available d. Specialized training required to interpret results

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Did you Hear the News? SCPhA has launched a new website! NACDS Community Pharmacy-Based Point of Care Testing Certificate Course SCPhA Headquarters Friday, August 17, 2018 8:00am- noon Register today at www.scrx.org

Same great service (and location) with easier navigation tools. www.scrx.org Questions or suggestions? Let us know! info@scrx.org or 803.354.9977

A continuous quality improvement program can be a lifesaver! M A K E YO U R PAT I E N TS A N D YO U R P H A R M ACY SA F E R .

FOR LESS THAN A DOLLAR A DAY ... • • • •

Increase patient safety – learn from collected safety data and online resources Maintain compliance – meet accreditation, credentialing, PBM and state QA requirements Reduce costs – increase operations efficiency, reduce potential risk and cut down on “re-do” Rxs Safeguard your data – Patient Safety Organizations offer confidentiality and legal protection

Learn more at www.medicationsafety.org or call us at (866) 365-7472. The Alliance of Medication Safety (APMS) is a federally listed Patient Safety Organization (PSO).

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Palmetto Pharmacist • Volume 58 Number 4


CLASSIFIEDS FOR SALE FOR SALE: PHARMACY SHELVING 1) Pharmacy Bay Shelving 12- 4 x 7 sections Pharmacy Bay Shelving 5 - 3 x 7 sections 2) Out-front Shelving 10 - 4x8 (5) shelf Out-front Shelving 4 - 4x 6 (4) shelf Out-front Shelving 3 – 3x6 (4) shelf Call 864-288-0911 for details

FOR SALE: SIMPLEX 3 COMPARTMENT CLEAN ROOM Simplex 3 compartment clean room; 2 Kirby Lester pill counters, RAM powder mixture. Make offer, Tom Holley RPh in Aiken 803-640-8931

Services

PALMETTO CONSULTANT, LLC Non dispensing drug and pharmacy consultant. Registered BS in Pharmacy & 6 years experience as a consultant. Contact via email at PalmettoConsultant@sc.rr.com or 843.319.6957 NEED HELP WITH MEDICATION THERAPY MANAGEMENT? Contact: Bryan Ziegler, PharmD, MBA, Pharmacy Service Consulting, LLC Phone: (803) 269-6333 Email: Rxserviceconsulting@gmail.com Services Provided: MTM education, Identification of MTM Opportunities, Staff Training, Workflow Analysis, Business Analysis STORE FIXTURES/PLANNING Planning to expand, remodel or open a new pharmacy? Since 1973 Display Options, Inc. has provided professional store planning, Installation, quality store fixtures and customer service to Pharmacies across the Southeast. Please allow us the opportunity to assist you with your plans & dreams. Call us toll free at (800)321-4344 or visit our web site at www.displayoptions.com.

ETC.

TRANSFORMING THE SOUL OF PHARMACY, BY MINISTERING TO THE HEARTS OF PHARMACISTS Christian Pharmacists Fellowship International, a nonprofit organization, is a worldwide fellowship of individuals working in all areas of pharmaceutical services and practices. For membership information, call (888) 253-6885 or visit our website at www.cpfi.org. BOOKS FOR SALE Christian Book Available at Amazon, Barnes and Noble, and etc. It is Called Choices ( The secret to Making Wise Choices) by Carolyn Gault wife of pharmacist Horace Gault Jr. The book is about our moments in history as we face choices that are confusing, in out rapidly changing culture. The proceeds will go to Mission to the World to help missionaries and their families. OXYGEN EQUIPMENT 18-Portable oxygen cylinders, 1 devilbiss oxygen conservator, 1-5 liter concentrator invacare, 7-oxygen regulators,1-Salter labs ultrsonic oxygen indicator. Call 864-843-9207, liberty family pharmacy $200

715 King Street, Charleston, SC 29403 • Direct Dial (843) 266-2625 • jon.wallace@fordwallace.com

Palmetto Pharmacist • Volume 58, Number 4

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More Convention Pictures!

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Palmetto Pharmacist • Volume 58 Number 4

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