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Palmetto Pharmacist The Official Journal of the South Carolina Pharmacy Association • Vol. 53, Num. 3

2013-2014 Board of Directors

Steve McElmurray, RPh President & Board Chair

Palmetto Pharmacist • Volume 53, Number 3

We provide the support you need to serve your customers. R

Each day every employee at Smith Drug Company has one goal: to help independent pharmacies grow and prosper. That’s why we work to do things how you need them rather than make you fit into a rigid corporate model. It’s why we provide dozens of services like merchandising programs, DME specialists and other services at no cost to our


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Palmetto Pharmacist • Volume 53 Number 3

Volume 53, Number 3

June/July 2013

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.

Palmetto Pharmacist What’s Inside... 5

Metathesiophobia President Steve McElmurray discusses the irrational fear of change


State Phair 2013 A look at SCPhA’s 2013 Annual Convention


Legislative Wrap Up At the close of the legislative session, see how things tied up


A Perspective on Pet Medications Information on veterinary medications


My SCPhA Rotation Journal SCCP Student Michelle Nations discusses her rotation with SCPhA


Pharmacy Camp Attracts Young Audience A special camp at SCCP provides a unique experience for students

Board of Directors President/Chairman of the Board Steve McElmurray, RPh Immediate Past President John Pugh, PharmD, RPh President-Elect Bryan Amick, PharmD, RPh Treasurer Pamela Whitmire, PharmD, RPh Low Country Region Kristy Brittain, PharmD, RPh Pee Dee Region Jarrod Tippins, PharmD, RPh Midlands Region Patti Fabel, PharmD, RPh Upstate Region Ed Vess, PharmD, RPh At-Large Director William Wynn, PharmD, RPh Speaker, House of Delegates Michael Gleaton, PharmD, RPh Speaker-Elect, House of Delegates Sarah Braga, PharmD, RPh CEO Craig Burridge, MS, CAE REGION DELEGATES Low Country Region Midlands Region Don Neuroth, RPh Craig Harmon, RPh David Proujan, RPh Sarah Braga, PharmD, RPh Tray Till, RPh Lynn Connelly, RPh Wayne Weart, PharmD Kevin Brittain, PharmD, RPh Brian Clark, PharmD, RPh Upstate Region Pee Dee Region David Banks, RPh Jim Shuler, RPh Steve Greene, PharmD, RPh Kelly Jones, PharmD, RPh Walter Hughes, RPh Dan Bushardt, RPh Linda Reid, RPh SCPhA STAFF Craig Burridge Chief Executive Officer Laura Reid Director of Events Keenan Grayson Director of Membership Cassandra Hicks-Brown Director of Operations/ACPE Lauren Sponseller Director of Communications Jon Wallace, BS Pharm, JD SCPhA General Counsel Cecily DiPiro, RPh PPN Network Coordinator

Regular Columns 18 SCCP 32 Financial Forum 36 Journal CE 33 Classifieds Advertisers 2 Smith 4 Pharmacists Mutual 15 Mutual Drug of North Carolina 34 Display Options 42 PACE 43 Jon Wallace, Attorney at Law 44 QS1

PALMETTO PHARMACIST STAFF Jennifer Simmons Craig Burridge

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Palmetto Pharmacist • Volume 53, Number 3


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Palmetto Pharmacist • Volume 53 Number 3

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Metathesiophobia By Steve McElmurray, RPh| SCPhA’s 2013-2014 President and Chair

Metathesiophobia - the fear of change It has been said that the only thing constant in this world is change. Change is an inevitable part of our daily lives. There are many people who fear change. They actually experience strong anxiety, physical reactions, and even seek out treatment. I think they are looking at change in a negative light. They are seeing change as being an end to something. I believe that change signifies a new beginning – an opportunity. Over the years, we’ve seen many changes in the practice of pharmacy. With the addition of health care reform, we will see many more. These changes, though, will bring a plethora of new opportunities for us as pharmacists. We just have to look at it from that perspective. The best change that I’ve seen happening and that I’m excited to continue exploring is our ability to showcase our cognitive assets. The people in our profession are overflowing with experience, knowledge, and expertise. While we’ve always had this depth of information, I don’t believe that the public has been fully made aware of what we can offer. New opportunities, such as MTM services, can help to bring awareness to our profession and practice. At our convention, we were excited to host Assistant Surgeon General and Chief Pharmacy Officer, RADM Scott Giberson. RADM Giberson talked about this very same subject. He talked about how all of these changes give us the chance to transform the profession. This is our time to make the profession what we want it to be. When it comes to change, we also have to think about our approach to it. Do we continue down the same path, or do we try to think outside of the box? Personally, I like the latter. If we look inside of the box, our opportunities are pretty limited. They are safe and close, but they are definitely confined. If we look outside of the box, though, the opportunities

are endless. During my time as the President of SCPhA, I want to push us all to look outside of the box and see what other prospects there are on the horizon. There may even be some amazing venues for pharmacy to try that we just haven’t thought of yet! SCPhA, itself, has gone through some major changes over the past year. In addition to the expected transfer of leadership, the Association staff has had an overhaul. In the past year, we’ve welcomed Craig Burridge as our new CEO, Keenan Grayson as Director of Membership and Laura Reid as Director of Events. This new staff composition provides us with a new energy and I can’t wait to see where they help SCPhA grow. Of course, how far the Association can grow is up to you. We need your support this year to help to make this profession and this Association stronger. The staff is here to help, but we’ll need each and every one of you to help make a difference. Encourage your peers to join. We need as many members as we can to make an impact at the State House. Contribute what you can to our Foundation or to the Pharmacy Advocacy Committee. Attend as many SCPhA events as you can. Even if you think you don’t need continuing education, take every chance you get to learn more about the profession and the activities of SCPhA. Let’s make this year our best year ever!

Palmetto Pharmacist • Volume 53, Number 3

Pharmacy Nights are back!

Pharmacy Night Locations

ʊ Network with your peers while you eat dinner. ʊ Get 2 hours of continuing education. ʊ Meet SCPhA’s new CEO, Craig Burridge. ʊ Get to know your Region SCPhA leadership. ʊ Learn about the Association, events and activities. ʊ Renew your SCPhA membership!

6:00 PM - 7:00 PM: Registration and Dinner 7:00 PM - 9:00 PM: Program (2 Hours CE) $15 for 2013-2014 SCPhA Members $25 for Non-Members $10 for Students (no CE credit provided)

August 20, 2013 and March 18, 2014: Greenville Virginia College ŏ 78 Global Dr., Greenville, SC September 10, 2013: Myrtle Beach Grand Strand RMC ŏ 809 82nd Pkwy., Myrtle Beach, SC September 24, 2013 and February 11, 2014: Columbia SCPhA Office ŏ 1350 Browning Rd., Columbia, SC October 2, 2013 and February 4, 2014: Charleston Bon Secours Hospital ŏ 2095 Henry Tecklenburg Dr., Charleston, SC October 17: Florence Virginia College ŏ 2400 David H. McLeod Blvd., Florence, SC November 5: Rock Hill Piedmont Medical Center ŏ 222 S. Herlong Ave., Rock Hill, SC January 23: Aiken Aiken Tech ŏ 2276 J. Davis Hwy., Graniteville, SC *Locations are subject to change. Please check for specific event details closer to each Pharmacy Night.

Select the Pharmacy Night you wish to attend:

2013 Ō Greenville (August 20) Ō Myrtle Beach (September 10) Ō Columbia (September 24) Ō Charleston (October 2) Ō Florence (October 17) Ō Rock Hill (November 5) 2014 Ō Charleston (February 4) Ō Columbia (February 11) Ō Greenville (March 18) Ō Aiken (January 23)

*Cities with more than one Pharmacy Night will have different topics.

SCPhA Member: Qty. ______ ($15 ea.)

Non-Member: Qty. ______ ($25 ea.) Student: Qty. ______ ($10 ea.)

*If renewing or joining on this form, please select the member rate.

To renew or join SCPhA now, please select your member type below: Ō Pharmacist ($150) Ō Associate ($150)

Ō Retired ($75)

Ō First Year ($75)

Ō Technician ($35)

Ō Student (free!)

Name____________________________________________________________ Ō Technician Ō Pharmacist Ō Student Email_________________________________________________________ Phone______________________________ License/Reg #________________ NABP eID#______________________ Birthdate (MM/DD)__________________ Payment Type: Ō Check _________ Total Amount Due: $_____________ Credit Card Type: Ō MC Ō Visa Ō AMEX Ō Discover Name on Card________________________________________ Card #____________________________________________________ Exp. Date____________________ CVV_____________ Billing Address ___________________________________________________________________________________________

Cancellations will only be accepted if received more than 5 business days before the event. If applicable, a refund will be issued less a $5 processing fee. South Carolina Pharmacy Association is accredited by the accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This activity is eligible for ACPE credit; see final CPE activity announcement for specific details.

Complete this form and return to SCPhA, with payment, to SCPhA, 1350 Browning Road, Columbia, SC 29210 or fax  Palmetto Pharmacist • Volume 53 Number 3 to 803.354.9207. Visit to register online. Call 803.354.9977 with questions.


SCPhA State Phair June 6-9, 2013 Hilton Head, SC If

you didn’t make it to SCPhA’s 2013 Convention, then you missed out on the most exciting event of the year! SCPhA’s 2013 Convention had a “State Phair” theme, which made for an entertaining time. Throughout the next few pages of the journal, you’ll see highlights from the event. More photos and details can also be found on our Facebook page at

Palmetto Pharmacist • Volume 53, Number 3


The photos on this page were taken from the State Phair Night, benefitting the SC Pharmacy Foundation. Attendees could play games and enjoy carnvial food for fun. In addition, there were optional fundraiser activities, including a Silent Auction, in which proceeds benefitted SCPhA’s Pharmacy Foundation.

Palmetto Pharmacist • Volume 53 Number 3

CONVENTION Continuing Education Programming As if the fun and networking opportunities aren’t reason enough to attend SCPhA’s Annual Convention, the continuing education line up that SCPhA continues to provide is amazing.

This year, SCPhA featured a phenomenal array of speakers and topics. Attendees learned about topics such as Crohn’s disease, ulcerative colitis, immunization, health care reform, legislative action, self-care, and new drug information. Speakers such as Bryan Love, Patti Fabel, Julie Sease, Wayne Weart, Buddy Lingle, and Jon Wallace were a hit with the conference-goers. The highlight of the convention, however, was keynote speaker RADM Scott Giberson, who currently serves as the Assistant US Surgeon General. Giberson’s dynamic presentation was motivating, informative, and also had elements of humor. Attendees were really excited about this program and were talking about it even after convention.

Self Care Bowl A Smash Hit This year, SCPhA introduced the Self Care Bowl. Supported through a grant from NASPA, the challenge was hosted by Cecily DiPiro, PharmD, RPh, and featured teams from each of the pharmacy school campuses located in SC. The teams went head to head in a battle of self-care knowledge. While all of the teams excelled, the students from SCCP-USC were the winners. Teams were encouraged to decorate and create their own team outfits. We were really impressed with the creativity!

Palmetto Pharmacist • Volume 53, Number 3



Palmetto Pharmacist • Volume 53 Number 3

Exhibit Hall 2013

AbbVie Absolute Total Care American Associated Pharmacies American Pharmacy Cooperative, Inc. (APCI) AmerisourceBergen Assured Pharmaceuticals Boehringer Ingelheim Buy-Sell A Pharmacy Cardinal Health Christian Pharmacists Fellowship International (CPFI) Cost Effective Computers CVS Designer Greetings Dr. Comfort EPIC Pharmacies, Inc Fred’s, Inc. Hospira iMedicare Integral Solutions Group Janssen Pharmaceuticals, a division of Johnson & Johnson Janssen Pharmaceuticals, a division of Johnson & Johnson LMK Wealth Management Magellan Medicaid Administration McKesson

Meda Medicine On Time Merck Mutual Wholesale Drug Company Nephron Pharmaceuticals Novo Nordisk, Inc. PACE Alliance Pharmacists Mutual PPSC Presbyterian College School of Pharmacy Publix QS/1 Data Systems Return Solutions Rite Aid Rx Planning Solutions Sanofi Smith Drug Company South Carolina Board of Pharmacy South Carolina College of Pharmacy SC Deptartment of Health & Human Services South University School of Pharmacy Takeda Pharmaceuticals Teva Walgreens Wal-Mart

Thank You To All Of Our Exhibitors!

Palmetto Pharmacist • Volume 53, Number 3


SCPhA Awards 2013

Technician of the Year: Jane Babb Jane Babb of CVS in Charleston, SC, was named the 2013 Technician of the Year. To be nominated for the Technician of the Year award, individuals must be state certified technicians and members of SCPhA for at least twoconsecutive years. They must effectively communicate with patients and health care professionals. Nominations are submitted by pharmacists with direct knowledge of their work. Babb began her career in pharmacy in the summer of 1991 as a sales associate for Revco. After CVS’s acquisition of Revco, she got the opportunity to step behind the pharmacy counter and began her career as a pharmacy technician. Babb currently serves as the Field Colleague Trainer, conducting orientation for all new CVS employees. According to her nominator, “Jane’s work to improve the quality of care to patients through effective technician training and now through training all employees of CVS Pharmacy show her true commitment and loyalty to the practice of pharmacy.”


Excellence in Innovation: Jessica Puckett-Beasley Jessica Puckett-Beasley, from Charlotte, NC, is the 2013 Excellence in Innovation Award Recipient. The award, sponsored by the National Alliance of State Pharmacy Associations and Upsher-Smith Laboratories, was designed 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. Dr. Puckett-Beasley received this award because she has been instrumental in integrating innovative pharmacy services into community pharmacy. She was responsible for incorporating immunizations, medication therapy management, health testing, bedside delivery, and other specialty pharmacy services into 28 Walgreens pharmacies in SC and GA. She is responsible for developing a pharmacistprovided transplant medication consultation service in the Augusta, GA area. She has also piloted programs that involve a community pharmacist delivering medications to and counseling patients being discharged from a hospital. Palmetto Pharmacist • Volume 53 Number 3

Cardinal Health Generation Rx Champions Award: Presbyterian College School of Pharmacy ASP The South Carolina Pharmacy Association (SCPhA) is pleased to announce that Presbyterian College School of Pharmacy’s Academy of Student Pharmacists chapter received the Cardinal Health Generation Rx Champions Award at SCPhA’s 2013 Annual Convention. The Generation Rx Champions Award recognizes pharmacy professionals who have demonstrated excellence in community-based prescription drug abuse prevention. The award is intended to recognize outstanding efforts within the pharmacy community to raise awareness of this serious public health problem. It is also intended to encourage educational prevention efforts aimed at patients, youth, and other members of the community. The GenerationRx Project committee at Presbyterian College has provided poison prevention, drug abuse awareness and alcohol abuse awareness programs. Through involvement with undergraduate students at Presbyterian College and local law enforcement, as well as both elementary and high schools in the Clinton and Laurens community, the GenerationRx Project team was also able to host its first annual drug take back event at Presbyterian College. Several students, along with faculty advisor Kayce Shealy, PharmD, RPh, attended the Awards and Installation Banquet to receive the award.

Palmetto Pharmacist • Volume 53, Number 3

Pharmacist of the Year: Mel Rauton SCPhA was pleased to name Mel Rauton, RPh, as the 2013 Pharmacist of the Year. As a Past President of the South Carolina Pharmacy Association, Rauton exemplifies leadership and championship of the profession. Rauton is a pharmacist at the historic Pitt Street Pharmacy in Mt. Pleasant, SC, where he specializes in pharmaceutical compounding. Rauton has shared his expertise in compounding, serving as a mentor and preceptor for many pharmacists and pharmacy students. He has been an active advocate for pharmacists legislatively and has served in a variety of leadership positions within the Association. “Mel is not just a great pharmacist,” remarked outgoing SCPhA President, John Pugh. “He is an outstanding person. He is always willing to help out in any way that he can.”


Student Pharmacist of the Year: Carolin Griggs

Distinguished Young Pharmacist: Bryan Amick

Caroline Griggs has been an active member of APhA-ASP, NCPA, SNPhA and CPFI while in pharmacy school. A new graduate of SCCP - MUSC Campus, she is one of the dual degree students, simultaneously completing her PharmD and her MBA. Previously, she earned a BS in Biochemistry from Clemson.

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. The prestigious award is presented by Pharmacists Mutual Companies, nationally recognized as a leader in providing insurance and financial services to Pharmacy.

This year’s winner has engaged in a wide range of pharmacy experiences while in pharmacy school, including service as an ambulatory care intern at Newton and Associates MTM and Diabetes Coaching, a drug information intern and an intern for Walmart Pharmacy. She also served as a supplemental instructor for MUSC’s Center for Academic Excellence serving as a tutor to underclassmen needing assistance in pharmacy coursework. Her fourth year rotations have included experience in hospital and community pharmacy, ambulatory care, acute medicine (adult and pediatric), pharmaceutical industry, and academia. Following graduation, she will be completing a community pharmacy residency at Virginia Commonwealth University. About this award: This new award was created to honor outstanding students. Each of the schools was asked to nominate an oustanding student for this award. We thought that all of the nominees were amazing: • Kim Keeney - South University • Lillie Kelly - SCCP - USC Campus • Jeannie Norge - Presbyterian College 14

Bryan Amick is the 2013 Distinguished Young Pharmacist. Achievements of this year’s recipient include his recent appointment to Pharmacy Director at the South Carolina Department of Health and Human Services. His commitment to Pharmacy and the advancement of the profession is evident through his professional activities. This year’s winner currently serves on SCPhA’s Board of Directors as Speaker of the House, and is next year’s President-Elect. He is also a grant reviewer for PCORI, an editorial advisory board member of Pharmacy Today, peer review panelist for American Health and Drug Benefits, an admission interviewer for the Presbyterian College School of Pharmacy. In addition, he is a member of APhA, SCPhA, Phi Lambda Sigma and the Academy of Managed Care Pharmacy, where he is the SC State Advocacy Coordinator.

Palmetto Pharmacist • Volume 53 Number 3

Bowl of Hygeia: Linda Reid The South Carolina Pharmacy Association (SCPhA) is pleased to announce that Linda Reid, RPh, was awarded SCPhA’s 2013 Bowl of Hygeia Award. The award was presented on June 8, 2013, in Hilton Head, SC, at SCPhA’s Annual Convention. Reid lives in Greenville, SC, and currently works for Network Health Care. The Bowl of Hygeia is presented annually by participating pharmacy associations in each of the fifty states, the District of Columbia, Puerto Rico, and the ten Canadian provinces. The recipients are selected by their respective associations for their outstanding record of community service. The Bowl of Hygeia award is sponsored by the American Pharmacists Association Foundation, the National Alliance of State Pharmacy Associations with support from Boehringer Ingelheim. As a Past President of SCPhA, Reid has taken a very active role in professional leadership. She is a member of the American Pharmacists Association, Phi Lambda Sigma, MUSC College of Pharmacy Alumni Association, and has held several elected positions with the South Carolina Pharmacy Association.

Outgoing President Award: John Pugh Each year, Smith Drug Company proudly recognizes the Outgoing Presidents of the South Carolina Pharmacy Association. This award recognizes the Outgoing President and Board Chair for their leadership, sacrifices and contributions to the association. This year’s recipient, John Pugh, was incredibly deserving of this award. Throughout the year, John has provided phenomenal leadership in his role as President. He has given countless hours to the profession. In addition to his role as President, John also had the added challenge of filling in as interim CEO during staff transitional changes at SCPhA. John stepped up to the plate to serve the Association, all while managing his store, Prosperity Drug, and serving his patients. Ken Couch presented this award to John during the Awards Dinner. As a Former President himself, Ken is a wonderful example of a leader in the profession, who has remained active and involved long after his term as President came to a close.

Palmetto Pharmacist • Volume 53, Number 3



Legislative Wrap Up 2013 From Capitol Consultants, SCPhA’s Lobbying Team The General Assembly ended its regular session last week on June 6. They returned this week to complete work on the state appropriations bill and will return again next week to deal with the governor’s vetoes of state budget items. Below is a recap of the bills in which the SCPhA has been involved in 2013. When the legislature reconvenes, we anticipate a host of other pharmacy issues to be brought to the forefront. As always, the Lobby Team at Capitol Consultants will keep you advised of issues affecting the pharmacy profession and its patients.

Compounding Bills: H. 3161

At the request of the South Carolina Board of Pharmacy, Representative Kit Spires (R-Lexington) filed legislation to update the Pharmacy Practice Act to include current standards regarding pharmacy compounding. The State Board established a task force on this issue in 2011 composed of pharmacists from the settings of independent pharmacy, chain pharmacy, hospital pharmacy, nuclear pharmacy, and home health care pharmacy. The legislation now being considered is a result of the task force’s work. It incorporates safety standards and best practices from the United States Pharmacopeia (USP) for pharmacy compounding and adds new technical definitions; detailed environmental, safety and quality controls; and standards of practice for pharmacy compounding from Chapters 795 and 797 in the USP- National Formulary (USP-NF), which are nationally recognized and used by the FDA. H. 3161 passed the House in February and moved on for consideration by the Senate. When the bill was being heard by the Senate Medical Affairs Committee, Senator Shane Martin (R-Spartanburg) proposed two amendments: (1) to allow all continuing education for pharmacists to be completed online in addition to in person and (2) to allow a 3:1 16

ratio for pharmacy technicians to pharmacists. We later discovered that he was offering these amendments on behalf of Senator Kevin Bryant (R-Anderson). In committee, Addison Livingston from the State Board said that the Board would have problems with both of these and needed time to discuss. The Committee decided it did not want to delay the compounding bill because of these amendments, so Senator Martin withdrew them. The SCPhA immediately sent an alert to members to contact their senators, asking them to oppose these amendments. As the bill came up for debate in the full Senate, Senator Bryant again proposed his amendments. The continuing education amendment was killed by the Senate. When the opposition to the pharmacy technician amendment was obvious, Senator Bryant objected to the bill in its entirety keeping it from passing this year. When the legislature reconvenes, the bill will still be on the Senate Calendar.

Regulation of Out of State Pharmacies: H. 3444

Another bill prompted by the State Board is H. 3444 by Representative Bill Sandifer (R-Oconee) which seeks to regulate out of state pharmacies distributing in South Carolina. Specifically, H. 3444 would require that out of state pharmacies have a pharmacist in charge (PIC) licensed in SC. The board was already working on several issues related to out of state pharmacies and even compounding when the New England compounding Pharmacy (NECC) recall hit the headlines. That event only served to energize the board in what they had already been considering—more regulation on those out of state entities. The bill would also allow the board to inspect out Palmetto Pharmacist • Volume 53 Number 3

LEGISLATIVE of state facilities. The State Board could have a memorandum of agreement with another state board to allow them to do the inspections or may use a third party approved by SC’s board. This would also require a surety bond of $100,000 for wholesale distributors as well as a designated representative. Currently, no bond is required and only the owner/operator must be named. This bill passed the House of Representatives but stagnated in the Senate Medical Affairs Committee. It will be debated further when the General Assembly comes back into session.

Meth Bill: S. 447

Senator Mike Fair (R-Greenville) introduced legislation this session that would designate ephedrine, pseudoephedrine, and phenylpropanolamine as schedule III controlled substances. S. 447 provides for several other provisions aimed at attacking South Carolina’s meth production and consumption problems. It would require that information submitted to the DHEC Control Prescription Monitoring Program from Schedule II, III and IV controlled substances must be done in a manner consistent with certain National Pharmacy Automation and Exchange of Information Standards. Law enforcement would be able to obtain information on those three types of substances without conducting a specific drug related investigation on a designated person. S. 447 would also require a person selling a motor vehicle that was the site of a methamphetamine lab to disclose that information to the seller in writing. Additionally, DSS would be prohibited from placing a child who has been exposed to methamphetamine use, manufacture, sale, distribution or trafficking with a relative or associate involved in such illegal activity. The State Law Enforcement Division contacted SCPhA leadership months ago to discuss this initiative, but the bill has not seen a great deal of movement. Members shared some concerns about greater burdens for their law abiding consumers. The bill has not yet had a subcommittee hearing. A compromise version may be introduced in the coming weeks, and we will continue keep you up to date as discussions of South Carolina’s meth problems continue. Al-

though well publicized when introduced, this bill saw no movement.

Medicaid Expansion

The debate over whether South Carolina will expand its Medicaid program on the federal dime for three years continues. During its budget debate in March, the House of Representatives shot down all measures that would have expanded the program for even one year. In May, the Senate Finance Committee also refused to accept any plans for expansion. The debate has been extremely partisan—with only one republican voting in favor of expansion in the Senate Finance Committee, Sen. Ray Cleary, a dentist from Georgetown. Expansion was also shot down by the full Senate. A House bill (H. 4095) sponsored by Rep. Kris Crawford, a medical doctor from Florence, proposes a so-called alternative to expansion, which began with wide bi-partisan support including 75 co-sponsors. However, in the last weeks of session, Republican Representatives have been backpeddling their support with 25 representatives removing their names as sponsors. Crawford’s plan would provide health care to low-income, uninsured individuals through managed care plans and medical spending accounts (MSAs). If passed it would go into effect Jan. 1 2014 through Dec. 31, 2016 using Medicaid expansion funds from the Affordable Care Act (ACA). The bill focuses on preventive care, requiring managed care plans to provide a beneficiary up to $500 in preventive care services each year at no cost to the beneficiary. This bill will not pass this session and will therefore not go into effect in 2014, but as the implementation of the Affordable Care Act takes place in January, we are certain to hear more in this ongoing debate in 2014.

If you have questions about SCPhA’s legislative efforts, please feel free to call our office at 803.354.9977. Want to help? Contribute to our Pharmacy Advocacy Committee today!

Palmetto Pharmacist • Volume 53, Number 3


SCCP PharmD and MPH: An Ideal Match By Joseph DiPiro, PharmD, Executive Dean of the SC College of Pharmacy Pharmacy students can benefit greatly from a degree in public health – a field in which pharmacists can and do play a vital role. In 2012-13, the South Carolina College of Pharmacy (SCCP) began offering a new PharmD/masters of public health (MPH) dual degree so students interested in this area have access to the proper education and training to prepare them for a successful career improving public health. SCCP is one of fewer than 20 colleges of pharmacy in the United States offering this program. Pharmacists have an important part to play in public health. The American Public Health Association issued a policy statement in November 2006 highlighting the changing role of pharmacy practitioners and how these new roles, related to medication delivery and proper utilization as well as chronic disease management, are important to public health. In an American Journal of Pharmaceutical Education article in 2010, Hoai-An Truong University of Maryland School of Pharmacy) and Brooke Y. Patterson (University of Missouri Kansas City School of Pharmacy) noted that pharmacists now provide many

“micro-level” public health activities (disease management, wellness screening, immunizations and medication therapy management) but have an opportunity to fill unmet needs in “macrolevel” public health functions, such as assessment, policy development and assurance at the population-based level. Among other things, the study calls for more MPH programs to meet this challenge. At the College, we believe it is important for pharmacists to be prepared to fill this important role in public health. Students who have the interest and ability in improving public health should have the opportunity to train to do so. The program at SCCP is a collaboration between the College and The Arnold School of Public Health at the University of South Carolina (USC), available to students on the USC, Medical University of South Carolina (MUSC), or the Greenville Health System (GHS) campus of SCCP. Approximately one-half of the MPH curriculum is offered via asynchronous distance education, which allows students from multiple campuses to complete a portion of the program no matter their location. The remaining portion of the MPH program is available at the USC-Columbia campus. Our students have shown immediate interest. In the first year, we had six students from USC and five from MUSC enroll in the program. Of these 11 students, nine have begun classes already and the other two will begin this Fall semester. Students receive training in the five core educational disciplines of public health - biostatistics; epidemiology; environmental health sciences; health services policy and management; and health promotion, education, and behavior as part of the core curriculum. Students are then able to focus within an individualized selection of these disciplines to complete the


Palmetto Pharmacist • Volume 53 Number 3

remaining course requirements.

response or managed care organizations. A dual degree could facilitate work in hospital epidemiology, cliniBryan Ziegler, executive director of the Kennedy cal trials and investigations, research on the cost of Pharmacy Innovation Center (KPIC), helped develop pharmaceutical treatments, patient behavior related to the proposal that led to the program’s acceptance at medicine, disease surveillance and medication safety, USC. or health services research. A pharmacist with public health training could also prove to be highly effective “This new dual degree program provides a tremenat advocating and developing policies for the pharmadous opportunity for our graduates to be even more cy profession, including critical areas like regulation competitive in the marketplace and fulfill important and reimbursement. needs in patient care,” Ziegler said. “The KPIC has been supportive of this new dual degree program The College welcomes highly-motivated students and throughout the development process and now in this collaboration with the respected Arnold School of financially providing support to students as they Public Health creates another program at the College extend their education beyond the traditional PharmD to provide those students with the best possible educatraining.” tion we can offer. Students who have a master’s in public health can expand their career options in many ways. They can work for government agencies at the local, state or national level, participate in community health and immunology programs, or work in emergency




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Palmetto Pharmacist • Volume 53, Number 3


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Palmetto Pharmacist • Volume 53 Number 3

A Perspective on Pet Medications

Donna S. Harrison, Pharm.D., RPh, Associate Professor, South Carolina College of Pharmacy (SCCP), Medical University of South Carolina (MUSC) campus Jessica L. Gaskins, Pharm.D., FSVHP, RPh, Instructor, South Carolina College of Pharmacy, Medical University of South Carolina campus Pharmacist, Plantation Pharmacy, Charleston SC


his past winter, I brought my two healthy rescue dogs for a visit to our veterinarian for their annual checkup. Our veterinarian is wonderful and treats us like family and I am confident that my animals receive quality medical care. Upon checking out, I was presented a bill for a total amount of $731.20. The dogs had blood work, fecal testing, and shots, etc.; however $396.21 was my bill for a six month supply of routine heartworm and flea and tick prevention medications. I did not ask for prescriptions to take elsewhere to be filled, nor was I asked how I wanted to pursue this medication purchase. It was all packaged up and presented to me along with my bill as I was leaving. Fortunately for me, as a pharmacist, paying almost $400 for pet medications just the week before Christmas did not result in a major financial crisis. However for some pet owners, Palmetto Pharmacist • Volume 53, Number 3


PETS it could have posed a choice between medication for the dogs and food for the holiday dinner. We all want to receive quality medications for our pets, but what options do we have as pet owners for receiving safe and cost effective medications? I feel that you as pharmacists might find a little information helpful in making future choices regarding the medications your own pets require, and better understanding your potential roles in the pet medication industry. Most medications for people do not come directly from the physician, but come from the pharmacist. So why do we tend to limit prescription medications for our pets to be dispensed by our veterinarians? It is a very interesting and complex history involving several branches of our Government. For example, like human medications, the Food and Drug Administration (FDA) also regulates the safety and efficacy of most veterinary prescription drugs. On the other hand, the U.S. Department of Agriculture (USDA) monitors animal vaccines while the Environmental Protection Agency is responsible for topical flea and tick medications. Veterinarians were not even allowed to prescribe “people” medications for animals until the Animal Medicinal Drug Use Clarification Act (AMDUCA) was passed in 1994.?1 The process of prescribing medications for our pets is slowly evolving. In the future the process of filling your pet’s prescription may change even more if a bill called HR 1406 Fairness to Pet Owners Act, which has been introduced into the House of Representatives, gets passed. This bill will require your veterinarian to provide you with a hand written prescription that you can fill at your veterinarian’s office or at the pharmacy of your choice. The American Veterinary Medical Association (AVMA) is lobbying heavily against it2, but should this bill pass, it means you, as a local pharmacist, may be asked to provide your pet patients with more of their medication, along with your people patients’ medications. Would you feel comfortable filling prescriptions for animals? We fill prescriptions for a variety of aged people, so why shouldn’t you feel safe with filling pets’ prescriptions? There are often mixed feelings here, but there is a strong potential that you will need to perform this duty. Just as with human prescriptions, any dose that appears “odd” or any medication that might not seem appropriate for the patient’s condition should require a verification phone call to the Physician or the Veterinarian. As pharmacists, we have been reported to be the most trusted professionals for many of the past years. We are accessible, and our consultation is free. Unfortunately, just like any profession, a one bad pharmacist 22

may taint the reputation of all of us. However colleges of pharmacy graduate exceptional professionals each year who take an oath to protect and care for their patients, and no distinction is made between human or otherwise. I teach pharmacy school at the South Carolina College of Pharmacy (SCCP) at the MUSC campus. We instruct all of our future pharmacists on basic veterinary calculations and offer limited experience in compounding veterinary products during their schooling. We can always do more, and just this past year Dr. Jessica Gaskins, my co-author, joined our faculty and instituted an elective course in Veterinary Pharmacy. Both Dr. Gaskins and I see the future of veterinary pharmacy as a bright and delightful career option for some of our enthusiastic young pharmacists, allowing for better trained professionals who can accurately assess veterinary prescriptions and human prescriptions alike. These pharmacists may serve in a commercial retail setting, independent pharmacy setting, veterinary teaching hospital, or with government agencies such as the FDA or USDA. In addition, there are residency programs where pharmacists who have an interest in becoming a “veterinary pharmacy specialist” may work with veterinary professionals for additional training, and then serve their veterinary patients with expertise. The veterinary residencies available through veterinary medicine programs in the US are at North Carolina State (http://www.cvm.ncsu. edu/ed/res_clinicalpharm.html )and UC-Davis (http://www. cfm) Pharmacists will need to embrace the versatility of their profession with Continuing Education in Veterinary Pharmacy along with Human Pharmacy in order to best serve all patients. There are several ways that we as pharmacists help with pet medication needs. Traditional filling of prescriptions is one way. We can fill some of the pet’s prescriptions using the same medications we use for humans. The doses may vary, but many of the medications used in our pets are the same as in our people patients. Patients have easy access to pharmacists throughout the state in all our retail pharmacies. In addition, all pharmacists can offer general medication counseling to include side effects and drug interactions. Not comfortable with that? There are reliable websites for client counseling such as , a website recommended by veterinarians and veterinary pharmacists. This website offers information on important articles from ASPCA Poison Control Center, Pet Nutrition, Feline and Canine Behavior, plus Dermatology and endless other topics. Palmetto Pharmacist • Volume 53 Number 3

PETS Table 1: Reliable Websites for Veterinary Drug Information.

Other reliable websites for medication information are listed in Table 1. Also having a textbook in your pharmacy, such as “Plumb’s Veterinary Drug Handbook” by Donald Plumb, currently in the 6th edition, is important. It will offer you quick access to medications/doses/uses of many products in a variety of animal species. With your general pharmacy background, you should feel comfortable interpreting this information, and providing basic medication information to the owners of your veterinary patients.

Reliable Online References

Brief Description Pet Nutrition, Feline and Canine Behavior, Dermatology, Poison Control Free older version of the 5Minute Veterinary Consult text and another good source to get a quick overview of a particular disease state. Free but must register Has current & archived copies of the Compendium of Veterinary Products and offers client education information Aids pharmacists in determining dangerous clinical signs in pets, assists in understanding the veterinarian’s choice of therapy and provides service to search for disease states based on clinical signs for a particular species 24/7 available help for suspected ingestions but does have small fee for services Offers quarterly newsletter of important events, information dealing with regulatory issues and a variety of other helpful information for professionals Especially useful for drug information in food animals as well as veterinary biologics Legal information with regards to properly filling and dispensing veterinary products

Perhaps you do not want to dispense veterinary prescriptions; are you comfortable with recommending to your clients to use on-line pharmacies, such as the one you’ve probably seen on television called 1-800-Pet-Meds? You may be hesitant because you want to know, as any medical service provider, that they are reputable. Did you know that these on-line pharmacies provide the same medications for heartworms, fleas, ticks as the veterinarian, obtained from the same manufacturers and distributors, perhaps at a lesser price? Dr. Danielle Cain rightly pointed L_HEALTH out in her article in Lowcountry Dog Magazine last fall that the FDA has reported dishonest on-line veterinary pharmacies springing up and that we are to be forewarned.3 So how can we be sure an on-line veterinary pharmacy is legitimate and safe? The good news is that the National Association of Boards of Pharmacy (NABP) does offer Vet-Verified the medication if asked. This is a tracking of exactly Internet Pharmacy Practice Sites (Vet-VIPPS) and if you where and when the product was shipped since the go on their website and search time it left the manufacturer, and any stops along the Vet-VIPPS, there is a list provided of nineteen currently way. Florida is one state that now requires this of certified on-line pharmacies, of which 1-800-Pet-Meds all pharmacies. Since the pet pharmacy 1-800-Petis one. The NABP is the same organization which asMeds is based in Florida, it must adhere to this law sists all of our state Boards of Pharmacy by providing with respect to human medications for animal use a licensing exam to all of our pharmacists nationally, and can trace its products back to the manufacturer. so their role in assuring quality patient care should be Although not required by law to do so, this pharmacy unquestionable. A pharmacy having passed the rigorous can also trace animal medications back to the manustandards for Vet-VIPPS certification should provide facturer (Eddie Khoriaty, Pharmacist-in-charge, oral quality pet prescription service. Certification is not a communication, 1/2013). Because of this “pedigree” guarantee that mistakes will not ever happen, but it is a you can know your products have not been tampered positive step in the right direction of veterinary patient with or been left in poor environmental conditions. care. However, whether it’s human or veterinary pharSouth Carolina does not yet require this, but because macy, when there is a lack of “face time” with the phar- many wholesalers ship to these other states, they can macist and patients, errors can certainly be a concern. usually supply this information if requested. Hopefully soon this process will be required in all states. Do you know where retail or on-line pharmacies As a pharmacist can you tell your clients how they get their medications from? Most pharmacies order receive their own medications? These are questions through reputable drug wholesalers, while some order pet owners are being told to ask, so they and you can direct from the manufacturer. Some states have now be reassured that their pet’s medication is as safe as implemented a law that requires the pharmacy that their own. dispenses human medications to provide a “pedigree” of Palmetto Pharmacist • Volume 53, Number 3


Table2: Veterinary Pharmacy Training Resources:

You may have heard about pharmacies that are “partnered” with a veterinarian. VetSource is one such example ( that is a Vet-VIPPS certified pharmacy. These on-line pharmacies are partnered with veterinarians in a way such that the veterinarian delivers the prescription to the pharmacy electronically. The pharmacy fills the prescription and then mails the final product to the patient’s home. Some of these pharmacies deliver pet food products in addition to medications. In these pharmacies, usually the individual veterinarian sets the prices to be charged, not the pharmacy, and the veterinarian receives a portion of the profit. However, the pharmacist is available to fill the prescriptions, provide any medication counseling, and assure the patient receives their drug product. This is a relatively new concept, but facilitates dispensing of medications in that the veterinarians still control the source of the products, without having to purchase and store them in their hospital or clinic. In this situation, patients do not have a choice of the pharmacy or the price, but they can be assured of quality product and service through their pharmacist. There are many reliable compounding pharmacies which can dispense commercially available products, as well as compound drug products specific to pets’ individual needs, upon presentation of a prescription from the veterinarian. Plantation Pharmacy, with stores in West Ashley and on James Island in the Charleston area, is one such example. Dr. Gaskins, who is co-authoring this article with me, works part time at this pharmacy. Plantation Pharmacy, as any legitimate pharmacy, works closely with the prescribing veterinarian to ensure there is the appropriate Veterinary-Client-Patient- Relationship (VCPR) necessary from a legal and successful pharmacy experience perspective. Guerin’s Pharmacy in Summerville is another example of a pharmacy which does a large amount of veterinary compounding. These are just two examples of local pharmacies in the Charleston area which compound and dispense a relatively large number of veterinary prescriptions, albeit there are many others throughout our state. So no matter where you live, our pharmacist colleagues already expert in veterinary compounding are nearby to help with medication prescriptions, and to answer pet medication questions. Can we recommend over-the -counter medications to our pet owners? Unfortunately we cannot. The AMDUCA spelled out very clearly that any FDA approved medication cannot be given to an animal outside of its approved labeling unless there is a VCPR; this means that the “V” or veterinarian must be involved.1 Otherwise it is 24

Veterinary Pharmacy Education PCCA Compounding Boot Camp PCCA Veterinary Compounding Course Society of Veterinary Hospital Pharmacists

American College of Veterinary Pharmacists

American College of Apothecaries

Brief Description Basic overview of concepts of safe and efficacious compounding In depth look at the specifics of properly compounding for a variety of veterinary species Organization that seeks to preserve the education of veterinary pharmacists in a veterinary hospital setting with large annual meeting Experiential laboratory training sessions with 2 day basic veterinary compounding sessions including aseptic veterinary compounding Offer generalized information on compounding courses to include basics of veterinary compounding Lists of Colleges or Schools of Veterinary Medicine in the United States which often offer useful information on their websites for veterinary pharmacy; such as when CE would be offered

considered illegal. But we can recognize that within our legal limitations, we can still be very involved in our pet patients’ care. As pharmacists, we should be happy to be involved in the veterinarian healthcare area. As more and more pharmacists become better educated in this specialty area, we can become helpful to not only pet owners, but to veterinary professionals as well. Dr. Gaskins is an example of a pharmacist whose interest in veterinary pharmacy led her into additional training. She is a graduate of the SCCP and MUSC campus, following which she completed the Residency program at North Carolina State University’s College of Veterinary Medicine in Clinical Veterinary Pharmacy. She also volunteers as a pharmacist at the Charleston Aquarium! There are so many ways that we as pharmacists can help to improve the lives of our furry/feathery/scaly friends! Perhaps you wish to learn more about veterinary pharmacy? Table 2 provides some options for pharmacists desiring to learn more about veterinary pharmacy. References: 1. FDA. Accessed 5/14/2013. 2. AMVA. Accessed 5/14/13 3. Cain, D. Why Vets Distrust Online Pharmacies. Lowcountry dog Magazine. 2012; Aug/Sept: 22&29.

Palmetto Pharmacist • Volume 53 Number 3

ROTATIONS My SCPhA Rotation Journal bY Michelle Nations PharmD Candidate, SCCP Day 1 Monday, May 20, 2013

Day 2 Tuesday, May 21, 2013

Today Craig and I went to a Medicaid stakeholders meeting. During the meeting the SC Dept of Health and Human Services allowed for feedback, suggestions, and questions from the various stakeholders. Stakeholders in attendance included pharmacists, pharmacy owners, insurance company representatives, and many others. Recently, the SC Dept of Health and Human Services has hired a pharmacy director, Bryan Amick, who also serves on the SCPhA Board. After the meeting I met many of the meeting attendees, including a representative from the makers of Abilify, Kenna, and one of her colleagues, Elizabeth. Both Kenna and Elizabeth are interested in meeting with Craig (and potentially me if I am still on rotation with SCPhA) about partnering to increase medication adherence, particularly among the mental health population. I also gave Kenna the contact information for Greg Price and Shamala (PIC and mental health coordinator at Long’s on Millwood); she is very interested in partnering with Long’s for mental health medications in Columbia. She also mentioned possibly coordinating an in-service for the employees of Long’s who work with the mental health patients.

Today SCPhA’s Board of Directors met for their regularly scheduled meeting. The Board’s meeting taught me both about the association and about the current issues facing the pharmacy profession today, specifically in South Carolina. Representatives from SCSHP attended the meeting for the first time in order to better coordinate a unified front for the pharmacists of South Carolina, especially related to legislative issues. SCPhA’s treasurer, Pat Whitmire, told how the association has become progressively more financially stable over the past six to nine months. This was particularly exciting, because the upcoming annual convention was not yet factored into the numbers and statistics she presented. Richard, one of SCPhA’s lobbyists, and Annie, his colleague, briefed us on the current legislative issues pertaining to pharmacists in South Carolina. He reiterated the importance of partnering with other state pharmacy organizations to present a unified and, therefore, stronger case to our legislators, just as SCSHP had joined the SCPhA Board of Directors meeting today. One bill that was specifically addressed and discussed in regards to the proposed changes to the Pharmacy Practice Act, regarding compounding was H 3161 (along with S 0183), which was introduced in the House by Spires and Toole in January. Since it was introduced, this bill has been approved by the House and is now ready to be addressed by the Senate. During committee discussions in the House, Representative Shane Martin (R-Spartanburg, engineer by profession) brought forth two amendments. The two amendments were as follows: 1) changing the Pharmacy Practice Act to contain no requirements

I also gathered some pharmacy trivia for SCPhA’s convention. This stretched me to think of some topics that might be interesting yet lesser known than the traditional pharmacy trivia, which is often disciplinespecific.

Palmetto Pharmacist • Volume 53, Number 3


ROTATIONS for live continuing education (CE); and 2) increasing the technician-to-pharmacist ratio to 3-to-1 with no requirement for any of the technicians to be state certified. Another representative offered a rebuttal to both amendments, and, subsequently, they were abandoned before the House voted in favor of the bill. Later during the lunch break, Michael Gleaton received word that it is very likely that Kevin Bryant (R-Anderson, pharmacist by profession) will re-introduce similar amendments. The Board was fearful that because Kevin Bryant is a pharmacist, fellow Senators may be lead to believe that Senator Bryant speaks on behalf of and in agreement with all pharmacists in South Carolina. The Board established their official statement in opposition of both amendments. They were confident that Ronnie Cromer (R-Newberry, pharmacist by profession) would support their position and inform the other Senators that, in fact, he represents the opinion of the majority of pharmacists in South Carolina, rather than Senator Bryant. The South Carolina Board of Pharmacy had also requested that SCPhA delineate their position on the amendments (as they have previously endorsed the original bill in regards to its effects on compounding). The Board of Pharmacy as well as Richard were informed of SCPhA’s position, and Richard will lobby for the association in light of that. Other current legislative issues mentioned included Medicaid expansion (likely to be discussed this week but no significant action expected this year), a Board of Pharmacy bill regarding the regulation of out-of-state pharmacies, and the lack of a conducive environment for a bill regarding pseudoephedrine right now. Craig, the current CEO of SCPhA, introduced several ideas during the meeting. These included having a quarterly statewide pharmacy forum to create a unified front on any issues pertaining to pharmacy. He hopes to set up the first meeting in September of this year. Before approving the list of Junior Board Members for the 2013-2014 Junior Board Members Program, the Board of Directors spent considerable time discussing the most appropriate way to select the final participants. Additionally, the committee responsible for selecting the Junior Board Members met during lunch to finalize their list of appointees and to submit an appropriate manner to select the candidates in the future. Other topics discussed included establishing the opportunity for pre-pharmacy students to join SCPhA in order to gain access to valuable shadowing opportunities with the pharmacist members of the association. Another was concerning the Office of the Inspector General’s report 26

on South Carolina’s lack of a statewide prescription monitoring program. Craig shed light on how New York is currently enacting laws to address this issue. Laura Reid (staff member of SCPhA) presented the overall statistics and format of the upcoming convention to be held June 6-9, 2013 in Hilton Head, South Carolina. The Board meeting lasted most of the day, but afterwards I spend some time with Laura going over the details of the installation of SCPhA’s new president, Steve McElmurray, during the convention in a couple weeks. After that, I started a project to analyze the results of the surveys collected by SCPhA after several events over the past year to discover what CE topics the current pharmacists of South Carolina would like to see offered in the near future. Day 4 Thursday, May 23, 2013 First thing this morning I helped Keenan gather some fun trivia questions for a presentation about SCPhA that she was giving for pharmacy technician students at a local tech school. At 11:30AM Craig, Laura, and I participated in a planning meeting with the SC Board of Pharmacy regarding the upcoming meeting that South Carolina will host for the National Associations of the Boards of Pharmacy (NABP) and the Southeastern Pharmacy Officers in August of 2014. It was interesting to hear about the initial planning for a meeting that is still over a year away. The location has already been determined (a specific hotel in Charleston, SC), and they are working to book the venue for a dinner reception/social event one night during the meeting. As someone who has never really participated in planning such a large event, I was really naïve as to how early planning starts and when each detail falls into place. The “save the date” cards are being finalized so that they can be distributed during the annual meeting in Nashville, Tennessee this August. It was interesting to brainstorm on possible topics for the different sessions, since they want the topics to be relevant when the event happens, yet it is still almost 15 months away. Throughout the day the staff of SCPhA has received updates from Richard, one of SCPhA’s lobbyists, about the status of the compounding bill being introPalmetto Pharmacist • Volume 53 Number 3

Support Pharmacy in South Carolina

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Contribution Amount $____________ Payment type: Check enclosed Credit Card: Visa AMEX MC Discover Card #______________________________________ Exp. Date____________________ CCV#__________ Return to SCPhA: 1350 Browning Road, Columbia, SC 29210, or fax to 803.354.9207.

Palmetto Pharmacist • Volume 53, Number 3


ROTATIONS duced to the Senate floor and the likely possibility that Senator Kevin Bryant will introduce amendments concerning the live CE requirement and the pharmacist-to-technician ratio. Upon hearing that Senator Bryant would almost certainly introduce the amendments, SCPhA mobilized to make its members aware of the situation as well as SCPhA’s position. Sandy quickly sent out an alert email to let all the members know what was happening at the State today as well as to give them the phone number to contact their senators (and how to see who their senators are, if needed). Within minutes people started flooding the phone lines at the State House to inform their senators as to the general pharmacy profession’s stance on these amendments as well as the original bill. The meeting before ours at the SC Board of Pharmacy was even ended early for the attendees to take the last couple minutes to contact their legislators. It has been fascinating to watch this story unfold throughout the week and, specifically, today “as things happen” on the SC Senate floor. Day 6 Tuesday, May 28, 2013 The internet has been intermittent all morning, so I am learning how much we depend on the internet for our day-to-day lives. Granted, if I were a stayat-home homemaker, this would not present a huge problem; but because almost everything that SCPhA does is on the internet or via their wireless network, this is presenting a frustrating dilemma. It is not that the internet is completely down, 100% of the time, because it will load a webpage or two every few minutes, but there is no rhyme or reason to when it is working and when it is not. I have been trying to pull some statistics this morning both from the SC Budget and Control Board’s website and the Henry J. Kaiser Family Foundation website. I have found some pretty interesting statistics. For example, of the pharmacist actively employed in 2007, 48% will be eligible to retire by 2030. Additionally, 35% of children and 10% of adults in SC are covered by Medicaid. After gathering the statistics for Craig, I started working on convention preparation. I put the photos 28

into the frames to be placed on the tables as table decorations for the awards dinner. I then started preparing the registration envelopes for each convention registrant. Day 8 Thursday, May 30, 2013 Today was full of preparing for convention. With a little help from the SCPhA office staff, I folded all the convention attendee t-shirts and put them in individual bags to be ready for registration. Then we had a working lunch meeting to talk about some of the details of convention, including transportation, hotel rooms, and attire during each day of the convention. For the most part, today was lots of small tasks to get ready for convention. This included cutting lots of different paper items in preparation for convention. Because the paper cutter here at SCPhA was not working so well, I went and borrowed my parents’ paper cutter from their work. I am so glad I did, because there was so much cutting to do, and the paper cutter helped make it look neat and professional. Day 9 Friday, May 31, 2013 It is “packet stuffing day” at SCPhA. We prepared all the packets for both attendees and exhibitors to receive at registration. Once I got the assembly line with each item to be included up and ready, the process went fairly quickly.

Palmetto Pharmacist • Volume 53 Number 3

ROTATIONS Later in the day we started working on the exhibitors’ nametags. We prepared all the nametags to be printed, so that first thing Monday morning, we can print them and put them in the plastic nametag holders. We also checked each attendee packet to ensure that it contained the appropriate materials as well as nametag ribbons, dinner tickets, fair night tickets, t-shirt sizes, guest passes, etc. Day 10 Monday, June 3, 2013 We are into the final stretch before leaving for convention Thursday morning, so it is time to finish all the last minute tasks. We discovered this morning that there was a misprint in the convention programs, an incorrect day was printed. Jennifer made us some labels to put over the incorrect date that has the correct date, so we removed all the programs from the attendee registration packets, attached the sticker to correct the mistake, and re-distributed the corrected programs into the packets. The major theme for the day was nametags. We printed and assembled exhibitor nametags, printed the attendee nametags, and distributed them all to the appropriate registration packets. Finally, we did some inventory of what we are taking with us and what we still need to get ready to pack. We also made some additional signs needed. Jennifer had written the daily newsletters for attendees to pick up each morning, so I went to Staples to get colored paper to bring back to the office to copy the newsletters. Day 11 Tuesday, June 4, 2013 Today was full of last-minute preparations for convention. I had the fun task of decorating the box for the draw down (raffle) tickets to go in before the drawings. This was particularly fun, because I enjoy crafts and I got to use glitter puff-paint. I was very entertained and got pretty carried away with my fun project for the day. I ended the day by running to Staples to get more copy paper—man, as we get ready for convention, we are going through copy paper like it’s going out of style!

Day 12 Wednesday, June 5, 2013 We started the day by loading all the convention supplies into the U-Haul that Craig will drive to Hilton Head tomorrow and we also put some of it in Laura’s car for her to take down tonight to have ready in the morning before we arrive. Days 13 – 16 Thursday, June 6 – Sunday, June 9, 2013 Wow, convention was a whirlwind culmination of all the preparation and the entire event went very well (per the SCPhA staff as well as attendees and exhibitors). Thursday morning we met at the association to drive to Hilton Head. It rained for a good portion of the day, so it was time to institute plan B in terms of the activities that were scheduled for outside until the rain stopped (more details to come). Once we arrived at the hotel, we checked in, unloaded the U-Haul, and began to set up for registration as well as our Thursday evening programming (3 hours of CE and the welcome reception). The original plan was to have the welcome reception outside on the pool deck, but the rain moved that indoors. It was wonderful to begin to put faces with the names I have heard so often both in the past couple weeks as well as many throughout my pharmacy education career. Friday morning brought more excitement as I had the opportunity to sit in on the House of Delegates meeting. What a fantastic experience to see my pharmacy association in action! After another 2 hours of CE, it was time for the MUSC and USC alumni lunches. I attended the USC alumni lunch and enjoyed hearing more about what is happening at my campus as well as meeting several USC alumni. Friday afternoon we set up for the “State Phair” night for all the attendees. During the actual event I had the opportunity to mingle with many of the attendees and take pictures. It was so much fun to watch everyone enjoy themselves with some carnival-type games, a money machine, sno-cones, cotton candy, and a silent auction. I especially enjoyed seeing the children of many attendees participate in the games as well. While most of the SCPhA staff and me cleaned up, Jennifer and Keenan went to start the student trivia. After a not-so-stellar turn-out to the student lunch and games on the beach, there was an excellent turn-out for trivia. I am

Palmetto Pharmacist • Volume 53, Number 3


ROTATIONS told that all who attended really enjoyed the friendly competition. Saturday brought two big events: the exhibit hall and the awards dinner. The first half of the day was consumed with everything concerning exhibit hall, from setting up to orienting vendors to the actual exhibit hall event itself. I was very thankful for the opportunity to meet almost all the exhibitors throughout the morning; it was a wonderful networking opportunity, and in the pharmacy arena we know that networking is an essential part of everyone’s career. I also had the unique opportunity to meet the Rear Admiral Scott Giberson, the chief pharmacist at the US Public Health Service. Because he is over all of Indian Health Services and I have a rotation with Indian Health Services in Montana next March, I was especially delighted to meet him. He is such a powerful advocate for pharmacy on the federal level, and yet he is still “down-to-earth” and genuinely interested in meeting and talking to his pharmacy colleagues. After the exhibit hall closed, it was time for the OTC Self-Care Bowl. I was in charge of operating the PowerPoint slides, and I will admit that we had a couple mishaps with slides advancing before intended but both the contestants and audience were gracious in these instances. As soon as that was over, it was time to set-up for the awards dinner that evening. A few miscommunications and corrections later, the ballroom was on its way to being fully prepared for the night. The champagne reception and the awards dinner went very well, and, of course, everyone enjoyed the coffee and ice cream bar and dancing afterwards. By the time I got back to my room late Saturday night after the long day, I was exhausted, but the fact that it was a great day made it all worth it. Sunday morning was much more relaxed and laid back. There was a sunrise service, which I am told was wonderful. Dr. Wayne Weart had 4 hours of CE Sunday morning before the convention officially concluded at 12:30PM. After a brief Board of Directors lunch to discuss the weekend and to elect the vice chair of the Board (congratulations, Brian Amick), we drove back to Columbia.

ing with Kenna Ray and Rod Teat from Otsuka (the makers of Abilify® as well as the new Abilify Maintena®). We discussed the idea of a pilot research project for persistence (often termed “compliance” or “adherence” to most pharmacists and other clinicians) in mental health patients, specifically if transitioned to long-acting injectable medications. It was exciting to brainstorm about the possibilities as well as about whom we should invite to jump on to this unique opportunity. I was commissioned with the task of putting together a list of whom we should include on a steering committee for this project. I am particularly excited about this opportunity because I encounter mental health all the time at work (I am an intern at Long’s Drugs on Millwood in Columbia, SC, and we have hundreds of mental health patients). Day 18 Tuesday, June 11, 2013 I cannot believe that today was my last day of rotation. My time at the SC Pharmacy Association has flown by, and it has been a wonderful experience. The rotation blended two of my passions—pharmacy and organization in the details—due to the nature of the rotation as well as the unique opportunity to prepare for and participate in SCPhA’s annual convention. Students who are on rotation with SCPhA get to experience events like this and more. If you are interested in a rotation with SCPhA, talk to your Experiential Education Coordinator. Students rotating at SCPhA write articles, like this one, for the journal. The article is reviewed by the preceptor.

Day 17 Monday, June 10, 2013 Today SCPhA was closed, but Craig had a meet30

Palmetto Pharmacist • Volume 53 Number 3


Goodbye...Sort of... By Jennifer Simmons For the past seven years, I have served SCPhA as the Director of Communications. It is amazing to me to think about the changes that have happened within my time here at SCPhA. First of all, even as a Director of Communications I have seen a great deal of changes within my role and my job at SCPhA. When I first started, MySpace was just getting started, Facebook was solely for people with school email addresses, Youtube had just been founded and Twitter was not even in existence. Social media was not even a term at that point in time. I’ve seen changes in the profession. I have worked with many different boards and met a wide variety of leaders across the state. I have had the privilege of meeting and forming relationships with so many members. I came to SCPhA not really knowing much about pharmacy and am leaving with a giant respect for this profession. I see the amazing things you do and am proud to have played a little role in what you’ve been doing! However, I am off to be a middle school theatre teacher. For the past two and a half years, I’ve been working on getting my Masters of Arts in Teaching and will be heading out to live out my passion. While it has been wonderful working here and getting to know you all, I am sad to say that it is coming to a close…. Sort of. I will continue to do the design and layout of the Palmetto Pharmacist. I am excited for this opportunity because it does allow me to stay in the loop of what is going on. I’ll still get to see the awesome things that SCPhA is doing and get to hear about the membership. I have to say that the thing I will miss the most though is the memories that I share with the staff, both past and present, of SCPhA. Traveling to all of

these different meetings, you really spend a ton of time with the staff. The first month I started, I spent countless hours in the car with Tracy Russell, Carmelo Cinqueonce, Jan Torbert, and Jennifer Baker as we drove around the state to eight different Region Rallies in two weeks. We ate so much BBQ that none of us wanted to even look at BBQ for at least six months afterwards. There were the brainstorming sessions during staff meetings where we would be in tears laughing over some of the crazy ideas that were thrown out (I will not lie – most of the terrible ideas probably came from me). I have been honored to have been around Andrea Westmoreland and Cassandra Hicks-Brown for their engagements and their weddings. I was here when Jennifer Baker had her first child and was pregnant at the same time she was pregnant with her second. For 23% of my life, I’ve been in the SCPhA family. I will never forget the first convention where I made the board sing a silly parody of “Friends in Low Places”. I won’t forget laughing so hard and having such a good time with Steve and Jill Greene when we discovered chocolate made with Pop Rocks. I will also never forget Pam Whitmire and Ralph Wilkie wearing the brick costume, nor will I forget the convention flash mob. I’m so happy to have been there when Patti Fabel got the nick name “Boom Boom” and to have met James Franco at the 2013 Spa Weekend. Those are literally only a small fraction of the memories that I will take with me. I know that you are all in awesome hands at SCPhA and I can’t wait to see what you guys do next. I know that whatever it is – it will be amazing. I wish you all the best – and should you ever do another flash mob, someone better let me in on it!

Palmetto Pharmacist • Volume 53, Number 3




This series, Financial Forum, is presented by Pro Advantage Services, Inc., a subsidiary of 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.

EIGHT TIPS FOR PLANNING YOUR RETIREMENT Planning financially for retirement may feel overwhelming. For some, that feeling is what keeps them from really focusing on and implementing a plan. If you haven’t started planning for your retirement – do yourself a favor and make TODAY the day you begin. 1. The earlier the better. Time is definitely one of your greatest allies. A person who begins contributing a modest amount to a retirement plan in their early twenties could end up on par with someone who contributes much more aggressively but does not start until their mid-thirties. Even if you have to start small, start now. Whatever amount you can afford to set aside for later, do it – and let it grow. If you don’t have the luxury of starting young, don’t waste time worrying about it. Start now. You’ll never again be younger than you are today. 2. Be smart about what you’ll need. Yes, it’s true – the senior discount is alive and well, and the general cost of living may be less for those who have retired. But don’t forget, there are other costs to consider. Your healthcare costs, for example, may be greater in retirement simply because you’re not as healthy as you were in your youth. Additionally, you’ll want to take inflation into account. If you plan your retirement based on the cost of living and income of your 30’s, by the time you hit your retirement years, you may find you greatly underestimated your needs. 3. Be smart about how long you’ll need it. When Social Security was being developed, in the 1930’s, a male retiring in

the United States was really only expected to live about 12 years past his date of retirement.1 However, the average life expectancy of a United States citizen has risen fairly steadily throughout the last fifty years.2 Depending on when you retire, you may need to plan for 20 or more years of income. 4. Take advantage of tax-deferred contributions. It sounds like a no-brainer, but sometimes people determine how much they can afford to contribute to a retirement account based on their net income, rather than their gross income. You may decide you can only afford $50 less per paycheck, net. But remember that some contributions, like those to your 401(k) for example, may be made with pre-tax dollars. That means you can afford to contribute a bit more from your gross income and still only “miss” $50 from your net income. This is an important consideration. 5. Take advantage of matching contributions. If your employer offers a 401(k) match – consider scrimping here and there in order to take maximum advantage of it. It’s a very positive domino effect. The more you contribute, the more you earn in matching contributions (up to the maximum allowable amount). Think of it this way – if your employer offers a 50% match, then for every $100 you don’t contribute, you’re missing out on $50 in “free money”. You’re also missing out on the growth potential


of that money as well. 6. Do the math. This might be the most important retirement tip of all. Block off some time to sit down and do some calculations. Consider the different levels of contributions you could make and calculate how far those could take you by the time you reach retirement. Once you see what you COULD achieve, you may be more motivated to increase your contributions. 7. Trim the fat. Keep careful track of your spending for one month (if you bank online, you may have access to tools that help you do this). After one full month, sit down and take a careful look at what you spent money on. Did it all make sense? Was some of it frivolous? Any regrets? Taking a close look at exactly where your money is going is often the best way to discover areas that need improvement, and ways you could adjust your spending habits. Add up all the money you feel you spent unnecessarily, then add that amount to the contribution math you did previously … how much further might that extra monthly contribution have taken you? 8. Get help. These retirement tips are intended to help you get started down a path toward, potentially, a more successful retirement. But they’re just that – a starting point. While it’s definitely important to educate yourself and understand your finances, seeking the assistance of a financial professional may be one of the best moves you could make.

Palmetto Pharmacist • Volume 53 Number 3


Pharmacy Camp Attracts a Young Audience By Mario Cuadros,, Reprinted with permission

For many students interested in entering a scientific field, medical school seems to be the most obvious place to start. Job security is good and so is the compensation. However, there’s another path with similar benefits that many students are beginning to discover – pharmacy. The University of South Carolina has tapped into this emerging market by offering the Adventures in Pharmacy camp as part of the Adventure Series youth program. The annual camp, which ran ealier this summer, is for academically talented rising sixth through twelfth grade students and has been offered yearly since 2007. It’s now one of the most popular summer camps USC offers. “Summer camp at the College of Pharmacy is one of my most fulfilling and fun responsibilities as coordinator of the Pharmacy Practice Labs on the USC campus,” says Nancy Culberson-Taylor. “These students are excited to learn about a profession in which they can serve others. Their enthusiasm is gratifying to all of the instructors who are involved each summer.” Middle and high school students are beginning to realize the advantages of pharmacy and are becoming more interested in learning about the profession. Lauren Brown, an eighth grade student from South Carolina attending the pharmacy camp, is among these students. “I have enjoyed the camp,” she says. “Pharmacy is a science field and I’m interested in going into science so it’s a good experience.”

“Our goal has been to help these students explore the vast number of opportunities afforded by a profession in pharmacy and to inspire them to explore the choices they have in planning their futures,” says Culberson-Taylor. “More and more opportunities are available to pharmacists in the workplace today and we try to expose the campers to as many of those during their week here at the SCCP.” As pharmacy gains popularity, entry to pharmacy school has become more competitive. That’s part of the reason students are looking at pharmacy as a viable career option at an early age, says Patricia Fabel, assistant professor with the University of South Carolina College of Pharmacy. “In this program, they can get some experience and start thinking about the classes they need to take.” The College of Pharmacy has been doing its part in promoting the benefits of pharmacy at different high schools in South Carolina and neighboring states. Representatives of the college give presentations at high schools and feeder schools in order to persuade students to consider the profession. With the College of Pharmacy’s newly created Kennedy Pharmacy Innovation Center, the program will look to include entrepreneurship as a part of the curriculum, an addition that may attract even more students. “Most of what we do is we go through nuclear pharmacy, we’ll do hospital pharmacy and we’ll go

Gorilla Photo Courtesy: Ron Brasington/Riverbanks Zoo and Garden

Palmetto Pharmacist • Volume 53, Number 3


through compounding,” says Fabel. “With the Kennedy Center up and running, we will probably include some of the business aspect of pharmacy starting next year.” Each year, more instructors become involved with the camp, which, according to Culberson-Taylor, makes it an even better experience for all who participate, both campers and instructors. “Every year I feel that our camp gets better and better,” she says. Finding a job after graduation is one of the biggest concerns among college students, especially in today’s economy. Fabel believes this problem is less apparent in pharmacy, which according to the Bureau of Labor Statistics, is projected to see a 25 percent employment growth by 2020. “It is a good career path,” she says. “The salary rates are good and the job security is good, and it’s only going to get better.”

Division of Display Options, Inc. Rx Planning Specialist Roland Thomas 70 years combined experience in over 2,000 pharmacies.

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Palmetto Pharmacist • Volume 53 Number 3

Convention 14

Come do the Charleston in Hilton Head, SC in 2014

June 19-22, 2014

Hilton Head, SC

SCPhA’s 2013 attendees voted and the 2014 theme will be Roaring 20s

Palmetto Pharmacist • Volume 53, Number 3


CE Canagliflozin: A Novel Agent for the Treatment of Type 2 Diabetes Mellitus By Marquita D. Bradshaw, Pharm.D., BCACP and Rikki L. Tonet, Pharm.D. Candidate 2014 Objectives • Describe the pathophysiological defects in Type 2 Diabetes Mellitus (T2DM) incorporated in the ominous octet • Describe the mechanism of action of canagliflozin • Identify the potential place in therapy of canagliflozin • Summarize patient counseling points when dispensing canagliflozin • Identify available strengths of canagliflozin (Pharmacy technicians***) Conflict of interest statement: There is no conflict of interest involved in writing this article or in the subject matter of this article. Abstract: Several oral and injectable agents are available for the treatment of Type 2 Diabetes Mellitus (T2DM). A recent consensus statement published by the American Diabetes Association emphasizes a patient-centered approach.1 Canagliflozin belongs to a novel therapeutic class. It is the first agent in its therapeutic class approved by the Food and Drug Administration (FDA) for use adjunct to diet and exercise to improve glycemic control in adults with T2DM. Canagliflozin affords the opportunity for patients previously managed with diet, exercise, and other oral agents to achieve even further hemoglobin A1c (HbA1c) lowering. Canagliflozin is administered orally and may be a viable option for patients who refuse insulin and have not achieved optimal glycemic control. However, it is not devoid of unfavorable adverse effects. The objective of this article is to briefly discuss the pathophysiological defects of T2DM and potential role of therapy for canagliflozin in the treatment of T2DM. Key words: canagliflozin, diabetes mellitus, sodium glucose co-transporter 2 receptor inhibitor


INTRODUCTION T2DM is one of the four clinical classes of diabetes identified which results from a progressive insulin secretory defect on the background of insulin resistance.2 Signs and symptoms of T2DM include polyuria, polydipsia, and polyphagia which may not be overt. Often patients with T2DM are not diagnosed until complications appear; therefore resulting in subsequent reduction in quality of life if diabetes remains uncontrolled. Approximately 25.8 million children and adults in the United States are living with diabetes, including 7 million who are currently undiagnosed.3 This equates to 8.3% of the population in the United States. In 2010, South Carolina had the fifth highest prevalence of diabetes in the nation.4 The prevalence of diabetes in South Carolina is presently 9.6% and has increased more rapidly than the national rate.4 Previously it was thought that a triumvirate was responsible for the pathophysiological defects occurring in T2DM including muscle, liver, and beta cell involvement. Recently, five additional pathophysiological defects have been described including fat cell (accelerated lipolysis), gastrointestinal tract (incretin deficiency/resistance), alpha cell (hyperglucagonemia), kidney (increased glucose reabsorption) and the brain (insulin resistance).5 It is proposed that multiple pathophysiological defects warrant treatment with combination therapy targeting several defects (Table 1). Since 1995, when only two medication classes were available for the treatment of T2DM, many have been approved by the FDA. Among these medication classes are dipetidyl peptidase IV inhibitors, glucagon- like-peptide (GLP)-1 agonists, and the new sodium glucose co-transporter receptor inhibitors (SGLT). Canagliflozin (Invokana™, Janssen Pharmaceuticals) is the first agent included in the therapeutic

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CE class of sodium glucose co-transporter receptor inhibitors, approved March 2013, for use in the United States. It is indicated for use as an adjunct to diet and exercise to improve glycemic control in adults with T2DM.6

Table 1. Ominous Octet and Medications to Target Defects Origin of Defect

Medication Class Targeting Defect Muscle Insulin resistance TZDs (pioglitazone, rosiglitazone) Liver Insulin resistance Biguanides (metformin) and TZDs β-cell Insulin resistance ----------------------------Fat cell Accelerated lipolysis TZDs Gastrointestinal tract Incretin deficiency/resistance GLP-1 (exenatide, liraglutide), DPP-IV inhibitors (sitagliptin, saxalipitin, linagliptin, alogliptin) and amylin α-cell Hyperglucagonemia -----------------------------Kidney Increased glucose reabsorption Sodium glucose transporter receptor inhibitor (canagliflozin) Brain Insulin resistance Dopamine-2 Agonist (bromocriptine) TZDs = Thiazolidinediones; DPP = dipetidyl peptidase; GLP =glucagon like peptide

MECHANISM OF ACTION Homeostasis in the body is maintained via multiple organ systems. One of the major contributors to homeostasis of multiple endogenous and exogenous substances is the kidneys. The kidneys are well known for the maintenance of blood pressure; however they play a substantial role in the homeostasis of blood glucose as well. The primary mechanisms in which the kidneys regulate blood glucose are through the release of glucose into blood via gluconeogenesis and glucose reabsorption in the proximal convoluted tubule (PCT).7

Glucose reabsorption is accomplished with the active transport of glucose by sodium-coupled glucose co-transporters (SGLT1 and SGLT2) found in the kidneys.8 SGLT1 is located in the heart, intestine, trachea, and kidney, whereas SGLT2 is located only in the kidney.9 SGLT1 is shown to reabsorb 10% of filtered glucose reabsorption in the S3 segment of the PCT, where the SGLT2 has been identified to conduct 90% of reabsorption in the S1 segment of the PCT.10 The mechanism in which this new class of drugs (SLGT2 inhibitors) works is through inhibition of these SGLT2 co-transporters ultimately resulting in decreased renal reabsorption of the filtered glucose.6 This inhibition of glucose reabsorption results in increased renal glucose excretion into the urine defined as glucosuria. This increased excretion of glucose may have beneficial effects of weight loss.11 THERAPEUTIC EFFICACY Since the discovery of canagliflozin in the late 2000s, its safety and effectiveness was evaluated in nine clinical trials involving over 10,000 patients with T2DM, including patients with chronic kidney disease.12-21 As monotherapy at week 26, a statistically significant reduction in HbA1c was achieved from baseline with canagliflozin 100 and 300 mg compared with placebo (−0.77,−1.03 and 0.14%, respectively).6 Canagliflozin has also been studied in combination with metformin showing a reduction in HbA1c from baseline with 100 mg and 300 mg dose versus placebo (-0.79, ‑0.94, ‑0.17%, respectively),

Pathophysiologic Defect

with glimepiride vs. placebo (‑0.85,‑1.06, -0.13%, respectively), with metformin and a sulfonylurea vs. sitagliptin (‑1.03, 0.66%, respectively), with metformin and a thiazolidinedione (‑0.89, ‑1.03, ‑0.26, respectively), and in combination with insulin (‑0.63,‑0.72, 0.01%, respectively). Associated mean reductions in HbA1c (absolute reductions of 0.45– 0.92%), fasting plasma glucose (decreases ranged from 16.2% to 42.4%) and weight loss ranging from 0.7 to 3.5 kg were also observed in clinical trials.12-21 Dapagliflozin, an agent in the same therapeutic class, has been approved for use in Europe since 2012. The body of literature supporting its efficacy is also available. Decreased risk in macrovascular complications has not been established. In July 2011, an14 FDA Advisory Committee voted against the approval of dapagliflozin as they cited higher rates of breast and bladder cancer in the treatment arms of trials analyzed. 22 Further clinical trials with an extended duration are necessary. PHARMACOKINETICS In regards to absorption, canagliflozin is found to reach peak plasma concentrations within 1-2 hours postdose.6 The 100 mg oral tablet has an apparent half-life of 10.6 hours as compared to the 300 mg tablet which possesses a 13.1 hour half-life. Steadystate plasma concentration was reached after 4-5 days of administration.6 Canagliflozin can be administered without regards to meals, but improved glycemic control may occur when dosed before the first meal of the day due to delayed gastrointestinal absorption of glucose. The oral bioavailability of canagliflozin is nearly 65%.6 Canagliflozin is 99% plasma protein bound, mainly

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CE to albumin. The mean apparent volume of distribution was 119 L after single intravenous (IV) administration. Metabolism is mainly through O-glucuronidation by UGT1A9 and UGT2B4, producing two inactive metabolites. In humans, small amounts (7%) are metabolized through CYP3A4.6 The average clearance of canagliflozin was 192 ml/min when administered by IV route to healthy individuals. Approximately 33% and 41.5% of the administered dose was excreted in the urine and feces, respectively. The renal clearance of canagliflozin ranged from 1.30 to 1.55 mL/min.6 DOSING Canagliflozin is available as 100 mg and 300 mg tablets. The initial recommended dose for canagliflozin is 100mg by mouth prior to the first meal of the day. Maximum adult daily doses of 300 mg may be warranted in patients needing additional glycemic control with normal renal function, defined as an estimated glomerular filtration rate (eGFR) greater than or equal to 60mL/min/1.73m2. Canagliflozin is associated with increases in serum creatinine (SCr) and decreased eGFR. It is important to note the need for baseline renal function tests before initiation of therapy as well as regular renal function monitoring throughout the course of treatment in these patients.6 Patients with moderate renal impairment, eGFR 45-60 mL/min/1.73m2, are recommended to maintain maximum daily doses of 100mg, and careful monitoring of SCr and eGFR. Patients with severe renal impairment, eGFR less than 45 mL/min/1.73m2 should avoid the use of canagliflozin. Hypovolemic patients should avoid use of canagliflozin, until euvolemia is restored, due to the increased risk of symptomatic hypotension. No dosage adjustments are needed in patients with hepatic impairment.6 DRUG INTERACTIONS Co-administration of canagliflozin with UDP-glucuronosyltransferase (UGT) inducers poses a drug interaction and a dose increase may be warranted. Canagliflozin administered with nonselective inducers of UGT enzymes, such as rifampin, decrease canagliflozin efficacy by a 51% reduction in the area under the curve (AUC).6 Clinicians choosing to initiate concomitant administration of UGT inducers with canagliflozin should consider increasing the dose to 300 mg once daily under the following conditions: patient is currently tolerating canagliflozin100 mg 38

once daily, has an eGFR greater than 60 mL/min/1.73 m2, and requires additional glycemic control.6 Other antidiabetic agents should be considered for use in patients who require additional glycemic control and do not meet this criteria. Conversely, an increase in the area AUC and mean peak drug concentration (Cmax) of digoxin (20% and 36%, respectively) is expected when co-administered with canagliflozin 300 mg. Patients taking canagliflozin with concomitant digoxin should be monitored appropriately.6 SIDE EFFECTS Four placebo-controlled pooled studies revealed the five most common adverse effects as female genital mycotic infections, urinary tract infections, increased urination, male genital mycotic infections and vulvovaginal pruritus. Evidence supports that patients with a history of genital mycotic infections and uncircumcised males were more likely to develop genital mycotic infections. This subset of patients should be monitored and treat appropriately. Lab parameters and associated symptomology should be monitored to coincide with precautions including hyperkalemia, hypoglycemia, increase in low density lipoprotein, and impairment in renal function.6 Hypoglycemia was more likely to occur in patients taking canagliflozin and insulin or a secretagogue. Hyperkalemia was more likely to occur in patients taking other medications also known to increase potassium including angiotensin receptor blockers (ARB), angiotensin converting enzyme inhibitors (ACEI), or aldosterone antagonists. The FDA is necessitating five postmarketing studies be conducted by the manufacturer, three of which target the adult population: a cardiovascular outcomes trial; an enhanced pharmacovigilance program to monitor for malignancies, serious cases of pancreatitis, severe hypersensitivity reactions, photosensitivity reactions, liver abnormalities, and adverse pregnancy outcomes; and a bone safety study.23 SPECIAL POPULATIONS Pediatrics and Geriatrics The prevalence of T2DM in children is increasing. Use of canagliflozin has not been established in patients under the age of 18, due to insufficient evidence of safety and efficacy. Of the five aforemenPalmetto Pharmacist • Volume 53 Number 3

Table 2. Patient Counseling Take Home Points Side effects

 

Drug Interactions

 

This medication may affect how your immune system works and may cause a yeast infection or urinary tract infection. A change in electrolytes has occurred in patients taking canagliflozin.

CE leading to the conclusion that canagliflozin use should be avoided in nursing mothers.6

Some medications interact with canagliflozin. Inform your doctor, pharmacist, or other healthcare professionals if you have started a new medication or stopped any medications since your last visit including rifampin or digoxin. Dose adjustments may be made if you are taking medications that interact with canagliflozin.

CONCLUSIONS Canagliflozin represents the first of many agents in its class. It holds  promise to a unique mechanism to treat T2DM. The place of therapy Administration  For optimal results, canagliflozin should be taken with the first for canagliflozin has yet to be elumeal of each day. cidated. Expected HbA1c lowering observed was comparable to other Laboratory Test  Canagliflozin will cause you to test positive for glucose in your oral agents currently marketed to urine. treat T2DM including alpha glucosidase inhibitors, meglitinides, and tioned postmarketing studies to be conducted by the dipeptidyl peptidase inhibitors. Conversely, distinmanufacturer, two are pediatric studies including a guishing adverse effects may limit its use. Perhaps it pharmacokinetic and pharmacodynamic study and a is a viable option for adults with T2DM who cansafety and efficacy study.23 Recently published recnot achieve glycemic control with multiple agents ommendations regarding the management of T2DM but refuse injectable medications. Extensive patient favor the use of metformin as first-line therapy for counseling is warranted due to drug interactions, children and adolescents at the time of diagnosis.24 administration, and side effects (Table 2). A study found that canagliflozin use in geriatric RESOURCES FOR HEALTH CARE PROFESpatients was associated with increased risk of hypoSIONALS IN SOUTH CAROLINA volemic related adverse events such as hypotension, Useful Websites syncope, dehydration, and dizziness. These effects • Endocrinology-Diabetes Initiative of South Carowere reported at higher levels in geriatric patients lina: daily doses of 300 mg or patients 75 years of cine/divisions/endocrinology/dsc age or older.6 • South Carolina Department of Health and Environmental Control Diabetes Prevention and Pregnancy and Lactation Control: Canagliflozin is categorized as pregnancy level C. diabetes/links.htm There is no human data available for teratogenic • American Diabetes Association: http://www. effects from use during pregnancy and lactation. In studies using rats, it was observed that canagliflozin 15 • National Institute of Diabetes and Digestive and may affect renal development and maturation. It was Kidney Diseases (NIDDK), National Institutes reported that doses of 300 mg resulted in a greater of Health (NIH): or than or equal to 0.5 fold increased kidney weights and renal pelvic and tubular dilation. This expo• National Diabetes Education Program (NDEP): sure in rats was comparable to the second and third trimester of pregnancy in humans, concluding that • Juvenile Diabetes Research Foundation Internacanagliflozin use during pregnancy may result in tional (JDRF): fetal malformations. Careful consideration must be • International Diabetes Federation (IDF): http:// made if initiation during pregnancy is desired, and should only be used if the potential benefit outweighs 6 • American Association of Clinical Endocrinolopotential risk to fetus. gists: • The Endocrine Society: http://www.endo-sociEvidence is lacking on use during lactation in mans, though a study in rats found that canagliflozin • American Association of Diabetes Educators: is secreted in milk of rats at levels up to 1.4 times that of maternal plasma levels. These levels in rats have shown malformation of the developing kidney, Palmetto Pharmacist • Volume 53, Number 3


CE REFERENCES 1. Inzucchi SE, Bergenstal RM, Buse JB et al. Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012; 35 (6): 1364-79. 2. American Diabetes Association. Standards of medical care in diabetes-2013.Diabetes Care. 2013;36 (suppl 1):s11-66. 3. Diabetes Statistics [Internet]. American Diabetes Association. Accessed April 15 2013. 4. Heidari, K and Myers P. Brief Update on the Burden of Diabetes in South Carolina. Am J of Med Sci. 2013; 345(4):302-306. 5. DeFronzo RA. From the Triumvirate to the Ominous Octet: A New Paradigm for the Treatment of Type 2 Diabetes Mellitus. Diabetes. 2009; 58:773-795. 6. Invokana™ [package insert]. Titusville, NJ: Janssen Pharmaceuticals Incorporated; 2013. 7. Wright EM, Hirayama BA, Loo DF. Active sugar transport in health and disease. J Int Med. 2007; 261(1):32-43. 8. Triplitt CL. Understanding the kidneys’ role in blood glucose regulation. Am J Manag Care. 2012;18(1 Suppl):S11-6. 9. Nishimura, M. Naito S. Tissue-Specific mRNA Expression Profiles of Human ATP-Binding Cassette and Solute Carrier Transporter Superfamilies. Drug Metab Pharmacokinet. 2005; 20:452-477. 10. Marsenic O. Glucose control by the kidney: an emerging target in diabetes. Am J Kidney Disease. 2009;53(5):875-883 11. Neumiller JJ, White JR, Campbell RK. Sodium-glucose co-transport inhibitors. Drugs. 2010;70:377-385. 12. Devineni D, Morrow L, Hompesh M et al. Canagliflozin improves glycaemic control in subjects with Type 2 diabetes not optimally controlled on insulin. Diabetes Obes Metab. 2012; 14:539-45. 13. Rosenstock J, Arbit D, Usiskin K et al. Canagliflozin, an inhibitor of sodium glucose co-transporter 2, improves glycemic control and lowers body weight in subjects with type 2 diabetes on metformin (abstract 77-OR). Diabetes. 2010; 59 (suppl 1): A21. 14. Sha S, Devineni D, Gosh et al. Canagliflozin, a novel inhibitor of sodium glucose co-transporter 2, improved glucose control in subjects with Type 2 diabetes and was well tolerated (abstract 568-P). Diabetes. 2010; 59 (suppl 1): A155. 15. Nicolle L, Usiskin K, Capuano G et al. No increase in bacteriuria or urinary tract infections in patients with type 2 diabetes mellitus treated with


canagliflozin, a sodium glucose co transporter inhibitor (abstract 43-LB). Diabetes. 2011; 60 (suppl 1A):LB12. 16. Nyirjesy P, Zhao Y, Usiskin K et al. Efficacy of canagliflozin (CANA), a sodium glucose co-transporter 2 inhibitor, on vulvovaginal Candida colonization and symptomatic vulvovaginal candidiasis in patients with type 2 diabetes mellitus. Curr Med Res Opin. 2012; 28 (7) :1173-8. 17. Inagaki N, Kondo K, Iwaski T et al. Canagliflozin, a novel inhibitor of sodium glucose co-transporter 2 (SGLT2) improves glycemic control and reduces body weight in Japanese type 2 diabetes mellitus (T2DM) (abstract 999-P). Diabetes 2011: 60. 18. Wexler D, Vandebosch A, Usiskin K et al. Study of electrocardiogram intervals in healthy adults receiving single oral doses of canagliflozin (abstract 2177-PO). Diabetes. 2010; 59 (suppl 1): A571. 19. Sarich T, Devineni D, Ghosh A et al. Canagliflozin, a novel inhibitor of sodium glucose co-transporter 2, increases 24-h urinary glucose excretion and decreases body weight in obese subjects (abstract 567P). Diabetes 2010; 59 (suppl 1): A155. 20. Sha S, Devineni D, Ghosh A et al. Canagliflozin, a novel inhibitor of sodium glucose co-transporter 2, dose dependently reduces calculated renal threshold for glucose excretion and increases urinary glucose excretion in healthy subjects. Diabetes Obes Metab 2011; 13 (7): 669-72. 21. Yale JF, Bakris G, Cariouu B, Yue D, DavidNeto E, Xi L, et al. Efficacy and safety of canagliflozin in subjects with type 2 diabetes and chronic kidney disease. Diabetes Obesity Metab 2013; 15:463-473. 22. Burki TK. FDA rejects novel diabetes drug over safety fears. Lancet 2012; 279 (9815):507. 23. Copeland KC, Silverstein J, Moore KR, Prazar GE, Raymer T, Shiffman RN, et al. Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents. Pediatrics 2013; 131:364– 382. 24. Food and Drug Administration [Internet]. FDA approves Invokana to treat type 2 diabetes http://www. ucm345848.htm. Accessed April 15 2013.

Palmetto Pharmacist • Volume 53 Number 3

Canagliflozin: A Novel Agent for the Treatment of Type 2 Diabetes Mellitus Correspondence Course Program Number: 0171-9999-13-072-H01-P

1. Complete and mail entire page. SCPhA members can take the Journal CE for free; $15 for non-members. Check must accompany test. You may also complete the test and submit payment online at 2. Mail to: Palmetto Pharmacist CE, 1350 Browning Road, Columbia, SC 29210-6309. 3. Continuing Education statements of credit will be issued within 6 weeks from the date the quiz, evaluation form and payment are received. 4. Participants scoring 70% or greater and completing the program evaluation form will be issued CE credit. Participants receiving 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 pharmacy education. This article is approved for 1 contact hour of continuing pharmacy education credit (ACPE UPN 0171-9999-13-072-H01-P ). This CE credit expires 6/28/2016.

Name: _______________________________________________ License #: __________________________ Address: ________________________________________________________________________________ City: ____________________________________________ State: _____ Zip: ________________________ Phone: _______________________________________ Email:____________________________________ NABP eID: _________________________________ Birth Month/Birth Date (MMDD): ________________ Evaluation: Circle the appropriate response Did the article achieve the stated objectives? Not at all 1 2 3 4 5 Completely Overall evaluation of the article? Poor 1 2 3 4 5 Excellent Was the information relevant to your practice? No 1 2 3 4 5 Yes 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 Learning Assessment Questions:QUESTIONS: LEARNING ASSESSMENT 1. Which of the following statements about ADHD are true? 1. a Diagnosis The pathophysiologic 2 Diabetes Melof ADHD requiresdefect at leastin6Type symptoms of hyperlitus at the level of the kidney is: activity, impulsivity, and/or inattentiveness to be present for at least 6 months. A. b. Girls Hyperglucagonemia are diagnosed with ADHD more often than boys in the B. U.S. Increased glucose reabsorption C. c. Nonstimulants Incretin deficiency may be abruptly discontinued if no improveD. ment of Insulin resistance symptoms is seen d. All of the above


Canagliflozin works to inhibit:

2. All of the following FDA-approved medications for ADHD

A. Glucagon-like-peptide 1 B. Insulin growth factor 1 b. dextroamphetamine C. a atomoxetine Sodium glucose co-transporter 2 c. lisdexamfetamine

d. methylphenidate

of the following would be best for initial 3. 3. Which Canagliflozin is indicated fortheuse inchoice adult patients treatment of a 4-year-old boy recently diagnosed with ADHD? with: a.

A. b. B. c. C. d. D.


behavioral parent training program Diabetic Ketoacidosis long-acting methylphenidate Hyperglycemic Hyperosmolar State short -acting methylphenidate Type 2 Diabetes Mellitus Type 1 Diabetes Mellitus

5. Canagliflozin has been studied in combination with 5. Adverse effectsEXCEPT: of stimulants used for the treatment of all the following ADHD include all of the following except:

A. Insulin a. appetite suppression b. headache B. Insulin c. insomnia+ Sitagliptin d. weight gain C. Metformin + Pioglitazone D. +Glimepiride 6. WhichMetformin stimulant medication is a prodrug that is acti-

vated in the gastrointestinal tract once the lysine residue is

6. cleaved?Which of the following is NOT a common side effect experienced in patients on therapy? a. Concerta® b. canagliflozin Focalin® c.




A. Changes in urination B. Upper respiratory tract infection 7. Antidepressants such as bupropion and desipramine may C. Urinary tract infection be used for the infection treatment of in which of the followD. Yeast ofADHD the penis

ing instances? a. An instant response is needed 7. Inhibition of sodium glucose transport 2 results in a: b. Comorbid substance use disorder is present c. First-line FDA-approved treatment is required A. Higher renal threshold for glucose d. All of the above B. Decrease in sodium reabsorption

C. Decrease in urinary glucose excretion 8. WhichReduction agent usedof toreabsorption treat ADHD isofa filtered selectiveglucose inhibitor D. of norepinephrine reuptake?

4. tapered Canagliflozin is supplied as a tablet in which of the upon discontinuation? following doses? a. clonidine extended release

a. Adderall® 8. When administered concomitantly with an angiotensin blocker (ARB), angiotensin converting enzyme b. receptor Intuniv® inhibitor (ACEI), or aldosterone antagonist, canagliflozin may c. Strattera® cause: d. Vyvanse®

A. c. B. d. C. D.

A. B. C. D.

4. Which of the following medications for ADHD should be b.

dextroamphetamine extended release

50 methylphenidate and 100 mg extended release 100alland 300above mg of the 200 and 300 mg 200 and 400 mg


Hyperkalemia Hypernatremia Hypomagnesemia Hyponatremia

Palmetto Pharmacist • Volume 53 Number 1 Palmetto Pharmacist • Volume 53, Number 3


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Palmetto Pharmacist • Volume 53 Number 3


GAMECOCK/USC MERCHANDISE Official collegiate licensed merchandise for sale. T-shirts, car flags, tailgate gear. All designed by a SC Pharmacist. Please email Daniel Bundrick at or call/text 803.603.8622. Original designs, unique, edgy new designs too. Also look for our two mobile stores, our huge vans that go to events and football games. Check us out online at www. FOR SALE: MORTAR AND PESTLES Set of 8 Schering Pharmaceutical Corporation commemorative bronzed-like metal mortar and pestles, dated from the late 1960s and 1970s. They have been on display in our independent pharmacy in Florence, SC for over 40 years. We know those who are familiar with these will appreciate them and want them for their collections. They are all about 4 inches tall by 4 inches wide. They are in good condition. Call 843-992-0981 with offer, plus $30 shipping. Nights and weekends call 843-669-7439 or email FOR SALE: PRO ROBOT Script Pro Robot For Sale Model SP200, Excellent Condition. 110K. Send inquiries to FOR SALE: OWENS ILLINOIS PROMOTIONAL CHINA Owens Illinois Promotional China, glass ware and “silver” cutlery. About 85 assorted pieces. Please e-mail me at if you are interested. I can send you a list if you wish. Ralph Wilkie, 843-884-5751

Want to place an ad here? Members can post classified ads for free. Please visit and fill out our online classified form to get your ad posted here!


NEED HELP WITH MEDICATION THERAPY MANAGEMENT? Contact: Bryan Ziegler, PharmD, MBA, Pharmacy Service Consulting, LLC Phone: (803) 269-6333 Email: 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. PHARMACY OPERATIONS CONSULTANT

Pharmacists interested in changing you existing design and operation of your pharmacy - let the best in the business help you make those changes. Contact: Paul J. Hyer, Jr., RPh, PD at 843-814-2542 or write to 301 S. Magnolia St. Summerville, SC 29483.

RELIEF RPh RELIEF PHARMACIST AVAILABLE Experienced (retail, clinic, consulting, nursing home)pharmacist available on PRN or regular basis. Will travel. Competitive Rate. M-F, occasional Sat. JOHN W. OWEN, jwowensr@, (H)803-783-2979 (C)803-466-4783 PHARMACIST SEEKING EMPLOYMENT South Carolina Licensed Pharmacist would like to work in an independent pharmacy, prefer small-town setting. Tim McKittrick 704-585-6690


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 BEACH HOME FOR SALE OR RENT Pawley’s Island Beachhome - 5 Bedroom and 5 Baths. Beautiful view on the creek with eleveator. For sale or rent. Checkout 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. GATLINGBURG CONDO FOR SALE Gatlinburg, TN condo for sale. 3 BR & 3 Bath condo. Fully furnished. Beautiful views of pool, downtown, and mountains. Use for vacations or rental. Priced at $225,000.00. Call 843.908.3488 or email jshiott@lowcountry. com OXYGEN EQUIPMENT 18-Portable oxygen cylinders, 1 devilbiss oxygen conservator, 1-3 liter concentrator invacare, 1-5 liter concentrator invacare, 7-oxygen regulators,1-Salter labs ultrsonic oxygen indicator. Call 864-843-9207, liberty family pharmacy $900.00

Jon A. Wallace, B.S.Pharm., J.D. ♦

South Carolina Board of Pharmacy/licensing matters

Corporate legal counsel specific to pharmacies including purchase and sale

OBRA-90 and South Carolina patient counseling requirements

HIPAA and related privacy issues

Third Party issues including pharmacy benefit managers

Medicaid audits

DHEC and DEA/controlled substances

Risk management

Pharmacy Technicians

Federal compliance

602 Rutledge Avenue ♦ Charleston, SC 29403 ♦ (843) 266-2626 ♦

Palmetto Pharmacist • Volume 53, Number 3


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Palmetto Pharmacist • Volume 53 Number 3

June July 2013  

June July Palmetto Pharmacist