Keeping Tabs Volume 5| Issue 2

Keeping Tabs

ISSUE 5 | VOLUME 2 University of Florida College of Pharmacy

Table of Contents How a New Legislation is Impacting the Profession of Pharmacy

4-5

Take Pride in Being an Ally

6-7

Call to Action Anticoagulation in Atrial Fibrillation

8 9-10

Helping the underserved community of Jacksonville 11-12 Totally Toxic

13-14

Congratulations

To our new officers, chairs and co-chairs

President: Operation Heart: Gabriela Gonzales Alyssa Cox*, Daniela Luzardo President-elect: Operation Diabetes: Christine Ellis Bailey Parker*, Bobby Harris Patient Care Vice President: Operation OTC Medicine Safety: Megan Miller Blair Reece* Policy Vice President: Operation Immunization: Monica Bennett Lucy Phipps*, Elijah Searles Policy Vice President-Elect: Generation Rx: Dionna Shine Moya Reid* International Vice President: Operation Mental Health: Victoria Walker Lauren Hoggarth*, Morgan International Vice President-Elect: Cashman Won Lee Operation Women's Health: Communications Vice President: Clarisa Callejas*, Lillian Daboul Moya Reid Operation Pride: Membership Vice-President: Rachel Cufferi*, Christine Ellis Neissa Alabre Local Operation Administrator: Member-at-Large: Kristen Salem Daniela Luzardo IPSF Infectious Disease Finance Vice President: overseen by International VP Charles Burke Elect: Won Lee Thank you everyone for Industry Liaison: running and taking up these responsibilities Logan Langley even with the craziness Fundraising Chair: of COVID. I hope this year Carole Yazaji will be impactful and full of greatness.

*indicates chair position

How a New Legislation is Impacting the Profession of Pharmacy

BY KIMBERLY JAMES

Pharmacists have the ability to dispense

deficiency syndrome, obesity, hypertension,

prescription medications to patients, offer

hyperlipidemia, anti-coagulation management,

expertise about the safe use of prescriptions,

nicotine dependence, and opioid use disorder.

provide immunizations, and oversee the

Labs can also be conducted as long as the

medications given to patients. However, the

agreement states under which circumstances

growth of pharmacy has been lacking with the

the pharmacist may order or perform clinical

shortage of prescribing abilities.

tests.

Collaborative pharmacy practice agreements

Benefits of collaborative practice agreements

(CPA) have been a discussion in the state of

include the ability for pharmacists to use their

Florida for several years. A collaborative

scope of practice to provide specified patient

practice agreement is a legal agreement in

care services to the physician’s patients. This

which a licensed provider makes a diagnosis,

could be extremely beneficial to patients

supervises patient care, and refers the patients

because it will decrease barriers to receive

to a pharmacist using a protocol that allows

their medications in a timely manner.

the pharmacist to manage chronic health

Examples include prior authorizations and

conditions.

refill approvals. With a CPA, the pharmacist would be able to initiate a change of

For Collaborative practice agreements in

medication to a product that is on the patient’s

Florida, there are certain criteria that must be

formulary, thus the patient being able to start

met. A pharmacist can initiate, modify, or

treatment faster. A pharmacist would also be

discontinue medications for specific situations.

able to approve a refill for a medication so that

Conditions in which pharmacists can manage

the patient does not experience a gap in care.

include arthritis, asthma, chronic obstructive

This could potentially increase compliance and

pulmonary disease, type 2 diabetes, human

provide the patient a comprehensive patient

immunodeficiency virus or acquired immune

care experience.

There are also many problems that could occur with collaborative practice agreements.

In Florida, each pharmacist must have a collaborative practice agreement with each

References: Pharmacy, Florida Board of. “Pharmacist Collaborative Practice Certification.” Florida Board of Pharmacy, floridaspharmacy.gov/licensing/pharmacist-collaborativepractice-certification/#tab-requirements5e00-ae46.

physician. This could be problematic when

“New Florida Legislation Expands Pharmacist Scope of

there are multiple physicians in the same

Practice: Insights: Greenberg Traurig LLP.” Insights |

office. What happens if the prescriber is on vacation and has

Greenberg Traurig LLP, www.gtlaw.com/en/insights/2020/6/new-florida-legislationexpands-pharmacist-scope-of-practice.

another prescriber

“FAQ – Collaborative Practice Agreement " Continuing

taking their place?

Pharmacy Education " College of Pharmacy " University of

Another problem that is being faced is that each individual patient must be listed in the agreement.

If a new patient is being diagnosed with a qualifying chronic condition, an addendum must be made to the agreement. This must occur for each and every new patient that becomes involved in the agreement. Additionally, each specific drug that the pharmacist will manage must be listed for each patient.

The collaborative pharmacy practice agreement will not be automatically renewed.

It will be automatically terminated 2 years after execution if not renewed by both the pharmacist and the physician. Both the pharmacist and the collaborating physician must maintain the agreement on file at his or her practice location and must be available upon request or inspection by the department or board.

Florida.” UF Monogram, cpe.pharmacy.ufl.edu/resources/frequently-askedquestions/faq-collaborative-practice-agreement

TAKE PRIDE IN BEING AN ALLY

BY RACHEL CUFFERI As parades end, rainbow flags come down, and Pride month comes to a close, we have to remember Pharmacists should be Allies 365 days a year. Pharmacists are regarded as the most accessible healthcare provider, allowing us to have meaningful interactions with a diverse group of patients. Being in this unique position as health care providers who counsel patients on adherence and therapy outcomes, we become who they trust. Forming these intimate connections with our patients allows discussion of sensitive topics, which requires advanced training in cultural competency and communication skills. It is our responsibility to be well trained on the specific needs and possible barriers of care that many minorities experience so that we can use our voices to advocate and support them.

Due to limited access, lesbian, gay, bisexual, transgender and queer (LGBTQ+) individuals are more likely to have multiple health disparities. Many have experienced limited access to inclusive and affirming health care, with no shortage of discriminatory experiences to share. How can Pharmacists work on creating more inclusive and accepting environments for these patients? We need cultural competency and dedicated education on the LGBTQ+ population and the specific needs of them as patients. For years, Pharmacy schools all over the country have been debating on how to incorporate adequate training on LGBTQ+ health into their curriculum in order to help students be more aware, empathetic, and prepared when assisting with this population in practice.

One article touched on 5 strategies that can be incorporated into Pharmacy curriculum to include LGBTQ+ content for Doctor of Pharmacy programs. The first is integration into interprofessional courses which would give opportunity for professionals from different health care fields to collaborate on counseling LGBTQ+ patients. Next is integration into didactic courses where LGBTQ+ cases and topics would appear more frequently and in depth throughout Pharmacy

student’s coursework. Another would be integration into skills-based laboratory courses where students would practice sensitivity when communicating with and counseling LGBTQ+ patients. This would particularly be of importance when referring to a patients correct pronouns. Following that is integration into elective courses, which could be seen in the form of an entire elective dedicated to LGBTQ+ topics in Pharmacy that would give students the opportunity to broaden their knowledge. Lastly is integrating a combination of these differing strategies throughout multiple courses across the curriculum in order to ensure that complete cultural competency training is delivered to students.

The definition of an ‘Ally’ is someone who is associated with another to provide support and assistance during an ongoing struggle. As healthcare providers it is our responsibility to be Allies to all minority groups that we serve regardless of any personal biases. As Pharmacists, we dedicate ourselves to ensuring our patients’ safety and adherence regarding medications, thus we are charged with creating a safe and inclusive environment for our patients. It should be our honor to serve those in the LGBTQ+ community, who have had previous experiences of discrimination and marginalization from the health care system. Pride month is a beautiful time of love, acceptance, and celebration that must be carried in our hearts year-round.

References 1.Pharmacists are in a unique position as health care providers to counsel patients regarding medication use and offer a final crosscheck to ensure optimal adherence and health outcomes. As such, they are able to connect with patients in a personal manner to advise on sensitive matters that require both enhanced cultural and communication skills tailored to the individual patient.

2.Limited access to inclusive, affirming health care and exposure to stigmatizing and discriminatory experiences have resulted in multiple health disparities for lesbian, gay, bisexual, transgender and queer (LGBTQ) people.

CALL TO ACTION

BY MONICA BENNETT For whatever reason, policy tends to be intimidating for most students until their second or even third year in Pharmacy school. Have you ever sat through the law class and thought “Why do we do this or that?” Was there someone on your team or another campus who brought up a great point and made you think that a particular statute or regulation seemed unnecessary?

This summer while you are on your rotation (CIPPE or HIPPE) or working in the pharmacy and you see or hear something that does not make sense, ask your preceptor about it. That is a great time to potentially bring the issue forward. I challenge you to think about some of these issues and how policy changes may impact patients. Reach out to your friends and discuss the statute that the issue pertains to. Reach out to students involved in policy on campus such as myself and Dionna Shine.

As we get closer to the start of the fall semester, the policy team is always looking for inputs and resolutions to bring forward at MRM (APhA–ASP Midyear Regional Meeting). In APhA-ASP, we collaborate with other students on campus or across campuses; we even reach out to other faculty members or leaders working in policy. If you see something and it piques your curiosity enough to discuss it with a co-worker or teammate, then it is potentially worth exploring for solutions.

Rally in Tally? If you are on the fence about going to Tallahassee next spring for Legislative Days, I strongly encourage you to go. It is a great experience as a student pharmacist/constituent to go to the state capitol in your white coat and discuss bills that can have an impact on pharmacy practice and the patients you will one day serve. Know that there are typically talking points to help you understand Florida Pharmacist Association’s (FPA) stance on the bills. There will also be an opportunity to discuss the bills with members of FPA prior to meetings with representatives or senators. As bills are prepared and presented at committees, it is our responsibility to keep up with the changes to the bills and FPA’s position (support or opposition) of the bill. Additionally, during Legislative Days this past spring the Student Advocacy Outreach Team (SAOT) created a webpage with resources to prepare students for the discussions with legislators and is available at https://sites.google.com/view/pharmacylegislativedays/home. This is a great resource to see what bills are being advocated for during the Legislative session.

If you are interested in working on resolutions or being part of the policy committee next year, please reach out for more information! Contact Monica Bennett, APhA-ASP Policy Vice President, Jacksonville Campus (monica.bennett@ufl.edu).

ANTICOAGULATION IN ATRIAL FIBRILLATION

By Moya Reid

Atrial fibrillation (AFib or AF) is a quivering or irregular heartbeat, called an arrhythmia, that can lead to blood clots, stroke, heart failure and other heart-related complications. As the name suggests, this occurs in the atrium or the upper chambers of the heart. Due to the atrium not beating correctly, they are not able to effectively deliver blood to the ventricles. This inefficiency can cause clots to form.

Development of atrial thrombi can occur with any type or severity of atrial fibrillation whether it be paroxysmal, persistent, or permanent. It can also happen in both valvular and nonvalvular AF. Valvular AF generally refers to moderate to severe mitral valve stenosis or the presence of a mechanical heart valve and is an indication for long term anticoagulation. Nonvalvular is the absence of these conditions.

Ischemic stroke is the most common manifestation, however it can embolize to other parts of the body and anywhere in the pulmonary and systemic circuits. Because of this, all patients with valvular AF and most patients with non-valvular AF are recommended to be on chronic anticoagulation.

Anticoagulation can reduce the risk of stroke by over 60% regardless of the baseline risk. As with all anticoagulation therapy, this can lead to an increased risk of bleeding and therefore CHA2DSVASc2 score is used to stratify the risk.

A CHA2DSVASc2 score of 2 or greater indicates

need for anticoagulation therapy. A score of 1 means that it is up to the physician’s clinical judgement and there is no recommendation for a score of 0.

The drugs frequently used for anticoagulation are direct oral anticoagulants or DOACs (rivaroxaban, apixaban, dabigatran, edoxaban) and warfarin. If anticoagulation is indicated for a patient with AF, DOACs are preferred over warfarin according to the American Heart Association 2019 guidelines. This recommendation is based on four randomized control trials, RE-LY, ARISTOTLE, ROCKET AF and ENGAGE AF-TIMI 48, comparing DOACs to warfarin. These studies showed consistent evidence of at least non-inferiority for the outcomes of stroke or systemic embolisms.

These studies, along with their safety profile, pushed them to be recommended as first line therapies. There are some things that need to be noted about DOACs. It is important to know the patient’s creatine clearance as this will determine how DOACs are dosed. Edoxaban is

contraindicated in patients with a creatine clearance greater than 95ml/min due to increased ischemic stroke risk compared to warfarin. Rivaroxaban has to be taken with food while the others do not. Apixaban’s reduced dosing does not come from creatinine clearance, but from meeting two out of these three criteria: a serum creatinine greater than or equal to 1.5mg/dL and greater than or equal to 80 years of age or less than or equal to 60kg.

Treatment with DOACs have many advantages.

They have similar or lower rates of both ischemic stroke and major bleeding compared to adjusted dose warfarin in non-valvular AF. Adjusted dose is defined as when a patient’s INR is between 2 and 3. You do not need to go to clinics for routine INR testing and so it is convenient. There are also little dietary and drug interactions. They come with some disadvantages as well. There is a lack of safety and efficacy data in the chronic kidney disease population as they were generally excluded from the trials. There is no way to monitor blood levels and so it is also hard to assess compliance. Another big barrier is cost.

Though DOACs might be the preferred treatment, there might be some populations that stay on warfarin. Patients that are already on warfarin may be comfortable with periodically going to the clinic to have their INR measured and might even prefer it. These patients may stay on warfarin if they are well controlled, which is an annual time of being in therapeutic range (INR between 2 and 3) 65% of the year. Patients with valvular AF should not receive DOACs. Patients who may not comply with twice daily dosing should not receive dabigatran or apixaban. Patients might also not be able to afford DOACs as they are pretty expensive. Patients should not take DOACs if they have severe chronic kidney disease with a glomerular filtration rate of less than 30ml/min. The only exception is apixaban which has been approved in the US for end stage renal disease. There might also be some patients with contraindications to DOACs, such as those taking enzyme inducing antiepileptic drugs like phenytoin or patients with HIV on protease inhibitor based antiretroviral therapy.

References

▪Manning, W. J., Singer, D. E., & Lip, G. Y. H. (2020, October 27). Atrial fibrillation: Anticoagulant therapy to prevent

thromboembolism. UpToDate. https://www.uptodate.com/contents/atrial-fibrillation-anticoagulant-therapy-to-preventthromboembolism.

January, C. T., Wann, L. S., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Furie, K. L., Heidenreich, P. A., Murray, K. T., Shea, J. B., Tracy, C. M., & Yancy, C. W. (2019). 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation, 140(2). https://doi.org/10.1161/cir.0000000000000665 What is Atrial Fibrillation (AFib or AF)? (2016, July 31). www.heart.org. https://www.heart.org/en/health-topics/atrialfibrillation/what-is-atrial-fibrillation-afib-or-af

▪ ▪

HELPING THE UNDERSERVED COMMUNITY OF JACKSONVILLE By: Brenda Echevarria Munoz P h a r ma c i s t s h a v e t h e p o w e r t o i mp a c t p a t i e n t s ’ l i v e s i n mo r e w a y s t h a n j u s t i d e n t i f y i n g a dangerous drug-drug interaction that went unnoticed by a prescriber. Often, patients go to t h e p h a r ma c y t o p i c k u p t h e i r n e w l y p r e s c r i b e d me d i c a t i o n a f t e r a n E R v i s i t , o n l y t o f i n d o u t t h e y c a n n o t a f f o r d t o p a y f o r t h e me d i c a t i o n . T h i s c a n l e a d t o d e c r e a s e d a d h e r e n c e a n d mo r e p r o b l e ms d o w n t h e r o a d , w h i c h c a n e n d u p b e i n g mo r e costly for the patient but also further affect their health. Often, patients are not aware of the resources that surround them and can helps to h a v e b e t t e r a c c e s s t o h e a l t h c a r e . P h a r ma c i s t s c a n s t a y i n f o r me d a b o u t s i t e s i n t h e i r c i t y o f w o r k t o be able to give better advice to the underserved populations and thus being continued advocates for the health of patients.

Wh e t h e r i t i s f r e e c l i n i c s , h o me l e s s s h e l t e r s , o r f o o d b a n k s , s t a y i n g i n f o r me d c a n b e t h e r e a s o n a p a t i e n t w h o c a n n o t a f f o r d t h e i r me d i c a t i o n s o r t o get a checkup after feeling ill gets to feel better a n d s e e t h e i r h e a l t h i mp r o v e . A s f u t u r e p h a r ma c i s t s , w e s h o u l d h a v e t h e a b i l i t y t o b r i n g knowledge to the patients that are not getting the help they need and have been ignored in o t h e r a r e a s o f t h e s y s t e m. T o g e t y o u s t a r t e d , below is a non-exhaustive list of different resources around Jacksonville that aid underserved populations, their contact i n f o r ma t i o n , a n d a b r i e f d e s c r i p t i o n o f h o w patients can benefit from visiting the site. Let it serve as a guide to know what is available in the Jacksonville area that we can educate patients a b o u t a n d h o p e f u l l y ma k e a d i f f e r e n c e i n t h e i r lives.

Dispensary of Hope is a service that provides certain medications free of cost to patients who are below a certain threshold of the poverty line and cannot afford their medications. It is a charity that provides contracted pharmacies with the access to certain vital medications that have been donated by pharmaceutical manufacturers.

SETON PHARMACY (RIVERSIDE) (904) 308-7514 1 SHIRCLIFF WAY, RM 1734 JACKSONVILLE, FL 32204 SETON PHARMACY (SOUTHSIDE) (904) 450-6330 4201 BELFORT RD., SUITE G361 JACKSONVILLE, FL 32216 MISSION HOUSE CLINIC PHONE: (904) 241-6767 EXT. 117 800 SHELTER AVE. JACKSONVILLE BEACH, FL 32250

To find a pharmacy in your area that participates in this program go to: https://www.dispensaryo fhope.org/access-sitefinder

Free and Income-Based Clinics/Medical Outreach Programs

Homeless services

Food Banks

TOTALLY TOXIC BY: JOURDAN BOYLE-TAYLOR, PHARMD CANDIDATE 2022

In my Emergency Medicine rotation at University of Florida (UF), I learned about a significant number of toxicities. The toxicities that I am going to describe in this article are some that I experienced on my rotation.

Symptoms that may be present include nausea, vomiting, abdominal pain, etc. which are pretty nonspecific.

Hepatic injury can precipitate within the first 12 hours of ingestion if the overdose is significant enough. AST and ALT are used to determine hepatic

detail today. An acetaminophen

injury. AST rises and falls

level is drawn 4 hours after

faster and can be used to

ingestion and then plotted on

determine recovery of the

this graph. If the patient is above

liver.

150 micrograms/milliliter then

Treatment

they will be treated.

Activated charcoal can be

Dosing for NAC is a little

used if the ingestion

complicated, so special

occurred less than an hour

attention needs to be taken if

ago. However, in most cases,

this drug gets ordered. The

N-acetylcysteine (NAC) is

dosing is as follows: 150 mg/kg

used.

for the first hour, then 50 mg/kg

Acetaminophen (Tylenol):

The decision of when to treat

for the next 16 hours, then 100

Clinical presentation:

or not is determined by using

mg/kg for the remaining 4 hours,

In the first couple hours you

a chart called the Rumack-

equaling a total of 21 hours of

may not even have any

Matthew Nomogram. There

treatment time. You will not

symptoms, this can last up

can be many caveats

need to redraw acetaminophen

to a whole day after

associated with the

levels after giving NAC but will

ingestion of

nomogram, but I won’t go

still need to monitor the AST and

acetaminophen.

into too much

ALT for improvement.

Salicylates (Aspirin) Clinical Presentation After over ingestion of aspirin, vomiting

section of lead 1, in normal EKGs the R wave is absent. This could indicate someone is TCA toxic.

or emesis may be noted. Tachypnea may be subtle, but it will be present. Even though it is not very noticeable, this could be a sign of acidosis. This can lead to the toxicity of the central nervous system and more serious consequences.

Treatment Activated charcoal can be given in a ratio of 10:1, 10 mg of activated charcoal for

Treatment

every 1 mg of aspirin ingested. This may

A 1-2 mEq/kg bolus of Sodium

not always be feasible when the amounts

bicarbonate IV given every 3-5 minutes

ingested are extremely high

until the EKG starts to show normal

Alkalizing the urine with sodium

rhythms

bicarbonate can also be used, by “bolus of 1 to 2 mEq/kg of sodium bicarbonate IV

The results of all these toxicities can be fatal in

followed by an infusion of 3 ampules of

one way or another, which is why it is important

sodium bicarbonate (132 mEq) in 1 L of

to educate our patients on how to take their

5% dextrose in water administered at 1.5

medications properly.

to 2.0 times the maintenance fluid range.” (Lugassy) Tricyclic Antidepressants (TCA) Clinical Presentation When someone overdoses on a TCA, the

References Hendrickson, Robert G., and Nathanael J. McKeown.

manifestations are more cardiac in

"Acetaminophen." Goldfrank's Toxicologic Emergencies, 11e

nature. This can include arrhythmias, low

Eds. Lewis S. Nelson, et al. McGraw Hill, 2019,

blood pressure and low fluid volumes.

https://accesspharmacy.mhmedical.com/content.aspx? bookid=2569&sectionid=210270383.

Altered mental status can also be seen if

Lugassy, Daniel M. "Salicylates." Goldfrank's Toxicologic

there is toxicity of the central nervous

Emergencies, 11e Eds. Lewis S. Nelson, et al. McGraw Hill, 2019,

system.

https://accesspharmacy.mhmedical.com/content.aspx? bookid=2569&sectionid=210270941

TCA toxicity can actually be seen on an

Valento, Matthew, and Erica L. Liebelt. "Cyclic

EKG as well. The QRS can be very wide

Antidepressants." Goldfrank's Toxicologic Emergencies, 11e

and a R wave can be seen in the aVR

Eds. Lewis S. Nelson, et al. McGraw Hill, 2019, https://accesspharmacy.mhmedical.com/content.aspx? bookid=2569&sectionid=210274664.

Thank you!

To our writers: To our designer: Kimberly James Moya Reid Rachel Cufferi Monica Bennett Moya Reid Brenda Echevarria Munoz Jourdan Boyle-Taylor