The Kentucky Pharmacist Vol. 8 No. 4
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Transcript of The Kentucky Pharmacist Vol. 8 No. 4
Vol. 8, No. 4
July 2013
TTHEHE KKENTUCKYENTUCKY
PPHARMACISTHARMACIST
News & Information for Members of the Kentucky Pharmacists Association
MEMBERSHIP
MATTERS! To YOU!
To YOUR Patients!
To YOUR Profession!
2013-14-KPhA President
Duane Parsons with his
wife, Linda.
Below: Introducing
Roamey,
the KPhA Gnome
July 2013
THE KENTUCKY PHARMACIST 2
Table of Contents
Table of Contents
Table of Contents— Oath— Mission Statement 2 President’s Perspective 3 135th KPhA Annual Meeting 4 Message from Your Executive Director 7 2013 KPERF Golf Scramble 8 2013 KPhA House of Delegates Report 9 Images of the 135th KPhA Annual Meeting 10 Relevance and Relationships Review 12 KPhA Emergency Preparedness 13 Pharmacy’s Future: Student Participation at KPhA Annual Meeting 14 Saving the Bowl of Hygeia 15 July 2013 CE: Pediatric OTC 16 July Pharmacist/Pharmacy Tech Quiz 30
August 2013 CE: COPD and CVD 31 August Pharmacist/Pharmacy Tech Quiz 38 Senior Care Corner 39 KPhA New and Returning Members 40 KPhA Government Affairs/Pharmacy Health Screenings 42 Cardinal Health 43 Sponsors/Exhibitors of the 135th KPhA Annual Meeting 44 New Directors of the KPhA Board of Directors 46 Pharmacy Law Brief 48 Technician Review 49 Pharmacy Policy Issues 50 Pharmacists Mutual 52 APSC 53 KPhA Board of Directors 54 50 Years Ago/Frequently Called and Contacted 55
Oath of a Pharmacist
At this time, I vow to devote my professional life to the service of all humankind through the profession of phar-
macy.
I will consider the welfare of humanity and relief of human suffering my primary concerns.
I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy out-
comes for the patients I serve.
I will keep abreast of developments and maintain professional competency in my profession of pharmacy.
I will embrace and advocate change in the profession of pharmacy that improves patient care.
I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.
Kentucky Pharmacists Association
The mission of the Kentucky Pharmacists Associa-
tion is to promote the profession of pharmacy, en-
hance the practice standards of the profession, and
demonstrate the value of pharmacist services within the
health care system.
Editorial Office:
© Copyright 2013 to the Kentucky Pharmacists Asso-ciation. The Kentucky Pharmacist is the official jour-nal of the Kentucky Pharmacists Association pub-lished bi-monthly. The Kentucky Pharmacist is dis-tributed to KPhA members, paid through allocations of membership dues. All views expressed in articles are those of the writer, and not necessarily the official position of the Kentucky Pharmacists Association.
Editorial, advertising and executive offices at 1228 US 127 South, Frankfort, KY 40601. Phone 502.227.2303 Fax 502.227.2258. Email [email protected]. Website http://www.kphanet.org.
The Kentucky Pharmacy Education and Research Foun-
dation (KPERF), established in 1980 as a non-profit sub-
sidiary corporation of the Kentucky Pharmacists Associa-
tion (KPhA), fosters educational activities and research
projects in the field of pharmacy including career coun-
seling, student assistance, post-graduate education, con-
tinuing and professional development and public health
education and assistance.
It is the goal of KPERF to ensure that pharmacy in Ken-
tucky and throughout the nation may sustain the continu-
ing need for sufficient and adequately trained pharma-
cists. KPERF will provide a minimum of 15 continuing
pharmacy education hours. In addition, KPERF will pro-
vide at least three educational interventions through oth-
er mediums — such as webinars — to continuously im-
prove healthcare for all. Programming will be determined
by assessing the gaps between actual practice and ideal
practice, with activities designed to narrow those gaps
using interaction, learning assessment, and evaluation.
Additionally, feedback from learners will be used to im-
prove the overall programming designed by KPERF.
July 2013
THE KENTUCKY PHARMACIST 3
It’s a very humbling experience to be standing at this podi-
um as YOUR president. I’m so very honored. I would like to
thank each of our members and our Board for their faith in
bestowing this honor on me. I’d also like to thank Bob and
our hard-working staff, Kelli, Scott, Leah and Nancy for
their support to our Board and to our profession. Special
thanks to my family for allowing me to serve you. Thanks to
our sponsors and supporters and to the University of Ken-
tucky College of Pharmacy and Sullivan University College
of Pharmacy for all the support they provide as well.
I had the very valuable opportunity with Bob to attend the
annual meeting of the National Alliance of State Pharmacy
Associations (NASPA) in April. The primary conversation
for the meeting was the leadership responsibility for incom-
ing presidents for each state association and the role of
each Board they served. One of the topics that really in-
trigued both Bob and me was the Four Sights of the Board:
1.) Oversight, making sure the Board is true to its mission.
2.) Insight, asking the questions that are important.
3.) Foresight, looking at trends in the profession.
4.) Hindsight, evaluating what has been done in the past.
Foresight was particularly of importance. How do we get to
where we want to go?
Many of the sideline conversations we had with other state
associations centered on that. We heard a primary concern
from almost all state associations of how to work through
membership issues while trying to establish the relevancy
of our profession.
The mission of the Kentucky Pharmacists Association is to
promote the profession of pharmacy, enhance the practice
standards of the profession and demonstrate the value of
pharmacists’ services within the health care system. That’s
a very lofty and honorable mission statement. Over the
years, we’ve done a great job of promoting the profession
and enhancing practice standards. We have always strug-
gled with demonstrating the value of our services, NOT
with our patients. We have, however, not done a good job
of demonstrating the value of our services within the
healthcare system in order to attain provider status.
There are various reasons this has not happened to date.
A primary reason, I believe, is that we are not a very unified
profession. Pharmacy has many diverse pathways down
which we travel. That leads to different issues that are rele-
vant to different segments within the profession. What’s
important to some seems to have less relevancy to others.
We need to change that mindset. If it’s important to the
profession in any area, it needs to be important to the pro-
fession overall. We need to be unified in our approach.
That’s where KPhA can play a vital role. We need to be the
unifying leader for all issues that face the profession no
matter from which pathway they arise. There are very dis-
tinct advantages in speaking as a consolidated, unified
group representing large numbers with an even louder
voice.
That’s exactly why MEMBERSHIP MATTERS. It matters to
YOU. It matters to YOUR patients. It matters to YOUR pro-
fession.
Let’s focus on what matters to YOU. For YOU, membership
provides:
Legislative and Regulatory Advocacy
Networking with Colleagues
Access to State and National Resources on Pharmacy
Related Issues
Special Programs and Pricing on Insurance and Finan-
cial Services specifically designed for Pharmacists
through Pharmacists Mutual Companies
Special Pricing on Quality Improvement Programs to
meet the needs of Pharmacists offered by Pharmacy
Quality Commitment
Special discounts from Dell, Hertz and others
Free CE for members
Programs like Immunization Training for Pharmacists
PRESIDENT’S
PERSPECTIVE
Duane W. Parsons
KPhA President
2013-2014
Adapted from President
Parsons’s address at the
Ray Wirth Banquet at the 135th KPhA Annual
Meeting, June 8, 2013 in Louisville, KY
President’s Perspective
Continued on Page 6
July 2013
THE KENTUCKY PHARMACIST 4
135th KPhA Annual Meeting
2013 KPhA Professional Awards
Leon Claywell, Bardstown, Bowl of Hygeia Award sponsored by the American Pharmacists Associa-
tion Foundation and the National Alliance of State Pharmacy Associations with support from
Boehringer Ingelheim. Pictured with outgoing KPhA Chair Lewis Wilkerson, outgoing President Kim-
berly Croley and Amy Nicholas, Associate Director, Health Economics and Outcomes Research at
Boehringer Ingelheim.
Catherine Hanna, Lexington,
KPhA Distinguished Service Award
Trish Freeman, Lexington,
KPhA Pharmacist of the Year
July 2013
THE KENTUCKY PHARMACIST 5
135th KPhA Annual Meeting
Buddy Wheeler, Lexington, KPhA Excellence
in Innovation Award sponsored by Upsher-Smith
Laboratories, Inc.
Brooke Hudspeth, Lexington, KPhA Distin-
guished Young Pharmacist of the Year, spon-
sored by Pharmacists Mutual Insurance. Bruce
Lafferre presented for Pharmacists Mutual.
KPhA Professional
Promotion Award
Julie N. Burris,
Louisville
Walgreens Corporation,
Buddy McCaffery,
District Manager,
accepted for Walgreens.
Leslie Lochner and Robin Lillpop, Louisville,
KPhA Technician of the Year Representative Jeff Greer (D-Brandenburg),
KPhA Meritorious Service Award. KPhA Member
Jonathan Van Lahr assisted in the presentation.
Raymond Float, Danville (second from right), Cardinal Health
Generation Rx Award. KPhA Executive Director Robert McFalls,
President Duane Parsons, Todd Wright, Cardinal Health Retail
Sales Manager and David Kelly, Cardinal Health Pharmacy Busi-
ness Consultant presented the award.
July 2013
THE KENTUCKY PHARMACIST 6
President’s Perspective
The Kentucky Pharmacist is
online!
Go to www.kphanet.org, click on Com-
munications and then on The Kentucky
Pharmacist link.
Would you rather receive the
journal electronically?
Email [email protected] to be placed
on the Green list for electronic delivery.
Once the journal is published, you will
receive an email with a link to the
online version.
which allow members to enhance services offered
Opportunities to be engaged in making a difference
with your colleagues
How can each of us be engaged? Engagement doesn’t
necessarily mean that you need to serve on our Board,
although we should all give consideration to that. There are
various ways that we can all serve our profession through
KPhA that are less time consuming. Not all have the time
for a Board level commitment. We CAN, however, be en-
gaged in other ways.
We can help draft legislative priorities that affect us by
serving on a committee such as our Government Affairs
Committee.
We can serve as members of other committees as well.
Some of those are Organizational Affairs, Professional/
Public Affairs, New Practitioners, or Membership Engage-
ment.
We can be engaged in work groups such as Health Infor-
mation Technology (HIT) or Emergency Preparedness
when called upon.
We can serve as mentors to other members of the profes-
sion to help them understand the importance of becoming
KPhA members and getting involved themselves.
We can educate our legislators to help them understand
how important and valuable our services are to their con-
stituents.
We can engage in grassroots efforts involving issues that
affect our profession.
We can educate our patients on how important and benefi-
cial our services are to their personal health.
We can serve as ambassadors in our own areas to help
recruit and retain members.
We can actively promote KPhA membership to other mem-
bers of our profession.
If we are to attain provider status and expand patient ac-
cess to pharmacists’ services and receive reimbursement
for these services, we all need to be engaged. We need to
strengthen our membership numbers in order to speak with
a much louder voice. We need to present a more unified
appearance within our profession.
That will be a primary role as I serve as your President in
the upcoming year. Many of you will see Bob and me in
your workplaces throughout the coming year. We’ll be ac-
tively promoting membership benefits and membership
services as we travel. We challenge each of you to be
more actively engaged in this role and to get others actively
engaged. And, if you look close enough and follow us on
social media, you will be seeing our new KPhA Member-
ship Matters friend, Roamey the KPhA Gnome!
Continued from Page 6
Introducing!
Roamey the
KPhA Gnome!
Membership
Matters
Roamey, the KPhA
Gnome, visits
Wheeler Pharmacy in
Lexington
President Duane Parsons
accompanied Roamey on
a tour of several Lexington
pharmacies in July. Watch
the KPhA Facebook page
and the KPhA Website for
the adventures of Roamey
and Duane.
July 2013
THE KENTUCKY PHARMACIST 7
From Your Executive Director
MESSAGE FROM YOUR
EXECUTIVE DIRECTOR
Robert “Bob” McFalls
I hope and trust that your Summer is going really well.
From our perspective, it has been a great Summer thus far.
To all who attended and supported KPhA’s 135th Annual
Meeting & Convention in Louisville, I want to thank you for
your engagement and participation. We especially want to
thank all of our sponsors and exhibitors for your participa-
tion and financial support. By all accounts, it was a great
meeting that was filled with informative CE, recognition of
pharmacists and pharmacy technicians with great peer
awards and presentations, engaged networking opportuni-
ties and a golf scramble that refused to be rained out.
Along these lines, be sure to mark your calendar and save
the date for 2014 when the 136th KPhA Annual Meeting
and Convention will be held on June 5-8, 2014 at the Mar-
riott Griffin Gate in Lexington!
Another exciting development at this year’s Annual Meeting
was the appearance of, uh…, a new little colleague, sup-
porter and almost humanoid creature. Gartenzwerg!
Through the pages of this edition of The Kentucky Pharma-
cist, you are being introduced to Roamey, the KPhA Mem-
bership Matters Gnome. Roamey began his journey with
KPhA in Louisville at the Annual Meeting and will be travel-
ing throughout the Commonwealth in the coming days,
months and years. Not all that different from “GNOME” —
that desktop environment and graphical user interface that
runs on top of a computer operating system — Roamey’s
intention is to serve YOU by promoting the profession of
pharmacy and membership engagement with YOUR KPhA.
Roamey the KPhA Gnome’s heartfelt message is simple
but incredibly powerful:
Membership Matters:
To YOU! To YOUR Patients! To YOUR Profession!
When you engage with KPhA, YOUR voice matters as an
active member. You add the power of YOUR voice to ad-
vance the profession of pharmacy with your peers in terms
of other engaged pharmacists and pharmacy technicians
who are working in all practice settings.
YOUR membership helps YOUR KPhA to be stronger
as an Association that represents and informs others
about the myriad ways that YOU help YOUR patients
with their healthcare needs.
YOUR active membership helps promote the visibility
of the profession as well as YOUR KPhA’s involvement
in pharmacy and related health issues throughout Ken-
tucky and on a national level.
YOUR profession is strengthened through the collec-
tive power of being united in YOUR KPhA to advance
the role of pharmacy with other health professions, the
media and the general public.
YOUR concerns matter — YOUR KPhA brings phar-
macists and partners together to advance legislative
priorities and to safeguard the profession from unfair or
unnecessary regulations and actions.
YOUR financial support matters. Membership dues are
the lifeblood for YOUR KPhA, providing the Association
with the flexibility of being able to use funds where they
are most needed in terms of addressing urgent legisla-
tive issues and other critical priorities.
YOUR active engagement as a grassroots advocate
matters. Whether you talk with an elected official, write
a letter or speak at a community forum, YOUR efforts
are making a difference.
YOU matter — and YOUR involvement is making a
difference as evidenced by our legislative successes
for the profession during the past two state legislative
sessions.
Thank YOU for being an active member and participant in
the KPhA Family. We hope that you will welcome Roamey,
the KPhA Gnome, and support his efforts in spreading the
message that MEMBERSHIP MATTERS with YOUR KPhA!
P.S. Did you know that there are currently an estimated 25
million garden gnomes in Germany, but that there is only
one Roamey, the KPhA Gnome? Hmmm. Or could there be
more?
July 2013
THE KENTUCKY PHARMACIST 8
2013 KPERF Golf Scramble
2013
KPERF
Golf
Scramble
First Place: Duane Parsons, Lewis Wilkerson,
Jeff Mills, Joel Thornbury
Second Place: Nevin Goebel, Keith Stinson,
Josh Pitts, Eric Pitts
Last Place:
Jan Gould,
Cheryl Gould,
Gay Dwyer,
Joe Carr
Closest to the Pin:
Chris Stewart
Longest Drive: Kyle Carver
July 2013
THE KENTUCKY PHARMACIST 9
2013 House of Delegates
2013 Actions of the KPhA House of Delegates
Louisville, KY, June 7-9, 2013
Matt Martin , PharmD, 2013 Speaker of the House
Cassandra Beyerle, PharmD, 2013 Vice-Speaker and Chair of the Reference Committee
Kim Croley, PharmD, CGP, FASCP, FAPhA- 2013 Parliamentarian
At the 2013 KPhA House of Delegates, members from
throughout the Commonwealth gathered to discuss, debate
and make recommendations to not only shape the organi-
zation, but also to push forward our beloved profession.
Opening Session
The opening session was on Friday morning. Delegates
were slated and committee reports presented. Nominations
were requested for Vice-Speaker; none were presented.
Therefore, the nomination process was postponed until the
final session of the House to allow time for Delegates to
make nominations for Vice-Speaker.
Reference Committee
The Reference Committee met Saturday morning, bright
and early to discuss resolutions and make recommenda-
tions to the House. The meeting was open to all KPhA
members and chaired by Vice-Chair Beyerle. The members
of the committee were Barry Eadens, Judy Minogue, Lance
Murphy, Chris Clifton, Joe Carr and Kim Croley
(Parliamentarian).
Closing Session
The closing session took place Saturday afternoon. During
this session, recommendations of the Reference Commit-
tee were discussed and nominations for Vice-Speaker were
announced and voted upon. Adoption of committee reports
also took place at the closing session of the House.
Bylaw Changes
2013.01 Subsection 5.51 (amended)
Address ballots for election and the way they will be sent to
members. This was changed to solely electronic, unless
the member requests a paper ballot.
2013.02 Subsection 6.57 (added)
This addition allows Board meetings to be held telephoni-
cally or by video conference. This is to address the issue of
inclement weather or when a Board meeting may be called
on short notice to address an urgent issue.
2013.03 Subsection 11.2 (added)
This addition addresses indemnification and insurance for
Board members and it will now be provided for their ser-
vice.
Committee Reports
Adoption of the following committee reports:
Public and Professional Affairs
Policy Review
Government Affairs
Resolution Adoption
Submitted by Gloria Doughty, recognizing the ef-
forts of UK student pharmacists in the packing of
memorabilia from the Pharmacy Museum during
this time of transition.
The House also approved five candidates to be submitted
to the Governor for consideration for appointment to the
Board of Pharmacy. The five names submitted were: Debo-
rah Brewer (Morgan), Joseph Carr (Daviess), Scott Green-
well (Jefferson), Christopher Killmeier (Jefferson) and Don-
ald Kupper (Oldham).
Two nominations were made for Vice-Speaker: Ethan Klein
and Barry Eadens. A vote via paper ballots was held, and
Ethan Klein, PharmD, was officially elected and appropri-
ately sworn in as Vice-Speaker of the House of Delegates.
The 2013 House of Delegates, once again, was a time for
discussion and debate. This is when we decide the next
steps of YOUR KPhA and look forward to more involve-
ment and discussion in the House as we push our profes-
sion forward. To become more involved, step up, serve on
a committee, become a delegate in the House, voice
YOUR stance. KPhA is here for YOU!
-The KPhA House of Delegates will meet at the Mid-Year
Conference on Legislative Priorities in November.
July 2013
THE KENTUCKY PHARMACIST 10
135th KPhA Annual Meeting
Images from Louisville
July 2013
THE KENTUCKY PHARMACIST 11
135th KPhA Annual Meeting
July 2013
THE KENTUCKY PHARMACIST 12
Relevance and Relationships Review
I know the Agenda says this is a President’s Report, but I
will leave the listing of our accomplishments by Your KPhA
this year to our Executive Director. There have been many,
some small, some large, all well-deserved and all were the
result of a group effort.
Relevance and Relationships
This was the theme for my second Presidential year. I
chose this theme because it embodies everything that
pharmacists do. We are not purveyors of drugs; we are
providers of healthcare and most importantly, health infor-
mation about safe, effective medication use. Our patients
come to the pharmacy looking for answers; they pick the
pharmacy because they believe answers can be found
there. More than 186,000 people enter a pharmacy each
week and that cannot be by coincidence.
I have spent much of my time this year talking to other
pharmacists about the importance of what we do. Pharma-
cists tend to be humble, introverted, self-effacing individu-
als that do not draw attention to the wonderful things we do
for our patients. We tend to sit on the sidelines and wait for
recognition when instead we should be talking to everyone
about the positive patient outcomes we affect through our
daily work.
We struggle with anything controversial and try to fly under
the radar most of the time. If you had told me in November
when we had our Legislative Conference that we would be
able to affect change and achieve SB 107 which calls for
transparency by PBMs, I would have probably told you that
was a pipe dream. Everyone told us it could not be done,
yet we did. How do we build on this success, what is our
next hurdle to jump? In my part of the state, methampheta-
mine manufacture is a cash cow, much as marijuana pro-
duction used to be a cash crop. Should the healthcare pro-
fessional charged with safe, effective medication use revisit
again moving pseudoephedrine back to prescription status?
Should we push harder for a pharmacist-only class of drugs
which falls in the middle of the current prescription and non-
prescription classes? I don’t have any answers; I just have
the questions.
Can we unite as pharmacists and quit describing ourselves
based on practice site but on our place as the medication
experts to achieve provider status under the law? Of all the
questions, this one is my most challenging. I don’t care if
anyone calls me “doctor”, I just want them to call me
“pharmacist’ and know that the title comes with respect and
even awe of my ability to improve my patients’ quality of
life.
I attended my first KPhA convention here in Louisville in
June of 1984. This year marks my 29th consecutive annual
meeting. Next year as I finish my tenure as Chairman of the
Board, it will be my 30th anniversary. I have driven to
Frankfort an untold number of times in the last 29 years. I
have driven in rain, ice, snow and occasionally sunshine! I
have taken my daughter in her carrier to Budget meetings
and signed checks while she slept. My children have both
spent many nights at home with their father while I was
away at meetings representing KPhA. They also got to go
to places they probably would not have if I hadn’t been at-
tending yet another meeting.
One of our funny stories tells about Rachel staying at
friends of mine one evening while I was at a meeting. She
was about 4 years old and had her Barbie doll with her.
She asked my friend Darrell to help snap the clothes on the
doll because she was struggling with getting them on. Dar-
rell asked Rachel where “Barbie” was going and thought
she would say shopping but instead Rachel said “she has
to go to a meeting!” Both of my children are active in
groups that help other people. Rachel has volunteered hun-
dreds of hours while at UofL helping others, even tutoring
at a neighborhood center on 17th street. My son Rob is
working on his Eagle Scout project this summer and just
finished a week of teaching Bible School at church. I like to
believe that my work as a volunteer leader for KPhA has
set a good example for my children and for other pharma-
cists, and I would not trade a minute of it.
As a registrant for this Annual Meeting you each received a
ribbon attached to your nametag that says “Membership
Matters” I would declare to you that being a Member of
the Pharmacy Profession means YOU Matter. Stand up tall
YOU are a pharmacist!
I want to thank Bob McFalls, Scott Sisco, Kelli Sheets and
Nancy Baldwin for their dedicated service to Your KPhA.
They have made my job very easy this year. I want to thank
Lewis Wilkerson for his leadership and all the members of
the Board of Directors for their faithful service. Most of all I
want to thank you for the honor and privilege of serving as
President of Your KPhA for a second time. It has been my
pleasure.
RELEVANCE AND RELATIONSHIPS REVIEW Adapted from presentation at House of Delegates Opening Session, June 7, 2013 by outgoing President Kim Croley
July 2013
THE KENTUCKY PHARMACIST 13
KPhA Pharmacy Emergency Preparedness
For more information on how you can be involved in the KPhA Pharmacy Emergency Preparedness
Initiative, contact Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness at 502-227-
2303 or by email at [email protected]. KPhA is a partner with the Kentucky Department of Public
Health for emergency preparedness and disaster response.
For more resources, visit YOUR www.kphanet.org and
click on Resources—Emergency Preparedness.
KPhA Pharmacy Emergency Preparedness Initiative
Interest Form
Name: _____________________________________ QS/1 Experience: Yes____ No _____
Status (Pharmacist, Technician, Other): ___________________________
Email: ______________________________ Phone: ___________________________
For Pharmacists: Interest in serving as a volunteer: Yes____ No _____
If yes, please go to KHELPS link on KPhA Website to register (www.kphanet.org under Resources)
____ I would like to serve as pharmacy district coordinator (PDC). PDCs will serve as a point of contact
in their respective county and may assist in dispensing activities on the mobile pharmacy if deployed in
the event of a disaster.
Please send this information to Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness via
email at [email protected], fax to 502-227-2258 or mail at KPhA, 1228 US 127 South, Frankfort, KY
40601.
The Emergency Preparedness program is moving along
nicely!
Here are the latest accomplishments as well as next steps
that will involve all of you around the state:
The destruction of Tamiflu Suspension and the transport of
the antivirals to a central warehouse for storage has been
complete.
The mobile pharmacy's functionality including water, gener-
ator and utilities is being tested this month. KPhA hopes to
have it fully operational for deployment by August 15th.
Pharmacy district meetings for the fall are being sched-
uled. An emergency preparedness program has been ap-
proved for 1.25 hours of continuing education that can be
provided. KPhA is working with KDPH to possibly have the
mobile pharmacy available for touring at the district meet-
ings.
We are looking for volunteers to coordinate a meeting for
eastern and southern Kentucky.
July 2013
THE KENTUCKY PHARMACIST 14
135th KPhA Annual Meeting
PHARMACY’S
FUTURE: Student pharmacist
involvement
Team CHAOS, winners of the 2013 NASPA-NMA Student Pharmacist Self-Care Championship, Ryan P. Hickson – UK,
Mallory Megee – UK, Sharlonda Nunn – Sullivan, Clarissa Morey – Sullivan. Pictured with 2013 Host Brent Simpkins.
(Right) Lance Murphy (Sullivan) and Brooke Herndon (UK), members of Team Reigning Champs, discuss an answer.
Members of Kappa Psi were recognized for their ef-
forts in helping Gloria Doughty and other volunteers
pack the contents of the Kentucky Pharmacy Renais-
sance Museum. The museum’s contents will be stored
at KPhA headquarters until a permanent location is
established.
July 2013
THE KENTUCKY PHARMACIST 15
Bowl of Hygeia
Saving the Bowl of Hygeia The Bowl of Hygeia has a rich history within pharma-cy, and we need to step up and make sure this history continues. Given that this is an award presented at the state lev-el, the State Pharmacy Associations — including YOUR KPhA — along with NASPA, are working to-gether to help make sure this award we hold so dear-ly is never at risk of being extinguished. In order to sustain the award, each state association is working to build an endowment sufficient to generate divi-dends that will fund the program in perpetuity. The APhA Foundation, a national nonprofit 501 (c) (3), has agreed to be the home of the endowment ac-count, and to date we are almost half way to our goal of $600,000.
Our goal is to raise $5,000 as a collective gift from members of the Ken-tucky Pharmacists As-sociation. At the 135th KPhA Annual Meeting, 2013 Bowl of Hygeia recipient Leon Claywell pledged to match contributions to the fund from Ken-tucky up to $5,000. As of March 2013, we have collected $900. Won’t you please help by making a contribu-tion? Let’s earn that pledge and make Ken-tucky proud by dobling our participation! There are two ways to give:
Online at: http://www.aphafoundation.org and choose the Bowl of Hygeia endowment button. Kentucky will get credit by your address.
Or, you can send your check to:
APhA Foundation – Bowl of Hygeia 2215 Constitution Ave., NW
Washington, DC 20037-2985 Be sure to mark Kentucky on the memo section of your check. Thank you in advance for joining YOUR KPhA in this effort. September 16, 2013
University Club of Kentucky
Kentucky Pharmacy Law Review at 9 a.m.*
Golf Registration begins at 10 a.m.
Lunch available at 11 a.m.
Shotgun Start at Noon
Dinner, Awards Ceremony & Auction start at 5:30 p.m.
*This activity is eligible for ACPE credit; see final CPE activity announcement for specific details.
Registration available at www.ukalumni.net/pharmgolf2013
Long-time KPhA Member Gloria Doughty was granted
Honorary Membership status by the KPhA House of Dele-
gates at the 135th KPhA Annual Meeting.
July 2013
THE KENTUCKY PHARMACIST 16
July 2013 CE—Pediatric OTC
Pediatric Over-the-Counter Medication Refresher for Pharmacists
There are no financial relationships that could be perceived as real or apparent conflicts of interest.
By: Ashley S. Crumby, PharmD, Assistant Clinical Professor, Purdue University and Clinical
Pharmacist, Pediatric Infectious Disease, Riley Hospital for Children at IU Health
(Indianapolis); Rachel E. Bohard, 2013 PharmD Candidate, Purdue University; and Andrea J.
Bittner, 2013 PharmD Candidate, Purdue University.
Original article published by the Indiana Pharmacists Alliance (IPA). This activity may appear
in other state pharmacy association journals. Reprinted with permission. Copyright
© 2012 Indiana Pharmacists Alliance.
Universal Activity # 0143-9999-13-007-H01-P&T
1.5 Contact Hours (0.15 CEU)
Goal
The goals of this article include increasing pharmacist awareness of barriers to appropriate pediatric OTC medication mis-use, identifying methods to address these barriers, defining appropriate use of over-the-counter pharmacologic and non-pharmacologic treatment options for pediatric cough and/or cold and identifying situations in which physician referral is ap-propriate.
Objectives
At the conclusion of this article, the reader should be able to:
1. Identify challenges associated with over-the-counter (OTC) medication use in children.*
2. Identify situations in which physician referral is appropriate for pediatric patients with cough/cold and fever symptoms.*
3. Design a treatment plan, including specific counseling points for parents, for a pediatric patient with cough/cold symp-toms and/or fever.
*Pharmacy Technician Objectives
KPERF offers all
CE articles to
members online at
www.kphanet.org
Introduction:
Many over-the-counter (OTC) cough and cold product la-
bels may contain complex instructions and misleading
graphics which may guide caregivers toward administration
of inappropriate products to children. Due to low literary or
numeracy skills, some caregivers are at increased risk for
inappropriate administration of pediatric OTC products. A
recent study showed 85 percent of parents in the United
States treat their children with OTC medications prior to
seeking professional care. This makes addressing situa-
tions in which physician referral is necessary an important
role of the pharmacist.1 Misuse of OTC products can be the
direct result of incorrect indication, selection of an inappro-
priate product or incorrect dosing. Although rare, an esti-
mated 85 percent of pediatric fatalities caused by OTC
medications involved inappropriately dosed cough and/or
cold products.2 Factors leading to overdose of these prod-
ucts included administration of more than two medications
containing the same ingredients, inappropriate utilization of
measuring devices, use of adult products in situations
where pediatric products were indicated, selection of a
product which was not indicated and involvement of more
than two caregivers in the treatment or selection of the
OTC product.2 Pharmacists can play an important role in
the selection of appropriate OTC products (non-
pharmacologic and pharmacologic) as well as during the
provision of counseling regarding dosing, adverse effects
and administration techniques. It is essential for pharma-
cists to be aware of current OTC product labeling as well
as recommendations in order to assist caregivers with the
selection and use of OTC medications in children. It also is
beneficial for pharmacy technicians to understand when a
pharmacist consultation is appropriate when dealing with
caregivers of pediatric patients.
The Common Cold: A Brief Overview
The common cold is typically a self-limited viral infection
which can be caused by more than 200 viruses. The most
common virus seen in children is rhinovirus. On average,
most children will experience between six and eight colds
per year, each lasting between 10 and 14 days per epi-
sode.3 Following onset, cold symptoms tend to peak
July 2013
THE KENTUCKY PHARMACIST 17
July 2013 CE—Pediatric OTC
around day three or four and begin to diminish on or after
day seven.3 These symptoms may include stuffy or runny
nose, frequent sneezing, accumulation of mucus in the
back of the throat (often referred to as postnasal drip), sore
throat, cough and water eyes. Other symptoms such as low
-grade fever, decreased appetite and mild head or body
aches can also occur.4,5
Mucus production during a cold is
common and can be clear, white, yellow or even green in
color.4 Historically, caregivers thought the color of the mu-
cus was an indicator of illness severity, but it has been
shown that the colors merely represent the body’s produc-
tion of antibodies and have no significance in determining
whether antibiotic therapy is indicated.4 Because the major-
ity of cold cases are viral in nature, antibiotics are often
unnecessary and should generally be avoided. Communi-
cating this to caregivers is important and can often prevent
unnecessary physician visits. An important rule of thumb to
remember is “green snot doesn’t mean squat.”
Rest, increased fluid intake and the use of non-
pharmacologic as well as pharmacologic therapy can be
used for symptomatic relief during episodes of the common
cold.6 These methods will help to alleviate the cold symp-
toms, but will not shorten the length of illness.6 Although
the common cold is typically a self-limiting and mild viral
infection, it can sometimes lead to more serious complica-
tions including secondary bacterial infections.7 In some in-
stances, physician referral of seriously ill infants and chil-
dren is necessary, and pharmacists can play a vital role in
this referral process due to their increased accessibility and
contact with caregivers.
Non-pharmacologic therapy
Non-pharmacologic therapy can include a variety of ap-
proaches and should generally be considered “first-line”
for symptom relief as well as immune system support dur-
ing the common cold. Some recommendations include the
use of humidifiers to improve the environment as well as
increasing fluid intake to keep the body well hydrated. Be-
low you will find specific instructions regarding a variety of
non-pharmacologic options.
Symptomatic relief6,8
Humidifiers or cool mist vapors
In general, cold air humidifiers are recommended when
compared to warm air humidifiers due to safety concerns
with regard to children. Also, regular cleaning of humidifiers
and other treatment products is recommended due to the
increased risk of bacterial growth and mold which may oc-
cur. If these instruments are not cleaned regularly, they
may emit microorganisms into the environment and cause
serious illness due to pathogen inhalation.8
Bulb syringe with or without saline nasal drops
This approach is considered the treatment of choice for
nasal symptoms in infants. Nasal bulb syringes can be
used to clear the nose every 3 to 4 hours.6
Head elevation
Elevating the head of the bed can promote better drainage
of the sinus and nasal passages. A large wedge-shaped
pillow that raises the upper body by 6 to 8 inches is best if
the patient is experiencing significant drainage.9,10
Increased water ingestion
Water is considered the best expectorant for children.
Proper hydration thins the mucus which can ease the
child’s efforts to expel it and prevent dehydration.
Immune System Support5
The common cold is caused by a viral infection and re-
quires the body’s immune system for proper eradication.
General ways to promote immune system function include:5
Avoiding secondhand smoke or other air pollutants5
Avoiding unnecessary antibiotics5
Antibiotics can breed resistance, thus increasing the
chance of becoming ill with antibiotic-resistant infections.
Breastfeeding5
Breast milk contains antibodies which can be passed from
mother to child. These antibodies can provide protection
against infection even after breastfeeding is stopped.
Increasing fluid intake5
Drinking plenty of fluids during the common cold is im-
portant. Healthcare providers should always recommend
pediatric-specific fluids such as Pedialyte® because these
products contain the proper amount of fluid and electrolytes
and can help prevent electrolyte imbalances.
Eating yogurt
Active cultures present in certain yogurts and probiotics
contain beneficial bacteria which can aid in preventing
colds.5
Yogurts and probiotics containing Lactobacillus acidophilus
with Bifidobacterium animales were shown to reduce both
the incidence and duration of rhinorrhea, cough and fever
symptoms in children 3 to 5 years old.11
Although sufficient efficacy evidence is lacking, the CDC
considers Lactobacillus safe for use in children and infants
but does caution regarding the use of probiotics in patients
on concomitant immunosuppressive therapy.12
Yogurts containing live active cultures include(but are not
limited to):
Yoplait YoPlus, Stonyfield, Dannon Activia.13
Check labeling on individual products for specific infor-
mation.
Receiving adequate amounts of sleep
Adequate sleep promotes immune system function. 14
July 2013
THE KENTUCKY PHARMACIST 18
July 2013 CE—Pediatric OTC
Younger children require more sleep than older children
but in general, “adequate sleep” includes at least 10 to 12
hours.14
Pharmacologic Therapy
Although not always recommended in pediatric patients,
various pharmacologic agents can be used to treat the
symptoms of the common cold. In general, these options
include antihistamines, nasal decongestants, antitussives,
expectorants and analgesics. Other therapeutic options
include complementary or alternative medicine such as
chicken soup, vitamin C, zinc, Echinacea, Airborne Jr®
and honey. Below are recommendations for the use of
these products in pediatric patients.
Antihistamines
Antihistamines competitively bind, but do not activate the
H1 receptor and prevent histamine from binding.15
First
generation antihistamines are considered nonselective and
provide mostly sedative effects. This class of antihista-
mines includes diphenhydramine, clemastine and chlor-
pheniramine.15
Second generation antihistamines are pe-
ripherally selective and therefore provide less sedation due
to an inability to cross the blood brain barrier.15
Second
generation oral OTC antihistamines include loratidine,
fexofenadine and cetirizine.15
First generation antihista-
mines often are utilized during the common cold because
they are associated with anticholinergic properties such as
drying of mucus membranes. This association results in a
reduction of nasal, lacrimal gland and salivary hypersecre-
tion, thus decreasing the amount of mucus and drainage
present.15
When compared to first generation antihista-
mines, the second generation products are not considered
to be as beneficial due to reduced anticholinergic proper-
ties.
A Cochrane systematic review evaluating the use of anti-
histamines either alone or in combination with a decon-
gestant concluded antihistamine use as monotherapy did
not provide any clinically significant effects on general re-
covery in the course of the common cold in either children
or adults.16
First generation antihistamines were associated
with a small decrease in sneezing and rhinorrhea, but also
were associated with a significantly higher incidence of
side effects such as sedation.16
Many caregivers expect antihistamines to decrease nasal
symptoms because they provide this effect in the setting of
allergic rhinitis. The general population does not under-
stand the pathophysiology of allergic rhinitis and the com-
mon cold differ greatly. 16, 17
During allergic rhinitis, large
amounts of histamine are released in response to an aller-
gen while a common cold uses bradykinin as the major
cytokine mediator.16,17
Bradykinin can induce vasodilation
and lead to congestion, but this mechanism is unaffected
by antihistamines. Sedation of a sick child is the most likely
benefit seen with the use of antihistamines although the
use of these products for sedative effects alone is not cur-
rently recommended.18
Although safety and efficacy data regarding antihistamine
Agent Dose Available dosage forms
ADEs Drug Interactions Administration Recommendation
Antihistamines
Diphenhydra-mine3,15,19,45
2-6 yo: 6.25 mg q 4-6 h (max 37.5mg/d) 6-<12 yo: 12.5-25 mg q 4-6 h (max 150 mg/d) ≥12 yo: 25-50 mg q 4-6 h (max 300 mg/d)
Solution/syrup/elixir (typically 12.5mg/5mL)*, orally disinte-grating strip, orally disinte-grating tablet, caplet, capsule, tablet, gelcaps, fastmelt tablets
Mild: Seda-tion, dizziness, dry nasal/pharyngeal mucosa, som-nolence; Se-vere: hyper-sensitivity (anaphylaxis) Idiosyncratic: paradoxical excitement in young chil-dren, nervous-ness, restless-ness
Moderate inhibi-tion of CYP2D6; cumulative effects with con-comitant CNS depressants and anticholinergics
With food to avoid GI upset
Consult physician if patient <2 yo; monotherapy not recommended in pediatrics for common cold;3,16,19 combi-nation therapy with decongest-ant may be bene-ficial in adoles-cent patients; chewable tablet contains phenya-lanine-caution in phenylketonurics; caution in peptic ulcer disease, urinary obstruc-tion
July 2013
THE KENTUCKY PHARMACIST 19
July 2013 CE—Pediatric OTC
use in pediatric patients is sparse and somewhat conflict-
ing, the general consensus is that antihistamine use as
monotherapy provides no real benefit in terms of nasal
symptom relief and should be avoided in pediatric pa-
tients.3, 16, 19
Combination therapy including antihistamines
and decongestants has been shown to be ineffective in
small children, but may provide limited benefit in older chil-
dren and adults by relieving nasal symptoms such as runny
nose and post-nasal drip.3, 16, 17, 19
Nasal decongestants
Topical and systemic decongestants produce vasocon-
striction in the nasal mucosa, therefore reducing inflamma-
tion and swelling while improving ventilation.15
OTC decon-
gestants for oral use can be found in a variety of products
and include pseudoephedrine (immediate and sustained
release) as well as phenylephrine.15
These oral options
have a slower onset of action when compared to topical
decongestants, but often are associated with longer decon-
gestive effects and less local irritation.15
Of the oral options,
pseudoephedrine is the most frequently used oral decon-
gestant, and although considered safe, has been associat-
ed with the potential for increased blood pressure and heart
rate.15
Additionally, use of pseudoephedrine in patients with
a history of hypertension, vasospasm and/or cardiovascular
disease should be avoided due to increased risk for stroke
or heart attack.15
Use of pseudoephedrine also should be
avoided in the treatment of patients taking monoamine oxi-
dase inhibitors such as linezolid due to the risk of severe
hypertensive reactions.15
At this time, insufficient data exist to support the safety and
efficacy of phenylephrine as an oral decongestant in any
age. However, it is suggested that phenylephrine has mini-
mal effect on blood pressure even when taken at higher
than recommended doses, making it seem like a safer al-
ternative to pseudoephedrine.20
Although data is conflict-
ing, phenylephrine is “generally recognized as safe” and
may be an appropriate alternative for patients unable to
tolerate the adverse effects associated with pseudoephed-
rine.20
Topical OTC nasal decongestants are an option in patients
unable to take oral medications and include phenylephrine,
naphazoline, tetrahydrozoline, oxymetazoline and xylomet-
azoline.15
These topical products are extremely effective at
relieving nasal congestion and produce less systemic ad-
verse effects than oral decongestants, but may produce
burning, sneezing, stinging and dryness of the nasal muco-
sa.15
Additionally, prolonged use (>3 to 5 days) can result
in severe rebound congestion.15
Patients should be coun-
seled to discontinue the use of topical decongestants after
three days and to contact his/her doctor.
At this time, studies evaluating the safety and/or efficacy of
nasal decongestants in pediatric patients have not been
completed, making the use of these agents inappropriate in
children due to lack of sufficient data.16, 19
Some studies
have shown potential benefit, including relief from nasal
congestion, from oral or topical nasal decongestants in the
adolescent and adult populations, making recommenda-
tions for these groups more appropriate.16, 19
Antitussives
Cough is one of the most common and troublesome pre-
senting symptoms in children.21
This symptom is not only
troublesome for the child but, it also can be one of the most
intolerable symptoms for caregivers because it often pre-
vents sick children from getting enough sleep at night.21
The Slone Survey identified that in any given week, about 1
in 10 children in the U.S. receives some form of cough and/
or cold products.22
With these results, it is important to ad-
dress the high prevalence of medication use in children,
especially given the lack of efficacy data and potential for
adverse effects.22
Various review articles have helped to
characterize the use of cough and/or cold products in chil-
dren, but evidence to support the effectiveness of the
agents in the pediatric population remains inconclusive.23
One agent utilized in the treatment of cough is dextrome-
thorphan. This cough suppressant is used to depress the
cough center activity in the medulla and inhibits the
reuptake of serotonin in the presynaptic cleft.24
This sup-
pressive action can be harmful because it puts the patient
at potential risk for severe respiratory depression and sero-
tonin syndrome.24
These risks are especially dangerous in
the pediatric population due to a lack of sufficient data, thus
making the use of dextromethorphan for treatment of acute
cough an inappropriate recommendation in children.3, 23
Topical antitussive options also are available for use in chil-
dren to treat the symptoms commonly associated with
cough and cold. These products use medicated vapors to
relieve symptoms such as cough without causing the sys-
temic side effects (i.e., drowsiness or jittery feelings) that
have been associated with other cough and cold relief
products.25
One of the most commonly used topical antitus-
sives is Vicks VapoRub® which includes camphor, eucalyp-
tus oil and menthol. Vicks VapoRub® is approved for use in
children 2 years of age and older and can be applied to the
neck and chest up to 3 times per day.26, 27
This product is
not intended for use in children less than 2 years old due to
the camphor component, and also should not be applied in
the nostrils or under the nose.25-27
Side effects associated
with the use of Vicks VapoRub® include increased mucus
production, obstruction of small airways and rebound con-
July 2013
THE KENTUCKY PHARMACIST 20
July 2013 CE—Pediatric OTC
gestion.26,27
Another formulation, Vicks BabyRub®, does not include
camphor and is regarded as safe for children less than 2
years old when used as directed.28
This product is a combi-
nation of petrolatum, aloe extract, eucalyptus oil, lavender
oil and rosemary oil. Because it is marketed as
“unmedicated,” very little safety and efficacy data is availa-
ble regarding its use in the pediatric population.26,27
Expectorants
Expectorants, specifically guaifenesin, are used to reduce
the viscosity of respiratory tract fluid secretions and in-
crease sputum volume.29
These actions are thought to im-
prove the efficacy of the cough reflex as well as the action
of the ciliary in the trachea and bronchi, making it easier for
patients to expel bronchial drainage.29
However, like other
cough and cold products, limited evidence is available to
support the efficacy of guaifenesin for acute cough and up-
per respiratory tract infections.19
Water is considered the safest and most efficacious expec-
torant for children with an acute cough.30, 31
Little data sup-
ports the use of mucolytics or pharmacological expecto-
rants, but it is clearly understood that ample water intake
will promote thinning and loosening of the mucus and pro-
mote coughing.30, 31
Complementary and Alternative Medicine (CAM)
All use of herbal supplementation in children under the
age of 2, as well as in pregnancy and lactation, should be
done with extreme caution.32
Many CAM therapies are
associated with little clinical data regarding efficacy and
safety, especially in the pediatric population. Non-
pharmacologic therapy is the safest way to manage symp-
toms of the common cold in pediatric patients, and should
Agent Dose Available dosage forms
ADEs Drug Interactions Administration Recommendation
Decongestants
Pseudoephedrine46,47 <4 yo: 1 mg/kg/dose q 6 h (max 15 mg/dose) 4-5 yo: 15 mg q 4-6 h, max 60 mg/24 h 6-12 yo: 30 mg q 4-6 h, max 120 mg/24 h >12 yo (adolescents and adults): IR formula-tion: 60 mg q 4-6 h, max 240 mg/day ER formu-lation: 120 mg q 12 h or 240 mg once daily
Syrup, caplet, ER caplet, tablet, ER tablet
Agitation, irrita-bility, hyperten-sion, tremor, dizziness, nerv-ousness, tachy-cardia, dysrhyth-mia, anorexia, nausea, vom-iting, seizure, insomnia, dys-tonic reactions, headache
Antacids (other than Al(OH)3; ↓ excretion of pseudoephed-rine), sympatho-mimetics (enhance ADEs; tachycardia, tox-icity), SNRIs (enhances tachy-cardia) canna-binoids (enhances tachycardia)
Oral formula-tions: water or milk can ↓ GI distress Do not crush ER tablet or capsule
No studies in chil-dren; adolescents and adults may benefit; FDA approved in ages >4 yo for symptomatic re-lief of nasal con-gestion associat-ed with the com-mon cold, sinusi-tis, upper respira-tory allergies(ER formulations ap-proved in >12 yo); Do NOT use >72 hours due to risk of rebound con-gestion (esp. with topical nasal for-mulation)
July 2013
THE KENTUCKY PHARMACIST 21
July 2013 CE—Pediatric OTC
be used prior to pharmacologic therapy and CAM.
Vitamin C – Vitamin C is the most commonly used CAM
product associated with the common cold. 3 Vitamin C
should not be used for treatment, but limited evidence sug-
gests that prophylactic use may decrease the severity and
duration of symptoms.3 However, excessively high doses of
vitamin C should be avoided as they have been correlated
with adverse effects including headaches, intestinal and
urinary complications, kidney stones and significant interac-
tions with anticoagulants.3
Oral Zinc: 33
Oral zinc formulations have demonstrated a
dose-related reduction in the duration of the common cold
in adults; however, studies in children did not reveal the
same reduction when compared to placebo. This lack of
reduction could be attributed to differences in formulation,
dosing and frequency of administration. Differences in host
inflammatory responses, virus etiology and susceptibility
and even the lack of reliable third-party symptom reporting
also could account for the lack of evidence. If oral zinc ther-
apy is used in the pediatric population, it is important to use
Agent Dose Available dosage forms
ADEs Drug Interactions
Administration Recommendation
Antitussives
Dextromethorphan48 <4 yo: not for OTC
use
4-6 yo: Oral: 2.5-
7.5 mg q 4-8 hrs
ER formu-lation: 15 mg twice daily, max
30 mg/day
6-12 yo:
Oral: 5-10 mg q 4 h OR 15 mg q 6-8 hrs
ER formu-lation: 30 mg twice daily, max
60 mg/day
>12 yo:
Oral: 10-20 mg q 4 h OR 30 mg q 6-8
h ER formu-
lation: 60 mg
twice dai-ly, max
120 mg/day
Tablet, ER cap-sule, liquid cap-sule, lozenge,
solution/syrup/suspension, oral disinte-
grating strip, ER suspension
Confusion, excite-ment, irritability, nervousness, ser-otonin syndrome
Antipsychotics, CYP2D6 inhibi-
tors, da-runavir, MAO
Inhibitors, metoclo-pramide,
peginterfeon alfa-2b, quini-dine, selective
serontonin reuptake inhib-itors, serotonin
modulators, tocilizumab
Do not use with-in 14 days of stopping an
MAO inhibitor
No proven effica-cy in children.
July 2013
THE KENTUCKY PHARMACIST 22
July 2013 CE—Pediatric OTC
a recommended dose and to counsel patients regarding
common side effects such as nausea or bad (metallic)
taste.
Echinacea:5, 32, 34
This product is believed to act as a non-
specific immune stimulant and is used to stimulate white
blood cell function and cell-mediated immunity. It also is
reported to have broad-spectrum antimicrobial activity
against bacteria, fungi and viruses.32
Root preparations
may be effective in lessening the severity of cold symp-
toms, but clinical data is inconclusive. 5,34
The use of
echinacea also can trigger allergic reactions and should be
avoided in patients with allergies to ragweed, daisy, aster
and chrysanthemum.5, 34
Also, many tinctures have high
alcohol concentrations (15-90 percent), which should be
considered when evaluating the use of echinacea in pedi-
atric patients. 32
Use for greater than 10 days in any popu-
lation is not recommended.32
Airborne Jr®35,36
- This product is marketed for children
ages 4 to 10 as an herbal supplement designed to “boost
your immune system to help your body combat germs.”35
The primary ingredients listed are vitamin C (835 percent
of the daily recommended value), vitamin E, zinc and man-
ganese.35
This product has not been evaluated by the FDA
and has not been proven to be clinically effective for the
prevention or treatment of cough or cold.35
Airborne Jr® is
classified as an herbal supplement, holding a similar place
in therapy to vitamins with the same ingredients.36
Honey37
- Data supporting the effectiveness of honey for
the treatment of acute cough in children (minimum age of
12 months) due to upper respiratory infections is limited.37
A review of two trials containing a total of 268 patients, ag-
es 2-18, showed treatment with honey to be potentially su-
perior to treatment with diphenhydramine but these results
were consistent with “low to moderate quality evidence.”37
Chicken Soup – Limited clinically significant data is availa-
ble with relation to the use of chicken soup for the common
cold.3,30
Some individuals believe the hot steam from the
soup may help relieve sinus pressure and inflammatory
symptoms. This action is similar to the moistening of oral
and nasal passage seen with other hot beverages or warm
air humidifiers.3, 30
Individuals also like the use of chicken
soup during the common cold because it is one of the few
non-pharmacologic options that is safe for the pediatric
population and is not associated with adverse effects.
Prevention of the Common Cold: Disinfection and
Hand Washing
In general, viruses often spread via hand-to-hand contact
as well as through large-particle aerosolization.34
Avoiding
close contact with people who have colds or other upper
Agent Dose Available dosage forms
ADEs Drug Interactions
Administration Recommendation
Expectorants
Guaifenesin49 6 mos – 2 yo: 25-50 mg q 4 h, max 300mg/
day
2-5 yo: 5-100 mg
q 4 h, max 600 mg/day
6-11 yo: 100-200 mg q 4 h, max 1.2 g/day
>12 yo: 200-400 mg q 4 h, max 2.4 g/day
Caplet, oral granules, syrup,
tablet, ER tablet
Dizziness, drowsi-ness, headache, rash, decreased uric acid levels,
nausea, stomach pain, vomiting,
kidney stone for-mation
No known significant
drug interac-tions
Take with a full glass of water; Do not crush,
chew, or break tablet
No proven efficacy in children.
July 2013
THE KENTUCKY PHARMACIST 23
July 2013 CE—Pediatric OTC
respiratory tract infections (URTIs) can help prevent viral
exposure.4 Infected persons are most contagious during
the first three days of symptom onset and will likely no
longer be contagious by about day seven of illness.5 Rou-
tine disinfection of commonly touched surfaces such as
door knobs, sink handles and light switches can decrease
the risk of viral spreading.39
This disinfection should be
done using an EPA-approved product such as Lysol® to
ensure appropriate killing of the virus.39
Proper hand hy-
giene in both children and adults also may prove beneficial
in preventing illness and stopping the spread of the virus.4
Intermittent and frequent hand washing is recommended
for all ages and should be done using antibacterial soap or
hand sanitizers containing organic acids such as salicyclic
acid. Recent studies have demonstrated increased efficacy
at prevention of rhinovirus infection when using organic
acid-based when compared to ethanol-based hand sanitiz-
ers. This difference is thought to be the product of extend-
ed residual activity against rhinovirus seen with organic
acid products.39-41
These products can be found over-the-
counter and are generally considered safe for use in chil-
dren.40
Pain and Fever relief
One of the leading causes of parental concern with regard
to symptoms of illness is fever.38
The common belief chil-
Agent Dose Available dosage forms
ADEs Drug Interactions Administration Recommendation
Analgesics and Antipyretics
Aspirin50 10-15mg/
kg/dose Max: 4g/
day
Caplet, tablet, chewable
tablet
GI bleeding; platelet inhibi-
tion; Reyes syn-drome
NSAIDs, anticoag-ulants, antithrom-
botics
Administer with food or full glass of water to mini-mize GI disturb-
ances
NEVER use for fever or viral symptoms
in children; product is only available as a
solid dosage form
Acetaminophen51 10-15mg/
kg/dose every 4-6 hours
Max: 5
doses in 24 hours
Caplet, ER caplet, capsule,
elixir, gelcap, solution/
suspension/syrup, supposi-
tory, tablet, chewable tab-
let, oral disinte-grating tablet
GI hepatotoxicity (in case of over-
dose)
Anticholinergics Shake suspen-sion well before
pouring dose; take with food or milk; report
any unusual bleeding or
bruising
One concentration 160mg/5mL; drops are no longer avail-
able
Ibuprofen52 OTC an-algesic
dose: 4-10mg/
kg/dose every 6-8 hours
Max:
40mg/kg/day
OTC fe-
ver dose: 5-10mg/kg/dose every 6-8 hours
Max:
40mg/kg/day
Caplet, capsule, solution injec-tion, suspen-sion, tablet,
chewable tab-let
Cardiovascular edema; drowsi-
ness; GI bleeding or intolerance; platelet inhibi-
tion; acute renal failure
GI irritants; can decrease efficacy of some antihy-
pertensives
Administer with food
Only approved for patients >6 months; keep children well hydrated; multiple
concentrations (40mg/mL and
100mg/5mL); avoid in patients with renal disease or congenital heart
disease; may blunt sings/symptoms of
serious infection
July 2013
THE KENTUCKY PHARMACIST 24
July 2013 CE—Pediatric OTC
dren must maintain a “normal” temperature leads to the
misuse of antipyretics on a daily basis.38
Many parents are
not aware of the beneficial effects associated with fever
including slowing of bacterial and viral growth which in turn
helps the body recover more quickly from an infection.38
Due to this beneficial effect, the primary treatment goal for
a febrile child should not be normalization of body tempera-
ture but should actually include improvement of the child’s
general well-being including adequate fluid intake and pre-
vention of more serious symptoms.38
Another common misconception in the pediatric population
is with regard to the treatment of pain. In previous decades,
pain management for infants and children was not consid-
ered a significant priority due to the assumption that these
patients did not experience pain due to an “inadequately
developed neuroendocrine system and nerve pathways.”10
However, many clinical studies have since proven the pedi-
atric population may actually be more sensitive and poten-
tially experience more intense pain than adults.10
As a re-
sult, effective practices to appropriately manage pain in
children have become standard in the clinical setting, in-
cluding using pain assessment as the fifth vital sign.10
Like
adults, children can experience pain in a variety of situa-
tions including immunizations, acute illness (i.e. otitis me-
dia), chronic disease, injury and medical procedures, thus
making pain management an important part of treatment in
this population.10,32
Treatment of both fever and pain contain both non-
pharmacologic and pharmacologic options. Safe and effec-
tive OTC medication options for the treatment of pain and/
or fever include ibuprofen and acetaminophen.42,43
Either
choice, when used in appropriate doses, may be consid-
ered first line therapy when the patient requires an analge-
sic or antipyretic.42,43
Non-pharmacologic therapy
Fever10, 42
Environmental Control
Adjust room temperature to avoid extremes in heat or cold.
Remove excess clothing and/or use lightweight clothing.
Sponge baths with lukewarm water
Do not use cold water which can induce shivering thus fur-
ther increasing body temperature.
Do not use rubbing alcohol which can be systematically
absorbed and cause fume inhalation, both of which have
hazardous CNS side effects (i.e. increased heart rate,
headaches, dizziness and nausea).
Pain4, 23
Hot/Cold Packs
Use cold packs if pain is associated with inflammation and
swelling.
Use heating pad if patient is experiencing stiffness or
chronic pain.
Distraction
Consider using an enjoyable activity or item such as TV,
board games, ice cream, etc. as a distraction for children in
pain.
Massage/physical therapy
Make the child more comfortable and relaxed to positively
contribute to general well-being and allow the body to natu-
rally overcome the acute situation.
Pharmacologic therapy
Acetaminophen
The current recommendation for pharmacologic treatment
of fever and pain in children is the use of acetaminophen.
In the past, recommendations included the use of aspirin in
these situations, but due to a confirmed association be-
tween salicylates and Reyes syndrome in children, aspirin
is no longer considered a treatment option for this popula-
tion.42,43
The recommended dose of acetaminophen in chil-
dren is 10 to 15 mg/kg/day every 4 to 6 hours with a maxi-
mum dose of 75 mg/kg/day (or 5 doses) in 24 hours.42,43
OTC acetaminophen formulations for children include a
standard liquid concentration of 160mg/5mL as well as
chewable tablets and Meltaways®.42-44
The generally ac-
ceptable safe and effective duration of OTC use is five days
or less.42,43
Hepatotoxicity is a severe adverse reaction of
acetaminophen use and is seen in situations of suprathera-
peutic dosing (greater than 15 mg/kg/dose) or in prolonged
overdose situations in which appropriate single doses were
given at intervals shorter than four hours.42
Ibuprofen
Ibuprofen is another option for fever and pain in the pediat-
ric population and has been associated with a faster onset
and duration of action than acetaminophen. However, data
do not currently support a significant difference in safety or
effectiveness between the two agents, making them both
appropriate options in children. 42
Dosing recommendations
in children are different for the treatment of fever versus
pain. For children greater than 6 months of age, the dose
for treatment of fever is 7.5 mg/kg/dose given every 6 hours
with a maximum dose of 30 mg/kg/day. This is slightly dif-
July 2013
THE KENTUCKY PHARMACIST 25
July 2013 CE—Pediatric OTC
ferent than the dose for treatment of pain which is 5 to 10
mg/kg/dose given every 6 to 8 hours with a maximum dose
of 4 doses in 24 hours.42,43
Dosage forms for ibuprofen in
children include liquid preparations in concentrations of 40
mg/mL as well as 100 mg/5 mL.42
The variety of concentra-
tions makes selection of the appropriate product even more
important due to the risk of overdose if the wrong product is
used. Ibuprofen also is available as a chewable tablet .45
One critically important point to remember in this population
is the maintenance of adequate hydration while taking ibu-
profen or other non-steroidal anti-inflammatory agents.42
Although only limited case reports exist, renal insufficiency
has been directly correlated with the use of ibuprofen as a
result of prostaglandin inhibition that ultimately disrupts re-
nal blood flow.42
It is recommended to avoid the use of ibu-
profen in children who are dehydrated, have a history of
cardiovascular disease, have preexisting renal disease or
also are using other nephrotoxic agents.42
When to refer10, 19, 43, 46, 47
In general, non-pharmacologic therapy should be consid-
ered first line for treatment of cough and cold in pediatric
patients. If pharmacologic therapy is used to alleviate
symptoms, it is important for the caregiver to use OTC
medications only for the amount of time recommended.47
If
symptoms persist beyond the recommended amount of
time, the caregiver should be instructed to follow-up with
the primary care physician.
Here are some general situations in which physician refer-
ral is recommended:
Cough/cold symptoms6, 10, 31
Persistent cough >4 weeks31
Children <2 years old with cough31
Cough indicative of another disease state such as pertus-
sis, croup, bronchiolitis, asthma, GERD10,31
Symptoms lasting > 10 days6
Pain symptoms10, 43
Swelling or erythema at the site of pain
No relief, no improvement, or worsening of pain despite
adequate treatment
Fever10, 42, 43
Age > 6 months and temperature ≥103oF
Age > 2 months and rectal temperature ≥100.2oF
Age 3 to 6 months and temperature ≥101oF
No fever relief or improvement despite adequate treatment
Development of seizures or unusual drowsiness in addition
to looking more “ill”
Development of additional symptoms such as stiff neck,
inconsolable irritability, vomiting/diarrhea, rash, headache
or severe pain in throat or ear
Fever in an immunocompromised child such as one with
cancer, HIV or history of transplant
Barriers to Appropriate OTC Use in Children
Inappropriate dosing is one of the most important barriers
to proper OTC use in children and plays a significant role in
OTC-associated fatalities in this population.2 Dosing in-
structions on these products are often confusing and result
in both overdosing and underdosing situations. Because
pharmacists are such an accessible healthcare provider, it
is important they feel comfortable providing dosing recom-
mendations with regard to use of these products in chil-
dren.
Another barrier to appropriate OTC use in children is the
selection of combination products containing the same ac-
tive ingredients. Many caregivers unknowingly administer 2
-3 times the daily recommended amount of medications
such as acetaminophen because they are not aware of its
inclusion in multiple products used in cough and cold. For
this reason, single ingredient products should be recom-
mended in order to avoid an unintentional overdose of any
one ingredient.2
Selection of an inappropriate product is also a common
barrier to proper OTC use in pediatric patients.2 In some
instances, caregivers may select products not indicated for
a child’s symptoms or even substitute adult products when
pediatric formulations are indicated.2
Finally, improper utilization of measuring devices also con-
tributes to inappropriate OTC use.2 Although many caregiv-
ers are tempted to use household teaspoons and table-
spoons for medication dosing, these devices are not con-
sidered appropriate because the amount of medication de-
livered can vary greatly. In these situations, pharmacists
should offer to explain how to use the devices appropriately
or provide measuring tools which will provide the recom-
mended dose of medication with less difficulty.2
Putting it all together
Medication adherence is an important part of medication
use in children and can be negatively impacted by a variety
of factors including:10
Poor communication between the provider and the caregiv-
er and/or patient.
Lack of understanding regarding the severity of the illness.
Lack of interest regarding taking medication (especially in
adolescents).
Poor taste of drug formulations.
Uncertainty or anxiety regarding potential medication relat-
July 2013
THE KENTUCKY PHARMACIST 26
ed adverse effects.
Inconvenient dosage forms and dosing schedules (i.e. ad-
ministration three or more times daily).
Failure of the caregiver to remember to administer the
drugs.
Medication safety is another very important part of media-
tion use. Administration errors may result from the following
scenarios:10
Incorrect or inappropriate medication.
Incorrect or inappropriate dose.
Inappropriate medication administration technique.
Inappropriate dosing instrument.2
Administration of more than two medications containing the
same ingredients.2
Two or more caregivers contributing to the treatment and
selection of the OTC product.2
To avoid life-threatening events, pharmacists can remind
caregivers to keep all medications (OTC and prescription)
out of the reach of children. They also should keep all med-
ications in the original bottles or containers with the lids
tightly sealed.6
Recognizing and understanding common flaws in the medi-
cation-use process can help providers, caregivers and pa-
tients create strategies to prevent problems before they
arise.10
Clinical Pearls for Pharmacists
1. Not all OTC products are approved for use in children.
The FDA recommends against the use of cough and
cold products, such as pseudoephedrine, phe-
nylephrine, diphenhydramine, brompheniramine and
chlorpheniramine, in children younger than 2 years of
age. 57
Additionally, manufacturers of these products
voluntarily changed their labels to state: “do not use in
children under 4 years of age.” 57
Paying close attention
to product labeling, ingredients and instructions for use
allows pharmacists to provide appropriate recommen-
dations and guidance for patients.6
2. Although vitamin C is often used in the adult population
for prophylaxis of the common cold, it should not be
used as active treatment in adults or children.3
3. Antibiotic therapy is not appropriate for treatment of the
common cold in adults and children. Therapy directed
toward symptom relief is a more appropriate recom-
mendation.3
4. Antihistamines should not be recommended for the
treatment of nasal symptom relief in children.3,16,19
5. Currently, nasal decongestants are not recommended
in children due to limited safety and efficacy data. This
drug class should be reserved for adolescent and adult
populations.16,19
6. Dextromethorphan is not an appropriate treatment for
cough in pediatric children.3
7. Ibuprofen is an appropriate analgesic and/or antipyretic
for children greater than 6 months old.6, 42, 43
8. Aspirin should NEVER be given to children due to the
rare, but very serious, risk of Reyes syndrome. 6, 42, 43
9. Avoid cough and cold medications with multiple active
ingredients. Use single ingredient products to reduce
the risk of overdose.48
10. Pharmacists are the most accessible healthcare pro-
fessionals: it is critical to select the appropriate prod-
ucts based on the individual pediatric patient, screen
each patient for potential drug-drug interactions or con-
traindications, and thoroughly educate caregivers about
proper dosing and administration.
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Associated With Over the Counter (Nonprescription)
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3. Simasek M, Blandino DA. Treatment of the Common
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4. Centers for Disease Control and Prevention. Get
Smart: Know When Antibiotics Work: Common Cold
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getsmart/antibiotic-use/URI/colds.html. Accessed May
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5. National Institutes of Health. MedlinePlus. Common
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6. Centers for Disease Control and Prevention. Get
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7. Aguilera L. Pediatric OTC Cough and Cold Product
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8. Humidifier Health. What is the Source of the problem?
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10. Nahata MC, Taketomo C. Pediatrics. In: Pharma-
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July 2013
THE KENTUCKY PHARMACIST 27
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11. Lever GJ, Li S, Mubasher ME, et al. Probiotic effects
on cold and influenza-like symptom incidence and du-
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17. What is the Common Cold? New-Medical. Available at
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18. Consumer Healthcare Products Association. Statement
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19. Isbister GK, Prior F, Kilham HA. Restricting cough and
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20. Harron RC, Winderstein AG, AmKelvey RP, et al. Effi-
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21. Paul, Ian M. Therapeutic Options for Acute Cough Due
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22. Vernacchio L, Kelly JP, Kaufman DW, et al. Cough and
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23. Smith SM, Schroeder K, Fahey T. Over-the-counter
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24. Dextromethorphan. Respiratory Agents. Facts & Com-
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25. VICKS®. VapoRub
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26. OTC cough and cold medication: keeping children safe.
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27. Vicks Vapo-Rub – How dangerous for children? Child
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28. VICKS®. BabyRub
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29. Guaifenesin. Respiratory Agents. Facts & Compari-
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30. Aguilera L. Pediatric OTC Cough and Cold Product
Safety. US Pharm. 2009; 34(7):39-41.
31. Cold medicines for kids: What’s the risk? Children’s
Health. MayoClinic. Available at: http://
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32. Echinacea (Echinacea purpurea, Echinacea angustifo-
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online.lexi.com/crlonline. Accessed May 15, 2012.
33. Science M, Johnstone J, Roth DE, et al. Zinc for the
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35. Airborne. Product Information. Airborne, Inc. Minneap-
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36. Airborne Jr. Effervescent Health Formula Grape. Die-
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38. Gwaltney JM Jr, Moskalski PB, Hendley JO. Hand-to-
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40. Turner RB, Biedermann KA, Morgan JM, et al. Efficacy
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July 2013 CE—Pediatric OTC
of Organic Acids in Hand Cleansers for Prevention of
Rhinovirus Infections. Antimicrob Agents Chemother.
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41. Turner RB, Fuls JL, Rodgers ND. Effectiveness of hand
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42. Sullivan JE, Farrar HC. Clinical report – fever and anti-
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44. Smith SM, Schroeder K, Fahey T. Over-the-counter
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45. Motrin®. McNeil Consumer Healthcare Division. Availa-
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46. Chang AB, Glomb WB. Guidelines for Evaluating
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47. Chang AB, Landau LI, Van Asperen PP, et al. Cough in
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48. U.S. Food and Drug Administration. FDA Statement
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49. Diphenhydramine. Lexi-Drugs Online. Lexi-Comp
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50. Pseudoephedrine. Lexi-Drugs Online. Lexi-Comp
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SpecialFeatures/ucm263948.htm.
July 2013 — Pediatric Over-the-Counter Medication Refresher for Pharmacists
1. Which non-pharmacologic treatment is NOT RECOM-MENDED in a pediatric patient with a cough or cold? A. Increasing fluid intake with water B. Receiving at least 10 hours of sleep C. Using a warm air humidifier D. Use of nasal bulb syringes in infants with congestion 2. NK is a 12-year-old boy who presents to clinic with a runny nose, cough and nasal congestion. NK states that he has felt “really bad all over” for the past 2 days and hasn’t been able to sleep well because he can’t breathe through his nose. He has not had a fever. NK is not tak-ing any other medications, has NKDA and no significant PMH. Mom has not tried any form of therapy for his cold symptoms, but states she would like to get something to help him breathe at night so he can sleep. What would be the appropriate recommendation for NK?
A. Pseudoephedrine 30 mg q 4 to 6 hours; max 240 mg; appropriate counseling on all potential adverse effects
B. Diphenhydramine 12.5 mg q 4 hours; max 75 mg/day; appropriate counseling on all potential adverse effects
C. Phenylephrine 5 to 10 mg q 12 hours instead of pseudoephedrine; appropriate counseling on all potential adverse effects
D. Nonpharmacologic therapy including a cold air humidifier, head elevation, and increased fluid intake
3. Which is NOT a challenge associated with over-the-counter medication use in children? A. Administration by a single caregiver B. Inappropriate dosing C. Use of medications containing ≥2 active ingredients D. Use of an inappropriate measuring device
July 2013
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July 2013 CE—Pediatric OTC
4. A mom comes to your pharmacy with her 8 month old daughter, ML. She states ML has had a deep, non-productive cough for the last 5 days which is very bothersome and is even preventing her from getting enough sleep at night. Mom thinks it may be from something she picked up from her new daycare, espe-cially because she knows other kids have been sick recently. Mom wasn’t sure how she should treat the cough but states she was told to pick up some Chil-dren’s Tylenol Plus Cough and Sore Throat® (acetaminophen and dextromethorphan) by the mom of another kid. She has the product in her hand but wants to know what you would recommend for her daughter before she buys it. What would be your rec-ommendation? A. Nonpharmacologic therapy with increased fluid intake
using Pedialyte ®, adequate sleep, and use of cold air humidifier
B. Children’s Tylenol Plus Cough and Sore Throat®(acetaminophen 160 mg/5mL and dextromethorphan 5mg/mL); 5 mL q 4-6 h
C. Children’s Delsym® (dextromethorphan 30mg/5mL); 0.2 mL q 6 to 8 hours
D. Refer to physician 5. Which of the following statements is NOT true? A. Green mucous typically indicates a bacterial infection,
and most often requires physician referral B. Avoiding exposure to persons with cold symptoms and
proper hand hygiene may help prevent the common cold
C. Nonpharmacologic therapy should always be consid-ered as first line therapy in pediatric patients with mild cough/cold symptoms
D. Products including vitamin C or yogurt with active cul-tures can reduce the severity and duration of the com-mon cold in children
6. What is the MOST appropriate treatment for cough in a 10 year old boy with a sore throat and persistent, productive cough? A. Dextromethorphan 30mg every 4 hours as needed for
cough B. Increased water intake and elevation of the head of
the bed C. Guaifenesin 400mg every 4 hours as needed for
cough D. Ibuprofen 10mg/kg/dose every 4 hours as needed for
cough
7. JS is a 7 year old little girl who is complaining of a headache, cough, and lots of “drainage in her throat.” She says she has had the cough for about 24 hours without relief. JS confirms she does not have a history of allergies or sinus congestion. What is the best rec-ommendation for JS with regard to an expectorant? A. Acetaminophen 15mg/kg/dose every 4 to 6 hours as
needed for cough B. Drinking 8 to 10 glasses of water throughout the day C. Guaifenesin 50mg every 4 hours D. Dextromethorphan 10mg every 8 hours 8. NM is a 5 month old WM who just received three im-munizations. He is restless and will not stop crying. His mother suspects NM is experiencing lingering pain at the injection site. What is the best analgesic for NM at this time? A. Neonates do not experience pain. No treatment rec-
ommended. B. Ibuprofen 10mg/kg/dose x 1 dose C. Acetaminophen 15mg/kg/dose x 1 dose D. Aspirin 10mg/kg/dose x 1 dose 9. MR is a 4 month old female brought to your commu-nity pharmacy by her mother. MR is febrile with a tem-perature of 101.2ºF. Her mother is very concerned and asks you for the “quickest thing” to bring her daugh-ter’s fever down. What is your recommendation? A. MR should call her pediatrician or go to the emergency
room right away. B. Acetaminophen 30mg/kg as an initial loading dose,
followed by 10mg/kg/dose every 4 to 6 hours thereaf-ter until afebrile
C. Ibuprofen 10mg/kg/dose every 6 hours until afebrile D. No pharmacological therapy required. MR should be
taken home and given an ice bath. 10. Which is a common factor that positively affects pediatric medication adherence? A. A poorly tasting liquid formulation that does NOT in-
clude a sweetener or flavoring to mask the bitter taste B. A dosing schedule that requires administration every 6
hours C. A caregiver who doesn’t believe their child’s symptoms
or illness requires treatment D. Open and clear communication between the provider
and the caregiver
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THE KENTUCKY PHARMACIST 30
July 2013 CE—Pediatric OTC
PHARMACISTS ANSWER SHEET July 2013 — Pediatric Over-the-Counter Medication Refresher for Pharmacists Universal Activity # 0143-9999-13-007-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 7. A B C D 9. A B C D 2. A B C D 4. A B C D 6. A B C D 8. A B C D 10. A B C D Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________
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July 2013
THE KENTUCKY PHARMACIST 31
August 2013 CE — COPD and CVD: Role of Beta-Blockers
COPD and CVD: Exploring the Role of Beta-Blockers and COPD Treatments in Comorbid Disease By: Allison Meyer, PharmD and Debbie Minor, PharmD, The University of Mississippi Medi-cal Center, Departments of Pharmacy and Medicine, Jackson, MS Reprinted with permission of the authors and the Mississippi Pharmacists Association where this article originally appeared. This activity may appear in other state pharmacy association journals. There are no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-9999-13-008-H01-P&T 1.0 Contact Hour (0.1 CEUs)
Goal: To review the role of beta-blocker (BB) therapy in the management of cardiovascular conditions and discuss the effects of these medications as well as treatments for chronic obstructive pulmonary disease (COPD) on associated mor-bidity and mortality.
Objectives: At the conclusion of this lesson, the reader should be able to:
1. Describe the role of BBs in the management of cardiovascular disease (CVD).
2. Discuss potential benefits as well as adverse effects associated with the use of BBs in patients with COPD.
3. Identify the association of inhaled COPD medication use and possible cardiovascular consequences.
KPERF offers all
CE articles to
members online at
www.kphanet.org
INTRODUCTION
COPD is a highly prevalent disease affecting approximately
15 million Americans.1 In 2007 it was the third leading
cause of death in the United States.2 Numerous observa-
tional studies propose that patients with COPD are more
likely to have coexisting cardiovascular conditions, includ-
ing hypertension (HTN), heart failure (HF) and coronary
artery disease (CAD), as well as diabetes and atherosclero-
sis, compared to patients without this lung disease.3-8
A
history of COPD also is associated with poor CVD out-
comes, including increased mortality and rehospitalization
in HF and post-myocardial infarction (MI) patients, when
compared to those without COPD.9-15
Whether these asso-
ciations are due to the disease process, smoking history or
other factors is unclear.3,5-6
BBs are indicated for many of the cardiovascular conditions
that often accompany COPD, including HF, CAD, atrial fi-
brillation (AF) and HTN. Screening and proper manage-
ment of CVD is vital to improving patient outcomes. While
evidence suggests that BBs are generally well-tolerated in
patients with COPD, many do not receive these lifesaving
medications due to historical concerns for bronchocon-
striction and worsening lung function.16-17
The role of BBs in
CVD management as well as recommendations for use in
patients with COPD are highlighted in Table 1. The purpose
of this review is to explore this role and discuss the effects
of these medications and COPD treatments on COPD and
cardiovascular morbidity and mortality.
BETA-BLOCKERS IN CARDIOVASCULAR DISEASE
Heart Failure
In several large clinical trials, metoprolol succinate, carve-
dilol and bisoprolol have demonstrated a reduction in mor-
bidity and mortality in patients with systolic HF when added
to baseline angiotensin converting enzyme inhibitor (ACEI)
therapy.18-22
These agents decrease sympathetic nervous
system effects on the heart, resulting in improved left ven-
tricular (LV) ejection fraction and diastolic function, which
are major determinants of the progressive clinical course of
HF.23
Current guidelines recommend that the majority of
patients with reduced LV systolic function be treated with
one of these BBs even in the presence of concomitant
COPD, diabetes or peripheral vascular disease.24-26
The
presence of COPD is the most significant reason for pa-
tients failing to receive adequate treatment.27
Coronary Artery Disease
BB therapy is considered standard of care post-MI.28-29
Most trials supporting this recommendation were published
July 2013
THE KENTUCKY PHARMACIST 32
August 2013 CE — COPD and CVD: Role of Beta-Blockers
in the 1980s,
prior to the rou-
tine use of
ACEIs, thrombo-
lytics and percu-
taneous inter-
vention.30-31
More recent
studies have
demonstrated a
potential reduc-
tion in mortality,
reinfarction or
ventricular fibril-
lation post-MI
with use of car-
vedilol or
metoprolol suc-
cinate, though the primary endpoints were not significantly
reduced by allocation to a BB.20,32
Similarly, in a recent ob-
servational study, BB therapy did not reduce the primary
cardiovascular endpoint in patients with a remote MI histo-
ry, CAD without MI history or CAD risk factors only.33
Based
on previous affirmative evidence, a class I recommendation
remains for acute and long-term BB use in post-MI patients
with reduced LV function.28-29
In those with normal LV func-
tion, guidelines recommend using BBs for up to three years
after a cardiac event (class IB).29
BBs also are first-line
agents for symptomatic relief of stable angina, with an op-
tion of a calcium channel blocker (CCB) or long-acting ni-
trate in those intolerant to BBs.34
Treatment with selective
BBs is considered safe for patients with CAD and coexist-
ing COPD.27
Atrial Fibrillation
The most frequent cardiac arrhythmia is AF. Beta-blockers
are useful for rate control in patients with AF and were
shown to be more effective than CCB, both as monothera-
py and in combination with digoxin.35-36
They are recom-
mended as first-line initial therapy and may be used in com-
bination with a CCB and/or digoxin for patients with uncon-
trolled heart rate and persistent AF.35
While BBs will not
convert a patient from AF to normal sinus rhythm, they can
effectively maintain normal sinus rhythm. They also are
effective in maintaining sinus rhythm in post-cardiac sur-
gery patients.35
Patients with COPD have an increased inci-
dence of AF, and treatment can be challenging because of
the breathlessness and disability resulting from coexistence
of these disease states.27
Hypertension
Historically, BBs have been widely used as antihyperten-
sive agents, and
metoprolol and
atenolol remain in
the top 20 of the
200 most common-
ly prescribed medi-
cations.37
A meta-
analysis of 13 trials
comparing BBs to
other antihyperten-
sives or placebo
revealed a higher
risk of stroke and
no difference in MI
in patients taking
BB.38
With the
emergence of new-
er classes with
more favorable outcomes (i.e., diuretic, ACEI, angiotensin
receptor blocker [ARB], CCB), these medications are no
longer generally promoted as first-line therapy for treatment
of hypertension.39-40
The most prevalent cardiovascular
comorbidity in COPD is likely hypertension, which has im-
plications for COPD prognosis.27
BETA-BLOCKERS IN CHRONIC OBSTRUCTIVE PUL-
MONARY DISEASE
While no randomized controlled trials have been performed
to definitively prove the benefits of BBs in patients with
COPD, retrospective and observational data point to im-
proved survival and decreased hospitalizations with use of
these medications.38,41-43
In observational analyses, cardi-
oselective BBs appear to decrease mortality in COPD pa-
tients with CVD, including HTN, HF and atherosclerosis, as
well as those undergoing coronary artery bypass graft sur-
gery.9,44-46
However, these patients, especially those with
severe COPD, are less likely to receive a BB or may be
prescribed lower doses of BBs than those without
COPD.9,12-15,17
The benefits from BB use in patients with COPD may be
independent of their value in CVD. Contrary to previous
beliefs, the use of BBs does not appear to increase the rate
of COPD exacerbations.44-47
BBs may actually reduce the
incidence and severity of COPD exacerbations.47
Several
observational studies have demonstrated a mortality reduc-
tion with BB use during COPD exacerbations.41-43
Addition-
ally, patients with existing CVD and newly diagnosed
COPD have a higher mortality rate with BB discontinua-
tion.43
Most studies reviewing the use of BBs in COPD have been
conducted in patients with HF using carvedilol or bisoprolol.
Table 1: Recommendations for Use of BB in CVD and COPD
Condition Effects of BB Recommendations in COPD*
Heart Failure
Decrease sympathetic nervous system effects on
heart Reduce morbidity and mortality in systolic HF
Use in patients with systolic HF as tolerated
Coronary Artery Disease
Reduce morbidity and mortality acutely post-MI
Symptomatic relief of stable angina
Use in hemodynamically stable patients post-MI, as tolerated
May use BB, CCB, or nitrates for symptomatic angina
Atrial Fibrillation Rate control
Maintain sinus rhythm May use BB, CCB, or digoxin
Hypertension Potential increase in stroke,
no effect on MI risk No longer first-line agent
Use first-line agents (i.e. diuretics, CCB, ACEI, ARB)
before BB
*Cardioselective preferred in all conditions
July 2013
THE KENTUCKY PHARMACIST 33
August 2013 CE — COPD and CVD: Role of Beta-Blockers
These medications,
particularly carve-
dilol, may acutely
decrease forced
expiratory volume
in one second
(FEV1) and cause
mild, transient
dyspnea and
wheezing; howev-
er, this typically
does not result in
the need for BB
discontinuation or
in a decrease in health-related quality of life.48-54
If respira-
tory side effects occur, a trial of another BB is warranted. In
a crossover study of patients with HF and COPD, switching
from a cardioselective BB, i.e. bisoprolol or metoprolol, to
carvedilol did not cause excess intolerance.55
The Global Initiative for Chronic Obstructive Lung Disease
(GOLD) guidelines specifically address CVD management
in patients with COPD (Table 1). These guidelines recom-
mend that patients with HF, ischemic heart disease, AF
and HTN be treated as usual per respective guidelines as
evidence does not suggest treating them differently.27
The
use of BBs in patients with ischemic heart disease or HF,
including those with severe COPD, is warranted as the
morbidity and mortality benefits outweigh the potential risk.
The GOLD guidelines also support the use of BBs in AF;
however, with the availability of other options, a trial of an-
other class of medication might be reasonable. Lastly, BBs
can be used in patients with HTN, as an adjunct to first-line
agents. In all cases, the use of cardioselective BBs is rec-
ommended over other BBs.27
COPD TREATMENTS AND CARDIOVASCULAR
DISEASE
The most commonly prescribed medications for COPD in-
clude the inhaled beta-agonists (IBA), anticholinergics
(IAC) and corticosteroids (ICS). While these medications
are generally well-tolerated, there is some concern for ex-
acerbation of CVD, especially with the use of IBAs (Table
2). Most supporting data for the risk of CVD stem from ob-
servational studies in which cardiovascular morbidity and
mortality are secondary outcomes.
In reference to CVD hospitalizations, several case-control
studies have suggested a potential increase with use of
ipratropium or IBA, while neither tiotropium nor ICS had an
effect. Additionally, ipratropium may increase and ICS may
decrease CV mortality. IBA use had no effect on mortality
in these studies;56-59
however, a recent case-control study
reported an in-
creased risk of cardi-
ovascular mortality
with initial use of
IBAs.60
Initial use of
IAC also was associ-
ated with increased
mortality.60
Risk of
overall death and
cardiovascular
events appears to be
lowest with the com-
bination of long-
acting beta-agonists
(LABA) and ICS.61-62
Though tolerance usually develops, a common side effect
of inhaled short-acting beta-agonists (SABA) is mild, dose-
dependent tachycardia.63
Arrhythmias, though rare, can
occur with initial use of SABA and LABA,63-65
potentially
due to a decrease in serum potassium seen with these
agents.66
Most of these reports do not reflect clinically sig-
nificant arrhythmias, and the risk decreases over time.58,63-
66 Additionally, it has been proposed that impaired lung
function is an independent predictor of arrhythmias.67
There is a potential association between IBA use and HF
hospitalization and mortality, especially with chronic thera-
py. This risk is highest in patients with excessive use of
SABAs, i.e. > 3 canisters per month.66,68-70
There is no cor-
relation, however, between IBA use and HF development.70
Conversely, these agents may improve HF exacerbations,
potentially due to decreased cardiac workload resulting
from the decreased work of breathing.66
Some patients ac-
tually have hemodynamic improvement with acute use of
an IBA. Other potential benefits of these medications in HF
patients include increased cardiac output, decreased pe-
ripheral vascular resistance and improved pulmonary capil-
lary wedge pressure.66
An increased risk of acute coronary syndrome (ACS) with
the use of IBAs also has been reported .71-72
Similar to the
risk of arrhythmias and with HF, this effect appears to be
dose-dependent, with the greatest risk in patients using > 6
canisters of a SABA per month.72
Many studies, however,
have found that IBA use does not worsen myocardial ische-
mia or increase the risk of ACS.66,73
While there may be an association between IBA use and
cardiovascular events, most cases are mild and transient
and are typically related to excessive use of these medica-
tions. Counseling patients on appropriate use of SABA and
ensuring use of controller medications, as appropriate, is
important for prevention of these negative cardiovascular
Table 2: Inhaled Beta-Agonists and Potential CVD Complications
Tachycardia/Arrhythmias Heart Failure Acute Coronary
Syndromes
Initial use
Mild, transient
Usually not clinically significant
Chronic use may increase HF hospitalizations and mortality
No correlation to HF development
May improve HF exacerbations – relieve dyspnea
May increase risk of ACS
Dose-dependent, highest risk with excessive use of SABA
July 2013
THE KENTUCKY PHARMACIST 34
outcomes. Close follow-up is necessary, particularly with
severe disease.
The GOLD guidelines generally do not recommend altering
COPD treatment strategies with coexisting HF, ischemic
heart disease, AF or HTN as there is no direct evidence
that patients should be treated differently.27
For patients
with ischemic heart disease or AF, the guidelines state that
it is reasonable to avoid high doses of IBAs. Appropriate
heart rate control may be difficult in patients with AF using
high doses of IBAs. Patients with severe HF who are using
IBAs should receive close monitoring by their healthcare
providers due to the potential for an increased mortality and
hospitalization risk.27
CONCLUSION
BBs have established morbidity and mortality benefits in
many cardiovascular conditions that often coexist with
COPD. Additional research is needed to further define the
benefits and guide the treatment of patients with COPD
and CVD, and many of these patients may not receive BB
therapy due to concerns for bronchoconstriction. Evidence
suggests, however, that these agents are typically well-
tolerated in COPD patients and may reduce CVD and
COPD mortality as well as COPD exacerbations. Current
guidelines for COPD are consistent with those for CVD
management and support the role of BBs for treatment of
particular cardiovascular conditions, with preference for the
use of cardioselective agents. Additionally, proper educa-
tion and appropriate use of COPD medications, particularly
IBAs, will aid in the prevention of cardiovascular events.
Pharmacists encounter these patients on a daily basis. We
are in a unique position to influence patient care and deci-
sions, particularly in the areas of medication use and selec-
tion. By understanding current issues related to therapy, we
can effectively impact disease management and outcomes
for many patients with COPD.
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August 2013 CE — COPD and CVD: Role of Beta-Blockers
July 2013
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sels 2003;18:188-192.
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53. Salpeter SR, Ormiston TM, Salpeter EE. Cardioselective β-
blockers in patients with reactive airway disease: a meta-
analysis. Ann Intern Med 2002;137:715-725.
54. Salpeter SR, Ormiston TM, Salpeter EE, et al. Cardioselec-
tive beta-blockers for chronic obstructive pulmonary disease:
a meta-analysis. Respiratory Medicine 2003;97:1094-1101.
55. Jabbour A, Macdonald PS, Keogh AM, et al. Differences be-
tween beta-blockers in patients with chronic heart failure and
chronic obstructive pulmonary disease: a randomized crosso-
ver trial. JACC 2010;55:1780-1787.
56. Lee TA, Pickard AS, Au DH, et al. Risk for death associated
with medications for recently diagnosed chronic obstructive
pulmonary disease. Ann Intern Med 2008;149:380-390.
57. Singh S, Loke YK, Furberg CD. Inhaled anticholinergics and
risk of major adverse cardiovascular events in patients with
chronic obstructive pulmonary disease: a systematic review
and meta-analysis. JAMA 2008;300:1439-1450.
58. Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular ef-
fects of beta-agonists in patients with asthma and COPD: a
meta-analysis. Chest 2004;125:2309-2321.
59. Loke YK, Kwok CS, Singh S. Risk of myocardial infarction
and cardiovascular death associated with inhaled corticoster-
oids in COPD. Eur Respir J 2010;35:1003-1021.
60. Gershon, A, Croxford R, Calzavara A, et al. Cardiovascular
safety of inhaled long-acting bronchodilators in individuals
with chronic obstructive pulmonary disease. JAMA Intern
Med 2013;epub ahead of print.
61. Dong YH, Lin HH, Shau WY, et al. Comparative safety of
inhaled medications in patients with chronic obstructive pul-
monary disease: systematic review and mixed treatment
comparison meta-analysis of randomized controlled trials.
Thorax 2013;68:48-56.
62. Calverley PMA, Anderson JA, Celli B, et al. Cardiovascular
events in patients with COPD: TORCH Study results. Thorax
2010;65:719-725.
63. Sears MR. Adverse effects of β-agonists. J Allergy Clin Im-
munol 2002;110:S322-S328.
64. Wilchesky M, Ernest P, Brophy JM, et al. Bronchodilator use
and the risk of arrhythmia in COPD: part 1: Saskatchewan
cohort study. Chest 2012;142:298-304.
65. Wilchesky M, Ernest P, Brophy JM, et al. Bronchodilator use
and the risk of arrhythmia in COPD: part 2: reassessment in
the larger Quebec cohort. Chest 2012;142:305-311.
66. Maak CA, Tabas JA, McClintock DE. Should acute treatment
with inhaled beta agonists be withheld from patients with
dyspnea who may have heart failure? J Emerg Med
2011;40:135-145.
67. Buch P, Friberg J, Scharling H, et al. Reduced lung function
and risk of atrial fibrillation in the Copenhagen city heart
study. Eur Respir J 2002;21:1012-1016.
68. Mentz RJ, Fiuzat M, Kraft M, et al. Bronchodilators in heart
failure patients with COPD: Is it time for a clinical trial? J Car-
diac Fail 2012;18:413-422.
69. Au DH, Udris EM, Fan VS, et al. Risk of mortality and heart
failure exacerbations associated with inhaled beta-adrenergic
agonists among patients with known left ventricular systolic
dysfunction. Chest 2003;123:1964-1969.
70. Au DH, Udris EM, Curtis JR, et al. Association between
chronic heart failure and inhaled β-2-adrenoceptor agonists.
Am Heart J 2004;148:915-920.
71. Au DH, Lemaitre RN, Curtis JR, et al. The risk of myocardial
infarction associated with inhaled β-adrenoceptor agonists.
Am J Resp Crit Care Med 2000;161:827-830.
72. Au DH, Curtis JR, Every NR, et al. Association between in-
haled β-agonists and the risk of unstable angina and myocar-
dial infarction. Chest 2002;121:846-851.
73. Suissa S, Assimes T, Ernst P. Inhaled short acting β agonist
use in COPD and the risk of acute myocardial infarction.
Thorax 2003;58:43-46.
August 2013 CE — COPD and CVD: Role of Beta-Blockers
July 2013
THE KENTUCKY PHARMACIST 37
Nominate your peers for a new feature in
The Kentucky Pharmacist
We are looking for members to profile in coming editions of
The Kentucky Pharmacist who are making the world a better place. Do you know
someone who goes above and beyond the “above and beyond the call of duty”? Let
us know!
Email Scott Sisco at [email protected] with a brief description of the story or
to schedule a time to discuss.
August 2013 — COPD and CVD: Exploring the Role of Beta-Blockers and COPD Treatments in Comorbid Disease
1. Patients with COPD are more likely to have: A. coronary artery disease B. hypertension C. heart failure D. diabetes E. All of the above 2. Which of the following statements is FALSE regarding beta-blocker use in heart failure? A. BBs increase sympathetic nervous system effects on the
heart. B. Metoprolol succinate, carvedilol, and bisoprolol are rec-
ommended for use in systolic HF C. BBs reduce mortality and morbidity in systolic heart fail-
ure D. Cardioselective BBs are recommended by GOLD guide-
lines for use in HF with coexisting COPD 3. In patients with COPD and coexisting AF, BBs: A. are contraindicated B. decrease mortality and should be used in all patients C. can be used for rate control 4. According to the data presented, BBs may improve survival in COPD patients with all of the following coex-isting disease states EXCEPT? A. Hypertension B. Heart Failure C. Atrial fibrillation D. Atherosclerosis 5. BBs may: A. reduce the incidence and severity of COPD exacerba-
tions B. be inappropriately prescribed in lower doses in patients
with CVD and coexisting COPD C. increase the rate of COPD exacerbations D. Both a. and b
6. Studies of BB use in COPD patients with HF indicate that an initial increase in respiratory side effects may oc-cur most often with which of the following medications? A. Carvedilol B. Bisoprolol 7. Management of CVD with coexisting COPD, as dis-cussed in the GOLD guidelines, should include: A. altering therapy with all cardiovascular conditions, includ-
ing avoidance of BBs B. no differentiation between use of cardioselective and non-
selective BBs C. use of cardioselective BBs in HF patients, including those
with severe COPD 8. Changes in heart rhythms, including tachycardia and arrhythmias, with use of inhaled beta-agonists: A. are typically mild and transient B. can occur with initial use of both short- and long-acting
beta-agonists C. may be due to a decrease in serum potassium seen with
these agents D. All of the above 9. With regards to HF, use of inhaled beta-agonists: A. may improve HF exacerbations by decreasing cardiac
workload from decreased work of breathing B. may result in development of HF C. in excessive amounts (i.e. > 3 canisters of SABA per
month) may increase hospitalization and mortality D. Both a. and c E. Both b. and c 10. In treatment recommendations for patients with COPD and CVD, the GOLD guidelines suggest the follow-ing EXCEPT: A. generally no alteration of COPD treatment strategies B. avoiding high doses of IBAs in patients with ischemic
heart disease C. avoiding high doses of IBAs in patients with hypertension
August 2013 CE — COPD and CVD: Role of Beta-Blockers
July 2013
THE KENTUCKY PHARMACIST 38
PHARMACISTS ANSWER SHEET August 2013 — COPD and CVD: Exploring the Role of Beta-Blockers and COPD Treatments in Comorbid Disease Universal Activity # 0143-9999-13-008-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D E 3. A B C 5. A B C D 7. A B C 9. A B C D E 2. A B C D 4. A B C D 6. A B 8. A B C D 10. A B C Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________
NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD)
This activity is a FREE service to members of the Kentucky Pharmacists Association. The
fee for non-members is $30. Mail completed forms to: KPERF, 1228 US 127 South,
Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile.
The Kentucky Pharmacy Education & Research Foundation is
accredited by The Accreditation Council for Pharmacy
Education as a provider of continuing Pharmacy education.
Expiration Date: July 16, 2016 Successful Completion: Score of 80% will result in 1.0 contact hour or 0.10 CEU.
Participants who score less than 80% will be notified and permitted one re-examination.
TECHNICIANS ANSWER SHEET. August 2013 — COPD and CVD: Exploring the Role of Beta-Blockers and COPD Treatments in Comorbid Disease Universal Activity # 0143-9999-13-008-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D E 3. A B C 5. A B C D 7. A B C 9. A B C D E 2. A B C D 4. A B C D 6. A B 8. A B C D 10. A B C Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________
NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD)
Quizzes submitted without NABP eProfile
ID # and Birthdate will not be accepted.
August 2013 CE — COPD and CVD: Role of Beta-Blockers
July 2013
THE KENTUCKY PHARMACIST 39
The Kentucky Renaissance Pharmacy Museum offers several ways way to show
support of the Museum, our state's leading preservation organization
for pharmacy.
While contributions of any size are greatly appreciated, the following levels
of annual giving have been established for your consideration.
Friend of the Museum $100 Proctor Society $250
Damien Society $500 Galen Society $1,000
Name______________________________________ Specify gift amount________________________
Address ____________________________________ City____________________Zip______________
Phone H____________________W________________ Email___________________________________
Employer name_____________________________________________________for possible matching gift.
Tributes in honor or memory of_____________________________________________________
Mail to: Kentucky Renaissance Pharmacy Museum, P.O.Box 910502, Lexington, KY 40591-0502 The Kentucky Renaissance Pharmacy Museum is a non-profit 501(c)(3) business entity and as such donations are tax deductible. A
notice of your tax deductible contributions will be mailed to you annually.
Questions: Contact Lynn Harrelson @ 502-425-8642 or [email protected]
Senior Care Corner from the KPhA Academy of Consultant Pharmacists
The Spring CE event took place on Saturday, April 20,
2013 at Sullivan University College of Pharmacy. We had
an excellent program offering 4 hours of CEU. Presenta-
tions included Long-Term Care Pharmacy Legislation and
Regulations in 2013 by Leah Tolliver, Medications as Risk
Factors for Dementia and Delirium by Noll Campbell, Geri-
atric Pharmacotherapy Principles: Not so obvious elements
leading to improved outcomes by Dee Antimisiaris, and
Speaker Panel: The Affordable Care Act & Accountable
Care Organizations: The changing face of pharmacy prac-
tice including BC Childress, Sean Jeffery, and Bonnie La-
zor. The president of ASCP, Sean Jeffery, was in attend-
ance to discuss national issues. Kim Croley represented
KPhA and the Academy in a promotional booth. Other pro-
motional booths included ASCP/KYASCP, SUCOP Drug
Information Center, KY Pharmacy Museum, and KHELPS.
The event was very successful. We are still waiting for the
final financial information to see what our profit will be.
The Academy met at the annual KPhA Annual Meeting at
the Louisville Downtown Marriott to discuss the LTC regula-
tions and put together a consensus statement. The primary
topic of discussion was the proposed regulations changing
and expanding the role of Automated Dispensing Machines
in LTC facilities as well as some changes in the roles of the
consultant pharmacist and pharmacist-in-charge that pro-
vide service to those LTC facilities. The lengthy discussion
centered around the potential of ADM use in place of the
current Emergency Box/First Dose Box that many pharma-
cy providers are utilizing in the facilities they serve. We
plan to elect new officers, and we currently have Peggy
Canler continuing as Academy Director of Government Af-
fairs. Chris Miles has been nominated as Chair, Joey Mat-
tingly as Vice Chair, Julie Owen as Academy Director of
Organizational Affairs, and an opening for Academy Direc-
tor of Public/Professional Affairs.
Respectfully,
Elisha Bischoff, PharmD, BCPS
Chair, KPhA Academy of Consultant Pharmacists
Senior Care Corner
July 2013
THE KENTUCKY PHARMACIST 40
KPhA New and Returning Members
KPhA Welcomes New and Renewing Members
May-June 2013
Cathy Adams Pineville, KY John Adams Lebanon, KY Kasey Alford Smiths Grove, KY Sandra Foster Anderson Monticello, KY Michael Anneken Melbourne, KY Mark Antis South Portsmouth, KY Karen M Arlinghaus Ft. Wright, KY William M Ashby Cadiz, KY Rosana W Aydt Villa Hills, KY Jason K Baker Louisville, KY Jennifer Baker Louisville, KY James D Ball Elizabethtown, KY Ellen Barger Mount Washington, KY Christopher Lee Barker Morehead, KY Larry R Barnett South Williamson, KY Barbara C Batsel Madisonville, KY Margaret Beeler Lebanon Junction, KY John K Beville Louisville, KY Danny Biliter Richmond, KY Joseph H Blandford Louisville, KY Ralph E Bouvette Frankfort, KY
Billy R Bowling Lexington, KY Dianna Bryant Hartford, KY Robert W Buckner Campbellsville, KY William Bucy Bowling Green, KY John Garland Byassee Clinton, KY Margaret Christopher Winchester, KY Kenneth Clayton Elkton, KY Robert Clement Cadiz, KY Arica C Collins Albany, KY David E Collins Mayfield, KY Teresa Collison Summersville, KY Paul M Cooper Morehead, KY Kimberly Sasser Croley Corbin, KY Robert E Croley Corbin, KY Robert E Cull Owenton, KY Jeffrey W Danhauer Owensboro, KY Steven Dawson McDowell, KY Thomas Detraz Hopkinsville, KY Dave Dickerson Morehead, KY Steve Doom Elizabethtown, KY Barbara A Dorris Russellville, KY
Ben Doyle Nicholasville, KY Debra Dunaway Henderson, KY James Dunaway Henderson, KY Anna Lee Dupont Louisville, KY Margret Mae Easterling Jenkins, KY Michael Eastridge Lebanon, KY David Edmundson Bowling Green, KY Harold Ellis Frankfort, KY Kevin Emberton Edmonton, KY Chad Evans Maysville, KY Lorie Evans Quincy, KY Jaime Janielle Fields Hindman, KY Justin M Fink Fort Wright, KY Jamie C Fletcher Hazard, KY Celeste C Flick Crestview Hills, KY Raymond Float Danville, KY Veronica Foster Munfordville, KY Cathy N Francisco Pikeville, KY Sheila A Franklin Bimble, KY Lisa Freeman Paducah, KY Patricia Freeman Lexington, KY
Kenneth Glass Midway, KY Thomas P Glover Providence, KY Robert Goforth Somerset, KY Wayne P Gravitt Wheelwright, KY Dwaine K Green The Villages, FL Monte J Gross Stanton, KY Jennifer Grove Madison, IN Donald Gubser Melvin, KY David Guion Russellville, KY Larry Hadley Frankfort, KY Catherine Hanna Lexington, KY Melodie Hawkins Mt Sterling, KY Pamela Hays McKee, KY Gregory Hines Bowling Green, KY Tom Houchens London, KY Morgan Howard Scottsville, KY Reymonda Howard London, KY Robert Hughes Lexington, KY Michael Ingram Cynthiana, KY Kyla James Sellersburg, IN Daniel Jones Paducah, KY
July 2013
THE KENTUCKY PHARMACIST 41
KPhA New and Returning Members
Donate online
to the
Kentucky
Pharmacists
Political
Advocacy
Council!
Go to
www.kphanet.org
and click on the
Advocacy tab for
more information
about KPPAC and
the donation form.
Melinda Joyce Bowling Green, KY Kyle Katterjohn Paducah, KY Amber Kayse Morning View, KY David Kelly Georgetown, KY Ann Keown Scottsville, KY Brian Key Pineville, KY Patricia Kinney Erlanger, KY Kristy Klebeck Maysville, KY Donald B Kupper Crestwood, KY Mike Leake Danville, KY Joe Lewis Hyden, KY Penny Liles Vanceburg, KY Michelle Lowe Paducah, KY Aleshea Martin Louisville, KY Matt Martin Louisville, KY Tamara Maynard Prestonsburg, KY Velda Mcdaniel Georgetown, KY John McFarland London, KY Aaron Mcintosh Midway, KY Roy Mckendree Murray, KY Lynita Mcwaters Paducah, KY Mark Meador Scottsville, KY Beverly Meeks Paducah, KY
Ross Melton Mount Sterling, KY Kelly Mink Lancaster, KY Bernardine Miracle Whitesburg, KY Jeffrey Moore Middlesboro, KY Sonya Muncy Russell, KY Ann Murphy Princeton, KY Frank Nicks Bowling Green, KY John F. Nie Independence, KY David O'Quinn West Liberty, KY Jamie Otte Florence, KY Eileen Palutis Richmond, KY Paul Patrick London, KY Kenneth Pearce Danville, KY Risa Perry Almo, KY Lavanya Wijeratne Peter Louisville, KY Brookes Pickard Louisville, KY Michael Pipkin Gilbertsville, KY Larry Powell Richmond, KY Elizabeth Prather Florence, KY Marcella Robinson Paducah, KY Donald Ruwe Fort Thomas, KY Denise Schickling Villa Hills, KY Lisa Schwartz Crestview Hills, KY
Ginger Scott Morgantown, WV Jan Scott Earlington, KY William Sewell Utica, KY Gina Sherrow Brodhead, KY David Shipley Henderson, KY John Simkins Somerset, KY Alan Simon Prospect, KY Sarah Slabaugh Louisville, KY Lisa Smith Dry Ridge, KY James Stallard Neon, KY Nancy Stanton Holmes Mill, KY Scott Stephens Cynthiana, KY Dan Stevenson Portsmouth, OH Jacquelyn Strickland Hopkinsville, KY David Bradley Stultz Flatwoods, KY Francis Britton Thompson London, KY Gene Thompson Lexington, KY Leah Tolliver Lexington, KY Earnest Watts Cornettsville, KY Lenville White Irvine, KY Thomas White Madisonville, KY Rodney Whittington Princeton, KY Gary Wientjes Morehead, KY
Charlsie Williams Paducah, KY Cindi Williams Hazard, KY James Wiseman Benton, KY Reginald David Woolf South Fulton, TN Whitney Wright Dixon, KY Mary Ann Wyant Finchville, KY Michael B Wyant Finchville, KY Jeanne Zeis Covington, KY
July 2013
THE KENTUCKY PHARMACIST 42
KPhA Government Affairs Contribution Name: ______________________________________________________________
Pharmacy: ___________________________________________________________
Email: ______________________________________________________________
Address: _____________________________________________________________
City: _______________________________________________ State: _________ Zip: ____________
Phone: ________________ Fax: _________________ E-Mail: ______________________________
Contribution Amount: $_________ Check ____ (make checks payable to KPhA Government Affairs)
Credit Card (AMEX; Discover; MasterCard; VISA)
Account #: ____________________________________________________ Expiration date: _______
CVV: ______________
Billing address (if different from above)
___________________________________________________________________________________
Mail to: Kentucky Pharmacists Association, 1228 US Highway 127 South, Frankfort, KY 40601
Pharmacy Health Screening Provide state of the art health screenings to help improve
YOUR patients’ health and your bottom line.
Schedule a Health Screening Day at your pharmacy to offer YOUR patients a ser-
vice to improve their health and potentially catch dangerous issues early!
The health screenings offer multiple advantages for your business including imme-
diate profit from the screening process and the early recognition of diseases that are
usually treated with medications as well as increase the health and longevity of your
patients.
The process is a partnership between the Kentucky Pharmacists Association and Xcel Diag-
nostics and YOUR pharmacy to bring state of the art health screenings to your patients. The
net profit is divided among the partners, including your pharmacy.
Call Xcel Diagnostics today to schedule your screening day.
(606) 218-5483
KPhA Government Affairs/Pharmacy Health Screenings
July 2013
THE KENTUCKY PHARMACIST 43
Cardinal Health
July 2013
THE KENTUCKY PHARMACIST 44
Sponsors for the 135th KPhA Annual Meeting
Annual Meeting Supporter Rx Systems, Inc.
Cardinal Health Customers in Kentucky
Matt Carrico
Kim Croley
Brian Fingerson
Humana
Grant County Drugs and Custom
Compounding Centers, Dry Ridge,
Williamstown, Crittenden
Medica Pharmacy and Wellness Center,
Bardstown-Shepherdsville
National Association of Chain Drug Stores
Bob Oakley
Duane Parsons
Poole’s Pharmacy Care
Donnie Riley
Richard Slone
Tolliver Management Group
Wellcare of Kentucky
Sam Willett
Lewis Wilkerson
KPERF Golf Hole
Sponsors AmerisourceBergen
American Pharmacy Services Corp.
Booneville Discount Drug
Capital Pharmacy and Medical Equipment
Care More, Kimper & NOVA Pharmacies
Congratulations Leon Claywell,
Bowl of Hygeia Award Recipient
Flexible Pharmacy Staffing
George Hammons, Frankie Abner
& Tom Houchens
Medica Pharmacy and Wellness Center,
Bardstown-Shepherdsville
Pharmacists Mutual Companies
Poole’s Pharmacy Care
Republic Bank & Trust
Rite Aid
Rx Discount Pharmacy
The Save-Rite Family of Pharmacies
Tolliver Management Group
Wayne’s Pharmacy
Annual Meeting
Event Sponsors American Pharmacy Services Corporation
Humana
Jefferson County Academy of Pharmacists
KY Governor’s Office of Health Information
Exchange
KPhA District 1
Kroger Corporation
McWhorter College of Pharmacy
at Samford University
Medica Pharmacy and Wellness Center,
Bardstown-Shepherdsville
Northern Kentucky Pharmacists Association
Rx Therapy Management
Sullivan University College of Pharmacy
University of Kentucky College of Pharmacy
Sponsoring Pharmacy’s Future
Student Pharmacist Support
135th KPhA Annual Meeting
July 2013
THE KENTUCKY PHARMACIST 45
AbbVie
American Pharmacy Cooperative, Inc.
AmerisourceBergen
American Pharmacy Services Corp.
Astrazeneca
Cardinal Health
Dr. Comfort
Eli Lilly & Co.
EPIC Pharmacies
HD Smith
iMedicare
Kentucky Cabinet for Health & Family
Services
Kentucky Renaissance Pharmacy Museum
KHELPS
KY Office of Health Information Exchange
Lifetime Financial
Growth Company
McKesson Corporation
Merck
Miami Luken
Morris & Dickson
Passport Health Plan
Pharmacists Mutual Companies
Pill Guard Medication Delivery Systems
QS/1
Rite Aid
RxMedic
Samuels Products, Inc.
ScriptPro
Smith Drug Company
SUCOP Student Organizations
TEC Laboratories
UK COP Experiential Ed/ CAPP
UK Student Organizations
UK Gerontology
Walgreens
Xcel Diagnostics
… and our 2013 Exhibitors
The outgoing members of the 2012-13 KPhA Board of Directors: outgoing President Kimberly Croley, Leah
Tolliver, Jeff Mills, Lance Murphy, Chris Clifton, Outgoing Chair Lewis Wilkerson, Trish Freeman and Molly
Trent.
135th KPhA Annual Meeting
July 2013
THE KENTUCKY PHARMACIST 46
Sullivan University College of Phar-
macy Student Representative Heather
Bryan is originally from Louisville, and
now resides in Mt. Washington with her
husband and three-year-old daughter.
She is a graduate of Murray State Uni-
versity with her Bachelors in Science
and Nursing and is in her 2nd year at
Sullivan. She loves being involved, stay-
ing busy, and being active.
University of Kentucky College of Pharmacy Student
Representative Brooke Herndon is a third-year student
pharmacist at UK. She holds a B.S. in
Chemistry with a minor in Biology
from Bellarmine University. Brooke is
a native of Louisville and currently
lives in Lexington to attend school.
She serves as the President of the
American Pharmacists Association –
Academy of Student Pharmacists and
is an active member in Rho Chi, Phi
Lambda Sigma and Lambda Kappa
Sigma. When not studying or participating in extracurricular
activities, Brooke enjoys cheering on the CATS and attend-
ing sports games.
Director Chris Killmeier enjoys being a part of solutions
for the profession of pharmacy. He has been a pharmacist
for 22 years with Walgreens. Within Walgreens, he has
held positions from staff pharmacist up to district pharmacy
supervisor and is currently pharmacy manager at
Walgreens on Lime Kiln Lane in Louis-
ville. He currently serves as chair of
the Advisory Council to the Kentucky
Board of Pharmacy. He has been mar-
ried to his wife, Denise, for 19 years,
and they have two wonderful children,
Bayley Shea, 14 and Olivia Blaire, 11.
He was born and raised in Louisville,
where he resides today.
Vice Speaker of the House of Dele-
gates Ethan Klein was born and raised in Dallas, Texas,
and earned his BS in chemistry from
the University of Texas at Austin in
2004. In 2010, he graduated from the
University of Charleston School of
Pharmacy in Charleston, W.V. He
then moved to Chicago to complete
his PGY1 residency at the North Chi-
cago Veterans Affairs. After complet-
ing the residency, he moved to Louis-
ville, where he practices pharmacy in
the community setting.
Director Chris Palutis is originally from the northeast
Pennsylvania area. He attended the Philadelphia College of
Pharmacy & Science and earned his Bachelor of Science
Degree in Pharmacy in 1995. Chris has more than 17 years
of innovative pharmacy management experience, including
positions in retail and long term care. He began his career
in the retail pharmacy sector, where he quickly rose
through key areas of functional leadership responsibility
2013-14 KPhA Board of Directors
Welcome to the New Directors
July 2013
THE KENTUCKY PHARMACIST 47
2013-14 KPhA Board of Directors
including operations, technology, cus-
tomer service, legal and regulatory
compliance, clinical services and sales.
He was promoted and led pharmacy
operations at national pharmacy chains
CVS and Rite Aid, as well as the na-
tion’s leading Long Term Care Phar-
macy provider, Omnicare. He successfully leveraged his
experience to maximize sales and profitability for these
premiere organizations.
After a successful stint with Omnicare, Chris decided to
venture out on his own. He and his wife, Consuelo (who is
also a pharmacist), decided to return to Kentucky and
open their own independent pharmacy in Lexington. The
pharmacy (C&C Pharmacy) opened in February 2009 and
has seen positive growth year after year. The pharmacy
now employs 2 additional full-time pharmacists (in addition
to Chris and Consuelo) as well as UK Interns and other
pharmacy technicians.
Chris and Consuelo reside in the Lexington area.
Past President Ron Poole was born in Covington, Ky.,
and raised in Williamstown, Ky. He married Lisa Wedding
in 1991 and they are the proud parents of Megan, Allie,
Evan and Emma.
He completed pre-pharmacy curriculum at Brescia Univer-
sity in Owensboro and graduated with a Bachelor’s De-
gree in Pharmacy from the University of Kentucky College
of Pharmacy in May 1990.
He started his career as a Staff Phar-
macist at Owensboro-Daviess County
Hospital before becoming owner and
pharmacist of Poole’s Pharmacy Care
in Central City, Livermore and Owens-
boro in October 1990. Ron is a Com-
munity Based Faculty Member for the
University of Kentucky College of
Pharmacy, Ohio Northern University- Raabe College of
Pharmacy, Samford College of Pharmacy and St. Louis
College of Pharmacy.
Director Mary Thacker, is a 1993 graduate of UK College
of Pharmacy. Having practiced community pharmacy for
17 years as both staff and pharmacy
management, she chose to pursue a
path in long-term care pharmacy and
has thoroughly enjoyed the challenge
the past two years. She lives in Louis-
ville with husband, Art, as well as kids
Jack (12) and Audrey (9). She enjoys
being a “soccer” mom, as well as a
roadie for her son’s band, and assis-
tant coach to both kids’ Quick Recall
teams. She loves music, gardening,
cooking, reading, watching NFL, visiting the Caribbean
and spending time with her newly adopted 11-year-old
Dachshund.
of the KPhA Board of Directors
Directors Chris Clifton and Jeff Mills were reelected to the KPhA
Board of Directors. Directors Trish Freeman and Chris Palutis were
appointed to fill unexpired terms.
2013-14 KPhA Executive Officers
Chair — Kimberly Sasser Croley
President — Duane Parsons
President-Elect — Bob Oakley
Secretary — Frankie Abner
Treasurer — Glenn Stark
July 2013
THE KENTUCKY PHARMACIST 48
Question: I have read somewhere that the federal
government has ratcheted up its level of activity with regard
to excluding health professionals from health care pro-
grams that receive any federal funds, e.g., Medicare, Medi-
caid, TRICARE, programs for veterans, etc. What is that,
are there implications for pharmacists and pharmacy and
what can a practitioner who is “excluded” do to get reinstat-
ed?
Response: A number of federal statutes enacted over
the years starting in 1977 have created a legal prohibition
on payment by federal health care programs for items or
services either furnished by an “excluded person” or at the
request of such an individual, e.g., a prescription issued by
an excluded provider. This applies whether the federal pro-
gram is funded wholly (think TRICARE) or in part (think
Medicaid) with federal funds.
Program exclusion may be directed at any person who
submits false or fraudulent claims for payment. Thus, this
could include the owner of a pharmacy seeking reimburse-
ment or an employee pharmacist who initiated the claim.
There also are potential civil monetary penalties that can
be directed at entities, e.g., pharmacies, that employ indi-
viduals who are currently subject to exclusion. It has been
reported that as of April 2013, there were 51,000 individu-
als and 3,000 business entities under exclusion.
But the implications are even more expansive. No federal
health care program payment may be made for items or
services furnished on the prescription of an excluded prac-
titioner. So if a prescription were issued by an excluded
prescriber a pharmacy could not be reimbursed for that by
a federal health program.
Does that mean the pharmacist needs to verify that each
and every prescriber from whom prescriptions are received
are not under an exclusion order? Payment could certainly
be denied in such situations. One way to avoid liability for
honoring an order from an excluded prescriber is to double
check that the pharmacy’s computer system includes an
edit for excluded prescribers at the point of dispensing.
Looking at an inpatient scenario, if a hospital employed an
excluded pharmacist who dispensed medications to a Med-
icare beneficiary whose bill was covered under that pro-
gram’s diagnosis-related group payment system, that bill
would not be honored for payment. Moreover, that pharma-
cist would be open to penalties for violating his or her ex-
clusion by causing a claim to be submitted for federal reim-
bursement during the period of exclusion.
Well, could an excluded pharmacist get around this by
moving into an administrative or managerial role where,
say, no direct dispensing activities occur? The answer is
no. Excluded individuals are prohibited from furnishing
such services if payment comes from federal health care
programs. Nor could that excluded pharmacist limit his or
her activities to inputting billing information or reviewing
treatment plans. Those activities also would run afoul of the
exclusionary order.
This author has received inquiries from pharmacists who
have been subject to exclusion orders asking several ques-
tions. First is “what can I permissibly do while excluded?”
The answer is, unfortunately, not much in pharmacy. One
possibility might be a position with a poison control center
that receives no federal funds. The second question is
“What can I do to get out from under the five year exclusion
order?” The answer to that, also unfortunately, is not much.
Passage of time is pretty much the only remedy with the
hope that programmatic reinstatement to eligibility will fol-
low.
How can it be determined whether a particular individual is
currently under an exclusion order? The website of the
HHS Office of the Inspector General presents this infor-
mation at http://oig.hhs.gov/exclusions.
Pharmacy Law Brief
Pharmacy Law Brief: Exclusion of Practitioners from Federally Funded Health Programs Author: Joseph L. Fink III, B.S.Pharm., J.D., Professor of Pharmacy Law and Policy and Kentucky Pharmacists Associ-
ation Professor of Leadership, Department of Pharmacy Practice and Science, UK College of Pharmacy
Submit Questions: [email protected]
Disclaimer: The information in this column is intended for educational use and to stimulate professional discussion among col-
leagues. It should not be construed as legal advice. There is no way such a brief discussion of an issue or topic for educational or
discussion purposes can adequately and fully address the multifaceted and often complex issues that arise in the course of profes-
sional practice. It is always the best advice for a pharmacist to seek counsel from an attorney who can become thoroughly familiar
with the intricacies of a specific situation, and render advice in accordance with the full information.
July 2013
THE KENTUCKY PHARMACIST 49
Technician Review
Technician Review From the KPhA Academy of Technicians
In April 2013, the Kentucky Pharmacists Association Board
of Directors voted in favor of the petition to found a new
KPhA Academy for Pharmacy Technicians. The Academy’s
approved mission statement is: To unite the pharmacy
technicians throughout the Commonwealth to have one
voice toward the advancement of our profession.
The founding 25 members have a wide footprint throughout
the state of Kentucky.
The selected officers for 2013-2014 are as follows:
Don Carpenter — Chair
Patricia Robinson — Vice Chair
Christen Schenkenfelder — 1st Director
Heather Daniels — 2nd Director
Kristina Blanton — 3rd Director
Raychel Stevens — 4th Director
The Academy plans to continue recruiting additional techni-
cians to become involved within our profes-
sion. Our objectives will be presented to the
KPhA Board of Directors and the Board of
Pharmacy Advisory Council.
We are excited about the changing environ-
ment in the pharmacy profession and look
forward to being a part of that change. If you
are a technician member of KPhA, you are
eligible to be a member of the Pharmacy
Technician Academy. There is no extra cost
involved or responsibility. Our goal is for the
role of the pharmacy technician to grow and
evolve as a profession. We want to invite eve-
ry technician to join the academy to have a
voice in guiding our profession.
For more information on how to join the Phar-
macy Technician Academy please email Don
Carpenter at [email protected].
Sincerely,
Don Carpenter, BS, CPhT III 222 Medical Circle Drive Morehead, KY 40351 606-783-6741 [email protected]
Check out resources
for Pharmacy
Technicians at the
KPhA Website:
www.kphanet.org
July 2013
THE KENTUCKY PHARMACIST 50
Pharmacy Policy Issues
PHARMACY POLICY ISSUES:
Overcoming Barriers to Implementing Pharmacogenetic Services in Community Pharmacy Author: Jonathan Hughes is a third professional year Pharm.D. student at the UK College of Pharmacy. Jonathan re-
ceived his Bachelor of Science degree in Biology and Biochemistry at the University of Mississippi and is a native of
Madison, Miss.
Issue: Implementing pharmacogenetic services into community pharmacy practice promises to bring community practice
into the 21st century. However, many patients express fear that their insurance company or employer may use such
information to discriminate against them. What can pharmacists seeking to implement pharmacogenetic services do to
allay these fears?
Discussion: Of the several barriers existing to the imple-
mentation of pharmacogenetic services in community phar-
macy, one of the most prominent—and, as I hope to show,
most easily allayed—are fears regarding the use and priva-
cy of genetic information. As has been discussed exten-
sively in bioethical literature and such popular publications
as The Immortal Life of Henrietta Lacks, genetic infor-
mation is integral to who we are; indeed, it is our very blue
print. In the past decade, the biomedical sciences have
exploded in understanding how our genes affect our health,
from the progression of disease to variations in drug effica-
cy and toxicity. However, patients often shrink away from
even considering the potential benefit afforded by genetic
testing because of fear that entities such as their employer
or health insurance carrier may use such information to
discriminate against them.
In order to allay this fear and successfully incorporate phar-
macogenetic services into their practice, pharmacists need
to be familiar with and educate their patients regarding the
Genetic Information Nondiscrimination Act (GINA) of
2008;1 While protected health information is always held
confidential under HIPAA, a patient’s health insurance
company may receive a patient’s genetic information inci-
dental to data exchanges as part of its regular course of
business. Title I of GINA specifically prohibits insurance
companies from denying patients coverage2 or charging a
higher premium on the basis of a genetic test result.3 Title
II, on the other hand, focuses on employers, making it un-
lawful for them to make decisions on hiring, promoting or in
any way discriminating against an employee on the basis
of a genetic test4 or to even attempt to acquire such genet-
ic information5.
Ensuring patients that their genetic information can only
help them attain improved health outcomes without risk of
losing insurance coverage or discrimination from employ-
ers will certainly encourage them to use pharmacogenetic
services. Many community practitioners express concerns
that their patients will not embrace such services if offered
because of the fears posited above. Properly armed with
knowledge about GINA, pharmacists can help diminish or
remove this barrier between patients and improved health
outcomes.
Many direct-to-consumer (DTC) genetic testing companies
now exist and several are seeking partnership with commu-
nity pharmacies. In this model (see Fig 1), the pharmacist
would advertise the service and obtain buccal swabs from
the patient to send to the DTC company for testing. The
results of this test would then be sent back and incorpo-
rated into the patient’s health record to be consulted during
drug utilization review or medication therapy management.
To facilitate incorporation of this information, the partner
DTC lab often provides software that will automatically de-
tect gene-drug interactions when received.
= = =
Interested in finding out more about incorporating phar-
macogenetic services into your practice? Join the
CAPPNet listserv (http://pharmacy.mc.uky.edu/capp/
cappnet.php) and stay tuned for CPE from UK College of
Pharmacy on Implementing Pharmacogenetic Services in
Community Pharmacy Practice!
1. Pub.L. 110-233, 122 Stat. 881
2. 42 USC §300gg–53(a),(c)
3. 42 USC §300gg–53(b)
4. 42 U.S.C. §2000f-1(a)
5. 42 U.S.C. §2000f-1(b)
July 2013
THE KENTUCKY PHARMACIST 51
Pharmacy Policy Issues
Have an Idea?: This column is designed to address timely and practical issues of interest to pharmacists, pharmacy interns and phar-
macy technicians with the goal being to encourage thought, reflection and exchange among practitioners. Suggestions
regarding topics for consideration are welcome. Please send them to [email protected].
Proposed Community Pharmacy Pharmacogenetic (PGx) Services Model
Figure 1. Proposed Pharmacogenetic Services Model in a Community Pharmacy.
Patient inquires about
new PGx services
PGx services advertised
through in-store signage,
patient leaflet inserts, or
targeted recommendation
Collect buccal swab to
obtain genetic sample
Consent
Direct-to-Consumer
(DTC) Genetic Testing
Laboratory Partner
Mail sample
Patient Genetic Information
Pharmacy electronic
health record (EHR)
Patient presents with
R.Ph. performs DUR Comprehensive Medication
Review (CMR) conducted as
part of Medication Therapy
Results returned to pharmacy
PGx interaction detected
during computer-assisted
DUR
R.Ph. Review and Assessment Prescriber
R.Ph. counsels patient on conse-
Patient health outcomes are im-
proved and patient-pharmacist
relationship is strengthened
Interprofessional consultation and recommendation
July 2013
THE KENTUCKY PHARMACIST 52
Pharmacists Mutual
July 2013
THE KENTUCKY PHARMACIST 53
APSC
July 2013
THE KENTUCKY PHARMACIST 54
KPhA BOARD OF DIRECTORS
Kimberly Croley, Corbin Chair
[email protected] 606.304.1029
Duane Parsons, Richmond President
[email protected] 502.553.0312
Bob Oakley, Louisville President-Elect
[email protected] 502.897.8192
Frankie Hammons Abner, Barbourville Secretary
[email protected] 606.627.7575
Glenn Stark, Frankfort Treasurer
Ron Poole, Central City Past President
Directors
Heather Bryan, Mt. Washington Student Representative
Matt Carrico, Louisville
Chris Clifton, Erlanger
Trish Freeman, Lexington
Brooke Herndon, Louisville Student Representative
Chris Killmeir, Louisville
Jeff Mills, Louisville*
Chris Palutis, Lexington
Richard Slone, Hindman
Mary Thacker, Louisville
Sam Willett, Mayfield
* At-Large Member to Executive Committee
HOUSE OF DELEGATES
Cassandra Beyerle, Louisville Speaker of the House
Ethan Klein, Louisville Vice Speaker of the House
KPERF ADVISORY COUNCIL
Kim Croley, Corbin
Ann Amerson, Lexington
KPhA/KPERF HEADQUARTERS
1228 US 127 South, Frankfort, KY 40601
502.227.2303 (Phone) 502.227.2258 (Fax)
www.kphanet.org
www.facebook.com/KyPharmAssoc
www.twitter.com/KyPharmAssoc
Robert McFalls, M.Div.
Executive Director
Scott Sisco, MA
Director of Communications & Continuing Education
Kelli Sheets
Office Manager
Leah Tolliver, PharmD
Director of Pharmacy Emergency Preparedness
Nancy Baldwin
Receptionist/Office Assistant
KPhA Board of Directors/Staff
KPhA sends email announcements
weekly. If you aren’t receiving: eNews,
Legislative Updates, Grassroots Alerts
and other important announcements,
send your email address to
[email protected] to get on the list.
July 2013
THE KENTUCKY PHARMACIST 55
Kentucky Pharmacists Association 1228 US 127 South Frankfort, KY 40601 (502) 227-2303 www.kphanet.org Kentucky Board of Pharmacy State Office Building Annex, Ste. 300 125 Holmes Street Frankfort, KY 40601 (502) 564-7910 www.pharmacy.ky.gov Pharmacy Technician Certification Board 2215 Constitution Avenue Washington, DC 20037-2985 (800) 363-8012 www.ptcb.org
Kentucky Society of Health-System Pharmacists P.O. Box 4961 Louisville, KY 40204 (502) 456-1851 x2 (502) 456-1821 (fax) www.kshp.org [email protected]
American Pharmacists Association (APhA) 2215 Constitution Avenue NW Washington, DC 20037-2985 (800) 237-2742 www.aphanet.org
National Community Pharmacists Association (NCPA) 100 Daingerfield Road Alexandria, VA 22314 (703) 683-8200 [email protected]
Drug Information Center Sullivan University College of Phar-macy 2100 Gardiner Lane Louisville, KY 40205 (502) 413-8638 www.sullivan.edu Kentucky Regional Poison Center (800) 222-1222
Frequently Called and Contacted
50 Years Ago/Frequently Called and Contacted
KPhA Remembers KPhA desires to honor members who are no longer with us.
Please keep KPhA informed by sending this information to [email protected].
Deceased members for each year will be honored permanently at the KPhA office.
50 Years Ago at KPhA MEET THE BARBECUE CHAMPION
A.E. Tucker, RPh, Bowling Green, who owns a drug store and is a State Representative,
recently was featured in the Sunday Courier-Journal as a champion at cooking barbecue.
Here’s the story:
Pharmacist’s Barbecue Could Win Votes
Bowling Green residents who have sampled State Representative A.E. Tucker’s barbecue
dishes would be inclined to vote overwhelmingly for his cooking.
The Democrat, who’s a pharmacist and owner of a drugstore, learned his barbecueing “20 years ago camping, while
out hunting and fishing.”
He does some cooking indoors, but prefers outdoor barbecues for 12 to 20 guests.
For the past 10 years he has been using the same recipe for barbecue chicken. “I tried a number of others, but nev-
er found one I liked as well.”
- From The Kentucky Pharmacist, July 1963, Volume XXVI, Number 7.
July 2013
THE KENTUCKY PHARMACIST 56
THE
Kentucky PHARMACIST
1228 US 127 South
Frankfort, KY 40601
SAVE THE DATES KPhA Mid-Year Conference
on Legislative Priorities
November 2013 (Time and place TBD)
136th KPhA Annual Meeting and
Convention
June 5-8, 2014
Marriott Griffin Gate Resort and Spa
Lexington, KY