Winter 2012

Winter 2012 / Volume 55, no. 1

Special Features

Membership Highlights

See page 4-5

New Requirement for CE Partcipants

See page 27

Northwest Pharmacy Convention

See page 6

2012 Winter SeminarJanuary 8 - 10, 2012Westin Riverfront Resort and Spa, Avon, CO Pg. 32

Northwest Pharmacy ConventionMay 31st - June 3, 2012Coeur d’Alene, Idaho

Pg. 6

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SeattleDistributionCenterlocatedat:801CStreetNWAuburn, WA 98001

SaltLakeCityDistributionCenterlocatedat:955West3100SouthSaltLakeCity,UT84119

Continuing Education 21Health Information Exchange 17Rx and the Law 31Upcoming Events 32

WSPA BoArd oF directorS

PreSidentJulie Akers

PreSident-electBrian Beach

immediAte PASt PreSidentRon Williams

SecretAry/treASurerSteve Singer

BoArd memBerSBeth Arnold

Kurt Bowen (Student)Jill Carrier (Technician)

Shaelah Easterday (Student)Heather Ferguson

Christopher Foley (Student)Melissa Hansen

Andrew Heinz (Student)Kirk Heinz

Anne Henriksen Paul M. Iseminger (Technician)

Greg Matsuura Cindy WilsonRoger Woolf

mAnAging editorKathleen Goodner

PuBliSherThe Washington Pharmacy is owned and published

by the Washington State Pharmacy Association to provide information, news and trends in the

profession of pharmacy. Opinions expressed by the contributors, whether signed or otherwise, do not

necessarily reflect the attitudes of the publishers nor are they responsible for them. Subscription rate is

$24 per year domestic / $59 foreign (including first class postage.)

Per copy rate is $6.Washington Pharmacy ISSN (1539-1469) is

published quarterly for $24 per year domestic / $59 foreign including first class postage by Washington State Pharmacy Association at 411 Williams Ave. S,

Renton, WA 98057. PERIODICALS Postage paid at Renton, WA and at additional mailing offices.

PoStmASterPlease send address changes to:

Washington State Pharmacy Association411 Williams Avenue S

Renton, WA 98057

miSSion StAtementThe Washington State Pharmacy Association exists

to advocate on behalf of its members to ensure pharmacy professionals are recognized, engaged

and valued as essential to the health care team.

ViSit WSPA’S WeBSite Atwww.wsparx.org

Winter 2012/Volume 55, no. 1

dePArtmentS And SPeciAlS

memBerShiP 4Why you should renew your membership

northWeSt PhArmAcy conVention 6Register Today!

legiSlAtiVe And regulAtory AFFAirS council neWS 11Legislative Update

legiSlAtiVe dAy 12

School neWS 13Get the Latest WSU/UW Information

FeAtureS

AdVertiSerS

Agility Recovery 31Bi-Mart 30Cardinal Health 2 Good Neighbor Pharmacy 18McKesson 16Pace Alliance 19 & 20Pharmacists Mutual 29RxRelief 30

Jenny Arnold, Director of Pharmacy Practice Development

danyal henderson, Administrative Coordinator

dedi hitchens, Director of Government Affairs

Kathleen goodner, PR & Communications Manager

maria lieggi, Membership & Education Administrator

Jeff rochon, Chief Executive Officer

StAFF

Washington Pharmacy4

IT’S YOUR FUTURE

Health care is in a dynamic state of change. Decisions impacting pharmacy are made all the time. As the adage goes, “If you are not at the table, you are on the menu.” The WSPA is your invite to the table. Since health care reform is implemented at a state level, it is crucial that you are engaged and involved in those decisions.

The WSPA is your voice to advocate for advancing the profession and protecting your livelihood.

AMPLIFYING YOUR VOICE

WSPA advocates for the profession on numerous levels to: strengthen and expand our role in patient care; protect access to pharmacy-provided services and products; and reinforce the value of pharmacies in ensuring patient safety and quality health outcomes.

WSPA works within multidisciplinary committees, patient advocacy groups, regulatory agencies, public health jurisdictions, other professional associations, health insurance payers and employers.

On a legislative level, WSPA works within LRAC to ensure lawmakers understand the pharmacy profession.

member only information

WSPA is the source for news and information about the pharmacy profession and the members it serves, and routinely provides members with relevant, valuable and timely information on the latest safety, regulatory and legislative news. Members receive:

• Access to “Members Only” online Resource Centers for Audit Avoidance & Protection, Handling of Hazardous Drugs, Billing for Patient Care Services, Compliance and Regulations, Medication Safety, Medicaid, Medicare, Labor and Industries Resource Centers, Pharmacy Security, Non-English Communication Tools and much more

• Timely and valuable information via email alerts and Washington Pharmacy, the association’s quarterly magazine

• WSPA Career Center and Salary Survey• Quality On Demand Online CE• If you are Washington State Legislative and

Regulatory Aff airs Council (LRAC) member, you will also receive LRAC updates. It’s easy to become a member! Just mark the LRAC box on the membership form

Why you Should renew today!

Washington State Pharmacy Association411 Williams Avenue South

Renton, WA 98057425-228-7171

Fax 425-277-3897www.wsparx.org

Follow the WSPA on Facebook, Twitter, and LinkedIn!

STRENGTHEN YOUR SKILLS

Opportunities abound for you as a WSPA member. Participate in quality conferences, seminars, and workshops that will contribute to your continuing education and professional development. Attending WSPA events helps to build your network and meet key players in pharmacy, while learning about new and upcoming therapies, products, services, issues and developments.

Whether you are looking for high-quality, timely CE that is relevant to your practice, or you want to learn about best practices from experts in your specialty, the WSPA has something for you.

MAKE CONNECTIONS

WSPA provides opportunities to meet and network with people in the pharmacy profession. When you join the WSPA, you have the opportunity to join one or more practice academies to connect with professionals from similar practice settings that allows you to: • Solve problems• Share ideas• Move your practice forward

WSPA academies include:• Ambulatory/Community Practice• Health Systems• Independent Pharmacy• Long Term Care• Students• Technicians

Whatever your practice setting or background, WSPA off ers plenty of resources to build a powerful network of professionals in pharmacy who can serve as mentors and support.

The Washington State Pharmacy Association off ers a comprehensive suite of benefi ts and services that give members of all practice settings and career levels the tools they need to succeed. Take a look at all WSPA has to off er and join your colleagues who are dedicated to pharmacy. Become a member today!

Together we are stronger!

Washington Pharmacy 5

IT’S YOUR FUTURE

Health care is in a dynamic state of change. Decisions impacting pharmacy are made all the time. As the adage goes, “If you are not at the table, you are on the menu.” The WSPA is your invite to the table. Since health care reform is implemented at a state level, it is crucial that you are engaged and involved in those decisions.

The WSPA is your voice to advocate for advancing the profession and protecting your livelihood.

AMPLIFYING YOUR VOICE

WSPA advocates for the profession on numerous levels to: strengthen and expand our role in patient care; protect access to pharmacy-provided services and products; and reinforce the value of pharmacies in ensuring patient safety and quality health outcomes.

WSPA works within multidisciplinary committees, patient advocacy groups, regulatory agencies, public health jurisdictions, other professional associations, health insurance payers and employers.

On a legislative level, WSPA works within LRAC to ensure lawmakers understand the pharmacy profession.

member only information

WSPA is the source for news and information about the pharmacy profession and the members it serves, and routinely provides members with relevant, valuable and timely information on the latest safety, regulatory and legislative news. Members receive:

• Access to “Members Only” online Resource Centers for Audit Avoidance & Protection, Handling of Hazardous Drugs, Billing for Patient Care Services, Compliance and Regulations, Medication Safety, Medicaid, Medicare, Labor and Industries Resource Centers, Pharmacy Security, Non-English Communication Tools and much more

• Timely and valuable information via email alerts and Washington Pharmacy, the association’s quarterly magazine

• WSPA Career Center and Salary Survey• Quality On Demand Online CE• If you are Washington State Legislative and

Regulatory Aff airs Council (LRAC) member, you will also receive LRAC updates. It’s easy to become a member! Just mark the LRAC box on the membership form

Why you Should renew today!

Washington State Pharmacy Association411 Williams Avenue South

Renton, WA 98057425-228-7171

Fax 425-277-3897www.wsparx.org

Follow the WSPA on Facebook, Twitter, and LinkedIn!

STRENGTHEN YOUR SKILLS

Opportunities abound for you as a WSPA member. Participate in quality conferences, seminars, and workshops that will contribute to your continuing education and professional development. Attending WSPA events helps to build your network and meet key players in pharmacy, while learning about new and upcoming therapies, products, services, issues and developments.

Whether you are looking for high-quality, timely CE that is relevant to your practice, or you want to learn about best practices from experts in your specialty, the WSPA has something for you.

MAKE CONNECTIONS

WSPA provides opportunities to meet and network with people in the pharmacy profession. When you join the WSPA, you have the opportunity to join one or more practice academies to connect with professionals from similar practice settings that allows you to: • Solve problems• Share ideas• Move your practice forward

WSPA academies include:• Ambulatory/Community Practice• Health Systems• Independent Pharmacy• Long Term Care• Students• Technicians

Whatever your practice setting or background, WSPA off ers plenty of resources to build a powerful network of professionals in pharmacy who can serve as mentors and support.

The Washington State Pharmacy Association off ers a comprehensive suite of benefi ts and services that give members of all practice settings and career levels the tools they need to succeed. Take a look at all WSPA has to off er and join your colleagues who are dedicated to pharmacy. Become a member today!

Together we are stronger!

Conventionhotel murano, tacoma, WA


Legislative Day 2012

The 2012 Pharmacy Legislative Day was another huge success! Pharmacy’s pres-ence in Olympia was evident as more than

100 students in white coats from UW and WSU joined faculty members, alumni and pharmacy practitioners to advocate for the value of the pharmacy profession in impacting patient care.

In a direct effort to advocate for the pharmacy profession, Jeff Rochon, Chief Executive Officer of the Washington State Pharmacy Association, Dedi Hitchens, Director of Government Affairs for Washington State Legislative and Regulatory Affairs Council and Lis Houchen, Regional Direc-tor of State Government Affairs for the National Association of Chain Drug Stores set the tone for several high profile speakers including: Lieuten-ant Gov Brad Owens; Senator Linda Evans-Par-lette, the only pharmacist legislator in Wash-ington; Jason McGill the Governor’s HealthCare Advisor; David Hanig, Senior Health Care Advisor for the Senate Democratic Caucus; Marty Brown, the Director of the Office of Financial Manage-ment; Senator Karen Kaiser, Chair of the Senate Health and Wellness Committee and Courtney Acitelli, Program Director for UW Impact.

The day included 56 meetings with Senators and Representatives from across the state. Pharma-cists and pharmacy students addressed key bills such as Including Pharmacists in the Legend Drug Act, Pharmacist Provided Medication Review for Medicaid Managed Care Enrollees, PBM Transparency, e-Prescribing of CII Medica-tions and Increasing Penalties for Crimes Against Pharmacies.

An event of this magnitude would not be pos-sible without dedicated volunteers and gener-ous sponsors. A special thank you to Kurt Bowen, Shaelah Easterday, Chris Foley, Nathan Deney and Andrew Heinz for coordinating the phar-macy student leaders. Thank you to Safeway for providing water and a big thank you to Bartell Drugs, Fred Meyer Pharmacy, and Spokane Pharmacy Association for providing the funding needed for the day’s event.


By dedi hitchens, director of government Affairs

LRAC News

The 2012 Washington State legislative session began in Janu-ary with a daunting $1.5 billion budget deficit despite a special session prior to regular session. State lawmakers are required by

state constitution to fill the budget hole for the 2011-2013 supple-mental budget biennium. Regular Session came and went and the budget was not resolved so a second 30 day special session was called in March. Here’s a summary of the flurry of activity and efforts by the Washington State Pharmacy Legislative and Regulatory Affairs Council (LRAC).

The first few weeks of the legislative session was filled with policy committee hearings on policy bills. LRAC began the session with an aggressive agenda including pushing for bills to create Pharmacy Ben-efit Manager (PBM) transparency requirements, include pharmacists in the Legend Drug Act, and increasing penalties for crimes against pharmacies. LRAC was successful in getting all of our bills heard in their respective committees.

PBm transparencyIn the first year for this legislation in Washington State, LRAC success-fully got this issue recognized by legislators. The PBM transparency bill had public hearings in both the House Healthcare and Wellness Committee and the Senate Health and Long Term Care Committee. Thank you to the LRAC members who testified in support of the PBM Transparency Bill. LRAC members representing independent and chain pharmacy educated lawmakers about their experiences with PBM’s. The hearing raised a number of questions and interest among lawmakers to look further into this issue. LRAC faced tremendous op-position from the powerful PBM lobby, and Insurance lobby. The PBM lobby recruited PhRMA and a few employer groups to create confu-sion for legislators. However, LRAC was successful in getting the issue heard in public hearings and now have some legislators interested in investigating PBM practices. This is a new issue to most lawmakers and one that can get confusing. This is going to be a long term effort and further work will be done educating lawmakers and executive policy staffers exposing PBM practices. LRAC will be working with the Chairs of the Senate and House Health Care committees organizing an interim work session on PBM’s.

increasing Penalties for crimes Against PharmaciesLRAC reintroduced a bill attempting to move the crime of robbing a pharmacy from a second degree offense to first degree offense. This bill was met with concerns in the Senate over the costs of increas-ing incarceration periods. An amendment which still increases the penalties by making the crime of robbing a pharmacy a mandatory 12 month jail sentence was agreed upon. It also permits the court the option to impose a stricter sentence based on consideration of the circumstances of the robbery. Unfortunately, the bill did get a fiscal note attached to it and that was the death of the bill. Under normal legislative circumstances the fiscal note would not have been an issue, however, lawmakers are hard pressed to move forward on any bills that have even a potential to fiscally impact the state. The good news, Washington State’s pharmacy robberies have decreased over the years. However, LRAC still views this bill as important and will continue to try and get this bill passed.

including Pharmacists in the legend drug ActThere were two bills aimed at including pharmacists in the Legend

Drug Act, SHB 2512 and SSB 6197, successfully moved past the sched-uled legislative cut off dates and were voted on in both the House and Senate. Both chambers voted and received unanimous support votes. During the second phase of the political process, legislators decided to move just one bill, SHB 2512. This bill was next in line for the Senate vote when three Democrats sided with the Republicans to successfully moved their proposed operating supplemental budget to the floor for consideration. This bold move occurred two hours prior to the 5 pm cut off and killed the bill and several others that needed to be voted on.

Senate Budget Fireworks In an unprecedented move, the Senate Republicans took the reins of the Democratic controlled Senate. The three Democrats sided with the Republicans procedural move to circumvent the public hearing process and successfully moved their proposed operating supple-mental budget to the floor for consideration. The Senate is narrowly controlled by the Democrats with a small margin 27 Democrats to 22 Republicans. Growing frustration with the Senate Democrats proposed supplemental operation budget prompted the Republicans to effectively gain control with the help of three Democrats, who also have also expressed frustration over the Democrats budget. This bold move occurred two hours prior to the 5 pm cut off and killed a number of bills that needed to be voted on. The Senate Republicans, with a narrow vote of 25-24 successfully passed their Operating Budget. This move shifted momentum in the legislature, resulting in a Special Session. The Senate Republicans disagree with the Democrats’ proposal to delay payments to public schools by one day – which is equivalent to $350 million. This delay in payment would have moved the budget deficit to the next budget cycle. The Republican budget cuts the Basic Health Plan and elimi-nates the Disability Lifeline program. Both programs were preserved under the Democrats proposal. Cuts to K-12 and Higher Education are also being proposed.

house of representatives’ BudgetThe Washington State House of Representatives is a different story and is likely to give back some democratic leverage to the operating budget negotiation. The House of Representatives does not have such a narrow margin of Democrat control. The House Democrats are in the clear majority with a margin of 56 Democrats to 42 Republi-cans. The Senate Republican’s budget is sure to run into road blocks in the House. LRAC successfully removed non-mandatory prescription co-payments from the House’s proposed operating budget and we fought off a professional license fee increase to fund the Prescription Monitoring Program.

While politics is a tricky world where victories are often not apparent, LRAC was very successful this year. Even though an unprecedented Senate upheaval killed the bills, issues were heard and supported by legislators. LRAC’s voice is prominent and we have worked in col-laboration with provider associations, patient advocacy groups and legislative leadership to recognize and support the role of pharmacy on the health care team. There is more work to be done as this ses-sion closes and LRAC is committed to work tirelessly throughout the interim to advocate for the pharmacy profession.


School News

construction of new building underway

Construction began in August 2011 on a new building in Spokane, which the College will share with the physician education program jointly administered by WSU and the University of Washington.The 2011 Washington Legislature allocated one-half the construc-tion funding for the building, and the College is anticipating the 2012 Legislature will provide the second half.

Sources of funding to furnish and equip the new building – includ-ing research laboratories, classrooms and space for faculty, staff and students -- are being sought. The College will move its Pullman facilities to Spokane once the building is finished.

Pharmacy undergraduate summer research program receives funding

Funding for an undergraduate summer research program in the College of Pharmacy has been renewed by the American Society of Pharmacology and Experimental Therapeutics.ASPET awarded the College $27,000 – or $9,000 per year – for the next three years and has funded the program for nine of the last 10 years, according to Raymond M. Quock, pharmaceutical sciences department chair.

The College must match the award with $5,000 per year, and the money allows student researchers to be paid a stipend for their 10 weeks of full-time work on research with a faculty mentor who is an ASPET member. Additional College funds and various research grants and fellowships are used to allow more students and faculty who are not ASPET members to also participate in the program. WSU PharmD Class of 2015 Profile• 84 students• 66 students have bachelor’s degrees• Average age is 25.3 years• 57 females, 27 males• 56 students from Washington state• 10 students from California• Other states represented are: Idaho, Oregon, Hawaii, Arizona,

Texas, Utah, Colorado

School news:

“U.S. News & World Report” has ranked the UW School of Pharmacy’s PharmD program 10th in the nation among all pharmacy schools.

The 2012 School of Pharmacy Don B. Katterman Lecture topic will be 'Demonstrating Impact: Making the Case for Pharmacy Services.' It is a panel discussion in which the panelists will offer examples of how to improve health outcomes while also increasing revenue. The panelists are Washington State Pharmacy Association Director of Pharmacy Practice Development Jenny Arnold, Walgreens Co. District Pharmacy Supervisor Daiana Huyen, Katterman’s Sand Point Pharmacy Co-owner and Pharmacist Beverly Schaefer, and Virginia Mason Medical Center Administrative Director of Pharmaceuti-cal Services Roger Woolf. The event is May 8th at 7 p.m. on the UW campus. A reception will take place beforehand at 6 p.m. CE credits are available. Visit www.pharmacy.washington.edu/katterman2012 for more information.

The Pharmaceutical Outcomes Research and Policy Program (PORPP) has created its first ever endowed directorship — the Stergachis Family Directorship. It is named after Andy Stergachis, professor of epidemiology and global health and adjunct professor of pharmacy, and his wife, JoAnn Stergachis, a sales executive with F5 Networks. Andy Stergachis was the founding director of PORPP and former chair of the Department of Pharmacy.

PORPP is also launching an online certificate program in health eco-nomics and outcomes research. Find out more at http://www.pce.uw.edu/certificates/health-economics/web-autumn-2012/. Faculty news

Dean and Professor of Medicinal Chemistry Thomas Baillie has received the 2012 Founders’ Award from the American Chemical Society Division of Chemical Toxicology. The award will be presented at the ACS Fall National Meeting on August 19, 2012 in Philadelphia. As the Founders’ Awardee, Baillie will organize an award symposium highlighting work in his area of research.

With the help of the UW Center for Commercialization, Professor of Medicinal Chemistry Dave Goodlett and Dr. Patrick Langridge-Smith of the University of Edinburgh have formed a company, Deurion LLC, to further develop and make commercially available the Surface Acoustic Wave Nebulization (SAWN) method of mass spectrometry. The Goodlett Lab developed this technology in 2011. In December, Deurion received a $150,000 National Science Foundation grant to continue its work. This grant built on a UW C4C Gap Fund of $50,000 that Goodlett received last summer to construct a prototype SAWN device.

Washington Pharmacy14 Washington Pharmacy 14

School News

Assistant Professor of Pharmaceutics Nina Isoherranen has been elected Secretary/Treasurer of the Drug Metabolism Division of the American Society for Pharmacology and Experimental Therapeutics.Associate Dean Nanci Murphy and pharmacy student Denise Ngo, ’14, received a Project CHANCE award from the American Pharmacists As-sociation-Academy of Student Pharmacists (APhA-ASP). They accepted the award from APhA-ASP and the Pharmacy Services Support Center of the Health Resources and Services Administration in March in New Orleans. This award will help fund an interprofessional student outreach project at Community Health Care in Lakewood.

Pharmacy Student news:

The UW student chapter of the American Pharmacists Association (APhA)-Academy of Student Pharmacists won the Chapter of the Year Award in the AAA division at the APhA convention in New Orleans. The group was honored for their community outreach to tribes, legislative advocacy and international health programs, among other activities.

Elise Fields, ‘12, recently returned from an advanced pharmacy practice experience rotation in Windhoek, Namibia, where the UW has a strong institutional relationship with University of Namibia, the Ministry of Health and Social Services’ Therapeutics Information and Pharmaco-vigilance Centre, and Management Sciences for Health-Namibia. For this experience, Fields received a UW Thomas Francis, Jr. Global Health Fellowship Award.

Kathy Glem, ’13, Cate Lockhart, ’13, Tahlia Luedtke, ’14, and Anne Spen-gler, ’13 won the UW Pharmacy and Therapeutics Competition. Denise Ngo, '14, received a scholarship from the National Association of Chain Drug Stores Foundation for her work supporting continuing education programs that focus on patient-centered care in community pharmacies. Blaze Paracuelles, '14, received a UW Medical Center Martin Luther King Jr. Community Service Award.

grad Student news:

PORPP student Carrie Bennette received a scholarship from the Ameri-can Society of Health Economists to attend the ASHE conference in Minneapolis in June.Veena Shankaran, a student in the Pharmaceutical Outcomes Research & Policy Program (PORPP), has received the PORPP Endowed Prize in Health Economics and Policy. This award recognizes her research on the risk factors for financial hardship in colon cancer patients.

Pharmaceutics graduate students Diana Shuster and Jenna Voellinger each received an Institute of Translational Health Sciences (ITHS) TL1 Multidisciplinary Predoctoral Clinical Research Training award of $21,600 for the upcoming academic year. The ITHS TL1 program spon-sors a year-long intensive clinical/translational research experience for predoctoral students to conduct an original research project.

PORPP student Heidi Wirtz’s project entitled, "Anticholinergic Medica-tion Use, Falls and Fracture in Postmenopausal Women: Results from the Women's Health Initiative" was accepted for an oral podium presenta-tion at the 2012 American Geriatrics Society (AGS) Annual Scientific

Meeting. The project was also named one of the top 50 student-submit-ted abstracts for the meeting. She will receive a travel stipend from AGS to attend the meeting. In addition, this same project was accepted as a podium presentation at the 2012 Southern Pharmacy Administration Conference and the Western Pharmacoeconomic Conference.

Friday, April 13, 20127:00-11:00 pm

University of Washington’s Kane HallWalker-Ames Room

Tickets: $15

Please support professional development of student pharmacists with your attendance or tax-deductible donation.

Contact: Kristine Kim ([email protected])

HoLLywooD Glamour

2012 uPPoW Auction


Sid Nelson

contributed by uW School of Pharmacy dean thomas Baillie

uW mourns one of their own

It is with profound sadness that the UW School of Pharmacy an-nounces that Professor of Medicinal Chemistry and Dean Emeritus Sidney “Sid” Nelson passed away suddenly on Friday, December

9th. He was 66 years old.

It is hard to put into words the impact that Dr. Sid Nelson had on this School, the University, the scientific community and everyone who knew him.

It’s not just about the awards and honors Sid received for his leader-ship, his teaching and his prolific research — and there were many: Dean of the Year from the American Pharmacists Association – Acade-my of Student Pharmacists, American Association of Colleges of Phar-macy Volwiler Research Achievement Award, UW Gibaldi Excellence in Teaching Award, UW School of Pharmacy Distinguished Alumnus Award, John J. Abel Award from the American Society of Pharmacol-ogy and Experimental Therapeutics, and the Frank R. Blood Award in

Toxicology from the Society of Toxicology, to name a few.

Nor is it just about the deep love he had for this School of Pharmacy, his colleagues and our students. Sid was a constant presence at student events, alumni events and industry events over the years. He was an enthusiastic supporter of the people around him — cheer-ing loudly in the audience (along with his wife, Joan) at academic and industry events when our pharmacy students received awards; proudly supporting his Ph.D. students at scientific conferences around the world; regularly nominating his colleagues for prominent scien-tific honors; sending personal notes to alumni and former classmates when he heard exciting updates about their lives; and giving gener-ously to the School of Pharmacy in the form of scholarships and a fund he and his wife created.

Indeed, there are just too many good things to say about Sid to encap-sulate what he meant to all of us. I suppose, when it comes down to it, what we will all miss about him most was his kind spirit. Sid Nelson was a caring, genuine man who made a positive impression on every-one who had the good fortune to know him. The School of Pharmacy is not going to be the same without him. We will all remember his off-color sense of humor, his giant collection of penguin paraphernalia and his enduring authenticity.

Sid himself was an alumnus of the University of Washington School of Pharmacy, graduating in 1968 with a B.S. in pharmacy. He went on to receive a Ph.D. degree in medicinal chemistry from the University of California, San Francisco. He joined the UW School of Pharmacy faculty in 1977.

He was dean of our School from 1994 to 2008. Under his leadership, the School converted from a B.S. degree to an entry-level Doctor of Pharmacy degree program and added a nontraditional approach that enabled existing pharmacists to obtain the Pharm.D. degree. He also evolved the graduate programs and worked tirelessly to expand the School’s faculty. In 2008, he returned full time to his research and teaching activities in the School’s Department of Medicinal Chemis-try. In recent years, Sid held an NIH fellowship to conduct research in metabolomics/metabonomics at Imperial College London and he was named a National University of Singapore distinguished professor.

On a personal note, I had known Sid for some 35 years, having first met him at a scientific conference in Europe while he was a fellow at NIH and I was a young faculty member at the University of London. We be-came good friends and kept in close contact over the years, eventually working together as faculty colleagues in the Department of Medicinal Chemistry at the UW in the 1980s through 1990s. When I returned to the School of Pharmacy in 2008 to take over as dean, I knew I had big shoes to fill, but I also knew that he had left me a remarkable institu-tion that he had played a major role in building — with an exceptional community of faculty, staff, students and alumni.

His death is a major loss to our School, the University of Washington, academic pharmacy nationally, and the global scientific community. It was an honor to know him as an educator, mentor, colleague and friend.

"Students and colleagues of Sid Nelson will recall the large collection of pen-guin paraphernalia in his office. Over the years, he amassed this collection — many of the items were gifts — after he made a stuffed penguin the unofficial mascot of his lab."


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What are your key interests in health

information exchange (hie)?

The collaboration between the Washington State Pharmacy Association (WSPA) and OneHealthPort is entering a new phase. Over the past year Sue Merk, WSPA member, Senior

Vice President at OneHealthPort and the person leading the statewide HIE effort has spoken in a number of WSPA venues. She has described the early stages of the HIE and shared some initial thoughts about how the HIE can benefit Pharmacists. Sue’s experience and the tremendous feedback she received have convinced OneHealthPort of the need to explore the HIE issue in greater depth with the Pharmacy Community.

OneHealthPort and WSPA discussed a variety of approaches to gather information with an eye toward tailoring an HIE offering specifically to Pharmacy. Ultimately, both groups decided what was needed was more than a survey, what was needed was a conversation. To facilitate this conversation, OneHealthPort was very pleased to discover just the right person at just the right time. At the end of March, Susan Boyer will complete her work as Executive Director of the Washington State Board of Pharmacy and become an independent consultant. OneHealthPort has secured Susan’s services to lead a conversation with the Pharmacy Community about the HIE opportunity.

As OneHealthPort has worked to deploy the HIE in Washington state, it has gained a number of insights. One key insight has been the emergence of “Communities of Interest.” By definition HIE is an “exchange,” it is not a solitary activity within a single enterprise, it is at least two and often multiple organizations that come together around a specific information need. These organizations share a common interest in electronic health information exchange and so form a “community.” The interests can be:

• Geographical – health care organizations located near each other that want to form a local network

• Transactional – different enterprises that want to exchange a specific data set

• Business based – satisfying a key business or grant requirement

The key question Sue Merk and Susan Boyer will be exploring is what are the highest priority communities of interest for Pharmacy with the HIE? Some possibilities might be:

• Using a common referral management form to share information with physicians about adverse drug reactions or patient compliance.

• Connecting groups of local pharmacists with their local physician trading partners to do eprescribing without those expensive transaction fees

Learning more about these ideas and most importantly filling in that last blank with new ideas is what Susan Boyer’s engagement for OneHealthPort is all about. OneHealthPort wants to understand:

• How current arrangements with SureScripts and others are working or not?

• What Pharmacy information exchange needs are currently being met, where?

• What urgent information exchange needs are not being addressed with current solutions?

The HIE is a flexible, low-cost exchange service. This is your chance to create a community of interest around your exchange needs, with your key trading partners and solve your pressing problems.

Susan will begin her work on OneHealhPort’s behalf in mid-April. At that time she’ll be reaching out to the Pharmacy Community. In the interim you can check out the latest news about the HIE at:

http://www.onehealthport.com/HIE/index.php

OneHealthPort and WSPA are both looking forward to the upcoming conversation beginning in April.

Health Information Exchange (HIE)Q&A on hie


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Thomas A. Gossel, R.Ph., Ph.D., Professor Emeritus, Ohio Northern University, Ada, Ohio andJ. Richard Wuest, R.Ph., PharmD, Professor Emeritus, University of Cincinnati, Cincinnati, Ohio

Gossel Wuest

continuing educat ion for pharmacists

Rest less Legs Syndrome and ManagementVolume XXX, No. 2

Dr. Thomas A. Gossel and Dr. J. Richard Wuest have no relevant financial relation-ships to disclose.

Goal. The goal of this lesson is to review restless legs syndrome, with emphasis on presenting key points of information to pass along to patients.

Objectives. At the completion of this activity, the participant will be able to:

1. demonstrate knowledge of restless legs syndrome including its causes and triggers, epidemiology and prevalence, pathogenesis, and clinical impressions;

2. explain the mechanism of action and major adverse events associated with the drugs used in treating restless legs syndrome;

3. select nonpharmacologic measures that are reported to modify symptoms of restless legs syndrome; and

4. demonstrate an understand-ing of information relative to restless legs syndrome to convey to patients and their caregivers.

Background Restless legs syndrome (RLS), also known as Ekbon’s syndrome, was named after Swedish neurolo-gist/physician Karl Ekbon. In the mid-1940s, Ekbon described the condition as a common and dis-tressing condition, but one that is readily treatable. Two to 15 per-cent of the general population of

the United States may experience RLS symptoms, although the exact prevalence may be much higher because it is generally held that many patients fail to discuss their symptoms with healthcare provid-ers. Patients may believe their condition is too insignificant with which to bother their physician, or they may not recognize that RLS can be symptomatic of more serious pathology that requires physician intervention. A sensorimotor (both sensory and motor) neurologic movement disorder, RLS causes patients to experience an almost irresistible urge to move their legs. Usually worse during periods of inactivity or rest, walking or other physical activity involving the legs can usually alleviate the sensa-tions. Often associated with a sleep complaint, the inability to rest can have a negative impact on the patient’s quality of life due to agita-tion, discomfort, frequent wak-ing, chronic sleep deprivation and stress. These conditions, in turn, can negatively affect job perfor-mance, social activities, and family life. Disturbed sleep and inability

to tolerate sedentary activities can lead to a compromised ability to enjoy life, and serious problems maintaining relationships.

RLS hardly receives the atten-tion it deserves. It has attracted lit-tle attention in medical textbooks until recently. A study conducted jointly in the United States and Europe suggests that the condi-tion is not only under-reported, but also greatly under-diagnosed and under-treated. A 1996 report described the outcome of a group of patients who delayed seeking medical help for many years, but even after they did receive help, ac-curate diagnosis frequently took a decade or more. The Restless Legs Syndrome Foundation has taken account of these observations and often reminds its constituency that RLS is “the most common disorder you have never heard of!”

This lesson describes RLS, including its clinical features and medical management. It stresses information that will be useful not only to pharmacists, but also to patients who experience the condi-tion.

Epidemiology and Prevalence RLS can affect persons of any race or ethnic group, but it is more com-mon in persons of Northern Euro-pean descent. African Americans are affected significantly less often than Caucasians. Its prevalence is distinctly lower in Asian popula-tions, ranging from 0.1 percent in


Singapore to 4.6 percent in elderly Japanese. Epidemiological studies in the general population of the United States and Europe show widely different prevalence rates, probably related to the variety of experimental design. Prevalence of RLS among patients in primary care settings has also been esti-mated. Results from a large survey of primary care centers in Europe and the United States reported that overall, 11.1 percent of pa-tients experienced any degree of RLS symptoms, while 9.6 percent reported symptoms at least once weekly.

RLS has a variable age of onset with prevalence increasing with advancing age. It can also occur in children. Studies confirm that in patients with severe RLS, one-third to two-fifths experienced their first symptoms before age 20 years, although a precise diagnosis of RLS was made much later. Women are twice as likely as men to develop RLS.

Etiology and Pathophysiology Although RLS is a disorder of the central nervous system, it is not a psychophysiologic pathology; how-ever, it may contribute to or be ex-acerbated by such conditions. RLS can generally be categorized into primary (idiopathic) and secondary forms. Primary RLS is not related to other identifiable abnormalities; secondary RLS is associated with an underlying pathology. When no specific cause can be identified for initiating RLS symptoms, it is considered a primary condition.

It is thought that RLS may be due to dysfunction of dopamine-producing cells in the nigrostriatal areas of the brain. Pharmacologic studies have shown a dramatic improvement in RLS symptoms with administration of levodopa, the precursor of dopamine, or with dopaminergic agonists that act on dopamine receptors in the brain. Conversely, dopamine antagonists will worsen symptoms in patients with RLS. Advanced brain imaging has revealed decreased dopamine D2 receptor binding in the striatum of patients with RLS. Hypoactive dopaminergic neurotransmission in RLS has recently been demon-strated and study results suggest that both striatal and extrastriatal brain regions are involved.

The high incidence (40 to 60 percent) of familial cases of RLS strongly suggests a genetic origin for primary RLS, especially if the condition onsets at an early age. Family and twin studies have proposed both autosomal-dominant as well as recessive modes of in-heritance. Genetic studies suggest several chromosomal loci associ-ated with RLS. At present, five loci have been mapped for RLS in single families, and three suscep-tibility loci have been identified in a genome-wide association study. Secondary causes of RLS are more common in persons who develop symptoms for the first time in later life; secondary RLS occurs in over 70 percent of persons with onset at age 65 years or more. It is impor-tant to rule out secondary RLS

when attempting to control symp-toms.

Secondary Causes. A number of secondary causes of RLS have been identified. For example, symp-toms of RLS may be associated with iron deficiency. A patient’s iron stores may be deficient with-out causing anemia. Studies have shown that decreased iron stores (i.e., ferritin levels below 50 µg/L) can exacerbate RLS symptoms. Iron is an essential cofactor for tyrosine hydroxylase, the rate-lim-iting enzyme for dopamine synthe-sis. Animal studies demonstrate that iron deficiency is associated with hypofunction of dopamine D2 receptors that is corrected by iron replacement. The fact that the extent of iron deficiency correlates well with symptoms and that iron is an effective therapy, at least in iron-deficient patients, provide strong support for the role of iron deficiency in the pathogenesis of some patients with RLS. Physi-cians often order serum ferritin levels in patients with newly diag-nosed RLS or RLS patients with a recent exacerbation of symptoms. Once iron levels are corrected (dis-cussed subsequently), symptoms are reduced.

RLS has been reported in per-sons with spinal cord and periph-eral nerve lesions, and in patients with vertebral disc disease. The exact pathological mechanism remains unknown.

RLS occurs in up to one-half of patients with end-stage renal fail-ure. Symptoms may be especially bothersome during dialysis when the patient is in a forced resting position. Improvement in RLS symptoms has been shown after renal transplantation.

One in five women experi-ence symptoms during pregnancy, especially in their last trimester. Some women, in fact, report RLS for the first time during pregnancy. Symptoms can be severe, but usu-ally subside within four weeks postpartum.

RLS symptoms may be wors-ened or unmasked by a variety of medications (Table 1). As a group,

Table 1Drugs reported to

exacerbate RLS

• Alcohol• Analgesics (NSAIDs, non-opioid)• Anesthetics (bupivacaine, mepivacaine)• Anticonvulsants (methsuximide, phenytoin, topiramate, zonisamide)• Antidepressants (mirtazapine, SSRIs, trazodone, tricyclics, venlafaxine)• Antihistamines (older)• Antipsychotics (clozapine, olanzapine, quetiapine, risperidone)• Beta-adrenergic blockers (pindolol)• Caffeine• Donepezil• Interferon-alfa/ pegylated interferon-alfa• Levothyroxine• Lithium• Methadone (withdrawal)• Metoclopramide• Nicotine• Sodium oxybate


antidepressants are the drugs most commonly implicated in secondary RLS with almost all classes report-ed to worsen symptoms. Persons with RLS who take one or more of the listed drugs are advised to discuss with their physician the possibility of changing medications to improve symptoms.

Clinical Assessment A diagnosis of RLS is based pri-marily on a careful patient history and detailed physical and neuro-logical examination. There is no laboratory test that can affirm the presence of RLS. The patient’s physical examination is often normal, except for those who have symptomatology suggestive of a secondary form of RLS or a comor-bid condition.

Symptoms may be described by patients as ranging from mild to intolerable. Due to the subjective nature of the disorder, however, patients often experience difficulty in describing their symptoms. Oftentimes their sensation defies description (Table 2). Confirmation of RLS is not easy. A population study showed that a large number of patients do not seek medical aid because of their motor condition, but rather because of the conse-quences of their disorder such as insomnia or decreased quality of life.

Most patients with RLS ex-perience the feelings in their

lower legs (calves); however the aggravating sensations may also occur any place in the legs or feet. They may also occur in the arms or elsewhere. The feelings seem to originate from deep within the limbs, rather than from the joints, or on the surface. The sensations are usually bilateral, but may oc-cur in one leg, move from one leg to the other, or affect one leg more than the other. The pain is more of an ache rather than sharp, jab-bing pain. Symptoms are generally worse in the evening and night, and less severe in the morning. Symptoms appear with rest, sitting or lying down. The more comfort-able the patient is, the more likely it is that RLS symptoms will occur. The reverse is also true – the less comfortable the patient is, the less likely it is that symptoms will on-set. As a result, some patients may prefer to sleep on a hard surface including the floor rather than in a comfortable bed. The condition should be distinguished from sleep-related disorders of the legs.

Periodic Limb Movements in Sleep. The presence of repeti-tive and highly stereotypic periodic limb movements in sleep (PLMS) supports, but does not confirm, a diagnosis of RLS. PLMS is also known as periodic limb move-ments and periodic limb movement disorder, and was formerly referred to as myoclonus. PLMS is noted as repetitive movements, typically in the lower limbs, that occur every 20 to 40 seconds. Symptoms can also occur in the arms. Hundreds of these involuntary, rhythmic muscular jerks in the lower limbs may occur, sometimes throughout the night. Affected persons are often not aware they are experienc-ing the movements. In a person with severe RLS, these involuntary kicking movements may also occur while awake. PLMS is common in older adults, even those without RLS, and doesn’t always disrupt sleep. Eighty percent of persons with RLS also experience PLMS, which correlates with RLS sever-ity, but less than half of those with PLMS also have RLS.

Essential Criteria that Con-firm RLS. The International Rest-less Legs Syndrome Study Group in collaboration with the National Institutes of Health has estab-lished criteria for diagnosis of RLS

Table 2Terms patients may use

when describing RLS symptoms

Aching Flowing waterBurning NumbBuzzing PainfulCramping PullingCrawling RestlessCreeping SearingDrawing TenseElectric current-like TinglingGnawing TuggingIndescribable UncomfortableItchingFeeling of worms or bugs crawling under my skin

Table 3Criteria for diagnosis

of RLS

Diagnostic criteria*

•Compelling urge to move the limbs, usually associated with paresthesias/dysesthesias•Motor restlessness as noted in activities such as floor pacing and rubbing the legs•Symptoms present or worse during rest, with temporary relief by activi-ties such as walking or stretching, at least as long as the activity continues•Symptoms worse in evening and at night than during the day, or occur only in the evening or night

Supportive clinical features± •Sleep disturbance and daytime fatigue•Normal neurological examination in primary RLS•Involuntary, repetitive, periodic, jerking limb movements during sleep or while awake•Positive family history of RLS•Positive response to dopaminergic therapy

Associated features§ •Natural clinical course: Onset age is variable, in patients with earlier onset (<50 years) the symptoms are insidious, while patients with later onset have a more aggressive course. RLS is usually a chronic disease with a progressive clinical course; in the mildest forms of RLS, the clinical course can be static or intermittent.•Sleep disturbances: disturbed sleep is usually associated with RLS.•Medical evaluation/Physical exami-nation: physical and neurological ex-amination is generally normal (except for secondary RLS). Medical evalua-tion should be addressed to identify possible causes for secondary RLS.

*Minimal criteria for positive diagnosis of RLS±Supportive clinical features common in RLS but not required for diagnosis§These features may provide additional information about the patient’s diagnosis


(Table 3). Four essential criteria must be present to establish a posi-tive diagnosis. A mnemonic to help remember these points is URGE: Urge to move, Rest induced, Gets better with activity, Evening and night accentuation. In the absence of the core clinical features of RLS, a positive diagnosis of RLS cannot be made, and other causes of PLMS or isolated periodic limb movement disorder must be considered. The relation between PLMS and RLS is unclear, but treatments used for RLS may also be effective in PLMS as well. The presence of supportive and associated clinical features as shown in Table 3 is not necessary for a positive diagnosis, but they are definitely helpful to the differ-ential diagnosis.

Differential Diagnosis. RLS should be differentiated from other conditions including:

•Nocturnal Leg Cramps. These typically include painful, palpable, involuntary muscle contractions, often focal, with a sudden onset. Nocturnal leg cramps are usually unilateral.

•Akathisia. This is a closely re-lated disorder, described as a condi-tion of motor restlessness, ranging from a sense of inner disquiet, to inability to sit or lie quietly or to sleep, with no sensory complaints. The restlessness is generalized and internal rather than localized to the limbs and associated with par-esthesias. Akathisia often does not correlate with rest or time of day, and often results as a side effect of medication such as neuroleptics or other dopamine blocking agents.

•Peripheral Neuropathy. This can cause leg symptoms that are different from RLS. Symptoms are usually neither associated with motor restlessness nor lessened by movement. The condition is not worse during the evening or night-time. Sensory complaints include numbness, tingling or pain. Small fiber sensory neuropathies such as those seen in diabetes mellitus may be confused with RLS. Patients with neuropathies may have both neuropathic and RLS symptoms.

•Vascular Disease. Conditions

such as deep vein thrombosis can be confused with RLS.

RLS in Children Although RLS is generally dis-cussed as a disease of adults, over the past 20 years there has been increasing recognition that it also occurs in children. Adults with the diagnosis often retrospectively recall having had symptoms during their childhood. Case series have described children as young as 18 months of age with features of RLS.

Diagnosing RLS in children is particularly difficult because clini-cians rely heavily on the patient’s description of symptoms. Even for adults with RLS, an accurate de-scription of its subjective symptoms may be difficult. Children may describe RLS symptoms differently than adults, using terms such as oowies, ouchies, tickle, spiders, twitchy, jerky, boo-boos, want to run, and a lot of energy in my legs. Or, children may have at least two of the following: sleep disturbance, a biological parent or sibling with RLS, or polysomnographic-docu-mented PLMS. Determining RLS in children can be aided using the same four criteria as for adults (see Table 3).

According to a recent survey of more than 10,000 families in the United States and the United Kingdom, RLS affects about 2 percent of children. A pediatric RLS prevalence of 5.9 percent was noted at one pediatric sleep disor-ders clinic. Another study found a prevalence of 1.3 percent in 12 pediatric practices, and another re-ported its occurrence in 6.1 percent of Canadian children ages 11 to 13 years. The U.S./U.K. study found a strong genetic component to RLS. More than 70 percent of children with RLS had at least one parent with the condition. There is also evidence suggesting that children with attention deficit hyperactiv-ity disorder (ADHD) and a family history of RLS are at risk for more severe ADHD.

Most children with RLS do not require pharmacologic treatment

and indeed, there are no FDA-approved drugs for use in children with RLS. Case histories and anecdotal reports suggest it is best to begin with good sleep hygiene measures, cognitive behavioral therapy and caffeine restriction (including restriction of caffeinated soft drinks). If these measures are ineffective, screening for anemia and checking the patient’s serum ferritin level makes sense. For children, elemental iron in doses of 3 mg/kg/day given for three months was shown to improve PLMS and clinical symptoms, but more data are needed to determine effective-ness in pediatric RLS. Dopaminer-gic drugs used “off-label” in chil-dren have been shown to improve RLS symptoms. In cases of associ-ated ADHD, dopaminergics may benefit ADHD symptoms as well.

Treatment in Adults There is no cure for primary RLS. Both nonpharmacologic measures and pharmacotherapy, however, are helpful in relieving symptoms in many patients. It is important to note that both severity and frequency of RLS are variable; therefore, nonpharmacologic thera-pies alone may be appropriate for milder forms of RLS and indeed, these measures should be consid-ered first in all but the most severe cases. It is also important to note that many pharmacologic agents are used in an “off-label” basis. Successful treatment for secondary RLS requires treating the underly-ing cause. Goals of treatment are to prevent or relieve symptoms, increase the amount and improve the quality of sleep, and treat or correct any underlying condition that may trigger or worsen RLS.

Lifestyle and Behavioral Changes. For those with mild-to-moderate symptoms, prevention is key to their control. In gen-eral, simple lifestyle changes that promote good health can play an important role in alleviating symp-toms of RLS. The measures listed in Table 4 may help reduce the discomfort and excessive leg move-ments. The websites listed in Table


5 provide valuable information that can be passed along to patients.

Pharmacologic. Although nonpharmacologic strategies may work for some patients with milder symptoms, most individuals with mild-to-moderate symptoms will require medication to help make symptoms tolerable. Medical management of RLS is a rap-idly developing field. Large-scale multicenter trials in RLS became common only since the beginning of the 21st century. To date, only three drugs have earned FDA approval for RLS: ropinirole (Requip®) in May 2005, pramipexole (Mirapex®) in November 2006 and gabapentin enacarbil (Horizant™) in April 2011. Since symptom severity var-ies greatly between patients, no single medication or combination of drugs will work predictably for all

patients. Treatment must there-fore be individualized. Selection of pharmacologic agents is influenced by a number of factors, including:

•Patient Age. Benzodiazepines, for example, may cause cognitive impairment in elderly patients.

•Symptom Severity. Patients with mild symptoms may elect to forgo using medications due to cost, adverse effects or other reasons. Others may benefit from a dop-aminergic agent or a dopamine agonist. Severe symptoms may require a strong opioid.

•Symptom Frequency. Persons with infrequent symptoms may benefit greatly from a single dose of medication given on an as-needed basis, such as an opioid or levodo-pa.

•Pregnancy. Neither safety nor efficacy of medications for RLS has been assessed in clinical trials involving pregnant women.

•Renal Failure. Most pharma-cologic agents are generally safe in patients with renal failure, al-though dose frequency and quanti-ty may be modified if the drugs are excreted via the kidney. Moreover, for dialysis patients, some medica-tions are dialyzable (e.g., gabapen-tin) while others are not.

Dopaminergic Agents. Discovery that levodopa was ef-fective in RLS revolutionized its management. Every dopaminergic agent tested has been shown to be effective against RLS and PLMS. Levodopa/carbidopa (Sinemet®, and others) provides near-immediate relief from RLS. The response is so characteristic that a brief course of therapy may be considered in patients whose diagnosis of RLS is in doubt. Levodopa is also effec-tive in hemodialysis patients with RLS. In general, the drug is very well tolerated. Levodopa-induced dyskinesias have not been reported in RLS patients.

Two troublesome and common problems develop with prolonged use of levodopa, which limits the value of this otherwise almost ideal agent for RLS: rebound and aug-mentation. Rebound is an outcome of the drug’s short half-life; after

a while, patients start to awaken early in the morning with recur-rence of their RLS. Sustained-re-lease formulations can delay onset of rebound until later in the morn-ing, although the long-term efficacy of this approach remains unknown. Augmentation is more serious. It may shorten symptom-free periods at rest. Also, symptoms develop earlier in the day (morn-ing or afternoon instead of evening or night) and may become more severe; and symptoms may develop in parts of the body that were not previously involved. Augmenta-tion occurs in up to 80 percent of patients treated with levodopa as early as four weeks into treatment. Approximately one-third have sufficiently severe symptoms that warrant a change in therapy. The precise mechanisms contributing to augmentation are unknown. The need for higher doses of levodopa and development of more severe RLS may predict development of this complication. Levodopa is, therefore, no longer the treat-ment of choice for RLS, although it remains a therapy of choice for persons with only intermittently severe symptoms.

Dopamine Receptor Ago-nists. These are now regarded as the first-line treatment for RLS.

Table 4 Nonpharmacologic

management of RLS

•Identify any underlying disorders and treat, if feasible•Eliminate precipitants of RLS -Drugs (see Table 1) -Common stimulants and depres- sants: caffeine, alcohol, nicotine•Practice good sleep hygiene -Establish regular sleep and wake times -Restrict bed to sleep and intima- cy; remove TV, stereo -Avoid perturbing activities immediately before sleep -Avoid bright lights in late evening or night -Have a light snack before bedtime•Apply simple behavioral interventions -Brief walk before bedtime -Hot bath or cold shower -Massage limbs -Practice meditation and/or yoga -Avoid heavy meals within 3 hours of bedtime -Avoid excessive napping during daytime•Moderate exercise: neither inactivi-ty nor unusual and excessive exercise•Weight management: healthy diet and adequate activity•Information and support: use web-sites and patient support groups (see Table 5)

Table 5Support groups for RLS

•Restless Legs Syndrome Foundationwww.rls.org

•Worldwide Education and Aware-ness for Movement Disorders (WE MOVE)www.wemove.org

•National Sleep Foundationwww.sleepfoundation.org

•National Institute of Neurological Disorders and Stroke (NINDS)www.ninds.nih.gov/disorders/restless_legs/restless_legs.htm

•National Heart, Lung and Blood Institute (NHLBI)www.nhlbi.nih.gov/health/dci/Diseases/rls/rls.htm


The non-ergot agonists ropinirole and pramipexole have been shown to benefit RLS in randomized con-trolled trials. There is no indication based on the numerous compara-tive clinical trials reported for the dopamine receptor agonists that efficacy of one agent is better than another. The drugs are chemically distinct from dopamine, but their mechanism of action in the central nervous system is similar to that of the endogenous neurotransmitter.

Studies suggest that the drugs are well tolerated in patients with severe RLS who have failed other therapies and in those with aug-mentation. Augmentation and tolerance have been reported, although at a much lower inci-dence than seen with levodopa, and they seem more likely to occur in patients who previously developed similar problems with levodopa. Dose reduction may be required if augmentation or tolerance develop, but, unlike with levodopa, a change in medication is rarely needed. Several reports of unusual compul-sive behaviors occurring in persons taking dopamine receptor agonists include pathological gambling and increased sexuality.

Other Medications. The therapeutic effect of opioids is well known. Intermittent use of low-potency opioids or opioid recep-tor agonists, usually taken before bedtime, can be effective. Studies have shown positive short-term and long-term responses of various opioids. In severe disease, opioids may be considered a second-choice treatment after dopaminergic agents. There is a chance for de-pendence, and these drugs should be used with caution in persons with a history of addiction.

Benzodiazepines or benzo-diazepine receptor agonists, taken before sleep, may be use-ful. This is especially relevant if the patient has another cause of poor sleep in addition to RLS, such as psychophysiologic insom-nia. Most data have been derived with clonazepam (Klonopin®, and others). Some investigators have shown this drug to be well toler-

ated in older patients; however, its long duration of action may result in more adverse effects, such as an unsteadiness leading to falls during the night and drowsiness or cognitive impairment in the morn-ing.

Antiepileptics including carbamazepine (Tegretol®, and oth-ers) and gabapentin (Neurontin®, and others), have been reported to be efficacious in treating RLS, but are not commonly used in clinical practice due to their high incidence of adverse effects. Antiepileptics may be effective in patients with RLS who also suffer from painful paresthesias or underlying neur-opathy. The most recently ap-proved drug for RLS, gabapentin enacarbil (Horizant™) is a prodrug of gabapentin and accordingly, its therapeutic effects in RLS are at-tributable to gabapentin.

The management of RLS continues to evolve as new drugs become available. Cabergoline (Dostinex®, and others), a dop-amine agonist, is of interest be-cause of its long half-life (65 hours). This theoretically might produce less augmentation. Magnesium has been reported in a small open-label trial to be an effective therapy for RLS.

Selecting the Best Treat-ment for a Particular Patient. This usually proceeds in a “hit or miss” manner. Drugs should be used at their lowest effective dose, and only when necessary should the dose be slowly titrated upward. Medication should be taken early enough to permit absorption and action before the onset of sleep. Divided doses may be needed, often provided with the evening meal and later at night. If the first drug does not work, then a second agent with a different mode of action should be substituted. Sometimes a combination of medications works better than any single agent.

Iron Replacement in Sec-ondary RLS. As noted earlier, a serum ferritin concentration below 45 to 50 µg/L has been associated with increased severity of RLS. A common treatment regimen

is 325 mg ferrous sulfate three times daily along with 100 to 200 mg vitamin C with each dose to enhance absorption. Oral iron can cause constipation and abdominal discomfort, and the dose may need to be reduced in some patients. Oral iron should ideally be taken on an empty stomach to enhance absorption. If gastrointestinal symptoms develop, it should be taken with food. Follow-up ferri-tin determinations are indicated, initially after three to four months and then every three to six months until the serum ferritin level is greater than 50 µg/L. Iron therapy can then be discontinued. For patients with severe iron deficiency (ferritin ≤10 µg/L) and oral iron intolerance, intravenously admin-istered iron can be considered. Of note is that RLS does not always respond to an increasing serum fer-ritin concentration, even if it was low initially.

Prognosis RLS is usually a lifelong condi-tion that has no cure. Although it has a variable course, symptoms may gradually worsen with age, albeit more slowly for those with the primary form of RLS than for patients who also suffer from an associated medical condition. Nonetheless, current therapies can control RLS, minimizing symptoms and maximizing periods of restful sleep. Some patients experience remissions, periods during which symptoms decrease or disappear for days, weeks or months; how-ever, symptoms usually reappear. A diagnosis of RLS that onsets dur-ing adulthood does not indicate the onset of another neurologic disease. Individuals with RLS secondary to an underlying condition may note resolution of symptoms when their underlying condition is treated. Medication, when needed, usually provides relief of symptoms.

Summary and Conclusions RLS is a common but under-recog-nized disorder associated with dis-comfort in the legs that is hard to describe and a distressing urge to


Program 0129-0000-12-002-H01-PRelease date: 2-15-12

Expiration date: 2-15-15CE Hours: 1.5 (0.15 CEU)

The authors, the Ohio Pharmacists Foundation and the Ohio Pharmacists Association disclaim any liability to you or your patients resulting from reliance solely upon the information contained herein. Bibliography for ad-ditional reading and inquiry is avail-able upon request.

This lesson is a knowledge-based CE activity and is targeted to pharmacists in all practice settings.

The Ohio Pharmacists Foundation Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

move them. It increases in frequen-cy with aging, but is also found in children. Sleep disruption in RLS may impact daytime functioning and quality of life. For patients with mild symptoms, no drug treat-ment may be necessary; nonphar-macologic measures may be all that is needed. In patients with moder-ate to severe, troublesome symp-toms, a dopamine receptor agonist is the current treatment of choice, although it should be noted that there have been few satisfactory studies comparing different phar-macotherapies. If dopamine ago-nists are poorly tolerated or ineffec-tive, levodopa may be a satisfactory option for many people, especially for those with intermittent symp-toms, such as during a long trip or sitting through a boring lecture! It takes only 15 to 30 minutes to be-come effective, and augmentation is not a risk with intermittent use.

neW requirement for ce Participants: cPe monitordo you have your nABP eProfile id number?CPE Monitor is a national, collaborative effort by NABP and the Accreditation Council for Pharmacy Education (ACPE) to provide an electronic system for pharmacists and pharmacy technicians to track their completed continuing pharmacy education (CPE) credits. It will also offer state boards of pharmacy the opportunity to electronically authenticate the CPE units completed by their licensees, rather than requiring pharmacists and technicians to submit their proof of completion statements upon request or for random audits. This initiative will streamline processes for pharmacy practitioners to ensure they are maintain-ing professional competency requirements. CPE Monitor is expected to save pharmacists, pharmacy technicians, state boards of pharmacy, and CPE providers time and money.

Pharmacists and pharmacy technicians will receive a unique ID after setting up their e-Profile with NABP. As ACPE-accredited providers begin transitioning their systems to CPE Monitor throughout 2012, pharmacists and pharmacy technicians will need to begin providing their NABP e-Profile ID and date of birth to the provider when they register for CPE or submit a request for credit. The system will then direct electronic data from ACPE-accredited providers to ACPE and then to NABP, ensuring that CPE credit is officially verified by the providers. Once information is received by NABP, pharmacists and pharmacy techni-cians will be able to log in to access information about their completed CPE activities. After a transition period, ACPE-accredited CPE providers will no longer be required to distribute statements of credit.

In addition, boards of pharmacy will be able to request reports on their licensees, elimi-nating the need for pharmacists and technicians to send paper copies of CPE statements of credit. Instead, records kept in CPE Monitor will be sent to the boards for CPE activities taken from ACPE-accredited providers.

In Phase 2 of the CPE Monitor initiative, CPE Monitor will add a function to record CPE from providers not accredited by ACPE in addition to CPE activities from ACPE-accredited provid-ers. Until Phase 2 is completed, pharmacists and technicians will need to submit proof of completion of CPE from providers not accredited by ACPE directly to the board of phar-macy when required to do so.

To prepare for the new process, pharmacists and technicians are encouraged to obtain their NABP e-Profile ID now to ensure their e-Profile is properly setup. Many ACPE-accredit-ed CPE providers are now requiring pharmacists and pharmacy technicians to submit their e-Profile ID and date of birth to receive credit for completed CPE.

To get you NABP e-Profile ID number, go to www.nabp.net.

Once you obtain your NABP e-profile ID number, don’t forget to log in and update your WSPA profile at www.wsparx.org.

February 2012

continuing educat ion quiz Rest less Legs Syndrome and Management

Program 0129-0000-12-002-H01-P0.15 CEUPlease print.

Name________________________________________________

Address_____________________________________________

City, State, Zip______________________________________

Email_______________________________________________

NABP e-Profile ID*__________________________________*Obtain NABP e-Profile number at www.MyCPEmonitor.net.

Birthdate____________ (MMDD)

Return quiz and payment (check or money order) to Correspondence Course, OPA,

2674 Federated Blvd, Columbus, OH 43235-4990

Completely fill in the lettered box corresponding to your answer.1. [a] [b] [c] [d] 6. [a] [b] 11. [a] [b] [c] [d]2. [a] [b] [c] [d] 7. [a] [b] [c] [d] 12. [a] [b] [c] [d] 3. [a] [b] 8. [a] [b] [c] [d] 13. [a] [b] 4. [a] [b] [c] [d] 9. [a] [b] 14. [a] [b] [c] [d] 5. [a] [b] [c] [d] 10. [a] [b] [c] [d] 15. [a] [b] [c] [d]

I am enclosing $10 (member); $15 (nonmember) for this month’s quiz made payable to: Ohio Pharmacists Association.1. Rate this lesson: (Excellent) 5 4 3 2 1 (Poor)2. Did it meet each of its objectives? yes no If no, list any unmet_______________________________3. Was the content balanced and without commercial bias? yes no4. Did the program meet your educational/practice needs? yes no5. How long did it take you to read this lesson and complete the quiz? ________________ 6. Comments/future topics welcome.

1. Restless Legs Syndrome (RLS) is: a. a motor disorder. b. a sensory disorder. c. both a motor and a sensory disorder. d. neither a motor nor a sensory disorder. 2. RLS is more common in which of the following groups of people? a. African Americans c. Asian Americans b. Northern Europeans d. Southern Europeans

3. RLS is NOT a psychophysiologic pathology. a. True b. False 4. An essential cofactor for tyrosine hydroxylase, the rate-limiting enzyme for dopamine synthesis, is: a. magnesium. c. calcium. b. iodine. d. iron.

5. The group of drugs most commonly implicated in secondary RLS is the: a. antidepressants. c. antipsychotics. b. antiepileptics. d. antirheumatics.

6. Diagnosis of RLS can be easily determined by a spe-cific laboratory test. a. True b. False 7. Periodic limb movement disorder was formerly re-ferred to as: a. dyskinesia. c. myoclonus. b. intermittent claudication. d. Raynaud’s disorder.

8. The condition characterized by symptoms that are usually neither associated with motor restlessness nor lessened by movement is: a. akathisia. b. intermittent claudication. c. nocturnal cramps. d. peripheral neuropathy.

9. Most children with RLS require pharmacologic treat-ment. a. True b. False 10. All of the following are considered to be good sleep hygiene management EXCEPT: a. avoid bright lights in late evening or night. b. establish regular sleep and wake times. c. avoid perturbing activities immediately before sleep. d. do not eat anything after the evening meal.

11. All of the following drugs have been approved for treating RLS EXCEPT: a. gabapentin. c. quinine. b. pramipexole. d. ropinirole.

12. Which of the following drugs is dialyzable? a. Gabapentin c. Quinine b. Pramipexole d. Ropinirole

13. The troublesome and common problem that develops with prolonged use of levodopa that is more serious is: a. augmentation. b. rebound. 14. Which of the following is regarded as first-line treat-ment for RLS? a. Benzodiazepines b. Dopamine receptor agonists c. Dopaminergic agents d. Opioids

15. Most data on the use of benzodiazepines to treat RLS have been derived with: a. alprazolam. c. clonazepam. b. chlordiazepoxide. d. diazepam.

To receive CE credit, your quiz must be postmarked no later than Feb-ruary 15, 2014. A passing grade of 80% must be attained. CE state-ments of credit are mailed February, April, June, August, October, and December until the CPE Monitor Program is fully operational. Send inquiries to [email protected].

*This is not a claims reporting site. You cannot electronically report a claim to us. To report a claim, call 800.247.5930.**Compensated endorsement.Not all products available in every state. The Pharmacists Life is licensed in the District of Columbia and all states except AK, FL, HI, MA, ME, NH, NJ, NY and VT. Check with your representative or the company for details on coverages and carriers.

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PharmacistFull or part-time for independent Compound-ing Pharmacy located in Long Beach, WA, a PCCA Member.

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Rx and The Law

By don mcguire, r.Ph., J.d.

recordKeePing iSn’t thAt imPortAnt, iS it?

Terry at Midtown Pharmacy was dealing with another recurring frustration. Their usual generic brand of atenolol was backordered again. Terry ordered in a couple of 100 count

bottles to hold them over until their usual brand was available again. Terry didn’t bother to update their computer database to reflect this change because she would then just have to change it back again 2 days from now. The change isn’t really that important anyway, right?

Wrong. Your documentation is the only thing you will have later to prove what you did today. We all forget things, especially when they come up weeks or months later. Consider the following claim scenario.

A pharmacy was sued by a former patient over some faulty transdermal fentanyl patches. The patient alleged that he was injured due to the patch releasing the medication too quickly. The patient’s profile indicated that he received the patch manufactured by company A. Company A’s product had in fact been recalled due to this very problem. The patient was sure that the excessive dose delivered had caused him to be hospitalized. The pharmacy staff went through months of anxiety and expense while producing records and being deposed. What everyone learned at the end was that the patch received by the patient wasn’t manufactured by company A. He had received patches manufactured by company B. This was discovered when reviewing the invoices from the time period in question. Company B’s product had been purchased because of the recall of company A’s patches. However, the patient profile indicated that the patient had received Company A’s patches. Proper recordkeeping would have most likely prevented this pharmacy from suffering through months of litigation.

A second consideration here is billing. In today’s world, it is more important than ever to bill for what was actually dispensed. Third party payers expect and demand that their customers receive the product that is billed to the third party payer. While the 2 different fentanyl patches discussed above may be clinically interchangeable, they are probably not the same when it comes to acquisition cost or reimbursement rates. One of them may have been non-formulary, for example. This difference is multiplied if one product is the brand name one. Clinically, none of the differences are significant. However, we aren’t talking about therapeutics. We are talking finances and recordkeeping. This sort of discrepancy can lead to repayment demands, even penalties and interest, following an audit.

The importance of recordkeeping shouldn’t be overlooked. In litigation, documentation is everything. If it wasn’t documented, it wasn’t done. Many cases have turned on seemingly small documentation issues. Perpetual inventory totals, timecards, delivery records, pick-up logs, documentation of counseling (or refusal of counseling) are some other examples of records that

have become key points in a case. The lesson here is that no record is too small or too trivial to be skipped over. Update those inventory changes as they come in. It may seem burdensome at the time, but there are potential benefits later.

__________________________________________________________

© Don R. McGuire Jr., R.Ph., J.D., is General Counsel at Pharmacists Mutual Insurance Company.

This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly.

Agility is in the business of saving businesses. We bring together innovative products, affordable services and, most important, great people – experts with the know-how and passion to help you plan and recover from disasters. Agility is the difference between giving in to a crisis and surviving one.

Agility Recovery is the endorsed provider of disaster recovery services to the Washington State Pharmacy Association. For more information call 720.490.4572 or visit www.agilityrecovery.com.

TECHNOLOGY SPACEPOWER CONNECTIVITY

uPcoming eVentSimmunization PracticumApril 11, 2012 | Rosauers Supermarkets, Inc. | Spokane, WA

This program is designed specifically to train pharmacists and pharmacy students to participate in an Immunization program for adults and adolescents. The content derived from the CDC program “Epidemiology & Prevention of Vaccine-Preventable Diseases” and adapted to Washington State specific pharmacy law and practice. By completing this course, pharmacists can earn 15 hours of continuing education credit while becoming certified to administer adult and adolescent vaccines.

clinical Pharmacology Series 2012: may 10, may 18, June 8, 2012Shoreline Conference Center | Seattle, WA

This series of five, one-day courses is designed as a pharmacology update at the advanced practice level. Sessions focus on current recommendations and controversies regarding drug therapy for common problems and include appropriate pharmacotherapeu-tic principles and recommendations for patient education. Teaching methods include lecture, discussion, and case analysis.

Each day is structured as a separate course so that participants can attend those courses most pertinent to their needs. Partici-pants are encouraged to bring case studies for discussion with faculty.

northwest Pharmacy conventionMay 31 - June 3, 2012 | Coeur d’Alene Resort | Coeur d’Alene, ID

Come see the new renovations at the Coeur d’Alene Resort! Enhancements include a brand new lobby, fitness center, restaurants & lounge, additional meeting space, event center & garden, private lake view terrace, outdoor infinity pool with private cabanas and more! The 2012 Northwest Pharmacy Convention is the premier annual meeting place for the pharmacy communities of Washington, Idaho and Montana. The event will feature 70 exhibits, more than 40 continuing education sessions and 500 phar-macy professionals who are interested in seeing and learning about all that is new in the world of health care. Make plans now to join us May 31-June 3 at the Coeur d'Alene Resort in Idaho.

immunization PracticumJuly 19, 2012 | WSPA Office | Renton, WA

This program is designed specifically to train pharmacists and pharmacy students to participate in an Immunization program for adults and adolescents. The content derived from the CDC program “Epidemiology & Prevention of Vaccine-Preventable Diseases” and adapted to Washington State specific pharmacy law and practice. By completing this course, pharmacists can earn 15 hours of continuing education credit while becoming certified to administer adult and adolescent vaccines.

WSPF Scholarship ScrambleAugust 26, 2012 | Willows Run | Redmond, WA

The Washington State Pharmacy Foundation is proud to announce this year’s WSPF Scholarship Scramble will be held on August 26, 2012 at Willows Run Golf Course. All proceeds from the Golf Scramble will go towards the Foundation’s mission to provide scholarships for pharmacy students at Washington State University and University of Washington.

2012 Annual meetingNovember 1-4, 2012 | Great Wolf Lodge| Grand Mound, WA

This is truly a family event! Gather the latest information from pharmacy experts, exchange ideas with others facing similar chal-lenges, and build a personal and professional network while the family stays and plays! Each room is significantly discounted - $149/night, comes with four water park tickets, discounted spa rates, and is close to outlet malls and the Lucky Eagle Casino. This event will feature exhibits, a variety of continuing education sessions, and our annual awards banquet honoring the finest in our pharmacy community today.

Winter 2012

Documents

Transcript of Winter 2012