Inside: START/ STOPP 2014 Update Pages 1-2 UConn School of Pharmacy Update Page 3 Save the Date! Schwarting Senior Symposium Page 4-5 Warmest Holiday Wishes! Page 6 Notes ‘n Votes— November 2014 Page 7

Which recommendations have been STARTed and STOPPed in the START/STOPP Criteria 2014 Update? Lauren Manganiello, Pharm.D.

1 | Winter 2014 CT-ASCP Chapter Newsletter

The Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria are widely used tools in the practice of pharmacists specializing in the care of geriatric patients. The STOPP criteria present a list of potentially inappropriate medications to consider discontinuing in older patients due to increased risk of adverse drug events and the availability of safer alternatives1. The START criteria provide recommendations for medications that may be under-prescribed, yet may provide benefit for elderly patients based on disease state2. Since the original STOPP/START criteria were published, recommendations incorporated into these criteria have been shown to greatly reduce adverse effects in older patients as well as reduce length of stay by an estimated three days when elderly patients are hospitalized due to acute illnesses3. With new evidence emerging throughout the past several years as well as new medications available on the market, an update was performed to ensure accurate information on safe prescribing was reflected. A European expert panel of geriatric practitioners convened to evaluate new evidence and ensure older recommendations had support in the literature. The result was the updated STOPP/START criteria version 2 published in 20143. The summary below presents several highlights of changes which have occurred within the new version, however, it is important to note that this list is not all-inclusive. Updates to the STOPP Criteria: One of the most striking changes in the STOPP criteria was the creation of several new categories of inappropriate drug use. The new antiplatelet/anticoagulant category in the STOPP criteria contains many similar recommendations found in the cardiovascular section of version 1, however, the scope of this criteria has been expanded to include stopping new agents such as direct thrombin inhibitor or factor Xa inhibitors in specific patient scenarios (high bleeding risk, prolonged treatment duration unnecessary based on indication). This section also includes new recommendations such as stopping aspirin in combination with anticoagulation agents in atrial fibrillation if there is no additional indication for aspirin (due to lack of additional benefit), stopping ticlopidine in any circumstance (as clopidogrel and prasugrel have stronger evidence and fewer side effects), and stopping dual antiplatelet therapy (aspirin plus clopidogrel) as secondary stroke prevention with several exceptions. A new section titled drugs affecting renal function or affected by renal function includes recommendations on eGFR cut-offs for metformin, colchicine, dabigatran, and new factor Xa inhibitors (rivaroxaban and apixaban). Finally, the new anticholinergic burden category suggests avoiding concomitant use of two or more drugs with antimuscarinic/anticholinergic properties.

CT-ASCP's

SenioRx Care Perspective

Winter 2014 Volume VIII No. 4

2 | Winter 2014 CT-ASCP Chapter Newsletter

Additional changes to the STOPP criteria include several new recommendations in established categories. New cardiovascular recommendations including stopping digoxin for heart failure with normal systolic ventricular function (due to lack of evidence of benefit), stopping amiodarone use as first line in supraventricular tachyarrhythmias (due to side effect profile), and stopping loop diuretics for treatment of hypertension in patients with urinary incontinence. CNS additions include stopping the use of tricyclic antidepressants as first-line treatment for depression (due to anticholinergic adverse effects), restricting antipsychotics (other than quetiapine or clozapine) in Parkinsonism or Lewy Body disease (due to EPS risk), and stopping the use of acetylcholinesterase inhibitors in patients with a known history of persistent bradycardia (less than 60bpm), recurrent syncope, or concurrent treatment with medications that reduce heart rate. Additionally, twelve recommendations were not included from the STOPP criteria version 1 such as stopping aspirin in patients with no history of coronary, cerebral or peripheral arterial occlusive symptoms, using aspirin and warfarin in combination without a H2 receptor antagonist or PPI, using calcium channel blockers in patients with chronic constipation, and stopping long-term opioids in patients with dementia (unless indicated for palliative care or chronic pain syndrome) or fall history4. START Criteria:

Three new START categories were also added to the updated criteria including urogenital system drugs, analgesics, and vaccines. The urogenital category advocates adding alpha-1 receptor blockers and 5-alpha reductase inhibitors in patients with symptomatic prostatism, where prostatectomy is not considered necessary. The analgesics category recommendations include starting high-potency opioids for moderate-severe pain not responding to paracetamol [acetaminophen], NSAIDs, or low-potency opioids and starting laxative agents in patients receiving regular opioid therapy. Vaccine recommendations suggest patients receive the trivalent influenza vaccine annually and the pneumococcal

vaccine at least once after age 65. Additional START criteria were added in established categories such as adding vitamin D supplementation in older patients who are

housebound, experiencing falls, or with osteopenia. Additionally, xanthine-oxidase inhibitors (e.g., allopurinol, febuxostat) should be added to patients with a history of recurrent gout. Acetylcholinesterase inhibitors should be added for mild-moderate Alzheimer’s dementia (memantine addition was not advocated in this criteria). START criteria regarding anticoagulation therapy initiation in atrial fibrillation was also expanded to include newer factor Xa inhibitors and direct thrombin inhibitors. Three recommendations from version 1 were not included in the new

criteria including addition of metformin in patients with diabetes in the absence of renal impairment and addition of aspirin and statin for primary prevention of cardiovascular disease in patients with diabetes4.

In Summary: The new STOPP and START recommendations present 114 criteria which is a 31% increase from version 1. Interestingly, the vast majority of changes arose from new trial information presented in the evidence and recommendations from experts practicing in the field of geriatrics not from new medications on the market. It is important to note that the STOPP/START criteria present a list of potentially appropriate clinical recommendations on medication use in the elderly, but clinical judgment should be used when determining if these recommendations apply to a particular patient’s scenario. Although these criteria may be useful in reducing harm from medication use in the elderly, the STOPP/START is a lengthy document which the authors suggest is a limitation to its use. Research is currently being completed (through the European Commission Seventh Framework Programme project) to determine if this new criteria will offer further adverse drug event prevention benefits to older patients3. References: 1. Hamilton H, Gallagher P, Ryan C, Byrne S, O'Mahony D. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med. 2011 Jun 13;171(11):1013-9. 2. Barry PJ, Gallagher P, Ryan C, O'mahony D. START (screening tool to alert doctors to the right treatment)--an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing. 2007 Nov;36(6):632-8. 3. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate 4. prescribing in older people: version 2. Age Ageing. 2014 Oct 16. [Epub ahead of print] 4. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. [supplemental material] Age Ageing. 2014 Oct 16. [Epub ahead of print]

Which recommendations have been STARTed and STOPPed in the START/STOPP Criteria 2014 Update?

3 | Winter 2014 CT-ASCP Chapter Newsletter

University of Connecticut School of Pharmacy Update Andrew Barna, Pharm.D. Candidate

UCONN Chapter of ASCP The UCONN chapter of ASCP consists of 33 members. This coming spring we will be meeting bi-weekly on Tuesdays from 4-5pm in the School of Pharmacy. We are looking to attract more pharmacy students to become members for the spring semester. Our E-Board consists of 6 members: President- Andrew Barna (P3), Vice President- Heather Jones (P3), Secretary- Alexa Sanna (P3), Treasurer- Alyssa Weers (P3), PSG Representative- Robert Ambrose (P3), and Historian- Matthew Merola (P2). Fall 2014 The UCONN chapter of ASCP had a very insightful fall semester where we learned a lot of valuable information about Consultant Pharmacy. The knowledge gained from the following events really exposed many members to consider a future career path in Consultant Pharmacy. Some members were even fortunate enough to attend shadowing opportunities from various organizations involved in Consultant Pharmacy. Our two most notable events included: attending the ASCP Annual Meeting and our guest speaker, Jennifer DiMauro, PharmD. ASCP Annual First of all, we would like to give a very big THANK YOU to Dr. Sean Jeffery, Mark Wrabel, David Cooper, Michel Fortin, and Mike Gemma for their generous donations to our chapter and attending members. Without their support, our members would not have been able to attend. Nine members from our chapter attended the 2014 ASCP Annual Meeting and Exhibition in Orlando, FL from November 5-7. At this event, we truly gained a diversity of knowledge regarding Consultant Pharmacy by attending the seminars presented by physicians, pharmacists and pharmacy residents. It was also a great networking opportunity; not only did we meet other pharmacy students from the University of Rhode Island, University of Maryland, and University of Florida, but we also plan on working with them in the spring.

We would also like to formally thank Jennifer DiMauro, PharmD, a consultant pharmacist for Omnicare, for coming and speaking to us on November 20, 2014 during our chapter meeting. She truly gave us a better sense of the field in regard to a normal work day and responsibilities. She also allowed our members to ask her any further questions regarding her job and responsibilities. Spring Semester 2015 We currently have a few events planned for the spring semester. They include the Senior Symposium and the URI Winter Ball. The Schwarting Senior Symposium will take place on March 17, 2015 at the Aqua Turf in Southington, CT. Our chapter will be responsible for making the lecture slide handouts for the event that will be distributed to the attending guests. Also, a few members plan on being there and helping out in any way possible. The URI’s Winter Ball will take place on January 26th from 4-6pm at an assisted living facility in Kingston, Rhode Island. This should be an exciting event because we are working with the URI ASCP members we met at Annual. Our chapter is also selling UCONN School of Pharmacy drawstring bags. They will be available for purchase at the Schwarting Senior Symposium on 3/17/15. Please also contact Andrew Barna, at ascp.uconn@gmail.com if interested.

Again, if there are any opportunities to shadow at various sites, participate in brown bag events, or volunteer for events that would allow us to further our education into consultant pharmacy, we would greatly appreciate it. Please contact our chapter President, Andrew Barna, at ascp.uconn@gmail.com if interested. Happy Holidays!

4 | Winter 2014 CT-ASCP Chapter Newsletter

The University of Connecticut School of Pharmacy,

Office of Pharmacy Professional Development And the CT Chapter of the American Society of Consultant Pharmacists present:

SAVE THE DATE

Tuesday, March 17th, 2015 The Aqua Turf Club 556 Mulberry Street

Plantsville, CT

Three Tracks Available: Senior Symposium

Arthur E. Schwarting Pharmacy Practice Symposium – MTM for Patients with Diabetes

Immunization Training for Pharmacists

5 | Winter 2014 CT-ASCP Chapter Newsletter

SAVE THE DATE: Tuesday, March 17th, 2015

Senior Symposium – Track #1 Schedule 6:30 – 7:00 am Registration 7:00 – 8:00 am Estimating Renal Function in Elderly Patients and Implications for Medication Management Rachel Eyler, PharmD, BCPS; Assistant Clinical Professor of Pharmacy Practice, University of Connecticut School of Pharmacy Contact Hours: 1 8:00 – 9:00 am Breakfast Product Theater – Sponsor: Actavis 9:00 – 10:45 am COPD: Tackling the Transition Erika Cappelluti, MD, PhD, FCCP, ABIHM: The Center for Integrative Healthcare & Healing Jeanne Reardon, APRN; Pulmonary Clinical Nurse Specialist, Hartford Hospital Corinne Ewing, PharmD; Assistant Professor, University of Saint Joseph School of Pharmacy Contact Hours: 1.75 10:45 – 11:45 am Exhibit Hall 11:45 – 12:45 pm Understanding CMS Ratings and the Pharmacist’s Role Jeanne Manzi, PharmD, CGP, FASCP; Clinical Advisor, CVS Health Contact Hours: 1 (Law) 12:45 – 2:15pm Lunch Product Theater – Sponsor: Novo Nordisk 2:15 – 3:45 pm New Drug Update Stephanie Hattoy, PharmD, BCPS, CGP; Assistant Professor, University of Saint Joseph School of Pharmacy Christine Eisenhower, PharmD, BCPS; Clinical Assistant Professor of Pharmacy, University of Rhode Island Contact Hours: 1.5 3:45 – 4:00 pm Break in Exhibit Hall Area 4:00 – 5:00 pm Adverse Drug Events in the Elderly: An Update for 2015 Dennis Chapron, MS, RPh; Medication Safety Pharmacist, St. Francis Hospital & Medical Center Contact Hours: 1

6 | Winter 2014 CT-ASCP Chapter Newsletter

CT-ASCP would like to wish you

and your family a HAPPY and HEALTHY

2015!

7 | Winter 2014 CT-ASCP Chapter Newsletter

SPONSOR RECOGNITION Carrieann Kumor was thanked for the sponsorship. REVIEW OF PAST MINUTES The minutes of the 10/6/14 meeting were reviewed and unanimously approved. LEGISLATIVE NEWS Pharmacists are still working to gain support for H.B.4190 (pharmacists being recognized as providers) and increase the number of co-sponsors. G. Memoli brought up that there has been a shift in the ownership of pharmacies since the separation of consulting and dispensing was proposed. M. Gemma stated that as of 11/1/14 CMS will lift the exemption for long-term care pharmacies that had previously allowed the use of HL7 and computer-generated faxes for ordering. Pharmacies will now use a NCPDP platform which may cause some disruption in ordering as characters can be limited. Orders through manual fax are still allowed. CHAPTER NEWS Please continue to contact A. Huie-Li with suggestions or articles for the communications committee newsletter. Elections will be held prior to SSS15 with the need for a new president-elect and appointment of secretary/treasurer. Also there is a need for two new board members (2015-2018) as well as a replacement for the rest of M. Gemma’s BOD term through 2017. ASCP’s Annual Meeting is being held in Orlando this week. M. Gemma reminded those that are attending that there will be a breakfast held Wednesday morning from 7-8am for the CT chapter. SCHWARTING-SENIOR SYMPOSIUM (SSS15) – March 17, 2015 at Aqua Turf, Southington, CT The planning committee will meet 12/1 and was reminded to please RSVP. Planning committee members need to fill out two disclosure forms this year. One speaker is still needed for the pulmonary program but speaker packets have been distributed. Save the dates will be priced and discussed. Product theaters are also under discussion as there is a possibility for a third program. UCONN/USJ NEWS USJ has a few openings for faculty positions and recently held their preceptor appreciation dinner. UConn hosted their white coat weekend and also had their preceptor appreciation dinner with R. Eyler receiving faculty preceptor of the year! Meeting adjourned at 7:00pm Next Meeting: 1/5/15 at @ 5:30pm Machiavelli’s 75 Center St, Southington, CT (sponsored by Cubist Pharmaceuticals) Respectfully submitted, Kim L. Daley, PharmD, CDP CT-ASCP Secretary/Treasurer

Sponsorship: Carrieann Kumor from Activis Guests: Gene Memoli, Paul Belcher, Andrea Leschak, Dennis

Chapron, Amy Huie-Li, Bob Tendler, Jennifer Dimauro, Joanne Nault, Amanda Sihabout, Thomas Levay, Alyssa Weers.

MEMBER NAME & TITLE Oct Nov Dec

Kevin Chamberlin President // SS Committee

X X

Mark Wrabel Imm. Past-President

X

Mike Gemma President-Elect / Legis. Committee

X X

Kim Daley, Secretary / Treasurer

X X

Stephanie Hattoy Board 2014-2017/ CE Committee

X X

Anna Torda, Board 2014-16/Comm. Committee

X X

Rachel Eyler Board 2014-16

X

Kathy White, Board 2011-15 / Senior Symposium

X X

Karen Rubenfeld Board 2014-15

X X

Editorial Board ¾Amy Huie-Li, PharmD, CGP, MPH ¾Anna Torda, PharmD ¾Kim Daley, PharmD ¾Kevin Chamberlin, PharmD ¾Brian Pelletier, PharmD, CGP ¾Jennifer Kloze, PharmD, BCPS ¾Kristina Niehoff, PharmD, BCPS

Notes 'n Votes - November 2014 Board Meeting Kim L. Daley, Pharm.D., CT-ASCP Secretary / Treasurer