inside: ascp's seniorx care perspective - … · 2 | winter 2013 ct-ascp chapter newsletter...

Inside: Major Depressive Disorder & Seratonin Syndrome Pages 2-4 Polypharmacy Deprescribing Page 5 Save the Date! Schwarting Senior Symposium Page 6 Warmest Holiday Wishes! Page 7 Notes ‘n Votes— November 2013 Page 8

Update from ASCP Annual Meeting and Exposition 2013 Stephanie Hattoy, Pharm.D., BCPS, CGP

1 | Winter 2013 CT-ASCP Chapter Newsletter

I had the pleasure of attending the Chapter Council and Affiliates Meeting as well as the Chapter Leaders Meeting this

year at the ASCP Annual Meeting and Exposition in Seattle, WA. Here are some of the highlights:

ASCP state and regional chapters are encouraged to continue to use the State Chapters Manual for information

regarding membership, elections, planning programming, and other chapter related functions and should brainstorm new

ideas and updates to the Manual accordingly. Chapters are also encouraged to attend conference calls that are set up

through the Council to stay abreast of topics important to members and chapter functions. The CCA also encouraged

chapters to submit requests for ASCP leaders to attend local and regional meetings and events as well as nominate

members for leadership positions within the organization.

The Chapter Leaders Meeting provided information about each department at ASCP National that could assist with the

functions of each chapter. Jeff Delafuente, ASCP President, spoke about his yearlong goal for consultant pharmacists to

“Engage, Embrace and Expand.” He also described his committee structure and introduced several new task forces

including Abstract Process and Revision, Practice Expansion and Entrepreneurial, Membership Engagement, and

Provider Status Task Forces as well as a new committee for Awards and Recognition. The Policy and Advocacy

Division has been very busy hiring new staff, coordinating their roles, and working on national and state legislative

issues including provider status, compounding regulations, and antipsychotic use reduction to name a few. Members are

encouraged to participate in monthly conference calls pertaining to legislative issues and contribute to the PAC and

Advocacy Fund. Marketing and Communications mentioned many improvements to the ASCP website and asked

chapters to submit dates for their meetings and events to notify the entire membership using the tools available through

the website. The Finance department is currently working on getting chapter statements released on time and

incorporating new staff onto the team. Joe Gerber provided an update from ASCP Education; encouraging members to

accredit programming through ASCP and look out for potential CGP certification programs to be presented at local and

regional meetings.

Overall the meeting was quite informative and provided a chance for chapter leaders to network and talk about how their

chapters operate.

CT-ASCP's

SenioRx Care Perspective

Winter 2013 Volume VII No. 8


Major Depressive Disorder and Serotonin Syndrome Paulina Jankowska, Pharm.D. Candidate & Stephanie Hattoy, Pharm.D., BCPS, CGP University of Saint Joseph School of Pharmacy

Mental health is an important part of our human existence. One said that healthy minds give us healthy lives1. Some mental illnesses

present suddenly such as schizophrenia or bipolar disorder. It is crucial for providers, including pharmacists, to be able to recognize the early

signs of mental illness.

What signs and symptoms should we, as health care professionals, be concerned about? An emerging major mental disease may be

suspected if a patient is experiencing some of the common signs and symptoms of the mental illness, including1:

Social withdrawal and loss of interest

Apathy and loss of desire to participate in any activity

Problems with concentration, functioning, memory, speech or logical thoughts

Failing grades in school, decrease in functioning at work

Increased sensitivity to sights, sounds, smells or touch

Changes in sleep patterns, appetite, and/or personal hygiene

Mood swings

There are several mental health disorders and issues that are commonly seen in geriatric patients. These include depression, Alzheimer’s

dementia, schizophrenia, major depressive disorder, obsessive-compulsive disorders, phobias, posttraumatic stress disorders, and suicide1.

Major depressive disorder is one of the most common psychiatric disorders and if left untreated could be fatal. It is believed to be caused

by a combination of genetic, environmental and psychological factors2. Patients with depression often present with persistent sadness, feelings

of emptiness, hopelessness, feelings of guilt, fatigue, decreased energy, changes in appetite, pessimism, and sometimes body aches2.

According to American Psychiatric Association practice guidelines, in order to diagnose someone with major depressive disorder at least

five of the following symptoms must be present for two weeks and must show a change from baseline4:

Depressed mood most of the day, nearly every day

Changes in weight (significant loss when not dieting or gain)

Insomnia or hypersomnia nearly every day

Fatigue or loss of energy, feelings of worthlessness

Problems with thinking or concentration, indecisiveness

Recurrent thoughts of death

Decreased interest in pleasures and activities

Psychotherapy, cognitive behavioral therapy and electro-convulsive therapy are examples of non-pharmacologic treatment strategies

for the management of depression. These methods have been shown to be efficacious and safe when medications are contraindicated or are

ineffective3. Symptomatic improvement with medications used to treat depression may be seen within the first two weeks of therapy3. Some

antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) may take six

to eight weeks to reach their full effect. According to American Psychiatric Association guideline, antidepressants have shown a response in 50

to 60 percent of adults with major depressive disorder.

SSRIs are most commonly used as a first-line treatment option in major depressive disorder. This class includes citalopram,

escitalopram, paroxetine, fluoxetine and sertraline. The most common side effects experienced with this class include jitteriness, sleep

disturbances, nausea, diarrhea, delayed ejaculation, fatigue, dizziness, and weight gain5. Severe toxicity with SSRIs is rare but can induce

seizures, rigidity, hypo- or hypertension, QT wave prolongation, coma, and serotonin syndrome5.

SNRIs are the second most commonly used class of medications for the treatment of major depressive disorder and can also be

considered a first line option. Examples include venlafaxine, desvenlafaxine and duloxetine. The side effect profile of SNRIs is similar to

SSRIs, but also includes tachycardia, urinary retention, and reduction of the seizure threshold3. There is limited evidence stating that one SSRI

is more efficacious than another or that SSRIs are more efficacious than SNRIs.

Tricyclic antidepressants (TCA) and monoamine oxidase inhibitors (MAOI) are two additional classes of medications used to treat

depression. Examples of TCAs include amitriptyline, doxepin, imipramine, desimipramine, nortriptyline, and

trimipramine. An overdose with a TCA can be very dangerous and can cause cardiac conduction

delays that may lead to arrhythmias3. MAOIs are strictly reserved for patients who have failed other

therapies. The MAOI class includes selegiline, phenelzine, tranylcypromine, isocarboxazid, and

moclobemide. The interaction of MAOIs with tyramine-rich foods and with serotonergic drugs may

result in hypertensive crisis or serotonin syndrome, respectively3. It is important to allow a two-week

washout period after discontinuing an MAOI before starting a new therapy with an SSRI, SNRI or

TCA3.


Major Depressive Disorder and Serotonin Syndrome, continued from page 2 Paulina Jankowska, Pharm.D. Candidate & Stephanie Hattoy, Pharm.D., BCPS, CGP University of Saint Joseph School of Pharmacy

Serotonin Syndrome

An elderly patient was admitted to the hospital for a cerebral vascular accident and a complaint of shoulder pain. He was continued

on his home regimen of medications including fluoxetine (SSRI) for depression. The presence of depression and mood changes was due to

his continuing pain. Before discharge, the patient was prescribed amitriptyline (TCA) for “its pain relieving benefits” and help with sleep.

After discharge to a long-term care facility, the patient started to complain of chest pain and palpitations. The patient also had a history of

coronary artery disease and atrial fibrillation. An EKG was performed, the patient was diagnosed with tachycardia, and metoprolol 25 mg

was prescribed to control his heart rate. According to the covering nurse, the patient felt confused, less alert, agitated and diaphoretic with a

fever of 99.20F. Serotonin syndrome was suspected due to being on two serotonergic medications. Amitriptyline was discontinued the next

day and then fluoxetine thereafter. A few days after, the patient felt more awake and alert and was prescribed duloxetine (SNRI) only to treat

his depression.

Serotonin syndrome occurs due to increased concentrations of serotonin in the brain. It can occur with the administration of one or

more agents that increase the serotonin concentration in the central nervous system. Serotonin syndrome is rarely seen in monotherapy with

SSRIs, SNRIs, TCAs or MAOIs. However, the concurrent use of different serotonergic agents may lead to this sometimes-fatal condition4.

Serotonin syndrome may be seen in all age groups; from newborns to the elderly. The true incidence of serotonin syndrome may be

under-estimated due to misdiagnosis.

The highest risk of serotonin syndrome may occur when an MAOI is co-administered with SSRI, SNRI, or TCA. Also, serotonin

syndrome may occur when a patient is being transitioned from an SSRI or SNRI to an MAOI without the recommended washout period of a

minimum of two weeks. However, when changing a patient from fluoxetine to an MAOI, the waiting period is at least five weeks due to the

long half- life of fluoxetine. In addition, serotonin syndrome has been also associated with the use of SSRIS in combination with4:

tramadol

high-dose triptans

metoclopramide

ondansetron

dextromethorphan

meperidine

methadone

carbamazepine

cyclobenzaprine

sibutramine

linezolid (which possesses some ability to inhibit monoamine oxidase)

over-the-counter cold products such as chlorpheniramine, St.John’s wart, or ginseng

The clinical features of serotonin syndrome include4:

mental status changes

- hypomania, confusion, agitation, restlessness, seizures, coma, uncoordination

autonomic abnormalities

- hypertension, hypotension, diaphoresis, tachycardia, diarrhea, fever

muscle tone

- myoclonus, tremor, shivering, hyper-reflexia, rigidity

The most common symptoms include restlessness, uncoordination, hypomania, myoclonus, tremor, shivering and diaphoresis and usually

present rapidly.


Major Depressive Disorder and Serotonin Syndrome, continued from page 3 Paulina Jankowska, Pharm.D. Candidate & Stephanie Hattoy, Pharm.D., BCPS, CGP University of Saint Joseph School of Pharmacy

The treatment of serotonin syndrome depends on the severity of the presenting symptoms. If the symptoms are minor, the treatment

usually involves discontinuation of the offending agent and an evaluation by a provider. The following treatments may be initiated5:

Benzodiazepines such as diazepam or lorazepam can help with agitation, seizures, rigidity, and myoclonus.

Cooling measures can be used to help control hyperthermia.

Cyproheptadine (a serotonin antagonist) dosed at 12 mg, followed by 4 to 8 mg every 4 to 6 hours if symptoms persist, up to a

maximum of 32 mg in 24 hours can be used in severe cases.

Supportive care with oxygen and intravenous fluids are used to manage dehydration.

Medications to control heart rate and blood pressure such as beta-blockers (bismolol, esmolol, atenolol, metoprolol, or

sotolol), ACE inhibitors (lisinopril, ramipril, enalapril or benazepril) or ARBs (valsartan, olmesartan, irbesartan, or losartan).

Neuromuscular paralysis with non-depolarizing agents can be used when intubation is required (in about 25% cases) any

muscle tone related problems.

Serotonin syndrome is uncommon and difficult to diagnose, but early recognition is essential to decrease the risk of complications and

death. It is necessary for patients and physicians to be aware of the risks and side effects of the medications used for major depressive

disorder as well as the signs and symptoms of serotonin syndrome in order to quickly initiate appropriate treatment strategies. It is also

important to prevent serotonin syndrome by limiting the prescribing of two or more serotonergic agents and follow the recommendations

regarding washout periods when switching between classes of serotonergic drugs.

Clinical Pearls

Counsel patients about side effects of antidepressants such as dry mouth, insomnia, increased bleeding, suicidal thoughts,

sexual dysfunction, etc.

Explain that symptom reduction may take a few weeks after starting the therapy to the patient.

Ask patients about any new medications to avoid co-administration of medications that may cause serotonin syndrome

including the over-the-counter products containing dextromethorphan.

Instruct patients to report symptoms including chest pain, shortness of breath, syncope, palpitations, high fever, agitation, or

confusion immediately to their health care provider.

Advise patients that abrupt discontinuation of drugs may worsen the symptoms of MDD and adverse reactions.

Educate patients and providers that the concomitant use of aspirin, NSAIDS, warfarin or other anticoagulants may increase the

risk of bleeding when used in combination with some antidepressants.

Follow the recommendations regarding washout periods when switching between classes of serotonergic drugs.

1 American Psychiatric Association.Depression.2012. Retrieved from http://www.psychiatry.org/mental-health/key-topics/depression on

November 10, 2013. 2 National Institute of Mental Health.Depression.Retrieved from http://www.nimh.nih.gov/health/topics/depression/index.shtml on

November 10, 2013. 3 Psychiatry.The Medical Letter, Vol 11; 130. June 2013. 4 American Psychiatric Association: Practice Guideline for the Treatment of Patients With Major Depressive Disorder, 3rd ed. Am J

Psychiatry 2010 5Micromedex.DrugInformation.TruvenHealth. Antipsychotics: Serotonin Reuptake Inhibitors. Retrieved November 10, 2013.

http://www.psychiatry.org/mental-health/key-topics/depression

http://www.nimh.nih.gov/health/topics/depression/index.shtml


A new approach to polypharmacy: Shared medical appointments at a Veterans Affairs interprofessional outpatient program John Thomas, MD, Marcia Mecca, MD, Kristina Niehoff, PharmD, BCPS, Anne Hyson, MD, MSc VA Connecticut Healthcare System

Polypharmacy is common in older patients and is associated with negative health outcomes and poor

adherence.1 Shared medical appointments (SMAs) have shown promise as a care model for older patients

with chronic conditions, but have not been applied in the context of polypharmacy.2 Healthcare providers

from the Veterans Affairs (VA) Connecticut Healthcare System’s Center of Excellence in Primary Care

Education, an outpatient interprofessional team training program, collaborated to pilot a polypharmacy

intervention involving an SMA for older veterans as a means to decrease inappropriate prescribing and

streamline regimens. The interprofessional team consisted of physicians, pharmacists, nurse practitioners,

and health psychologists.

For the pilot session, patients 80 years or older with 10 medications or more were invited to participate

after being referred by their primary care provider. The session consisted of an SMA and an individual

provider visit. The SMA was co-facilitated by members of all participating professions and consisted of

interactive discussions about polypharmacy, adherence, and patients’ beliefs about medications. The

individual visit included a medication reconciliation, standard geriatric assessments (including the St. Louis

University Mental Status Exam, activities of daily living, and orthostatics), shared decision making

regarding medication changes, and a detailed follow-up plan. Discussions were aided by the patient’s

reported side effects, BEERS criteria,3 and various organizational guidelines focused on specific disease

states.

Of the 7 eligible patients contacted for the first pilot session, 1 declined, and 1 was living in another state.

All 5 scheduled patients attended. The average age was 85, and the average number of medications was 18.

In the SMA, most of the patients agreed they did not understand the indications for all their medications,

but they trusted their providers’ judgment of medication appropriateness. Many felt that having multiple

providers made their care plan confusing. Patients exchanged ideas about how to increase adherence. In

the individual visit, an average of 2.4 medications were discontinued. In one instance, a patient, his family,

and the healthcare team weighed the risks and benefits of continuing warfarin and decided to discontinue

based on prior adverse drug events, the patient’s overall dissatisfaction with taking it, and a comparison of

two relevant risk scores. There were 3 identified instances of hazardous prescribing and referrals were

made as appropriate to geriatrics, health psychology, and home services.

In conclusion, an interprofessional team from VA Connecticut Healthcare System’s Center of Excellence in

Primary Care Education has successfully executed a pilot SMA as a polypharmacy intervention for older

veterans. Patients expressed limited understanding of their medications, and instances of unnecessary or

inappropriate prescribing were identified in each patient. The team is continuing to improve the design and

flow of the clinic and will continue further pilot sessions in March 2014.

Hajjar EJ, Cafieio AC, Hanlon JT. Polypharmacy in Elderly Patients. Am J Geriatr Pharmacother. 2007;5:345-351.

Patterson SM, Hughes C, Kerse N, Cardwell CR, Bradley MC. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database of

Systematic Reviews 2012, Issue 5. Art. No.: CD008165. DOI: 10.1002/14651858.CD008165.pub2. American Geriatric Society. American Geriatric Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc.

2012;60:616–631.


Arthur E. Schwarting Pharmacy Practice Symposium

TWO GREAT NAMES IN CONTINUING EDUCATION

ONE AMAZING MEETING!

UCONN School of Pharmacy and CT-ASCP

Invite you to the

2014 Schwarting-Senior Symposium

SAVE THE DATE Tuesday, May 13, 2014

The Aqua Turf Club Plantsville, CT

Three Tracks Available! Senior Symposium Track

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

Immunization Training for Pharmacists Track


CT-ASCP

would like to wish you and

your family the

happiest of holidays

and a wonderful

New Year 2014!


SPONSOR RECOGNITION

Jim McDonald & Carrieann Kumor from Forest were thanked for the

sponsorship.

REVIEW OF PAST MINUTES

The minutes of the 10-7-13 meeting were reviewed and unanimously ap-

proved.

CHAPTER NEWS

M. Wrabel is finalizing the ballots for the BOD election. There are cur-

rently 6 members that have accepted nomination but there is still an open

nomination for President-Elect.

LEGISLATIVE AFFAIRS

G. Memoli explained that pharmacists across the country are seeking legal

opinions for possible class action lawsuits against CMS due to unfair re-

imbursement. M. Gemma warned the group that mistakes identified during

the auditing process by the state can lead to huge fines and consulting and

pharmacy contracts are now being evaluated as well.

FALL CE PROGRAM

The Fall CE program had 31 attendees and a $600 profit. Great speakers/

topic along with the free space and a product theater contributed to the

success. K. Chamberlin thanked the CE planning committee for all their

hard work.

SENIOR SYMPOSIUM (SS14)

At the last meeting K. Chamberlin explained that the group was ap-

proached by an outside organization. K. Chamberlin, G. Memoli, and M.

Wrabel met with members from the UConn School of Pharmacy in Octo-

ber to discuss a joint venture and since then the BOD has discussed the

possibility by email. K. Chamberlin explained that the meeting would be

a 1-day program with a track devoted to geriatrics and other programs

planned by UConn SOP to include MTM and Immunization training with

a 50/50 split. The meeting will likely be in May and offer up to 7 credits.

A possible education schedule was reviewed and product theater offers

were discussed. UConn SOP is able to provide CE accreditation and

online registration while the CE planning committee would work on

speakers/topics. B. Pelletier made a motion to approve a joint venture

with CT-ASCP and UConn SOP and K. White seconded. After much

discussion the BOD unanimously approved it. An official budget will be

created and submitted to National for approval and the SS14 committee

will plan on meeting later this month for futher discussion/planning.

SCHOOL OF PHARMACY NEWS

USJ and UConn both recently hosted their preceptor appreciation dinner.

A. Leschak explained the interdisciplinary safety day hosted at UConn on

10/28. The Dean Search at UConn is continuing with hopes of it being

finalized by February. UConn’s CE finale will be 12/20 with 3 encore

webinars offered on 12/21.

Meeting adjourned at 7:50pm

Next Meeting: 12-2-13 at Machiavelli’s, 75 Center St, Southington,

CT @ 5:30pm Respectfully submitted,

Kim L. Daley, PharmD

Secretary/Treasurer

Sponsorship: Jim McDonald & Carrieann Kumor from Forest with

speaker Srinath Kadimi

Guests: Stephanie Hattoy, Catherine Kulis-Robitaille, Daniela Benea,

Christopher Sibicky, Jill Fitzgerald, Jennifer Dimauro, Andrea

Leschak

MEMBER NAME & TITLE Sept Oct Nov

Kevin Chamberlin President // SS Committee

X X X

Mark Wrabel Imm. Past-President

X X X

Gene Memoli, SS Chair

X X

Kim Daley, Secretary / Treasurer

X X X

Mike Gemma Board 2009-12 / Legislative Committee

X X

Amy Huie-Li, Board 2009-12 /Communication Chair & SS

X X X

Brian Pelletier, Board 2010-13 / Communication Committee

X

Paul Belcher, Board 2010-13 / Legislative Committee

X X

Kathy White, Board 2011-14 / Senior Symposium

X X X

Rudy Dajie, Board 2011-14

Anna Torda, Communication Committee

X X X

Bob Tendler, Legislative Committee

X X X

David Cooper, Past President / Sales Senior Symposium

X

Dennis Chapron, Senior Symposium Committee

X X

Sean Jeffery, Past-President / SS Committee

Michel Fortin, Past President

X X

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

Notes 'n Votes - November 2013 Board Meeting Kim L. Daley, Pharm.D., CT-ASCP Secretary / Treasurer

inside: ascp's seniorx care perspective - … · 2 | winter 2013 ct-ascp chapter newsletter...

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