january/february 2014

PalmettoThe Official Journal of the South Carolina Pharmacy Association • Vol. 53, Num. 5

Palmetto Pharmacist • Volume 54, Number 1 1

PharmacistPalmetto

The Official Journal of the South Carolina Pharmacy Association • Vol. 54, Num. 1

2 Palmetto Pharmacist • Volume 54 Number 1

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Palmetto PharmacistVolume 54, Issue 1 January/February 2014The Palmetto Pharmacist, the official publication of the South Carolina Pharmacy Association, is distributed to association members as a membership service. Statements of fact and opinion are made by the authors alone and do no imply an opinion on the part of the officers or members of SCPhA. For advertising rates and other information, contact SCPhA.

What’s Inside...

5 2014 Brings Exciting News President Steve McElmurray talks about new opportunities in the new year

7 What’s in the ‘Stars’ For Pharmacy CEO Craig Burridge discusses the latest challenge for pharmacies

16 Provider Status: Game On APhA CEO’s latest blog encourages pharmacists to bring it on!

19 Creating a Competitive Strategy for Independent Pharmacy Success The latest in a series of articles aimed at helping independent pharmacists

22 Understanding Health Literacy Two SCPhA rotation students look at health literacy

Regular Columns 11 Members 14 SCCP 27 Financial Forum 29 Journal CE 39 Classifieds

Advertisers 2 QS/1 4 Pharmacists Mutual 24 Display Options 24 Mutual Drug 26 PACE 39 Jon Wallace, Attorney at Law 40 Smith Drug Company


Palmetto PharmacistVolume 53, Number 3 June/July 2013 The Palmetto Pharmacist, the official publication of the South Carolina Pharmacy Association, is distributed to association members as a membership service. Statements of fact and opinion are made by the authors alone and do no imply an opinion on the part of the officers or members of SCPhA. For advertising rates and other information, contact SCPhA.

Board of Directors

President/Chairman of the Board

Steve McElmurray, RPh

Immediate Past President John Pugh, PharmD, RPh

President-Elect Bryan Amick, PharmD, RPh

Treasurer Pamela Whitmire, PharmD, RPh

Low Country Region Kristy Brittain, PharmD, RPh

Pee Dee Region Jarrod Tippins, PharmD, RPh

Midlands Region Patti Fabel, PharmD, RPh

Upstate Region Ed Vess, PharmD, RPh

At-Large DirectorWilliam Wynn, PharmD, RPh

Speaker, House of Delegates Michael Gleaton, PharmD, RPh

Speaker-Elect, House of Delegates Sarah Braga, PharmD, RPh

CEO Craig Burridge, MS, CAE

REGION DELEGATESLow Country Region Midlands Region Don Neuroth, RPh Craig Harmon, RPhDavid Proujan, RPh Sarah Braga, PharmD, RPh Tray Till, RPh Lynn Connelly, RPhWayne Weart, PharmD Kevin Brittain, PharmD, RPh Brian Clark, PharmD, RPh Upstate Region Pee Dee Region David Banks, RPh Jim Shuler, RPhSteve Greene, PharmD, RPh Kelly Jones, PharmD, RPh Walter Hughes, RPh Dan Bushardt, RPh Linda Reid, RPh

SCPhA STAFF Craig Burridge Chief Executive Officer Laura Reid Director of EventsKeenan Grayson Director of Membership Cassandra Hicks-Brown Director of Operations/ACPELauren Sponseller Director of CommunicationsJon Wallace, BS Pharm, JD SCPhA General CounselCecily DiPiro, RPh PPN Network Coordinator

PALMETTO PHARMACIST STAFF

Jennifer Simmons Layout/Design/ContentCraig Burridge Managing Editor

What’s Inside...

5 Metathesiophobia President Steve McElmurray discusses the irrational fear of change

7 State Phair 2013 A look at SCPhA’s 2013 Annual Convention

16 Legislative Wrap Up At the close of the legislative session, see how things tied up 21 A Perspective on Pet Medications Information on veterinary medications

25 My SCPhA Rotation Journal SCCP Student Michelle Nations discusses her rotation with SCPhA

33 Pharmacy Camp Attracts Young Audience A special camp at SCCP provides a unique experience for students

Regular Columns 18 SCCP 32 Financial Forum 36 Journal CE 33 Classifieds

Advertisers 2 Smith 4 Pharmacists Mutual 15 Mutual Drug of North Carolina 34 Display Options 42 PACE 43 Jon Wallace, Attorney at Law 44 QS1

Lauren Lesesne

Megan Montgomery, PharmD, RPh

General CounselJon Wallace, BS Pharm, JD


Palmetto PharmacistVolume 53, Number 3 June/July 2013 The Palmetto Pharmacist, the official publication of the South Carolina Pharmacy Association, is distributed to association members as a membership service. Statements of fact and opinion are made by the authors alone and do no imply an opinion on the part of the officers or members of SCPhA. For advertising rates and other information, contact SCPhA.

Board of Directors

President/Chairman of the Board

Steve McElmurray, RPh

Immediate Past President John Pugh, PharmD, RPh

President-Elect Bryan Amick, PharmD, RPh

Treasurer Pamela Whitmire, PharmD, RPh

Low Country Region Kristy Brittain, PharmD, RPh

Pee Dee Region Jarrod Tippins, PharmD, RPh

Midlands Region Patti Fabel, PharmD, RPh

Upstate Region Ed Vess, PharmD, RPh

At-Large DirectorWilliam Wynn, PharmD, RPh

Speaker, House of Delegates Michael Gleaton, PharmD, RPh

Speaker-Elect, House of Delegates Sarah Braga, PharmD, RPh

CEO Craig Burridge, MS, CAE

REGION DELEGATESLow Country Region Midlands Region Don Neuroth, RPh Craig Harmon, RPhDavid Proujan, RPh Sarah Braga, PharmD, RPh Tray Till, RPh Lynn Connelly, RPhWayne Weart, PharmD Kevin Brittain, PharmD, RPh Brian Clark, PharmD, RPh Upstate Region Pee Dee Region David Banks, RPh Jim Shuler, RPhSteve Greene, PharmD, RPh Kelly Jones, PharmD, RPh Walter Hughes, RPh Dan Bushardt, RPh Linda Reid, RPh

SCPhA STAFF Craig Burridge Chief Executive Officer Laura Reid Director of EventsKeenan Grayson Director of Membership Cassandra Hicks-Brown Director of Operations/ACPELauren Sponseller Director of CommunicationsJon Wallace, BS Pharm, JD SCPhA General CounselCecily DiPiro, RPh PPN Network Coordinator

PALMETTO PHARMACIST STAFF

Jennifer Simmons Layout/Design/ContentCraig Burridge Managing Editor

What’s Inside...

5 Metathesiophobia President Steve McElmurray discusses the irrational fear of change

7 State Phair 2013 A look at SCPhA’s 2013 Annual Convention

16 Legislative Wrap Up At the close of the legislative session, see how things tied up 21 A Perspective on Pet Medications Information on veterinary medications

25 My SCPhA Rotation Journal SCCP Student Michelle Nations discusses her rotation with SCPhA

33 Pharmacy Camp Attracts Young Audience A special camp at SCCP provides a unique experience for students

Regular Columns 18 SCCP 32 Financial Forum 36 Journal CE 33 Classifieds

Advertisers 2 Smith 4 Pharmacists Mutual 15 Mutual Drug of North Carolina 34 Display Options 42 PACE 43 Jon Wallace, Attorney at Law 44 QS1



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As2013cametoaclose,itisonlynaturaltoreflecton the events that have taken place over the past twelvemonths.Asawhole,SCPhAhashadarathersuccessfulyear!Therearesomanymilestonesandmarkers that make 2013 a memorable one. To name afew,webroughtonboardCraigBurridge,SCPhA’sCEOwhosevastexperienceandrichhistoryofthepharmacyindustryhastakenustonewlevels.Weareextremelygratefulfortheknowledgethathehascarriedoverfromhispreviousassociation,andincorporatedhereinSouthCarolina.Craighasahostofsupportbehindhim-astaffofhardworkingindividualswhoworktirelesslytocreateevents,drivemembership,relayinformationandopportuni-tiestoourmembersonadailybasis.Inadditiontothestaff,thereisadedicatedBoardofDirectorswhovolunteers their time to ensure that we, as an Asso-ciation,makedecisionsthatareinthebestinterestofallwhoarerelatedtopharmacy.RoundingoutthearmyofSCPhAsupportisajuniorboard,studentswho are willing to relay our information to the studentsattheirschools—thefutureofpharmacy.Withouteachofthesepeople,it’ssafetosaythatSCPhAwouldnotbewhereitistoday.

Whilewereflectonwherewe’vebeen,it’swithoutquestionthatwemustlookaheadtowherewearegoing…andasfarasIcansee,thefutureofphar-macy looks promising. On page 10 of this journal, youcanfindinformationonourPAC.Inordertobringattentiontopharmacy-relatedissues,wemust“put our money where our proverbial mouths are”, sotospeak.We’vegatheredinformationtoshowyouwhereSCPhAstandsindonations,incompari-sontootherassociationsthroughoutthestate.It’snosurprisethatmoneytalks,andwewanttobepreparedtoexpressouropinions,whenneeded.IchallengeeachofyoutostronglyconsiderdonatingtothePAC.Togetherwecanmakeadifference.

Thisyearisalsobringingabigchange:anupdateofourwebsite,www.scrx.org.Weareexcitedaboutwhatthisnewsitewilldoandfeature.Wehopethatyouwillvisitoursitefrequentlyandmakeityourfirststopforallthingspharmacy!

My last request for 2014 is to challenge yourself to becomemoreinvolvedinTheAssociation.Whether

PRESIDENT’S PLATFORM

it’sattendingmoremeetings,sharingwithnon-members the importance of joining the association, or expressinganinterestinleadershiproleswithinSC-PhA,weneedyou!It’salwaysimportanttoremem-ber that you only get out what you put in to anything. Ican’twaittoseewhat2014hasinstoreforSCPhA!

Together we can make a difference.


PRESIDENT’S PLATFORM

2014 Brings Exciting News


Name

License/Registration Number Degree(s)

Address

City State Zip

Phone Fax

Email

Company/Pharmacy Name

Address

City State Zip

Work Phone Work Fax

NABPeID BirthDateandMonth(DDMM)

Membership Type: (Please select one) Regular RPh Member ($150) Associate(Non-RPh)Member($150)VestedMember($2000one-timefee,noadditionaldues)First Year Practicing RPh Member ($75) RetiredRPhMember($75)Pharmacy Technician Member ($35) Spouse/Joint Membership ($250 per couple): Spouse Name:__________________

Additional Contributions:

SC Pharmacy Advocacy Committee: While your SCPhA duesautomaticallyassistpharmacyadvocacyefforts,youraddi-tionalcontributiontothePharmacyAdvocacyCommitteesup-portsgreateradvocacyinthelegislativearena.Contribution Amount: $50 $100 $250$500 $1,000 Other $______ *Contributions to the PAC are not tax-deductible.

SC Pharmacy Foundation:Helppreservethepastandin-vest in the future of pharmacy. ContributionstotheSCPharma-cyFoundationarecompletelytaxdeductible.Contribution Amount: $50 $100 $250$500 $1,000 Other $______

Payment Information: Total Due to SCPhA: $___________________ Check;check#__________(madepayabletoSCPhA)CreditCard: MC Visa AMEX DiscoverBillingAddress__________________________________Billing City, State, Zip _____________________________CardNumber____________________________________Exp. Date___________ CVV #____________________

ReadytobeapartofSouthCarolina’sleadingprofessionalpharmacyassociation?FillouttheformbelowandreturntoSCPhAwithpaymenttojoinfor2013-2014today.SCPhA’smembershipyearisfromOctober1,2013-September30,2014.

Please return to SCPhA, along with payment, to: 1350 Browning Road, Columbia, SC 29210

or you can fax credit card payments to 803.354.9207. Register online at www.scrx.org For questions, call 803.354.9977

SCPhA dues are NOT tax deductible as charitable contributions for income tax purposes. However, they may be tax deductible as ordinary and necessary business expenses subject to restrictions imposed by law with respect to asso-ciation lobbying activities. The Revenue Reconciliation Act of 1993 states that Association dues used for lobbying activities are not deductible as a business expense. As a result 15% of SCPhA dues cannot be deducted as a business expense for federal income tax purposes.

SCPhAMembership2013-2014

What’s new this year? SCPhA Student Association Fall 2013

willmarktheinauguralyearoftheSouthCaro-linaPharmacyStudentAssociation,undertheumbrellaofSCPhAandtheleadershipoftheJuniorBoard.

Member Referral Program This is an exciting new incentive to encourage your peers to join SCPhA! Each time that a member refers someone who joins SCPhA, their name will be enteredintoadrawingtowin$1,000 CASH!ThewinnerwillbedrawnatSCPhA’sAnnualConvention in June 2014!

New Website! Therumorsaretrue—weareswitchingtoanewdatabaseandwebsitethatwillallowourmembersgreateraccesstoinfor-mation 24/7!

Manypharmaciesarenotyetawarethattheirpharmaciesarebeingratedonthequalityoftheircareforpatients.In2008,CMSbegana“StarRatings”programforMedicareprescriptiondrugplans(bothMA-PDsandPDPs)basedonseveralqualitymetrics.Morerecently,thishasledtheMedicareplanstoscruti-nize the performance of their pharmacy networks using the same quality metrics that CMS uses to evaluate theplans.Thisisbecausethepharmacy-drivenqualitymetricsmayaccountforasmuchas45%ofaMA-PD’soraPDP‘sPartDstarrating.

So,whatexactlydoesthismeanformypharmacy?IfyourpharmacyisdraggingdownthestarratingofaMedicarePartDnetworkyou’reareparticipatingin,yourpharmacymaynotbeinvitedtoparticipateintheirnetworkin2015.Why?CMShasbothrewards(asin5%bonusesforMedicareAdvantageplans)andpunishment(asininabilitytoenrollmoreMedicareparticipantstoexpulsionfromMedicareforpoorplanperformers)basedontheirstarratings.Yourpharmacy’sstarratingcanpotentiallygetyouashareofthosebonusesorattheveryleast,aplaceina“PreferredPharmacyNetwork.”AreyoubeinglockedoutofalotofPartDnetworksnow?Knowyourstarratingandlearnhowtogetbackin.

Wheredidthe‘StarRating”systemcomefrom?ItallstartedwiththecreationofthePharmacyQualityAlliance(PQA)inApril2006.PQAisaconsensus-based,multi-stakeholder,organizationcommittedtoimprovinghealthcarequalitywithafocusontheappropriateuseofmedications.Thealliancehasover130memberorganizationsandgivesavoicetopharmacistsinhowthequalityof“medicationuse”willbemeasured.ThePQAMeasureshavebeenadoptedfortheMedicareStarRatingsandforhealthplanratingsbytheNationalBusinessCoalitiononHealth,aswellasaccreditationprogramsfromURAC.

Wanttoseehowstarratingswork?YoucanviewStarRatingsforMedicareplansbygoingto:www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerfomanceData.html.

What’s in the ‘Stars’ for Pharmacy?SCPhA’s Five Star Challenge

by:CraigM.Burridge,MS,CAECEO, SCPhA

Medicare


Whatwillpharmacyberatedon?IntheMedicarePartDprogram,thereare15qualitymeasuresusedby CMS to assign anywhere from 1 to 5 stars to a Part D contract. Several of these measures can be directlyaffectedbycommunitypharmacists.Theseinclude:• MedicarePartDMeasuresfromPQA:

o Two measures on Patient Safety• HighRiskMedicationsintheElderly• Appropriatetreatmentofbloodpressureinper-

sons with Diabetes o ThreemeasuresinMedicationAdherence-ProportionofDaysCovered–(PDC)

• OralDiabetesMedications• CholesterolMedications(statins)• BloodPressure(renin-angiotensinsysteman-

tagonists) (RASA) o ComprehensiveMedicationReviewComple-tion Rate

• MedicarePartD‘DisplayMeasures’(fromPQA)–AlthoughnotpartoftheCMSstarratings,CMSstillmonitors‘displaymeasures’toas-sessesplanperformance.Thosedisplaymeasuresrelevanttopharmacyinclude: o Drug-DrugInteractions; o Excessivedosesoforaldiabetesmedications; o HIVantiretroviralmedications

For2014,39Medicarecontractsreceiveda“LowPerformance icon” on the CMS website by consis-tentlybeingbelow3-starsforeitherPartCorPartD.Therewere107contractsthathad2-starsorloweronall3PDCadherencemeasures.ManyofthesepoorperformingplanswereinAL,GA,SC,LA,MS,TN,TXandPR.

SCPhA 5-Star ChallengeHereistheSCPhA5-StarChallenge:Wewouldliketo work with all pharmacies in South Carolina to assistyouingettingyourpharmacy’sstarratinguptoa“5.”Tohelpyoudothis,we’dliketoreferyourpharmacytoPrescribeWellness,aCalifornia-basedcompanywhos“VoiceofAuthority”anduniquepatient-specificdeliverysystemcanincreaseyour“Will-Call’pick-upsbyanaverageof30%therebyhelpingyouinpatientadherence.TheyhavealsosuccessfullyincreasedFluVaccineclinicattendanceasmuchas400%.YoucancontactPrescribeWellnessandaMr.AlBabbingtonat(513)310-9222oremailhim at: [email protected].

IfyouneedaservicewhocantrackyourprogresstowardaFIVESTARrating,youcancontactacol-laborativecalledEQuIPP.TheEQuIPPprogramisofferedbyPharmacyQualitySolutions,acompanythatisprimarilyownedbyPQA.TheemailcontactforEQuIPPisinfo@EQuIPP.organdthewebsiteis: www.equipp.org. Finally, if there are areas of concernwhereyouneedadditionalhelp,SCPhAwilltrytoassistthoughCEprograms,bestpracticesandour Diabetes program in those areas where we have contracts.SCPhAwantsyourpharmacyaroundforaverylongtime.Let’sgetyoutoa5-StarRating!SCPhAwishestoexpressourdeepestgratitudetoDavidNau,RPh,PhD,CPHQ,FAPhA,PresidentofPharmacyQualitySolutionsandLauraCranston,RPhatPQAforsharingtheirslidepresentationssothat we may share this valuable information with all of you.

Medicare


Saturday, February 22, 2014

9:00 am—1:00 pm

SCPhA Office, 1350 Browning Road,

Columbia, SC 29210

SCPhA Members: $50 / Non‐Members: $80

Registra�on Informa�on: □ Member: $50 □ Non‐Member: $80 □ Join SCPhA and Register: $85 Name_________________________________________ NABPe ID#____________________________ Address_______________________________________ City, State, Zip ________________________ Email_________________________________________ Phone_______________________________ Payment Informa�on: Payment Type: □ Check _____________ Total Amount Due: $ ___________ Credit Card Type: □ MC □ Visa □ AMEX □ Discover Name on Card___________________________ Card #_____________________________________ Exp. Date______________ CVV_____________ Billing Address_____________________________________________________________________

The South Carolina Pharmacy Associa�on is accredited by the Accredita�on Council for Pharmacy Educa�on as a provider of con�nuing pharmacy educa�on. Con�nuing educa-�on credits will be available to par�cipants who fully a�end the program and then com-plete an online educa�onal ac�vity evalua�on. A unique code given at each ac�vity must be provided in the evalua�on to receive credit. Grievances regarding the educa�on program must be submi�ed in wri�ng to the SCPhA ACPE Adminis-trator immediately following the program.

REGISTER ONLINE TODAY AT

WWW.SCRX.ORG

Complete this form and return, with payment, to SCPhA at 1350 Browning Road, Columbia, SC, or fax to (803) 354‐9207. Visit www.scrx.org to register online. Ques�ons? Call Laura Reid at (803) 354‐9977.

Cancella�ons will only be accepted if received more than 5 business days before the event. If applicable, a refund will be issued less a $15 processing fee. Please note that the threat of inclement weather is not considered

sufficient to override our cancella�on policy.

Faculty: Pamela W. Cain, RPh, MPH

Cri�cal Thinking (1 hour) 1. Dene cri�cal thinking. 2. List the benets of cri�cal thinking. 3. List the characteris�cs of cri�cal thinkers. 4. Recognize situa�ons where pharmacy technicians can

use cri�cal thinking skills.

Medica�on Safety for the Young & Old (1.5 hours) 1. Iden�fy the ages for pediatric and geriatric pa�ents. 2. List the types of medica�on errors for these pa�ents. 3. Recognize the pharmacy technician’s role in preven�ng

medica�ons errors for these pa�ents.

Pharmacy Inspec�ons (1.5 hours) 1. Iden�fy Federal and State regula�ons reviewed during

an inspec�on. 2. Discuss different forms used by inspectors from the SC

Board of Pharmacy and from SCDHEC Bureau of Drug Control.

3. Recognize the pharmacy technician’s responsibili�es to comply with Federal and State regula�ons.

TOPICS AND OBJECTIVES



What Does This Mean For YOU? SCPhA membership is approximately 2,000 strong

If each member would make a single contribution equal to the cost of an average dinner out ($30.00), SCPhA’s PAC would be at $60,000!

A strong PAC is essential to advance our advocacy goals, and is an integral part of SCPhA’s membership. Your PAC contributions are more important now than ever!

2012 South Carolina PAC Expenditures: SC Trucking Association: $121,750 SC Optometric Association: $90,400

SC Automobile Dealers Association: $102,413 SC Trial Lawyers Association: $80,000

Political Action

Committee

(PAC) Quick Facts

Julian Reynolds Jessica Legge John Pugh Carolina Pharmacies Unlimited SCPhA Foundation– 8th District Pamela Whitmire Dawn Devine Eugene Sawyer

2012-2013 Contributors to SCPhA PAC Craig Harmon

Walter Hughes

Gregory Mayer

Lynn Connelly

Christopher James

Tom Simpson

Randy Todd

Davis Hook

Pharmacy Partners

Regina Boswell

Tommy Simmons

Spartanburg Treatment Associates

Phillip Hall Landrum Drug Company

James Shuler Gordon Brown

Ways you can donate: Call our office (803)354-9977, visit our website at www.scrx.org or mail your contribution to

SCPhA, 1350 Browning Road, Columbia, SC 29210 (Attn: PAC Fund). We appreciate your support!

SC Pharmacy Association: $ 32,700

YOUR NAME HERE


CompiledbyKeenanGrayson,DirectorofMembership

Name: Zoom H. Heaton, RPh, CDEPharmacy:TLCMedicalCentre,Inc.Location: Aiken, South Carolina

How long have you been a member of the South Carolina Pharmacy Association? 22 years

What do you see as the greatest benefit of being a member of the South Carolina Pharmacy Associa-tion?The Association is a single source to represent the interestandfutureofpharmacist.TheAssociationshouldbeaproactivelobbyinfluencingStatelegisla-tiveissues,whichpromotethefinancialwellbeingofindependentpharmacies.

Further,theAssociationshouldbeonthecuttingedgeoftechnologiesdevelopingintheworldofpharmacy

aswellaspromotingnewdisciplineswhichwillposition pharmacist to capture opportunities. These opportunitiesshouldareeitherevolvingasaresultofadeficientinhealthcareresourcesorthecontinuingsupportofcommunitybasedprogramming.

What are some professional successes that you have experienced? InnovativePharmacyPracticePharmacyoftheYear/Reader’sChoicePharmacistoftheYear/Reader’sChoiceFeaturedinawidevarietyofpublicationsfromtheQS-1monthlymagazinetolocalandcommunitymagazinesandpublicationsGoodNeighborPharmacysitefornationaladcam-paignRecognizedforfinancialsupport:WoundedWarriorProject, Habitat for Humanity, Toys for Tots, support for numerous church mission tripsSpeakingatSCPhA’sSoutheastern“GirlsofPhar-macy”leadershipweekend

MEMBERS

Meet Zoom Heaton

What Does This Mean For YOU? SCPhA membership is approximately 2,000 strong

If each member would make a single contribution equal to the cost of an average dinner out ($30.00), SCPhA’s PAC would be at $60,000!

A strong PAC is essential to advance our advocacy goals, and is an integral part of SCPhA’s membership. Your PAC contributions are more important now than ever!

2012 South Carolina PAC Expenditures: SC Trucking Association: $121,750 SC Optometric Association: $90,400

SC Automobile Dealers Association: $102,413 SC Trial Lawyers Association: $80,000

Political Action

Committee

(PAC) Quick Facts

Julian Reynolds Jessica Legge John Pugh Carolina Pharmacies Unlimited SCPhA Foundation– 8th District Pamela Whitmire Dawn Devine Eugene Sawyer

2012-2013 Contributors to SCPhA PAC Craig Harmon

Walter Hughes

Gregory Mayer

Lynn Connelly

Christopher James

Tom Simpson

Randy Todd

Davis Hook

Pharmacy Partners

Regina Boswell

Tommy Simmons

Spartanburg Treatment Associates

Phillip Hall Landrum Drug Company

James Shuler Gordon Brown

Ways you can donate: Call our office (803)354-9977, visit our website at www.scrx.org or mail your contribution to

SCPhA, 1350 Browning Road, Columbia, SC 29210 (Attn: PAC Fund). We appreciate your support!

SC Pharmacy Association: $ 32,700

YOUR NAME HERE


MEMBERS

What are some successes that your pharmacy has experienced?Increasingbusinessdespitetheprescriptiongiveaway programs, which are truly a community health issue.Independentpharmacyissocriticaltothecommunitybecausewearehealthcareproviderswhodotakethetimetoensureourpatientsarewellandsafe.

Where do you see the profession of pharmacy in 10 years? The profession of pharmacy has taken a huge blow fortheworsesinceIstartedthepracticein1992.WiththeadventofthePharmacyBenefitsManagerplayingbothsidesofthetablewhenitcomestoreimbursementandcontractsandmandatoryfillingatspecific“preferred”pharmacies.

BilldeBlasio,newMayorofNewYorkCity,inhisinauguraladdresssaidthisverywellandIthinktheanalogyisworthdiscussinghere:

“Werecognizeacitygovernment’sfirstresponsibili-ties:tokeepourneighborhoodssafe…toensurethatthosewholivehere–andthosewhovisit–cangetwheretheyneedtogo….Butweknowthatourmissionreachesdeeper.Wearecalledtoputanendtoeconomicandsocialinequalitiesthatthreatentounravelthecitywelove.…It’sinourDNA.”

Where New York is the greatest City, Pharmacy is the greatestprofession.Ourlegislator’sfirstresponsibil-ityistokeepourneighborhood“pharmacies”safe,allow those who live here to go to the pharmacy of their choice with equitable reimbursement. But, we knowOURmissionreachesdeeper.Wearecalledupontoendthedisparitiesthatthreatentheprofes-sionwelove—CommunityPharmacy.Yes,itisinOURDNA!

Tell us about yourself.

Well,therearethreeofus,orfourwiththedog,Bos-phorus. Family is the most important element in my lifesinceitisaGodlycreation.Westrivetostudy,travelandlearntogether.Myhobbyforthepastyearshasbeenadvancingmyunderstandingofhormones,bloodnutritionandbloodvaluesandmostrecentlythepursuittobeaCertifiedClinicalNutritionist.

Ihopetoexpandthehorizonsofpharmacy.Asrev-enuesourcesdiminish,otheravenuesemerge.Thegreatestpublichealthdeficiencywehavetodayisthelossofthe“old”communitypharmacistwhoknowshiscustomer,remembershisclient,andisconsideredafriend.Believeitornot,relationshipsandempathycannotbereplacedwithvolume.Healthcarethatremovestheindividualfromthematrixisaflatline.

Tell us something that we don’t know about you.IwasborninSaigon,Vietnam.IamappreciativeandblessedtohavebeensavedbytheAmericanmilitarywhorescuedandplacedmeononeofthelasttrans-ports out of Saigon before it fell to the communist regime.

IamforeverthankfulforthisgreatNationandamanexampleofanimmigrantwhoisliving,befittingandcontributingtotheAmericanDream.GodBlessAmerica.

Tell us about your pharmacy.TLCMedicalCentre,Inc.issonamedbecauseweenvisionourmissiontobemorethanjustdispensingmedications.Welovegettingtoknowpeopleandbeing a part of taking care of them. We vaccinate all yearround;providemedicalequipmentneeds;giveinformativemonthlyin-houseseminarseducatingourcommunity;Wehaveacompoundinglabcustomizingmedicationsformanywithspecialmedicationneeds;Wespecializeinbio-identicalhormonereplacementtherapyforbothmenandwomenaswellasbloodnu-trition.Bloodnutritionisourlatestservicespecial-izinginbloodchemistryinterpretationandhelpingpatientswhohavenutritionaldeficienciestobesupplementedfornormalfunctiontoberestored.

Is there anything that you would like to tell our members?Agreatopportunityhaspresenteditselfforpharma-cistandCaliforniaisleadingtheway.ThePharma-cistScope-of-Practicebillisnowlaw.Thisisthestartforpharmacist,whoreceiveadditionaltraining,todomorefortheirpatientsandutilizethemanyskillsandknowledgewehave.

WemuststartnowandworkhardtoachievethismidlevelproviderdesignationinSouthCarolina.


2014’S UPCOMING SCPhA EVENTS

January 23: Aiken Pharmacy Night February 4: Charleston Pharmacy Night February 11: Columbia Pharmacy Night February 22: Technician Connection March 4: APhA MTM CTP Course March 12: APhA Diabetes CTP Course March 18: Greenville Pharmacy Night March 19: Legislative Day March 29: Cordially Yours at APhA April 11: APhA Immunization CTP Course May 12-14: Student Board Review June 19-22: Annual Convention

REGISTER AT www.scrx.org

IMPORTANT DATES March 1: -Awards nominations due -House of Delegates and Board of Directors applications due March 30: -Junior board member applications due April 1: Election voting opens April 30: Election voting closes May 9: convention scholarship applications due (students only)

CONTACT US

SC Pharmacy Association 1350 Browning Rd. Columbia, SC 29210 803.354.9977


SCCP

PEOPLELauraLeathers(pictured)andSaraStroutwonthirdplace in the national clinical skills competition for pharmacystudents,heldbytheAmericanSocietyofHealth-SystemPharmacists(ASHP).TheSouthCarolinaCollegeofPharmacy(SCCP)studentswerehonoredatanawardsceremonyontheopeningdayoftheASHP2013MidyearClinicalMeeting,whichwasDecember8-12inOrlando.

KristyBrittainwasawardedanMUSCInnovationsinTeachingandLearningPilotProjectProgramgrant–“Team-BasedLearningwithDistanceEducationDe-liveryofSelf-CarePharmacotherapyandAnalysisofFunctional Teams in the Classroom Setting.” She was alsoawardedoneoftheSCCP’s2013ExtraMilesAward,alongwithBetsyBlakeandWendyRehman.Allthreearepictured.OneotherwinnerontheUSCcampuswillbeawardedlaterthisweek. NicoleBohmwasawardedanMUSCIP/IDgrant–“TheRelationshipBetweenInterprofessionalTeamStructureandCompetenciesandRiskofAdverseEventsforHospitalizedInternalMedicinePatients.” AmyThompson,whoalsopassedherBCACPexam,washonoredasEmployeeoftheMonthbyMedicalUniversityHospitalonNovember14. JamesSterrett(renewal),ChristinaCoxandPhilipMohornpassedtheirBCPSexams. JosephT.DiPirohasbeenelectedasfellowoftheAmericanAssociationfortheAdvancementofSci-ence (AAAS). JenniferSchnellmannwasnamedthe2013Dis-tinguishedAlumnaofLyonCollege.SchnellmanngraduatedfromLyonin1992withabachelor’sinbi-ology.Shewentontoearnadoctorateinpharmacol-ogyandtoxicologyfromtheUniversityofArkansasforMedicalSciencesin1997. ScottGiberson,actingUnitedStatesdeputysurgeongeneralandchiefprofessionalofficerintheU.S.Pub-licHealthService,spoketofaculty,staffandstudentsontheMUSCcampus.HeistheauthorofthereporttotheUSSurgeonGeneral“ImprovingPatientandHealthSystemOutcomesthroughAdvancedPhar-macy Practice.”

Updates at SCCP by Joseph DiPiro, Dean SCCP Tiffany van Mannan receivedNationalCommunity Phar-macists Association (NCPA) scholar-ship. She was one of fewerthan35studentsnationally to earn one of the 2013 NCPA FoundationPartnersin Pharmacy Scholar-ships.Sheispicturedwithfromleft,NCPAFoundationboardoftrusteeJimRankinandNCPAimmediatepastpresidentDonnieCalhoun.

SERVICEThistimeofyear,studentsofourCollegeshowaninspiringanduncommonamountofservicetotheircommunities.Moststudentorganizationsraisemoneyand/orprovidegoodsorservicestofamiliesinneed.The following are just three illustrative highlights of ourstudents’contributions: LedbysecondyearpharmacystudentSarahKim,PhiDeltaChirecentlywasawardedsecondplaceintheSt.JudeGiveThanksWalkafterraisingmorethan$2,500fortheSt.JudeChildren’sResearchHospital.ThePhiDeltaChichapterisnewthisyeartotheUSCcampus. TheDepartmentofClinicalPharmacyandOutcomesSciencesrecentlyparticipatedinafundraisingeffortas part of Stocking Stuffers for the “Carolina Cares” program,raisingmoneytofillstockingsforsixdisad-vantagedchildren. TheChristianPharmacistsFellowshipInternational(CPFI)ChapteratMUSConceagainputtogetherholidaycarepackagesforstudentsinHaiti.Students,facultyandstaffpurchasematerialstomakepackageswithrice,beans,driedmeats,hygieneproducts,basicschoolsuppliesandsmalltoys.CPFIcreated47pack-ageswhichbecamepartofa175-packageshipmentto2,500studentsatGoodShepherdMinistries(GSM)ChristianSchoolsinMilot,BiclaireandSavaneCarree.DonatedfundsenabledtheshippingwithadditionalfundsappliedtoPhaseTwoofaproposedGSMHospi-tal in Savane Carree.


Where would you prefer to have your HIPAA training?

Option A Option B

Yep. That’s what we thought. Get your HIPAA training online, 24 hours a day, 7 days a week with SCPhA’s on-line HIPAA training program.

Assessing Your Pharmacy’s HIPAA Policies & Procedurescreated by Craig Burridge, MS, CAE, CEO, South Carolina Pharmacy Association Goals and Objectives:1. Identify the laws covering confidentiality and their lead up to HIPAA.2. Recognize the standard principles governing confi-dentiality as it relates to patient records.3. Identify the need for and responsibilities of a pri-vacy officer and workforce training requirements.4. Differentiate between the proper uses and disclos-ers of protected health information and permitted uses and disclosures.5. Recognize when authorization is necessary for protected information.6. Identify the requirements for the distribution of Privacy Practices Notices.7. Know how to develop an electronic protected health information policy.8. Recognize how to mitigate and notify affected individuals in case of a breach of protected health information.9. Identify the expanded HIPAA requirements under the Health Information Technology for Economic and Clinical Health Act (HITECH)

Fees:SCPhA Members: $15\Non-Members: $25Please note that this is required in order to obtain 2 hours of CE Credit.

The South Carolina Pharmacy Association is accredited by the Accreditation Coun-cil for Pharmacy Education as a provider of continuing pharmacy education. This home study is approved for 2 contact hours of continuing pharmacy education credit (ACPE UAN: 0171-0000-13-074-H03-P). This CE credit expires 8/08/2016.

Register online at www.scrx.org, or follow the QR code to the right!

ThepharmacistsofAmericamadetheirfirststandforproviderstatustodayonCapitolHill.LiketheAmeri-can colonists who fought the Battle of Bunker Hill, theoutcomemaynothavebeenwhatwewanted,butwelettheUnitedStatesCongressknowthatpharma-cistsarereadytoperformasprovidersofpatientcareservices!Todaywestoodupandsaid,“We’veonlyjust begun.”

JustgettingpharmacistsasprovidersmentionedattheCongressionallevel,letaloneintroducedintotheamendmentrecord,isasignificantaccomplishment.WhiletheproposedamendmenttotheSustainableGrowthRate(SGR)billwasnotintroducedorap-proved,wecanofficiallysaythatourefforttowardsproviderstatusison.Itwilllikelytakeaprolongedeffort,giventheatmosphereinWashington,andwe’rehereforthelonghaul.

TheSenateFinanceCommitteewastoconsideranamendmentthatsoughttoaddpharmaciststothelistofrecognizedprovidersintheaccountablecareorganizations(ACOs)nowemergingasmajordeliv-erymodelsinourhealthcaresystem.Unfortunately,therewereover140amendmentstobeconsidered.Most,includingthisamendment,werewithdrawnornotintroduced,whenthesustainablegrowthrate(SGR–“docfix”)billwenttovote.Thementionofpharmacistsintheamendmentrecordgivesushopeforfuturediscussionsaswecontinueanongoingna-tionaldebatearoundfixestoourhealthcaresystem.

Weknowthatourpatientsneedourservices,andweneedproviderstatustobeinapositiontohelp.Forthattohappen,weneedtocontinuesendingthatmessage to our Members of Congress. ACOs engage pharmacistsaspartoftheseteam-basedcaremodelsandencouragetheprovisionofpatientcareservicesbypharmacists,including:• Medicationmanagementandmedication check-ups• Transitionsofcareandmedication reconciliation services• Medicationaccessmanagement

• Chronicconditionmanagementand counseling• Preventionservices,suchasmedication educationandcheck-ups,immunizationsand screening assessments.

Pharmacists are an integral member on every health careteamandshouldberecognizedassuch.Weareconfidentthattoday’sactionplacesproviderstatusonthetableasanissueforfuturehealthcaredebates.WelookforwardtoworkingwithourteammatesandstakeholdersaswecontinueourworkwiththemandotherleadersinCongresstoimprovepatientaccesstopharmacistsasprovidersofpatientcareservices.

TheproposedGrassley-CarperAmendmentcanbeviewedonPage84oftheAmendmentstoanOriginalBilltoRepealtheSustainableGrowthRateSystemandMedicareBeneficiaryAccessImprovementActof2013.Inaddition,twootheramendmentsinvolv-ingpharmacists(Carper/Grassley-IncreasingPatientMedicationEducationandAdherenceRoberts/Casey-ExpansionofMTMtargetedbeneficiary)werewith-drawnwithacommitmentforfurtherdiscussionandevaluation,butcanbeviewedonpages58and98,respectively.

WethankIowa’sSenatorGrassleyandDelaware’sSenator Carper for working in bipartisan coopera-tion,andourGovernmentAffairsstaffforitsworkwiththeSenatetomoveourprofessionforward.AsIwroteinanearlierblog,SenatorsGrassleyandCarperrecognizetheuniqueandvaluableservicespharmacistsprovideeachandeverydayinallcities,towns,andhamletsacrossourcountry,andweknowtheywillcontinuetobeourpartnersastheproviderstatus effort continues.

Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhAAPhAExecutiveVicePresidentandCEO-From the APhA CEO Blog

Provider Status: Game On


APhA

Bowl of Hygeia State Association Challenge 2.0 –

Help South Carolina Take the Lead!

Goal: $600,000 Endowment Yet to raise: $150,000

How You Can Help:

• Save time: Make $10

quick donations by text - RxBowl to 52000

• We are encouraging all

former recipients to contribute!

Contact: Lynette Sappe-Watkins:

[email protected] or 202-429-7534

Prizes Funds for a Bowl of Hygeia Reception at

your next Annual Meeting

1st Place is $2,500: Awarded to the state raising the most over

$5,000 before APhA2014*.

2nd Place is $1,000: Awarded to the state raising the 2nd highest

amount over $5,000 before APhA2014*.

3rd Place is $500: Awarded to the state raising the 3rd highest

amount over $5,000 before APhA2014*.

NEW! 1st, 2nd and 3rd place winners may have the Bowl of Hygeia sent to

their meeting for your reception! * Funds must be received by the APhA Foundation by March 15, 2014



This is the Fifth of a Series of Topics that began with theimportanceofdevelopingapersonalizedbusinessmodelandbusinessplan,optimumpharmacysize,lo-cationevaluation,followedbyhowpharmacylayoutanddesignaredifferent.Iwillnowdiscussimpor-tantservicesanddepartmentselectionIrecommendandbelievesetsyouapartfromyourcompetition.

SERVICES Numerousstudieshaveshownthattheservicesprovidedbymostinde-pendentpharmaciesrankveryhighwith consumers. Service comes in secondtoconveniencewithcus-tomer preference when selecting a place to shop. They value how they aregreeted,thestaffknowingthembynameandthepharmacyprovid-ing a higher level of attention than they expect from competitors. Over thenextdecadeandbeyond,Ibe-lieve the role of the pharmacist will increasefarbeyondfillingprescrip-tions.Thetrendhasalreadybegunandcanhaveagreaterimpactonindependentpharmaciesthantheirlarger counterparts. Some states havealreadypassedlegislationdo-ingjustthat.Idiscussedinprevi-ousarticleshowbesttodrawnewcustomers to your pharmacy which fallsunderconvenience,exposureandvisibility.Oncetheyenter,hereisyourbestopportunitytoimpressthem.Yourpharmacyshouldhave an inviting appearance but may look just like another one 25 miles away. That, in itself, has no im-pactonthecustomer.Youdon’thavetolookuniquetobeunique.Thedifferenceiswhattheyperceiveasgoodvalue.HerearemyrecommendationsbasedonwhatIhavelearnedaboutthegeneralpublicandhowbesttocapitalizeonhowweexpectthemtorespond.

Awell-identifiedconsultationroomthatisadjacenttotheRxdepartmentandconvenienttothepatientwillpositionyoutotakeadvantageoftheexpandingroleof the pharmacist in our health care system. Although reimbursementsareslowincoming,Iwouldofferallkindsofservicessuchasscreenings,MTM,diabetic,obesityandsmokingcessationprograms.Initially,

thescreeningscanbeofferedonslowerdaysoftheweek.Diabetesandobesityhavebeencalledepidem-icsinthiscountry,evenamongouryouth,andtheindependentpharmacyisthebestsourceforhelpingthesepatients.Ihavevisitedpharmaciesthathavebeen successful in charging a reasonable fee for consultation.Healthprofessionals,registerednurses,masseusesanddieticiansmaybeinterestedinprovid-ing screenings at your pharmacy. This approach can

help increase your Rx volume with-outhavingtoconductunproductivesales promotions or trying to create alowerpriceimage.Ithinkmoreemphasiswillbeplacedonpreven-tion rather than cure because the costsaremuchlower.InConsum-ersReport’ssurveyin2011,94%ofthemorethan44,000respondentsrevealedtheyleantowarddo-ingbusinesswithanindependentpharmacy over the chain. Most of theirreasonswererelatedtoser-vice.However,thereisnodoubtinmymindthatmanyofthosesamepeople are chain store customers because of convenience . Remem-ber,inpaststudies,convenienceisfirst,thenselection,andpricecomesinthirdplacedependingonthepricepoint.

DEPARTMENTSNo matter what size store you have, there will always bearequestforanitemyoudonothave.Thathascausedpharmacyownerstostockitemsthatmaynotbring about the best outcome. The general public has learnedhowtocompartmentalizetheirshoppinghab-its.ItisnotunusualforcustomerstogettheirRx’sfilledatanindependentpharmacyandgotoalargerstoretobuytheirnon-healthitems.Althoughcontro-versial,Ifirmlybelievethatthesmallerindependentpharmacytodayshoulddisplayonlyhealth-relateddepartments.Thenon-Rxvolumehasdeclinedfromabout50%to6-7%overthepastfiftyyears.Ithinkthatthevastmajorityofthe6-7%canbeattributedtohealth-relateditems.Isuggestthatyourpharmacywill project a more professional atmosphere by specializinginhealth-relateddepartments.Iwould

Creating a Competitive Strategy for Independent Pharmacy Success By Roland Thomas

Pharmacy Design

Student Articles


leavethedollaritemstothedollarstores,giftstothegiftshops,toysandhouseholditemstothebigstoreswherethecustomercanfindawideselectiontochoosefrom.Iwouldemphasizeawell-stockedde-partmentthatincludesnaturals,homeopathic,herbs,supplements,andvitamins.Thisisagrowingmulti-billiondollarbusinessandtheindependentpharmacyisbetterequippedtoeducate.Thepharmacistorstaffmembermustbecomewellversedinhowtheseeitherhinderoracceleratetheireffectontheirprescriptionregimen.

Althoughyoumaynotbeinclinedtogetheavilyin-volvedincompounding,spacepermitting,aseparateroomwithadisplaywindowmakesastatementandsomethingtheywillnotseeatthechainstore.Ades-ignated,comfortablewaitingareawithaTVmonitoraddsaspecialtouchthatcustomersappreciate.Ifitweremypharmacy,Iwouldhaveasingle-cupbever-agedispenserandofferwaitingcustomerscoffee,hotteaorhotchocolate.IfyouplanonDME,Isuggestawideselectionwhichrequiresalotmorespaceandagainawell-trainedstaffmembertoassistthepatientandonethatisknowledgeablewithbillingissues.Al-thoughIproposeonlyhealth-relateddepartmentsin

today’ssmallerpharmacy,Ihavenomajorproblemwithhavingasmallgreetingcardspinner,abeveragecooler(suggesthealthybeverages)orcandy,espe-ciallythesugar-freekind.Displayingtoys,householditems,tobacco,fooditemsonlymakesyourphar-macy appear to consumers as a small version of the chaindrugstore.

Ihavespentyearsstudyinghowpeoplereactandhaveownedanexperimentalpharmacytolearnmoreabouthumanreactions.Yourpharmacyshouldmake a visual statement that you are a specialist in thehealthcarefield.Furthermore,byfollowingthisconcept,youaredifferentiatingyourbusinessmodelfromthebigguyswhichIthinkwillbeafeatherinyour cap. Our next topic will be focusing on mer-chandisetechniques.

Roland G Thomas is a Pharmacy Planning Specialist with Rx Planning Solutions – a division of Display Options in Charlotte, NC. Roland has had the privilege of working with pharmacists all over the Southeast United States, planning and designing pharmacies for over 40 years. Independent and multiple location owners have relied on his expertise in this field.

Student Articles


Asastudentinpharmacyschool,itiseasytobecomeoverwhelmedwithmanyorganizationmember-shipopportunities.Studentsaretoldto“becomeinvolved”and“boostyourrésumébybeingactiveinmultipleorganizations.”So,howdoyouchoosewhichgroupstojoin?Whatmakesoneorganiza-tionbetterthananother?Unfortunately,thesearetoughquestionsbecausethereisno‘right’or‘wrong’answer. While each group has an acronymic name thattakesmultipleattemptstodistinguish,theyhavespecificpurposesforsustainingasanentity.Eachstudenthasdifferentinterestsandcareerpaths,whichallow for many unique organizations to come to fruitioninordertorepresentuniquepersonalities.However, there is one organiza-tionthat,regardlessofyourper-sonalinterests,willbenefiteverystudentandpharmacistplanningto practice in the state of South Carolina. Before starting my rotation at the South Carolina Pharmacy Association(SCPhA),Ihadonlybeeninvolvedinafeworgani-zationsduetomyheavyworkschedulewhichIkeptinordertopay the constantly increasing tuition fees. During my secondyearofpharmacyschool,arepresentativeofSCPhArevealedtoourclassthatstudentmembershipwas free. This opportunity was perfect for my tight budget,soIacceptedthemembershipbutnevertookadvantageofitswonderfulopportunities.Lookingbacknow,IwishthatIcouldhavereadthearticlethatIamwritingnowsothatIwouldhavebeenawareofalltheresourcesIhadavailabletome. SowhatisSCPhA?TheSouthCarolinaPharmacyAssociationisastate-wideadvocacygroupthatservesallpharmacists,pharmacystudents,andpharmacytechniciansinSouthCarolinainordertoprotecttheprofession.Theyworkhand-in-handwithlobbyists,congressmen,federalandstateprograms,pharmacyandtechnicianschools,andmuchmorein

ordertomaintainandexpandour profession for the future. Whenever new legislation relatedtopharmacyispassedorvetoedinthestatecongress,realizethatthestaffofSCPhAhasservedasthevoiceforallpharma-ciststokeepourinterestsinmind.Notonlydotheyworkbehindthescenes,buttheyalsoworktoalertpharmacistsaboutupcominglegislationandnewagendasthatarebeingdiscussed.TheorganizationalsoprovidescountlessCEopportunitiesandtrainingprogramsthatallowpharmaciststobeup-to-dateontheir annual requirements. Being a member of SC-PhAwillallowyoufullaccesstoallthebenefitsthey

offerandwillprovidemanyop-portunities to network with other professionalsduringorganizedmeetingsandevents.Lastly,youhavereadilyavailableresources,such as professional liability insuranceandlegalcounseling,whichareverycrucialinordertocoveryourselfintoday’ssociety. Unfortunately,manyofthebenefitsprovidedbytheSouth

CarolinaPharmacyAssociationremainunderutilizedduetohecticschedulesthatoccurintheprofession.Myrecommendationistobecomeamemberasastudent,forfree,andgetinvolvedtofindoutwhatserviceswouldbenefityouthemostforyourfuturecareer. Employers love to see applicants that have involvement in professional organizations, especially leadershiproles.Also,whatmostpeopledonotcon-sideristhatyoudonothavetomakethisasecondjob. Participate in a few events that interest you, so thatyoucanfulfillyourotherpriorities.Youwillbeextremelysatisfiedwithyourexperiences.Also,reapthemanyopportunitiesofobtainingrequiredCEhours that are extremely cheap for SCPhA members. Realize that our profession is constantly evolving, andthosewhoareinvolvedandupdatedwithnewestchanges will be the most successful.

Importance of Involvement in SCPhA: An Inside Look Written by __________________________ need info from Lauren and let me know which pic to put here because they were not labeld ---->

Approximately17.9percentoftheUnitedStates’2011GrossDomesticProductisspentonhealthcare.That is a staggering $2.7 trillion.1 Of these $2.7 tril-lion,between$106and$238billioisestimatedtopayforthedevastatingresultsoflowhealthliteracy.2

Healthliteracyisdefinedasanindividual’sabilitytounderstandthehealthinformationnecessarytomakeappropriatehealth-relateddecisions.Levelsofhealthliteracycanbeclassifiedasbelowbasic,basic,inter-mediate,orproficient.Veryfewadultspossessthehealthliteracylevelrequiredtomaintainahealthylifestyle.Approximately90millionadultshavebasicor below basic health literacy skills.3 Ninety percent ofadultshavetroubleutilizingessentiallifesavinghealth information that is available to them.4

Whatfactorsareresponsibleforlowhealthliteracy?Contrary to popular belief, low health literacy is not solelydependentoneducationandsocioeconomicstatus. Numerous factors contribute to low health literacyincludingculture,ethnicity,communicationskills,languagebarriers,increasedage,impairedophthalmoceptionoraudioception,andlevelofcom-fortwithhealthcareprovider.

Lowhealthliteracycontributestoasignificantin-crease in healthcare costs, number of hospitalizations, andmedicationerrors,resultinginadeclineinanindividual’soverallhealth.Studieshaveshownthatlowhealthliteracywillleadtotheinabilityofunder-standingthebasichealthcareinformationavailablecontributingtopoorchronicdiseasemanagement.Theseindividualsarealsolesslikelytoseekpreven-tativemeasuresandscreenings.Itisestimatedthatlowhealthliteracyisassociatedwitha50percentincreaseinanindividual’sriskofhospitalization.Inaddition,itlimitsanindividual’sabilitytoeffectively

Understanding Low Health LiteracyTavyiaGooding,Pharm.D.Candidate2014,SCCPTigestLemma,Pharm.D.Candidate2014,SCCP

managetreatmentleadingtoincreasedhealthcarecosts.Comparedtohealthliterateindividuals,therecanbeafourfoldincreaseinhealthcarecosts.2In-creasingly,healthcarecostsareaclearindicatorofsociety’sneedtostriveforanimprovementinhealthliteracy.Thisimprovementcouldenhancemedica-tioncompliance,limittreatmenterrors,decreasehealthcarecosts,andprovideasignificantimprove-ment in overall health status.

HowCanWeHelp?Aspharmacists,wetookanoathtoapplyourskillsandexpertisetoourpatient’sdrugregimen in an effort to maximize pharmacotherapy. Toupholdthisoath,wemustalsoaimtoaidintheimprovement of the health literacy of our patients. There are a number of health literacy techniques that canbeincorporatedintoourdailypatientcounsel-ingroutine.Itisgoodpracticetoinitiatepatientcounselingasifallpatientsarehealthilliterate.Uselayterminology.Utilizepictograms.Itiscrucialtogivethemostimportantinformationfirst.Bespecificwhen possible.5

As the counseling process progresses, tailor the informationprovidedtotheintellectualneedsofthepatient. Create a comfortable, forgiving environ-mentforpatientstofreelyexpresstheirhealth-relatedquestionsandconcerns.Itisgoodpracticetoaskopenendedquestionssuchas“Whatdidyourphysi-ciantellyouthismedicationwasfor?”Onceyouhavecompletedcounseling,utilizethe‘TeachBack’method.The‘TeachBack’methodallowspatientstoexplainhowtheywillusethemedicationintheirownwords.Thiswillensurethattheypatientunderstoodthedirectionsasyouintended.Encouragepatientstoreportdrug-relatedadversereactions.

Student Articles


Increasinghealthliteracyskillsisvital.Notonlycouldweimproveoverallhealthoutcomesofourpatients,wecouldpotentiallydecreasethe$2.7tril-lionspentinhealthcarecosts.Utilizingthesesimpletechniqueswillallowustodoourpartandaidintheeffortstocombatlowhealthliteracyanditsdevas-tating effects. For more health literacy techniques, pleasevisithttp://www.cdc.gov/healthliteracy/.

References1. The World Health Bank. Health expenditure, total (% of GDP). Retrieved December 2, 2013 from http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS. 2. Vernon, J. A., Trujillo, A., Rosenbaum, S., & De-Buono, B. (2007). Low health literacy: Implications for national policy. Retrieved December 3, 2013, from http://www.gwumc.edu/sphhs/ departments/healthpolicy/chsrp/downloads/LowHealthLiteracyRe-port10_4_07.pdf. 3. Parker RM, Jacobson KL. Emory Schools of Medicine and Public Health. Feb 2012. Health Literacy. Retrieved December 2, 2013 from http://www.iom.edu/~/media/Files/Activity%20Files/Publi-cHealth/HealthLiteracy/HealthLiteracyFactSheets_Feb6_2012_Parker_JacobsonFinal1.pdf.4. Kutner, M., Greenberg, E., Jin , Y., & Paulsen, C. ( 2006 ). The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: U.S. Department of Education, National Center for Edu-cation Statistics.5. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Quick Guide to Health Literacy. Retrieved November 25, 2013 from http://www.health.gov/communication/literacy/quickguide/.

StudentsonrotationwithSCPhAwritearticlesaboutvaryingtopicsofinterest.ArticlesarereviewedbyCraigBurridge.InterestedinrotatingwithSCPhA?Contactyourschoolofpharmacy’sexperientialedu-cationdepartmenttolearnmore!

Fraud, Waste and Abuse Manual

Why waste your precious time starting something from scratch? Get help creating your Fraud, Waste, and Abuse Manual for your pharamcy by purchasing our starting template today!

This manual outlines the regulatory envi-ronment and essential elements of a com-pliance program and, in Part II, includes sample policies and procedures that may be useful to pharmacies in developing or updating their compliance programs. Be-yond this manual, however, each pharmacy must undertake a detailed risk assessment and self-audit to ensure that its particular compliance program is properly tailored to its business.

Pricing:SCPhA Members $195

Non-Members $495

Purchase it online at www.scrx.org!



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PENCIL IN THESE IMPORTANT DATES FOR SPRING 2014!

March 19: Legislative Day at the Capitol

March 30: Junior Board Member applications due

May 12-14: Student Board Review

May 9: Convention scholarship applications due

Interested in getting involved? Visit our “Student Hub,” which can be

found at www.scrx.org!

Questions? Call SCPhA at 803.354.9977

CALLING ALL STUDENTS!

Note from SCP hA’s General C ounsel, Jon Wal lace:

As you can see under 40-47-965, under scope of practice guidelines authorized by the supervising physician, a P A can now prescribe for a C-II in a limited manner--most importantly being a one-time 72 hour supply.

Section40-47-965.(A)Ifthewrittenscopeofpracticeguidelinesauthorizesthephysician’sassistanttoprescribedrugtherapy:......(5)thephysicianassistantmayrequest,receive,andsignforprofessionalsamplesofdrugsauthorizedinthewrittenscopeofpracticeguidelines,exceptforcontrolledsubstancesinScheduleII,andmaydistributeprofessionalsamplestopatientsincompliancewithappropriatefederalandstateregulationsandthewrittenscopeofpracticeguidelines;(6)thephysicianassistantmayauthorizeprescriptionsforanorallyadministeredScheduleIIcontrolledsubstance,asdefinedinthefederalControlledSubstancesAct,pursuanttothefol-lowing requirements:(a)theauthorizationtoprescribeisexpresslyapprovedby30thesupervisingphysicianassetforthinthephysicianassistant’swrittenscopeofpracticeguidelines;(b)thephysicianassistanthasdirectlyevaluatedthepatient;(c)theauthoritytoprescribeislimitedtoaninitialprescriptionandmustnotexceedaseventy-twohoursupply;(d)anysubsequentprescriptionauthorizationmustbeinconsultationwithanduponpatientexaminationandevaluationbythesupervisingphysician,andmustbedocumentedinthepatient’schart;and(e)anyprescriptionforcontinuingdrugtherapymustincludeconsultationwiththesupervis-ingphysicianandmustbedocumentedinthepatient’schart;

Clarification on Amended PA Practice Act



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inancial orumThis series, Financial Forum, is presented by Pro Advantage Services, Inc., a subsidiary of Pharmacists Mutual Insurance Company, and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

FINANCIAL FORUM

HOW IMPATIENCE HURTS RETIREMENT SAVINGKeep calm & carry on – it may be good for your portfolio

Whydosomanyretirementsaversunderperformthemarket?From1993-2012,theS&P500achieveda(compound)annualreturnof8.2%.Acrossthesameperiod,theaverageinvestorinU.S.stockaccountsgotonlya4.3%return.Whataccountsforthediffer-ence?1,2

Onebigfactorisimpatience.Itisexpressedinemo-tionalinvestmentdeci-sions. Too many people tradethemselvesintomediocrity–theyreacttotheheadlinesofthemoment,buyhighandsell low. Dalbar, the notedinvestingre-searchfirm,estimatesthisaccountsfor2.0%oftheabove-mentioned3.9%difference.(Itattributesanother1.3%of the gap to operating costsandtheremaining0.6%toportfolioturn-over within accounts)2 Impatienceencouragesmarket timing. Some investorsconsider“buyandhold”passé,butithascertainlyworkedwell since 2009. How didmarkettimingworkincomparison?CitingInvestmentCompanyInstitutecalculationsof equity account as-setinflowsandout-flowsfromJanuary2007 to August 2012, U.S.News&World

Reportnotesthatitdidn’tworkverywell.Duringthatstretch,investorseithersoldmarketdeclinesorboughtaftermarketascents57.4%ofthetime.Inaddition,whilethetotalreturnoftheS&P500(i.e.,includingdividends)was-0.13%inthistimeframe,equityaccountinvestorslost35.8%(adjustedfordividends).3

Mostofusdon’t“buyandhold”forverylong.Dal-bar’slatestreportnotesthatthe average equity account investorownedhisorhersharesfor3.3yearsduring1993-2012.Investorsinbalancedaccounts(amixofstocksandbonds),heldon a bit longer, an average of about 4.5 years. They didn’tcomeoutanybet-ter–thereportnotesthatwhile the Barclays Aggre-gateBondIndexnotcheda6.3%annualreturnoverthe20-yearperiodstudied,theaveragebalancedaccountinvestor’sannualreturnwasonly2.3%.2 What’sthetakeawayhereforretirementsavers?Thisamountstoadecentargumentfordollarcostaveraging–theslowandsteadyinvestmentmethodby which you buy shares over time, a little at a time. When the market sinks, you are buying more shares as they have become cheaper –meaningyouwillown


more (quality) shares when they regain value. Italsoshowsyouthevalueofthinkinglong-term.When you save for retirement, you are saving with a timehorizoninmind.Adistanthorizon.Consistentsavingfroma(relatively)earlyageandthepowerofcompoundingcanpotentiallyhavemuchgreateref-fect on the outcome of your retirement savings effort than investment selection. Keepyoureyesonyourlong-termretirementplan-ningobjectives,nottheshort-termvolatilityhigh-lightedintheheadlinesofthemoment.

Pat Reding and Bo Schnurr may be reached at 800-288-6669 or [email protected] Representative of and securities and investment advisory services offered through Berthel Fisher & Company Financial Services, Inc. Mem-ber FINRA/SIPC. PRISM Wealth Advisors LLC is independent of Berthel Fisher & Company Financial Services Inc.

This material was prepared by MarketingLibrary.Net Inc., and does not necessarily represent the views of

the presenting party, nor their affiliates. All informa-tion is believed to be from reliable sources; however we make no representation as to its completeness or accuracy. Please note - investing involves risk, and past performance is no guarantee of future results. The publisher is not engaged in rendering legal, ac-counting or other professional services. If assistance is needed, the reader is advised to engage the ser-vices of a competent professional. This information should not be construed as investment, tax or legal advice and may not be relied on for the purpose of avoiding any Federal tax penalty. This is neither a solicitation nor recommendation to purchase or sell any investment or insurance product or service, and should not be relied upon as such. All indices are unmanaged and are not illustrative of any particular investment

Citations.1 - finance.yahoo.com/news/p-fund-tops-p-500-142700129.html [5/3/13]2 - marketwatch.com/story/7-reasons-why-retire-ment-savers-fail-2013-06-26 [6/26/13]3 - money.usnews.com/money/blogs/the-smarter-mu-tual-fund-investor/2012/11/05/herd-behavior-hurts-fund-investors [11/5/12]

NOTICE FROM APhASeveralpharmacistsinanumberofstatesoverthelastfewmonthshavecontactedusregardingthemisuseoftheAPhA’sname,logo,andtaglineinconjunctionwithcertainadvertisingforadiscountdrugcardprogramintheirstate.Thesewerediscountdrugcardprogramsoperatedbyaprivateentitynotthestate.IneachcasethedrugdiscountcardprogramvendorandadministratorwereinappropriatelyusingtheAPhAname,logo,andtaglinewiththewords“ProgramFeaturedat2012Conference”incertainadvertisingmaterialstopro-moteitsdiscountprescriptiondrugcardprogram. PleasebeadvisedthatAPhAhasnotendorsedthediscountprescriptiondrugcardprogramofthisvendorinanystateandhasnotauthorizedtheprogramvendororadministratortousetheAPhA’snameorlogoortag-lineinanycapacity.WereferredtheinquiriesthatwereceivedtoAPhA’sGeneralCounselwhocontactedthecompanyanditsrepresentatives.APhAGeneralCounselalsohassentanumberceaseanddesistletterstotheprogramvendorandtheadministratordemandingthattheyimmediatelyceaseanddesistanyfurtheruseofAPhA’sname,logo,andtagline.WearepreparedifnecessarytotakeadditionalactionasnecessarytoprotectAPhA’srights. Please feel free to notify your state members of this situation. Your state members can certainly contact us if they have any questions about the matter.”



Objectives: After completing this activity, partici-pantsshouldbeableto:

1.Describetheclinicalandeconomicimpactofosteoporosis,aswellasdescribethepathophysiologyofthedisorder.2.Identifyriskfactorsofosteoporosisandfractures.3.Listdiagnosticcriteriaforosteoporosisandiden-tifypreferreddevicesforuse.4. Review treatment options for patients with osteo-porosis,includingnonpharmacologicandpharmaco-logic therapies.

AbstractSummary: Osteoporosisisacommonbonediseasethatisoftenconsideredsilent.TheconditionaffectsmillionsofAmericansandhasasignificantimpacton the healthcare system economically. Typically thought of as being more common in women, osteo-porosis may affect men as well.

Severalfactorsincreaseapatient’sriskofdevelopingosteoporosisand/orsustainingafracture.Nonmodi-fiableriskfactorsincludefemalegender,olderage,andCaucasianorAsianrace.Otherfactors,suchashighcaffeineandlowcalciumintake,alsoincreaseapatient’sriskofdevelopingthecondition.

Onceadiagnosisismade,severaltreatmentoptionsare available. Nonpharmacologic therapies such asweight-bearingexerciseandfallpreventionareimportant components of any treatment regimen. Pharmacologicagents,includingcalcium,vitaminD,andbisphosphonates,mayberecommendedandusedin most patients.

Conclusion: Osteoporosiscanhaveaprofoundimpactonaffectedpatients,aswellasthehealthcaresystem. Pharmacists play an important role in the managementofosteoporosis,includingidentifyingthoseatrisktocounselingpatientsonproperadmin-istrationofmedications.ThisCEwillreviewtheimpactandincidenceofosteoporosis,presentfactors

JOURNAL CEOsteoporosis: The Basics By Zachary Anderson, PharmD, BCACP and Kayce Shealy, PharmD, BCPS, BCACP Assistant Professors of Pharmacy Practice, Presbyterian College School of Pharmacy

thatmayincreaseapatient’sriskofdevelopingosteo-porosis or sustaining a fracture, as well as review diagnosticcriteriaandavailabletreatmentoptionsforosteoporosis.

Keywords: osteoporosis, fracture, bisphosphonate, calcium,vitaminD,denosumab,teriparatide,calcito-nin Introduction. Osteoporosisisthemostcommonbonediseaseinhumans.Itisconsideredasilentdiseaseuntilitiscomplicatedbyafracture.Affectingmorethan10millionAmericans,non-discriminateofraceorsex,osteoporosisisassociatedwithsignificantmorbidityandmortalityandhasamajoreconomicimpactonboththepatientandthehealthcaresystem.1-3 Ex-perts estimate that by 2025, osteoporosis will cost thehealthcaresystemmorethan$25billiondollarsper year.4Inaddition,theSurgeonGeneralestimatesthatthenumberofhipfracturesandtheirassociatedcostscouldtriplebytheyear2040.5 Approximately one-halfofCaucasianwomenandoneinfivemenwillsustainanosteoporosis-relatedfractureintheirlifetime,andbecauseofthis,itisvitalthatprovid-ersutilizeappropriateandeffectivepreventativeandmanagementstrategiesinordertominimizetheclini-cal,humanistic,andeconomicimpactthatosteoporo-sishasonthepatientandthehealthcaresystem.5

Sincepharmacistsarecommonlyregardedasthemost accessible healthcare professional, it is im-portant that pharmacists equip themselves with the knowledgeandassessmentskillsnecessarytoserveasanintegralpartofapatient’shealthcareteam.Inadditiontoprovidingareviewofosteoporosisasadiseasestateandthepharmacologicalmanagementofthisdisease,thisarticleisdesignedtohelpprovidepracticalknowledgeandareviewoftheassessmentskillsthatwillhelppharmacistsfulfilltheirroleashealthcareproviderstotheirpatientswith,oratriskfordeveloping,osteoporosis.


JOURNAL CEEpidemiology and EtiologyThereareseveralriskfactorsassociatedwiththedevelopmentofosteoporosis,includingbothmodifi-ableandnon-modifiableriskfactors.Non-modifiableriskfactorsincludeadvancingage,familyhistoryofahipfracture,CaucasianandAsianrace,andfemalegender.Modifiableriskfactorsincludelowestrogenin women, low testosterone in men, low calcium intake,vitaminDinsufficiency,highsaltorcaffeineintake,excessivealcoholintake(≥3drinks/day),in-adequatephysicalactivity,immobilization,lowbodymassindex(BMI),historyofsmoking,andcertainmedications.

Osteoporosisisclassifiedintotwocategories,pri-maryandsecondary.Postmenopausalosteoporosisandosteoporosisassociatedwithsenilityarecon-sideredprimaryosteoporosis.Duringmenopause,especiallywithinthefirstfiveyears,estrogenlevelsaremarkedlyvariable,whichcanleadtoestrogendeficiency.Thisestrogendeficiency,inadditiontootherhormonalchangesthatoccurduringmeno-pause, is responsible for bone loss in postmenopausal women.6Secondaryosteoporosisisassociatedwithotherlifestyleandgeneticfactors,comorbiddiseasestates,andmedications(Table1).

Table 1: Conditions,Disease,andMedicationsThatCauseor ContributetoOsteoporosisand

Fractures (adapted from reference 1)

Lifestyle Factors

Alcohol abuse

Excess vitamin A

Excessive thinness

High salt intake

Immobility

Inadequatephysicalactivity

Low calcium intake

Smoking (active or passive)

Vitamin D insufficiency

Comorbid Disease States

Adrenalinsufficiency

AIDS/HIV

Alcoholism

Anorexia nervosa/bulimia

Celiacdisease

Congestive heart failure

Cushing’s syndrome

Depression

Diabetes mellitus

Gastricbypass/GIsurgery

Hematologicdisorders(various)

Hyperparathyroidism

Inflammatoryboweldisease

Parkinson’s disease

Premature menopause

Renaldisease(various)

Rheumatoidarthritis

Stroke

Medications

Aluminum

Anticoagulants (heparin)

Anticonvulsants

Aromatase inhibitors

Barbiturates

Chemotherapy agents

CyclosporineAandTacrolimus

Depo-medroxyprogesterone

Glucocorticoids

GnRHantagonists

Lithium

Methotrexate

Parenteral nutrition

PPIs

SSRIs

Tamoxifen

Thiazolidinediones

Thyroidhormones(excess)

Abbreviations:GnRH,Gonadotopin releasinghormone;PPI,Protonpumpinhibitor;SSRI,selective serotonin reuptake inhibitor


JOURNAL CEPathophysiologyTheskeletonismadeupoftwotypesofbone,trabec-ularboneandcorticalbone.Corticalboneaccountsforalmost80%oftheskeleton.Innormalbonehomeostasis, there is synergistic equilibrium between the formation of bone by osteoblasts, maintenance byosteocytes,andboneresorptionbyosteoclasts.Thisprocess,knownasboneremodeling,isthekeycomponentofbone’sabilitytocontinuously“turnover”.Inosteoporosis,thebalancedequilibriumofboneremodelingistiltedtowardsboneresorption,orenhancedosteoclastactivity.Thisdisequilibriumleadstoreducedbonemass,whichisassociatedwithincreasedbonefragilityandanincreasedriskforfractures.

Thoughacompleteunderstandingisnotyetknown,continualscientificdevelopmentshavehelpedinvestigatorsandpractitionersbetterunderstandthepathogenesis of osteoporosis. A key revelation of the pathogenesis of osteoporosis notes that mem-bers of the tumor necrosis factor (TNF) receptor familyinfluenceosteoclastfunction.1,7 The process begins with the receptor activator for nuclear fac-torκB(RANK),whichisactivatedbyaninterac-tionwithRANKligand(RANKL).7TheRANKLissynthesizedandexpressedbybonestromalcellsandosteoblasts.7Withhelpfromacytokinecalledmac-rophagecolony-stimulatingfactor(M-CSF),RANKLworkstoconvertmacrophagesintobone-destroyingosteoclasts.7Therefore,RANKactivationisamajorstimulus for the process of bone resorption. How-ever,thisprocessdoesnotgounregulated.Osteo-protegerin(OPG),amoleculewhichisalsosecretedbystromalcellsandosteoblasts,canbindtoRANKLandantagonizeitsinteractionwithRANK,restrictingosteoclastformationandtheprocessofboneresorp-tion.7ThedysregulationofRANK,RANKL,andOPGislikelyakeycontributorinthepathogenesisofosteoporosis.Thiscanoccurduetoavarietyofrea-sons,includingadvancingage,estrogendeficiency,andchangesincytokineenvironment.7

Thereareseveraladditionalfactorsthatareknowntoaffectthepathogenesisofosteoporosis,includingage-relatedchanges,hormonalinfluences,geneticfactors,physicalactivity,andcalciumnutritionalstate. The growth factors that allow osteoblasts to replicateandsynthesizebonebecomelesspotentasapersonages.However,asapersongetsolder,osteo-clastsdonotsufferfromanyhindranceinregardstotheirsynthesisandabilitytoaffectboneresorption.

Asfemalesentermenopause,thedecreaseinestro-genlevelscanleadtoadeclineinbonemassofupto35%ofcorticalboneand50%oftrabecularbonewithin30-40years.7 This hypoestrogenic effect can beattributed,inpart,toaugmentedcytokineproduc-tion,leadingtoincreasedRANK-RANKLactivityanddiminishedOPG.7 Therefore, the remaining osteoblastactivityisinadequatetocompensateforosteoclast activity.

Mechanicalforcesstimulateboneremodeling,there-forereducedphysicalactivityleadstoincreasedboneloss,andinolderindividuals,cancontributetosenileosteoporosis.1,7Inaddition,themagnitudeofskeletalloadinginfluencesbonedensitygreaterthanthenum-berofloadcyclescompleted,sothetypeofphysicalactivity a person performs is important.7 Resistance exercises, such as weight training, increases bone massmoreeffectivelythanenduranceactivities,likewalking or jogging.7

Geneticfactors,suchasvitaminDreceptorpolymor-phisms,whichaccountforapproximately75%ofthemaximalpeakbonelossachieved,playaroleinthepathogenesisofosteoporosis.Inaddition,geneticvariablescaninfluenceparathyroidhormone(PTH)synthesisandresponses,aswellascalciumuptake.7

LowserumcalciumlevelstriggertheparathyroidglandtosecretePTHresultinginanincreaseinthenumberandactivityofosteoclasts.Dietaryintakeof calcium also plays a key role in the pathogenesis ofosteoporosis,especiallyduringatimeofrapidbonegrowthaswithadolescence.Inadequatedietaryintakeofcalciumduringadolescencemayleadtocal-ciumdeficiency,failuretoachievethemaximalpeakbone,andanincreasedriskofdevelopingclinicallysignificantosteoporosisatanearlierage.7

Diagnostic and Laboratory AssaysDiagnosisofosteoporosisisdependentuponbonedensitymeasurementsorthepresenceofafragilityfracture.4CriteriadevelopedbytheWorldHealthOrganization(WHO)toidentifypeoplewithosteo-porosisbybonedensitymeasurementsarebasedonobservationaldataregardingtheexpectedbonemassin a young, healthy reference population.

Dual-Energy X-ray AbsorptiometryDual-energyx-rayabsorptiometry(DEXAorDXA)scansareusedtomeasurebonedensityandareconsideredthestandardfordiagnosis.6Thesedevicesemitlowdosesofradiation,maybeusedatcentral


JOURNAL CEorperipheralsites,andarenotportable.Centralmeasurements(iehipandspine)arepreferredoverperipheralsitesforbaselineandsubsequentmeasure-ments.Thesesitesaremorelikelytodemonstratearesponse to treatment over others.

Otherinstrumentsanddevicesformeasuringbonemineraldensityareavailable,butarenotindicatedfordiagnosisofosteoporosis.Thesedevicesusetechniques such as peripheral quantitative ultra-sonometry,singleenergyx-rayabsorbtiometry,andcomputedtomography.Whilethesetechniquescanbehelpfultoidentifypatientsatrisk,onlyDXAre-sultsorpresenceofafragilityfractureshouldbeusedfordiagnosis.

Resultsforbonedensitymeasurementsarereportedinseveralways.Bonedensityisreportedasgramsofmineralspersquarecentimeterofexpectedbonearea.ThisisusedtodeterminetheT-scoreorZ-score,themorecommonexpressionsofbonedensity.TheT-scoreisthenumberofstandarddeviationsfromthenormalyoungadultmeanvaluesinthereferencepopulationandisusedfordiagnosticpurposes.TheZ-scoreisthenumberofstandarddeviationsfrommeanvaluesofmatchedsubjectsbasedonage,race,andgender.ThediagnosticcriteriasetforthbyWHOarelistedinTable2.

Bone Turnover MarkersThoughnotcurrentlyrecommendedforroutinemoni-toring,serumandurineboneturnovermarkersmayhelpassessbothapatient’sriskoffractureand/ortheir response to therapy.4 Bone resorption markers includeN-telopeptide,C-telopeptide,anddeoxypyr-idinoline(DPD).Boneformationmarkersincludeprocollagentype1propeptides(P1NP),bone-specificalkalinephosphatase(boneALP),andserumosteo-calcin.Ifpractitionerschoosetoroutinelymonitorbone turnover markers, urine or serum measure-mentsshouldbedrawnatbaselineandaboutthreemonthsafterstartingtherapy.Asignificantincreasewithteriparatidetherapyandasignificantdecreasewithantiresorptivetherapy,discussedlaterinthearticle,indicatesaresponsetotherapy.Asuboptimalresponsetotherapyisindicatedbynochangefrombaseline.

Patient ScreeningIn2010,TheUnitedStatesPreventiveServicesTaskForcereviewedavailableevidenceinanattempttoofferguidanceandrecommendationsforosteoporosisscreening.4 The American Association of Clinical Endocrinologists(AACE)recommendsscreeningusingbonemineraldensitymeasurementsinpatientswhoareatincreasedriskofosteoporosisorfracturesandinthosewhoarewillingtoconsiderpharmaco-logictherapyifreducedbonemassisfound.Thisincludesallwomen65yearsorolderandyounger

Table 2: WHO Definition of Osteoporosis Based on BMD (adapted from reference 1)

Classification BMD T-Score

Normal Within 1 SD of a young-adult

reference population

T-score at -1.0 or above

Osteopenia Between1.0and2.5SDbelow

that of a young-adultreference

population

T-score between -1.0and-2.5

Osteoporosis 2.5 SD or more below that of a

young-adultreferencepopulation

T-score at or below -2.5

SevereorEstablished

Osteoporosis

2.5 SD or more below that of a

young-adultreferencepopulation

T-score at or below -2.5 with one

or more fractures


JOURNAL CEpostmenopausal women with one of the following: historyoffragilityfracture,long-termsystemicglu-cocorticoidtherapy,radiographicosteopenia,clini-calriskfactorsforosteoporosis,lowbodyweight,cigarette smoking, family history of spinal or hip fractures,earlymenopause,and/orsecondaryosteo-porosis.6

Prevention of OsteoporosisPatientswhohaveriskfactorsfordevelopingosteo-porosisshouldpracticeappropriatenonpharmaco-logicstrategiestohelpstrengthentheirbonesandprevent fractures. There has always been controversy astowhetherornotpatientswithosteopeniashouldreceivepharmacologicaltherapy.In2004,theWHOpublishedareportthatemphasizedthattheuseoftheT-scorealoneisaninappropriatewaytoidentifypa-tients at high fracture risk, who may require pharma-cologic intervention.2Instead,theWHOsuggestedthata10-yearprobabilityoffracture,suchastheFRAXfractureriskassessmenttool,beemployedtodetermineneedfordrugtherapy.2

FRAX Fracture Risk Assessment ToolThe FRAX fracture risk assessment tool utilizes patients’meanfemoralneckT-scoreorbonemineraldensity(BMD)andadditionalpatientspecificfactors,suchashistoryoffracture,tobaccouse,andlong-termoralglucocorticoidtherapy,todeterminethe10-yearriskofhipandmajorosteoporoticfracture.AccordingtotheNationalOsteoporosisFoundation’s(NOF)guidelines,treatmentforthepreventionofos-teoporosisisindicatedinpostmenopausalwomenandmenage50andolder,patientswithlowbonemass,anda10-yearhipfractureprobabilitygreaterthanorequalto3%ora10-yearmajorosteoporoticfractureprobabilitygreaterthanorequalto20%.1

Therapeutic GoalsGoalsforosteoporosistreatmentareaimedmoreatpreventingfracturesandslowingboneloss.6 These goalsfocusonimprovingstrengthandreducingtherisk of falling; relieving symptoms of current frac-turesandskeletaldeformities;andmakingthemostof physical function.

Non-pharmacological TherapyNomattertheageorprevioushistory,abone-healthylifestyleisimportantforallpatients.ThisincludessufficientcalciumandvitaminDintake,smokingavoidance,andphysicalactivity.Otherkeyfactorstoahealthylifestyleandbonehealtharereducedalco-

holconsumptionanddrinkinglessthan24ouncesofcaffeinatedbeverageseveryday.6

Weight-bearingexerciseisrecommendedtobuildandsustainbonestrengthaspreviouslystated.Thiscanalsoimprovepostureandbalance,whichmayleadtoreducingfalls.Unlesscontraindicationstoac-tivityarepresent,patientsarerecommendedtoobtainatleast30minutesofexercisemostdaysoftheweek.Examplesofweight-bearingexerciseincludewalk-ing,jogging,stairclimbing,andtennis.

Prevention of falls is very important in patients with oratriskofdevelopingosteoporosis.1Therearemanymedicalconditionsandriskfactorsthatmayincreaseapatient’sriskoffalling,includingdepres-sion,malnutrition,vitaminDdeficiency,arrhythmias,urinary incontinence, poor vision, poor balance, weakmusclesanddehydration.Severalmedica-tionsmayalsopredisposeapatienttofalls,suchaspsychotropicagents,diuretics,analgesics,andsomeanticonvulsants.Itisimperativetocounselpatientswiththeseconditionsortakingthesemedicationsaboutthedangersoffalls,andprovidesomeguid-ance to prevent them. Some strategies that can be rec-ommendedincludevisioncorrectionwithsinglelensglassesifneeded,modificationofthehomeenviron-mentthatincludesremovingthrowrugsandinstall-ingsafetybars,andperformingexercisessuchasTaiChi to improve balance.

Over-the-Counter Pharmacological TherapyCalciumCalcium is vital for optimal bone health as it can decreasebonelossinpostmenopausalwomenandoldermen.8Calciumisnotproducedinthebody,therefore, exogenous intake of calcium is very impor-tantthroughfoodorsupplementation.9Foodshighincalciumincludedairyproducts,almonds,andgreenleafy vegetables.

Theamountofcalciumrecommendedvariesbyage.TheNOFsuggeststhatpostmenopausalwomenandmenovertheageof70shouldingestapproximately1200mgofcalciumdaily.1Menbetweentheagesof50and70areencouragedtohaveadailyintakeofapproximately1000mg.Thisshouldbeachievedthroughdietaryintakeifpossible.Ifinadequatedietaryintakeisfound,thensupplementationmayberecommendedtoachievetherecommendedamounts.Calcium supplementation, though, is not without con-cerns.Recentstudieshavesuggestedthatsupplemen-


JOURNAL CEtationwithcalciummayincreasetherisksofcardio-vascular events.10-12Onestudysuggeststhatwomenovertheage55haveanincreasedriskofmyocardialinfarction if calcium supplements are taken for at least 5 years.10 However,theincreasedriskwasnotstatisticallysignificant,anddifferencesinpatientcharacteristics between the groups limit the interpre-tation of the results. More patients in the calcium groupwerecurrentorformersmokerscomparedtotheplacebogroup.Ameta-analysistodeterminetherisksforcardiovasculareventsandcalciumsuggeststhat calcium supplementation without concomitant vitaminDmayincreasethepatient’sriskofmyo-cardialinfarctionashighas30%.11 Lastly, a cohort inGermanyfoundthatpatientstakinganycalciumsupplementationareatanincreasedriskofcardiovas-cularevents,evenafteradjustingformanyvariablesthatmayaffectone’sinherentrisk.12 However, this studyfoundthatadequatedietaryintakedidnotin-creasecardiovascularrisks.Moreinformationfromstudieswiththispotentialincreasedriskbeingtheprimaryendpointisneededtoclarifytheactualrisk,if any, of calcium supplementation.

Whileadequateintakeofcalciumisrecommendedinseveralosteoporosistreatmentguidelines,evidenceiscontroversial as to whether supplementation actually preventsfractures.TheWomen’sHealthInitiative,alargerandomizedcontrolledtrial,demonstratedareducedincidenceoffracturesinpatientswhowereadherenttocalciumandvitaminD,buttheresultswerenotstatisticallysignificant.13 Patients who are also taking pharmacologic agents for treatment ofosteoporosis,suchasbisphosphonatesordeno-sumabareencouragedtointakeadequateamountsofcalciumandvitaminDtoassistwiththeagents’efficacy.TheUnitedStatesPreventiveServicesTaskForce(USPSTF)hasconcludedthatthereisnotenoughevidencetodeterminethenetbenefitorharmof calcium supplementation greater than 1000 mg dailyasrecommendedinclinicalguidelinesfortheprimary prevention of fractures in postmenopausal women.14However,theUSPSTFalsoconcludedthatsupplementation of less than 1000 mg of calcium dailyinpostmenopausalwomenisnotbeneficialforthe primary prevention of fractures.

Otheritemstoconsiderinregardstocalciumsupple-mentationincludesaltformation,adverseeffects,anddosing.Theselectionofcalciumsupplement,whenwarranted,isveryimportant.Calciumcarbon-ateiswidelyavailableandisrelativelycheap,butit

requiresanacidicenvironmentforoptimalabsorp-tion.Therefore,patientswhoaretakingacidsup-pression therapy such as proton pump inhibitors or histamine-2receptorantagonistsshouldtakecalciumcitrateproductstoensureappropriateabsorption.Calciummayleadtoconstipationandincreasestheriskofdevelopingkidneystones.Calciumsupple-mentationthatexceeds500mgdailyshouldbetakenindivideddosestoensureabsorption.

Vitamin DVitamin D augments calcium absorption from the intestineandfacilitatesbonehomeostasis.Defi-ciencyinvitaminDisalsolinkedtoincreasedriskof falls.9TheNOFrecommendsthatallpatientsovertheageof50ingest800to1000internationalunits(IU)daily,buttheInstituteofMedicine(IOM)recommendsallpatientsupto70yearsoldingest600internationalunitsdailyandthoseolderthan70yearsingest800internationalunitsofvitaminDdaily.1,15

Cholecalciferol (vitamin D3) is more potent, espe-ciallyathigherdoses,butergocalciferol(vitaminD2)maybeusedaswell.16

TheUSPSTF’srecentrecommendationsregardingvitaminDdosingandsupplementationdifferslightlyfrom the NOF.14Likethefindingswithcalciumsupplementation,theUSPSTFconcludesthatthereisinsufficientevidencetosupportsupplementationof greater than 400 international units of vitamin D dailytopreventfractures,butlessthan400interna-tionalunitsdailyprovidesnobenefitinpostmeno-pausalwomenoroldermen.However,thegroupmaintainsapreviousrecommendationofvitaminDsupplementationincommunity-dwellingpatients65yearsofageoroldertopreventfalls.

Whilerare,vitaminDtoxicitycanoccuratdailydoseswellaboverecommendedlimits(ie>10000IU)forextendedperiodsoftime.Signsoftoxicityincludenausea,vomiting,constipation,weightloss,andweakness.17Itisimportantforpharmaciststocounselpatientsonproperdosageandadministration,as well as signs of toxicity.

Prescription-Only Pharmacological Therapy (Table 3)Pharmacologic agents that are available by prescrip-tion-onlyareoutlinedindetailbelow.Otherinfor-mationincludingdosinganddosageformsavailableishighlightedinTable3.


BisphosphonatesBisphosphonatesremainthegoldstandard,first-lineagents for the treatment of osteoporosis. Bisphos-phonatesexhibitanti-resorptivepropertiesduetotheir ability to inhibit bone turnover by mimicking andinhibitingpyrophosphate,whichisanendog-enousboneresorptioninhibitor.Thisanti-resorptiveactivityleadstodecreasedosteoclastmaturation,recruitment,number,adhesiontobone,andlifespan. Bisphosphonates, many of which are generic, comeinavarietyofformulationsanddosages,whichmakethemthemostcost-effectivetherapyforpatients.Inclinicaltrials,bisphosphonateshaverepeatedlyproventheirefficacyinincreasingbonemineraldensity(BMD)andreducingfracturerates. Commonadverseeffectsassociatedwithbisphos-

phonatesincludemild-to-moderategastrointestinalsymptoms,suchasnausea,vomiting,diarrhea,dyspepsia,abdominalpain,andesophagealreflux,andsomepatientsmayevenexperiencemyalgias.Inthosepatientsthatexperiencegastrointestinalsymptoms,itmaybebeneficialtoextendtheirdosinginterval,fromdailytoweekly,weeklytomonthly,etc.inordertoimprovetolerability.18,19Inaddi-tion,patientsshouldbecounseledtotakemostoralbisphosphonateswith6to8ouncesofwaterpriortotheirfirstmealandthattheyshouldremainuprightfor30to60minutesaftertakingthemedication.1Zoledronicacidisadministeredviaintravenous(IV)infusionoveratleast15minutesandshouldbeadministeredinalineseparatefromotherIVmedications.Itisimportanttocounselpatientsthattheymustbeproperlyhydratedpriortoreceivingan

JOURNAL CETable 3: FDA-Approved Pharmacotherapy for the Treatment of Postmenopausal

Osteoporosis

Product Available Formulations Therapeutic Dose Pricing*

Bisphosphonates - Alendronate(Fosamax) - Ibandronate(Boniva) - Risedronate(Actonel, Atelvia) - Zoledronicacid(Reclast)

Tablets – 5, 10, 35, 70 mg Oral solution – 70 mg WithvitaminD(mg/IU)– 70/2800,70/5600 Tablets – 2.5, 150 mg Syringe – 3 mg/ 3mL Tablets – 5, 35, 75, 150 mg IVinfusion– 5 mg/100 mL

10mgPOoncedaily 70 mg PO once weekly 2.5mgPOoncedaily 150 mg PO once monthly IVover15-30seconds

every 3 months 5 mg PO oncedaily 35 mg PO once weekly 75 mg PO 2 consecutive dayseachmonth

150 mg once monthly IVonceyearlyoverat

least 15 minutes

$87.80 $81.95 $138.73 $526.99 $169.13 $157.85 $170.99 $1302.60

Denosumab (Prolia) Syringe – 60 mg/1 mL 60 mg SQ every 6 months $990.00 Raloxifene (Evista) Tablets – 60 mg 60mgPOoncedaily $655.80 Calcitonin (Miacalcin, Fortical)

Intranasal– 200IU/spray 1 spray intranasally into 1 nostriloncedaily;alternatingnostrilsdaily

M: $177.91 F:$102.89

Teriparatide(Forteo) Prefilledsyringe– 20 mcg/2.4 mL

20mcgSQoncedaily $1431.48

*Pricing Medi-Span®,basedontypicalonemonthsupplyatAWPandgeneric,whenavailable,forJune2013.PricingofInjectiblemedicationsonlyincludeddrugacquisition cost.


infusionandthattakingacetaminophenafteradmin-istrationmayreducetheincidenceofacutereactions,suchasarthralgia,myalgia,andflu-likesymptoms.Bisphosphonateshavereceivedmuchpublicityre-gardingsomemorepotentiallysevereadverseeffects,includingosteonecrosisofthejaw,atypicalfractures,andatrialfibrillation,whichwillbediscussedinfur-therdetailwhentheevidenceisexaminedinparttwoofthiscontinuingeducationseries.

Denosumab (Prolia®)DenosumabisafullyhumanmonoclonalantibodyspecificforRANKL,inhibitingRANKL’sinteractionwithRANK.Thus,denosumabreducesthesynthe-sis,action,andlifespanofosteoclastsandthereby,decreasingboneremodelingandincreasingBMD.Denosumab is a subcutaneous injection that must be injectedevery6monthsatthepatient’shealthcareprovider’sclinic,typicallyafterthepatientmustfirstpurchasethemedicationfromtheircommunityphar-macy.Itiscontraindicatedinpatientswithhypocal-cemia,thereforeallpatientsreceivingdenosumabtherapy must also be receiving appropriate calcium andvitaminDsupplementation.Injectionsitereac-tions,backpain,andmusculoskeletalpainarethemostcommonlyreportedadverseeffects.

Raloxifene (Evista®)Raloxifeneisaselectiveestrogenreceptormodula-tor,actingasanestrogenagonistontheboneandcholesterolandanestrogenantagonistinthebreastandendometrium.Commonadverseeffectsincludelegcramps,fluidretention,anincreasedriskofVTE,andhotflashes,whichcanbeintolerableforsomepa-tients.Raloxifenedoeshaveablackboxwarningforpatientswithcardiovasculardiseaseandatincreasedrisk for VTE events. Patients with a previous venous thromboembolism(VTE)shouldnotreceiveraloxi-fene therapy.

Calcitonin (Miacalcin®, Fortical®)Calcitonin, a natural hormone, regulates calcium by bindingtoosteoclaststopreventboneresorption.Calcitonin’sefficacyandbenefits,whichwillbediscussedinmoredetailinPart2ofthisCEseries,arelimited,howeveritappearstohaveananalgesiceffectandmaybebeneficialinpatientssufferingfrom a vertebral fracture.20Inaddition,itistheonlyFDA-approvedagentforthetreatmentofosteopo-rosis that is shown to be safe in patients with renal insufficiency.Sinceitisinactivatedbygastricfluid,calcitonin is only available as an injection or a nasal

spray,buttheintranasalrouteistypicallypreferred.Commonadverseeffectsincluderhinitis,nasalirrita-tion,nosebleeds,andheadaches.

Teriparatide (Forteo®)TeriparatideistheonlyFDA-approvedtreatmentofosteoporosisthatdoesnotinhibitboneresorp-tion.Teriparatideisarecombinant-PTH,consideredananabolicagent,whichstimulatesosteoblastsandleadstotheformationofnewbone.Teriparatideisaoncedailysubcutaneousinjection,whichisavailableasapre-filledpen.Sincemanypatientsmaybecau-tioustobeginadailyinjection,themanufacturerofteriparatide,EliLilly,isworkingtodevelopalterna-tivedosageformulations.Duetoariskofosteosar-coma,observedonlyinanimals,teriparatidetherapyhasbeenrestrictedtoatotaldurationoftwoyears.Todate,therehavebeennoreportedhumancasesofosteosarcomaduetoteriparatidetherapy.Someotheradverseeffectsthatthepatientmayexperienceincludeinjectionsitereactions,nausea,headache,legcramps,dizziness,andorthostatichypotension,whichmayoccurafterthefirstseveraldoses.BasedonthephysiologicalroleofPTHanditsrelation-ship with calcium, some patients may experience an increase in serum calcium levels. Therefore, it shouldbeavoidedinpatientswithhypercalcemiaatbaseline.Thoughtherearenoguideline-basedrecommendationsregardingcalciumsupplementa-tionandmonitoringinpatientsreceivingteriparatidetherapy,providersshouldbediligentinmonitoringserumcalciumlevelsatbaseline,after1-3monthsoftherapy,andthenroutinelyevery6-12monthsinordertoassessappropriatenessofpatients’currentcalcium supplementation regimen.

ConclusionThough many may view osteoporosis as relatively benign,itisaformidablediseasewithsignificanthumanistic,clinical,andeconomicimplicationsonthepatientandthehealthcaresystem.Therearesev-eralnewermedicationstohelpcombatthisdisease,buttheywillonlybeeffectiveifusedappropriately.Pharmacists play a key role in the management of osteoporosisandshouldbeequippedwiththeknowl-edgeandskillstomakeapositiveimpactonthepatientandthehealthcaresystem.ThispartoftheCEseriesonosteoporosiswasdesignedtoreviewtheimpactandincidenceofosteoporosis,thepatho-genesisofthedisease,thefactorsthatmayincreaseapatient’sriskofdevelopingosteoporosisorsustainingafracture,diagnosticcriteria,andtheavailabletreat-

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mentoptionsforosteoporosis.InparttwoofthisCEseries,“theevidence”foreachpharmacologicalagentandvariousmanagementstrategieswillbeexamined.

References:1. National Osteoporosis Foundation. Clini-cian’s Guide to Prevention and Treatment of Osteo-porosis. Washington, DC: National Osteoporosis Foundation; 2013.2. WHO Scientific Group on the Assessment of Osteoporosis at Primary Health Care Level. Rep. Geneva, Switzerland: World Health Organization. 2004.3. Cooper C, Atkinson EJ, Jacobsen, et al. Population based study of survival after osteoporotic fractures. Am J Epidemiol. 1993;137(9):1001-1005.4. US Preventative Services Task Force. Screening for osteoporosis: U.S. Preventative Servic-es Task Force recommendation statement [published online ahead of print January 17, 2011]. Ann Intern Med. 2011;154(5):356-364.5. US Department of Health and Human Servic-es. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: 2004. US Depart-ment of Health and Human Services, Office of the Surgeon General; 2004.6. Watts NB, Bilizikian JP, Camacho PM, et al; for AACE Osteoporosis Task Force. American Asso-ciation of Clinical Endocrinologists Medical Guide-lines for Clinical Practice for the diagnosis and treatment of postmenopausal osteoporosis. Endocr Pract. 2010;16(suppl 3):1-37.7. Kumar V, Abbas A, Fausto N, and Mitchell R, eds. Robbins Basic Pathology. 8th ed. Philadelphia, PA: Saunders/Elsevier, 2007. Print.8. Daly RM, Brown M, Bass S, Kukuljan S, and Nowson C. Calcium and vitamin D3-fortified milk reduces bone loss at clinically relevant skeletal sites in older men: a 2-year randomized controlled trial. J Bone Miner Res 2006; 21: 397-405.9. Centers for Disease Control and Prevention. Nutrition for everyone: calcium and bone health. April 6, 2011. http://www.cdc.gov/nutrition/every-one/basics/vitamins/calcium.html (Accessed June 4, 2013)10. Bolland MJ, Barber PA, Doughty RN, et al. Vascular events in healthy older women receiving calcium supplementation: randomized controlled trial. BMJ 2008; 336: 262-266.11. Bolland MJ, Avenell A, Baron JA, et al. Effect of calcium supplements on risk of MI and car-

diovascular events: meta-analysis. BMJ 2010; 341: c3691.12. Li K, Kaaka R, Linseisen J, Rohrmann S. Associations of dietary calcium intake and calcium supplementation with MI and stroke and overall car-diovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC-Heidelberg). Heart 2012; 98: 920-925.13. Jackson RD, LaCrois AZ, Gass M, et al. Calcium plus vitamin D supplementation and the risk of fractures. NEJM 2006; 354(7): 669-683.14. Moyer VA. Vitamin D and calcium supple-mentation to prevent fractures in adults: US Preven-tive Services Task Force Recommendation Statement. Ann Intern Med 2013; 158: 691-69615. Ross CA, Taylor CL, Yaktine AL, et al. Dietary reference intakes for calcium and vitamin D. Washington, DC: National Academy Press; 2011. http://www.nap.edu/openbook.php?record_id=13050&page=R1 (Accessed June 12, 2013)16. Heaney RP, Recker RR, Grote J, Horst RL, and Armas LAG. Vitamin D3 is more potent than vi-tamin D2 in humans. J Clin Endocrinol Metab 2011; 96: E447-E452.17. Office of Dietary Supplements, National Institutes of Health. Dietary supplement fact sheet: vitamin D (health professional version). June 24, 2011 http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ (Accessed June 2, 2013)18. Blumenthals WA, Harris ST, Cole RE, et al. Risk of Severe Gastronintestinal evens in women treated with monthly ibandronate or weekly alendronate and risedronate. Ann Pharmacother. 2009;43(4):577-585.19. Binkley N, Martens MG, Silverman SL, et al. Improved GI tolerability with monthly ibandronate in women previously using weekly bisphosphonates. South Med J. 2009;102(5):486-492.20. Cranney A, Tugwell P, Zytaruck N, et al; for Osteoporosis Methodology Group and Osteporosis Research Advisory Group. Meta-analyses of thera-pies for postmenopausal osteoporosis. VI. Meta-anal-ysis of calcitonin for the treatment of postmenopausal osteoporosis. Endocr Rev. 2002;23(4):540-551.

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Osteoporosis: The BasicsCorrespondence Course Program Number: 0171-9999-14-007-H01-P . 1.Completeandmailentirepage.SCPhAmemberscantaketheJournalCEforfree;$15fornon-members.Checkmustaccompanytest.Youmayalsocompletethetestandsubmitpaymentonlineatwww.scrx.org.2.Mailto:PalmettoPharmacistCE,1350BrowningRoad,Columbia,SC29210-6309.3.ContinuingEducationstatementsofcreditwillbeissuedwithin6weeksfromthedatethequiz,evaluationformandpaymentarereceived.4.Participantsscoring70%orgreaterandcompletingtheprogramevaluationformwillbeissuedCEcredit.Participantsreceivingafailinggradeonanyexaminationwillhavetheexaminationreturned.Theparticipantwillbepermittedtoretaketheexaminationonetimeatnoextracharge.

SouthCarolinaPharmacyAssociationisaccreditedbytheAccreditationCouncilforPharmacyEducationasprovidersforcontinuingphar-macyeducation.Thisarticleisapprovedfor1contacthourofcontinuingpharmacyeducationcredit(ACPEUPN0171-9999-14-007-H01-P).ThisCEcreditbegins1/31/2014andexpires1/13/2017.CEcreditswillbeuploadedtotheCPEMonitorSystem.

Name: _______________________________________________ License #: __________________________

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City: ____________________________________________ State: _____ Zip: ________________________

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NABPeID:_________________________________BirthMonth/BirthDate(MMDD):________________Evaluation: Circle the appropriate response Didthearticleachievethestatedobjectives?Notatall12345CompletelyOverallevaluationofthearticle?Poor12345Excellent/Wastheinformationrelevanttoyourpractice?No12345YesHowlongdidittakeyoutoreadthearticleandcompletetheexam?______________CE credit will ONLY be awarded when a submitted test is accompanied by completing the evaluation above or online at www.scrsx.org

LEARNING ASSESSMENT QUESTIONS:

1.Allofthefollowingareriskfactorsfordevelopingosteoporosisexcept: A.femalegender B.advancingageC. African American race D. low calcium intake

2.Inosteoporosis,thebalancedequilibriumofboneremodelingistiltedtowardstheactivityofwhichofthefollowing:A. Osteoblast B. OsteocytesC. Osteoclasts D. Osteoprotegerin

3.Theligandforreceptoractivatorfornuclearfac-torκB(RANKL)issynthesizedandexpressedby__________________________.A.OsteoclastsandosteoprotegerinB.BonestromalcellsandosteoblastsC.OsteoprotegerinandosteoblastsD.ReceptoractivatorfornuclearfactorκB

4.Thepreferredorgoldstandarddiagnosticprocedureforassess-ingbonemineraldensityis:A.centraldual-energyx-rayabsorbtiometryB.peripheraldual-energyx-rayabsorbtiometryC.centralcomputedtomographyD. peripheral quantitative ultrasonometry

5. When interpreting bone turnover markers, which of the follow-ingwouldindicatearesponsetoteriparatide(Forteo®)therapy?A.AsignificantdecreaseinboneturnovermarkersB.AsignificantincreaseinboneturnovermarkersC.AsignificantdecreaseinbonemineraldensityD.Asignificantincreaseinbonemineraldensity

6.AccordingtotheNationalOsteoporosisFoundation,howmuchcalciumshoulda50yearoldmanconsumeonadailybasis?A.600mg B.800mgC. 1000 mg D. 1200 mg

7.VitaminDdeficiencyhasbeenlinkedtowhichriskfactorforfracturesrelatedtoosteoporosis?A. fallsB. low calcium intakeC.highsodiumintakeD. Caucasian race

8.Bisphosphonatesareavailableinallofthefollowingdosageformulations EXCEPT:A. Oral tabletsB.InjectibleC. Oral solutionD. Topical solution

9. Which of the following pharmacological agent(s) stimulate(s) osteoblastactivity?A.Alendronate(Fosamax®)B. Denosumab (Prolia®)C.Teriparatide(Forteo®)D. Raloxifene (Evista®)

10.Whichofthefollowingpharmacologicalagentswouldbemostappropriateforapatientwithsignificantrenalinsufficiency?A.Ibandronate(Boniva®)B. Denosumab (Prolia®)C.Teriparatide(Forteo®)D. Calcitonin (Miacalcin®, Fortical®)

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