CT-ASCP's

SenioRx Care Perspec ve

Inside: Hypertension and Cholesterol Guideline Update: A Review Pages 2-4 Senior Symposium Save The Date Page 5 Notes ‘n Votes— February 2013 Page 6 Spring 2014

Volume VIII No. 1

As the Fall semester came to a close, we looked back on the exciting events the UConn ASCP student chapter had experienced so far. This past November, we attended this year’s ASCP Annual Meeting & Exhibition that was held at the Sheraton Hotel and at the Washington State Convention & Trade Center in downtown Seattle, Washington. Just as our chapter has done last year, we attended the meeting to show our support for our own Dr. Sean Jeffery. Dr. Jeffery was inaugurated president of ASCP last year;; he now leaves his office to take up his new role as Chairman of the Board of Directors. For many of us, this is our first time attending an ASCP annual and it was an amazing experience. In Seattle, we visited many of city’s attractions including the Space Needle and the Pike Place Market. At the annual, we attended CE seminars, product theatres, and product exhibits. We also participated in ASCP’s first annual GeriPardy, a competition where ASCP student members from all over country get together to network while testing their knowledge in topics relating to geriatric pharmacy. We want to give special thanks to UConn School of Pharmacy and to ASCP Connecticut Chapter for their support in helping us attend this meeting. We members appreciated it greatly and we eagerly anticipate going to next year’s ASCP annual in Orlando, Florida!

Our student chapter also participated in the school-wide Trivia Night, a tournament hosted by our Pharmacy Student Government. During this event, our team of four members represented ASCP very well as they competed against several other pharmacy student organizations in various trivia games for the prize money, which was to be donated to a non-profit organization of winning organization’s choice. Our team made it very far into the tournament, scoring high points, until the team was knocked out of the tournament during the second to last round. Nevertheless, we look forward in participating in future events in order to promote ASCP’s presence in the School of Pharmacy and University-wide. During the current Spring semester, our chapter is planning a school-wide “What Not to Wear” event. With the help of our pharmacy faculty and our student members, hope to provide the pharmacy community a funny and informative perspective on how to dress professionally. Furthermore, our chapter is looking forward to participating in brown bag medication review events as well as shadowing opportunities and site visits with CT-ASCP members. We also look forward to attending the Schwarting Senior Symposium in May. Contact information: If you are interested in having stu-­dents shadow at your practice and/or if want to know more infor-­mation about the events mentioned, please feel free to contact our President, Jon Angus, at ascp.uconn@gmail.com.

UConn Student Chapter Update Sarita Bri o—UCONN ASCP Student Chapter Historian

1 | Spring 2014 CT-ASCP Chapter Newsletter

2 | Spring 2014 CT-ASCP Chapter Newsletter

New blood pressure and blood cholesterol guidelines have recently been released with notable changes pertinent to pharmacy practice. The Eighth Joint National Committee (JNC 8) has loosened treatment goals and limited the number of first-line medications used to treat hypertension. The American College of Cardiology and the American Heart Association (ACC/AHA) have collaborated to create new cholesterol guidelines that focus on the use of statins, without targeting specific high-density lipoprotein (HDL) or low-density lipoprotein (LDL) treatment goals. This article will provide a summary of the changes contained in the new guidelines. Eighth Joint National Committee (JNC 8) Guidelines for the Management of High Blood Pressure in Adults The JNC 8 has removed the classifications of blood pressure (e.g. pre-hypertension, stage-one, stage-two hypertension) that were present in JNC 7, loosened blood pressure goals and changed therapy recommendations for compelling indications.1 JNC 8 categorizes three broad groups and assigns a blood pressure goal of 140/90mmHg for individuals with chronic kidney disease (CKD) or diabetes, regardless of age, or individuals eighteen to sixty years old or 150/90mmHg for individuals older than sixty years old (Table 1). First-line therapy options have also changed in the JNC 8 and are summarized in Table 2. Calcium-channel blockers (CCB), angiotensin-converting enzyme inhibitors (ACE-Is), thiazide diuretics or angiotensin receptor blockers (ARB) are recommended as first line therapy due to comparable benefits on overall mortality and cerebrovascular, cardiovascular and renal health. JNC 8 does not suggest that one class is more beneficial than another, except in the case of heart failure. Unlike the JNC 7, the JNC 8 guidelines do not recommend beta-blockers or aldosterone antagonists as first-line treatment for hypertension. In addition, the JNC 8 indicates that were no randomized controlled trials of fair or good quality to recommend the use of dual alpha-1/beta-blocking agents (e.g. carvedilol), vasodilatory beta-blockers (e.g. nebivolol), central alpha-2 adrenergic agonists (e.g. clonidine), peripherally-acting adrenergic agonists (e.g. reserpine), loop diuretics (e.g. furosemide), direct vasodilators (e.g. hydralazine) and aldosterone receptor antagonists (e.g. spironolactone) as first line therapy.

If a patient’s blood pressure is not at goal after one month, the dose of the medication can be increased or a second drug from one of the recommended classes can be added. A third drug can be added if patients cannot reach their goal blood pressure on two medications, with the exception of ACE-Is and ARBs that should not be used in combination. Blood pressure should continue to be assessed and dosage or medication adjustments should be made until patients achieve their goal blood pressure. Table 1: JNC 8 Recommended Goals and Treatment

Table 2: First-Line Therapy According to Patient Characteristics

Hypertension and Cholesterol Guideline Update: A Review Sabrina Caico, PharmD Candidate, Kamal Jawad, PharmD Candidate, and Stephanie Hattoy, PharmD, BCPS, CGP University of Saint Joseph School of Pharmacy

Patient Group Blood Pressure Goal (mmHg) CKD

Less than 140/90 Diabetic patients 18 to 60 years of age

Greater than 60 years of age Less than 150/90 CKD – chronic kidney disease

Patient Group Recommended First-Line Therapy

Non-black patients, including those with diabetes

Thiazide diuretics CCB ACE-I ARB

Black patients, including those with diabetes

Thiazide diuretics CCB

Heart failure patients Thiazide diuretics

ACE-I CCB

CKD patients, regardless of age, race or diabetes diagnosis

ACE-I ARB

CCB – calcium channel blocker;; ACE-I – angiotensin converting enzyme inhibitor;; ARB – angiotensin receptor blocker

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American College of Cardiology and the American Heart Association (ACC/AHA) Guidelines for the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults The new ACC/AHA guidelines regarding the treatment of cholesterol to prevent and reduce the risk of cardiovascular events in adults replace the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Pressure in Adults (ATP III). The ATP III guidelines stratified LDL-cholesterol, total cholesterol and HDL-cholesterol into different target concen-­trations: total cholesterol less than 200mg/dL and HDL-cholesterol between 40mg/dL and 60mg/dL was considered optimal.2 Atherosclerotic disease risk equivalents and major or minor risk factors were identified in ATP III. Targeted LDL-cholesterol goals were designated based upon a patient characteristics and risk factors. ATP III recommended a variety of diet and exercise changes and medications to achieve LDL-cholesterol goals first. After LDL-cholesterol goals were achieved, HDL-cholesterol goals or triglyceride goals were targeted for therapy. If triglycerides were greater than 500mg/dL at the time of initial treatment, then they were considered the priority treatment target. The ACC/AHA guidelines have eliminated the treat-to-target model of ATP III. Instead, the ACC/AHA guidelines identify four major groups where the benefit of atherosclerotic cardiovascular disease (ASCVD) risk reduction with statins outweighs the potential for adverse effects (Table 3).3 Therapy recommendations were changed due to the potential for adverse effects with multidrug therapy, the unknown magnitude of risk reduction with different LDL-cholesterol targets, and insufficient clinical trial data indicating positive benefit of attaining specific cholesterol levels. The new guidelines have developed a new “lowest is best” perspective for the treatment of LDL-cholesterol. To determine risk category and recommended treatment options, the ASCVD risk calculator is used. This replaces the Framingham risk calculator and incorporates factors such as race, total cholesterol, HDL-cholesterol, systolic blood pressure, diabetes and smoking into an equation to generate a 10-year risk for developing coronary death, nonfatal myocardial infarction and fatal or nonfatal stroke. The 10-year ASCVD risk calculator can be found online through the AHA or ACC (http://my.americanheart.org/cvriskcalculator).

Patients should be assessed for cardiovascular risk every four to six years for traditional risk factors such as hyperlipidemia, high blood pressure, and diabetes. In addition, lifestyle modifications such as adhering to a heart-healthy diet (fruits, vegetables, whole grains, low-fat dairy, etc.) and participating in an exercise regimen (e.g. forty minutes of rigorous exercise, three to four times per week) are recommended. Guidelines still recommend that patients avoid smoking and maintain a healthy weight. Statins are heavily recommended in the ACC/AHA guidelines and the ATPIII recommendations for non-statin therapies have been abandoned. Non-statin therapy does not have sufficient data to suggest that there will be incremental cardiovascular risk reduction benefits that outweigh the potential for adverse effects or harm. The ACC/AHA guidelines only recommend non-statin therapy if a patient is statin-intolerant, if therapeutic response to statins is less than anticipated, or if triglyceride levels are greater than 500mg/dL. Based on the new treatment algorithms, individuals are eligible for therapy with either high-intensity or moderate-intensity statins. High intensity statins are drugs that lower LDL-cholesterol by greater than fifty percent from baseline, whereas moderate-intensity statins lower LDL-cholesterol by thirty to fifty percent. Patients are not candidates for high-intensity therapy if they are predisposed to statin-associated adverse effects such as impaired renal or hepatic function, history of statin intoler-­ance or muscle disorders, unexplained ALT elevations greater than three times the upper-limit of normal, concomitant drugs affecting statin metabolism, or age greater than 75 years old. Patients requiring high-intensity statin therapy that are ineligible based on contraindications should utilize moderate-intensity statin therapy instead when indicated. A few examples of new contraindications against certain combinations with simvastatin include azole antifungals, erythromycin, clarithromycin, telithromycin, HIV protease inhibitors, nefazodone, gemfibrozil, cyclosporine, danazol. More aggressive simvastatin dose limitations include: not exceeding 10 mg while taking amiodarone, verapamil, diltiazem and not exceeding 20mg while taking amlodipine, ranolazine.

Hypertension and Cholesterol Guideline Update: A Review - con nued Sabrina Caico, PharmD Candidate, Kamal Jawad, PharmD Candidate, and Stephanie Hattoy, PharmD, BCPS, CGP University of Saint Joseph School of Pharmacy

4 | Spring 2014 CT-ASCP Chapter Newsletter

Table 3: ACC/AHA Risk Groups and Treatment Recommendations

The new hypertension and cholesterol guidelines vary greatly from their predecessors. The JNC 8 hypertension guidelines have higher blood pressure goals and no longer emphasize compelling indications when selecting medication therapy or determining blood pressure goals. The ACC/AHA cholesterol guidelines abandon the “treat-to-target” method for treating cholesterol and instead recommend a “lowest is best” approach to treatment with statin therapy based on the patient’s risk category. Both guidelines simplify the treatment of hypertension and cholesterol and it will be interesting to see the impact they have on clinical practice.

References: James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults. Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2013 Dec 18. Grundy SM, Becker D, Clark LT, et al. National Cholesterol Education Program Expert Panel on Detection, Evalua-­tion, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). NIH. 2002 Sept. ePrint. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. J Am Coll Cardiol. 2013 Nov 12;; ePrint.

Hypertension and Cholesterol Guideline Update: A Review - con nued Sabrina Caico, PharmD Candidate, Kamal Jawad, PharmD Candidate, and Stephanie Hattoy, PharmD, BCPS, CGP University of Saint Joseph School of Pharmacy

Risk Group Recommended Treatment Clinical ASCVD

PLUS 21 to 75 years old

High-Intensity Statin Therapy

Atorvastatin (Lipitor®) 40 to 80mg Rosuvastatin (Crestor®) 20 to 40mg

No clinical ASCVD PLUS LDL Cholesterol > 190mg/dL

AND > 21 years old

No clinical ASCVD PLUS Diabetes

AND > 21 years old AND ASCVD risk > 7.5%

ASCVD risk > 7.5% AND 40 to 75 years old

Clinical ASCVD PLUS > 75 years old OR statin intolerant

Moderate-Intensity Statin Therapy

Atorvastatin (Lipitor®) 10 to 20mg Rosuvastatin (Crestor®) 5 to 10mg Simvastatin (Zocor®) 20 to 40mg

Pravastatin (Pravachol®) 40 to 80mg Lovastatin (Mevacor®) 40mg

Fluvastatin XL (Lescol XL®) 80mg Fluvastatin (Lescol®) 40mg twice daily

Pitavastatin (Liavlo®) 2 to 4mg

No clinical ASCVD PLUS LDL Cholesterol > 190mg/dL

OR > 75 years old OR statin intolerant

No clinical ASCVD PLUS Diabetes AND

> 21 years old

ASCVD – atherosclerotic cardiovascular disease

5 | Spring 2014 CT-ASCP Chapter Newsletter

Schwarting Senior Symposium 2014

Arthur E. Schwarting

Pharmacy Practice

Symposium

UCONN School of Pharmacy and CT-ASCP

invite you to the

The Schwarting Senior Symposium

Senior Symposium

Track #1 New Drug Updates

Medication Safety Topics Anticoagulants in the Elderly

Adverse Drug Effects in the Elderly and more.....

$99

Arthur E. Schwarting Pharmacy Practice Symposium

Track #2 MTM for Patients with Diabetes Certificate Program

$199

Immunization Training for Pharmacists Certificate Program

Track #3 $249

Tuesday, May 13, 2014

The Aqua Turf Club

556 Mulberry Street

Plantsville, CT Click at h p://pharmacy.uconn.edu/academics/ce/schwar ng/ for more information

6 | Spring 2014 CT-ASCP Chapter Newsletter

SPONSOR RECOGNITION Carrieann Kumor from Forest was thanked for the sponsorship. REVIEW OF PAST MINUTES The minutes of the 1-6-14 meeting were reviewed and unanimously approved. LEGISLATIVE AFFAIRS G. Memoli announced that CMS is proposing the collection of patient data from pharmacies regarding Part D and looking at prescribing patterns possibly by the end of the year. B. Tendler announced that four medical marijuana producers were approved. According to DCP as of 1/28/14, 1684 patients have been certified. SCHWARTING-SENIOR SYMPOSIUM (SSS14) - May 13, 2014 at Aquaturf, Southington, CT K. White is organizing volunteers for the program and new shirts will be ordered with a new logo for this year at $31.40 each. Please contact Kathy if you are able to volunteer for registration. M. Wrabel had previously suggested an App for the program but after group discussion it was agreed that it is not necessary at this time. Emails and mailings have been sent out to sponsors and D. Cooper reminded everyone to reach out to any companies. Forest, Abbvie, and Novo Nordisk have been upgraded to Platinum Sponsorship due to product theaters. 6-8 companies are at Bronze level and there are 20-30 booth spaces available overall. 7.5 credits of education are scheduled and all speakers are confirmed. All objectives should be in shortly so that registration can be opened. Student sponsorship will be available. An education grant from Merck was secured for MTM and the Immunization program. Drug Topics will have a ½ page advertisement in March. There was a discussion regarding Alumni Networking Ideas. Overall the group did not think this meeting was large enough to separate tables by location or schools of pharmacy. One suggestion was allowing attendees to identify themselves by schools on their name badges. CHAPTER/SCHOOL OF PHARMACY NEWS K. White announced that Jennifer Sharkey should send out ballots shortly and the turnaround time is fairly quick so she asked everyone to please respond ASAP. Results should be announced at the next meeting. Jen-­nifer Dimauro was on the Partnership to Improve Dementia Care in Nursing Homes conference call on February 4th sponsored by Qualidigm. Statistics for antipsychotics use was discussed and how to target facilities with inappropriate usage. Calls are every other month and the next one is April 22nd. Please contact Michelle Pandolfi at mpandolfi@qualidigm.org to join. The Bi-Annual State Coalition Call with Region 1 & Region 9 will be June 17, 2014 1:30pm-3:00pm. Huie-Li and the communications committee are working on the next newsletter, which will include a one-page ad for SSS14. Please email her at amy.huie-li@va.gov with future article ideas or submissions. The chapter has received a proposal for the consideration of a website update that includes a flat fee charge to convert our current website to a new format. The conversion was discussed and questions were compiled. A conference call will be set up and the chapter can also consider other options and negotiating with Bill Ward. James Halpert from the University of California San Diego School of Pharmacy has been selected as the new Dean for UConn School of Pharmacy.

Meeting adjourned at 7:45pm Next Meeting: 3-3-14 at, Luca Ristorante, 1721 Highland Ave, Cheshire, CT @ 5:30pm (sponsored by Cubist) Respectfully submitted, Kim L. Daley, PharmD - Secretary/Treasurer Sponsorship: Carrieann Kumor from Forest with speaker Dr. Richard Silverman Guests: Stephanie Hattoy, Kristina Niehoff, Jill Fitzgerald, Lindsey

Smyth, Rachel Eyler, Andrea Leschak, Dolores Ciccone, Joanne Nault, Jennifer Dimauro, Ben Gramlich

MEMBER NAME & TITLE Dec Jan Feb

Kevin Chamberlin, President / SS Committee

X X X

Mark Wrabel Immediate Past-President

X

Gene Memoli, SS Chair

X X X

Kim Daley, Secretary / Treasurer

X X

Mike Gemma Board 2009-12 / Legislative Committee

X

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

X X X

Brian Pelletier, Board 2010-13 / Communication Committee

X

Paul Belcher, Board 2010-13 / Legislative Committee

X X

Kathy White, Board 2011-14 / Senior Symposium

X X X

Rudy Dajie, Board 2011-14

Anna Torda, Communication Committee

X X X

Bob Tendler, Legislative Committee

X X X

David Cooper, Past President / Sales Senior Symposium

X

Dennis Chapron, Senior Symposium Committee

X X X

Sean Jeffery, Past-President / SS Committee

X X

Michel Fortin, Past President

X X X

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

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