Inside: A “Heart” Topic: Statin Discontinuation in Advanced, Life-limiting Illness Pages 2-4 Save the Date! Schwarting Senior Symposium Page 5 Warmest Holiday Wishes! Page 6 Notes ‘n Votes— November 2015 Page 7

My ASCP Annual Experience Amanda Mertz, Pharm.D. Candidate 2017

1 | Winter 2015 CT-ASCP Chapter Newsletter

Attending a pharmacy organization’s annual meeting is always an exciting experience as a student, but there is

something special about the ASCP Annual. This was my second year attending as a student and it was just enjoyable as

my last. As a second year attendee, I was already familiar with what the meeting would be like, but I still learned more

than I could have expected.

Like most annual meetings there are continuing education events, student-focused talks and product theaters where one

can visit vendors and learn about new drugs and technologies. All offer invaluable education and opportunity to learn

about the evolving field of pharmacy. One can go from learning about the Beers Criteria to solving an integrated case

with practicing pharmacists all within one afternoon. The student-focused events are especially great and focus on

relevant topics like becoming a strong residency candidate. One of my favorite activities was visiting the residency

tables and learning more about geriatric focused residencies available around the country. This educational experience

alone was enough to make the entire meeting worthwhile.

What really set the ASCP Annual Meeting apart for me were the people. I appreciated the opportunity to network with

pharmacists who are currently practicing what we, as students, aspire to one day accomplish. The members of ASCP

always welcome talking to students and sharing their advice. The connections you forge at these meetings can carry

through to your future. As this wasn't my first meeting, it was even more special to see people who remembered me from

last year. Members I had only met once or twice addressed me with an enthusiastic, “Hello!” and a big hug; a standard

gesture when you come to an ASCP meeting.

I cannot thank the members ASCP enough for taking the time to talk to students and teach us more about the

organization they love. If I could give advice to any student interested in consulting or geriatrics, it would be to attend an

ASCP Annual Meeting. I already have Dallas 2016 marked on my calendar and cannot wait to see you all there.

CT-ASCP's

SenioRx Care Perspective

Winter 2015 Volume XII No. 4

2 | Winter 2015 CT-ASCP Chapter Newsletter

Safe and effective medication use depends on proper medication selection and dosing based on

indication, monitoring for adverse effects, and discontinuation of medications when appropriate.1 Although evidence exists to guide the initiation and management of medications for chronic disease states, there is limited guidance for discontinuing these medications. As a result, medications accumulate for many patients, leading to complex medication regimens and increased medication burden. In observational studies, polypharmacy has been associated with functional decline and also has the potential to negatively impact other chronic conditions.1,2

For patients of advanced age or those with life-limiting illness, polypharmacy is particularly concerning. These patients may be prescribed an increased number of medications for common comorbidities, specific diseases, and for symptom palliation. In the last year of life, data suggests an even further increase in number of medications by approximately 50%.1,3 In addition, advanced age or disease may alter a patient’s absorption, distribution, metabolism, and excretion (ADME) of medications, leading to increased risk of adverse effects. Many providers advocate for discontinuation of unnecessary medications in the setting of advanced, life-limiting illness to decrease the risk of adverse effects, medication burden, and cost, however, identifying which medications to discontinue, as well as timing and safety remains unclear. 3

Statins are widely used for both primary and secondary prevention of atherosclerotic cardiovascular

disease (ASCVD), given the significant amount of evidence for cardiovascular morbidity and mortality benefit. Although there is compelling evidence for prescribing statins for primary or secondary prevention for people who have a long life expectancy, little guidance exists for discontinuing therapy in patients with limited prognosis. Despite the lack of guidance, statin therapy is commonly considered for discontinuation in those patients with advanced age or life-limiting illnesses. Although statins are generally well tolerated, their side effect profile includes gastrointestinal symptoms, myalgia, and in rare but serious cases, rhabdomyolysis. These side effects may become more common and problematic in older patients, due to ADME changes.3

In May 2015, a randomized trial evaluating the safety and clinical impact of statin discontinuation in

palliative patients was published in the Journal of American Medicine. The study was a multi-center, open label, randomized trial, looking at 381 patients with a life expectancy of less than one year, but more than one month. Patients were randomized to continue or discontinue statin therapy. Baseline characteristics were similar between groups and included a mean age of 74, approximately half female and half male, predominantly Caucasian, 58% with a history of cardiovascular disease (CVD), 22% with cognitive impairment (more in discontinuation group), 36% enrolled in hospice, and 49% with cancer as an end-of-life diagnosis. Of these patients, 69% were on a statin for more than 5 years. Of note, individuals with active CVD or at high risk of active CVD were excluded from the study.3

A “Heart” Topic: Statin Discontinuation in Advanced, Life-limiting Illness Macayla Landi, PharmD, PGY-1 Pharmacy Practice Resident, VA Connecticut Healthcare System

3 | Winter 2015 CT-ASCP Chapter Newsletter

A “Heart” Topic: Statin Discontinuation in Advanced, Life-limiting Illness Macayla Landi, PharmD, PGY-1 Pharmacy Practice Resident, VA Connecticut Healthcare System (cont…)

The primary outcome looked at a difference in 60-day mortality, with secondary outcomes including

cardiovascular events, quality of life (QOL) using the validated McGill Quality of Life Questionnaire, performance status, symptoms, number of medications, and satisfaction with care and cost. The trial was originally designed to look at overall mortality; however, given that survival in both arms was longer than expected, the primary outcome was changed to 60-day all-cause mortality. Overall, there was no difference in the primary outcome between groups, however, patients in the discontinuation group scored higher on QOL measures and were also found to have reduced costs of medication.3

This trial suggested that patients with a life expectancy of less than one year who do not have active

CVD or high risk for active CVD, discontinuation of statin therapy does not increase 60-day all-cause mortality when compared to statin continuation. Discontinuation may also be associated with improved QOL and reduced medication costs.3 Although this trial provided some information regarding discontinuation of statins, there were many limitations. Some limitations included adjustment of the primary endpoint to only 60-days mortality rates, the study not being blinded which could introduce bias, and the application of the trial to clinical practice requiring patient prognosis, which could be difficult to determine.

When evaluating the risks versus benefits of medications in patients with advanced age or life-

limiting disease, several considerations should be made including life-expectancy and patient/provider goals of care. Potential adverse effects and benefits of therapy, in addition to consideration of treatment costs and the impact on QOL should be weighed as important patient specific factors. Discontinuation of statins should be considered when potential benefits are no longer clinically significant, such as in advanced age or limited life expectancy.2,4 In these cases, preserving function and avoiding both frailty and injury in the short-term will likely take priority over long-term goals such as preventing cardiovascular events in the future. Statins should also be considered for discontinuation in frail elderly patients who experience adverse effects from their use.2,4 Although there are guidelines for appropriate initiation of statin therapy, the discontinuation of these medications remains a patient-specific decision. Patient-centered decision making should be utilized when considering if statin discontinuation is appropriate. A step-wise approach (See figure 1.) may be useful when considering discontinuation of a statin or other medications4 in a patient of advanced age or those with limited prognosis.

4 | Winter 2015 CT-ASCP Chapter Newsletter

A “Heart” Topic: Statin Discontinuation in Advanced, Life-limiting Illness Macayla Landi, PharmD, PGY-1 Pharmacy Practice Resident, VA Connecticut Healthcare System (cont…)

Figure 1. Step-Wise Approach to Discontinuing Medications

References:

Currow DC, Stevenson JP, Abenethy AP, et al. Prescribing in palliative care as death approaches. J Am Geriatr Soc.

2007;55(4):590-595.

Bain KT, Holmes HM, Beers MH, et al. Discontinuing medications: a novel approach to revising the prescribing stage of

the medication-use process. J Am Geriatr Soc. 2008;56(10): 1946-1952.

Kutner JS, Blatchford PJ, Taylor DH, et al. Safety and benefit in discontinuing statin therapy in the setting of advanced, life

-limiting, illness. JAMA Intern Med. 2015;175(5):691-700.

NPS Medicinewise. Consultation Snapshot — Using statins in an older patient. 2013. www.nps.org.au

5 | Winter 2015 CT-ASCP Chapter Newsletter

Arthur E. Schwarting Pharmacy Practice Symposium

TWO GREAT NAMES IN CONTINUING EDUCATION

ONE AMAZING MEETING!

UCONN School of Pharmacy and CT-ASCP

Invite you to the

2016 Schwarting-Senior Symposium

SAVE THE DATE Thursday, April 7, 2016

The Aqua Turf Club Plantsville, CT

6 | Winter 2015 CT-ASCP Chapter Newsletter

CT-ASCP

would like to wish you and

your family the

happiest of holidays

and a wonderful

New Year 2016!

7 | Winter 2015 CT-ASCP Chapter Newsletter

SPONSOR RECOGNITION

Sponsorship: Angela Hathaway (Boehringer Ingelheim)

REVIEW OF PAST MINUTES

The 10/5/15 minutes were reviewed and approved (KR/KD).

CHAPTER NEWS

Legislative: The pharmacist provider status bill has enough votes to pass

in the House and Senate; however, they will not be brought up for a

vote until it is initiated by the Speaker. The Mega Rule comment

period has ended. M. Gemma discussed that any duel eligible

Medicare Part B patients not in skilled nursing facilities will have a

copay for medications.

Website Maintenance: There are 7 hours left of training that B. Pelletier

would like for the other Board members to complete. B. Pelletier, S.

Hattoy, and K. Chamberlin have completed the training already. A.

Sampieri suggested that we complete the training together at the next

board meeting. K. Niehoff will follow up with B. Pelletier to see if

this is possible.

CT Pharmacists and Student Pharmacists: The board discussed having

a recruitment event for students and pharmacists throughout

Connecticut at a central location. The student chapters are very

interested in helping to plan this event as well as the Massachusetts

chapter and Rhode Island members.

ASCP National Meeting Stipend: The board agreed that a $1,500 stipend

would be given to the chapter president to attend the ASCP National

meeting. If the president cannot attend, the stipend would be given to

the president-elect. If the president-elect cannot attend, the stipend

would be split among the members of the Board attending the

meeting. The member attending would be expected to be an active

attendee and cannot be receiving duplicate funding from multiple

sources.

CPA: A. Leschak discussed that CPA is having a charity even for organ

transplants. A. Leschak will follow up.

Fall Continuing Education Webinar: The anticipated date for the

Webinar is December 2nd, 2015.

SSS16 Committees: K. Chamberlin suggested to alert the Massachusetts

and the Rhode Island ASCP members to Save the Date for SSS16. K.

Niehoff will send an email.

Education: Brian Pelletier, Andrea Leschak

Volunteer/Passport Committee: Kim Daley, Amy Huie-Li,

Lauren Manganiello, Anna Sampieri, Karen Rubinfeld,

Kristina Niehoff, Anna Torda, Macayla Landi, Melissa

Strigilio

Vendors: Dave Cooper

Other committee members: Bob Tendler, Beth Esstman, Kevin

Chamberlin

UConn Update: There is an open faculty position that will be for an

Assistant Clinical Professor in geriatrics. It will be a partnership with

Integrated Care Partners Hartford HealthCare. Andrea Hubbard

stepped down and is now back on the faculty.

USJ Update: A. Leschak has 5-7 students that are interested in helping to

coordinate a consultant pharmacist panel come to speak on campus.

The board tentatively set a date for February 1st. Dinner will be

served to the students and ASCP members. The board meeting will

be held after the panel. K. Niehoff will help organize the event.

Meeting adjourned at 7:06pm.

Next Meeting: 12/7/15 at 5:30pm at Omnicare

(sponsored by NovoNordisk)

Guests: Melissa Strigilio, Jill Fitzgerald, Dan Rocki, Mark Wrabel

Notes 'n Votes - November 2015 Board Meeting Kristina Niehoff, PharmD, BCPS, CT-ASCP Secretary / Treasurer

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

MEMBER NAME & TITLE Oct Dec Nov

Mike Gemma President / Legislative Committee

X X

Kevin Chamberlin Immediate Past President

X X

Brian Pelletier President Elect

X

Kristina Niehoff Secretary / Treasurer, Comm. Committee

X X

Kim Daley Board 2015-17 / Communication Committee

X X

Anna Torda, Board 2014-16 / Communication Committee

X X

Rachel Eyler Board 2014-16

Andrea Leschak Board 2015-18 / SS Committee

X X

Karen Rubenfeld Board 2014-15

X X

Anna Sampieri Board 2015-18

X