the kentucky pharmacist vol. 8 no. 4

Vol. 8, No. 4

July 2013

TTHEHE KKENTUCKYENTUCKY

PPHARMACISTHARMACIST

News & Information for Members of the Kentucky Pharmacists Association

MEMBERSHIP

MATTERS! To YOU!

To YOUR Patients!

To YOUR Profession!

2013-14-KPhA President

Duane Parsons with his

wife, Linda.

Below: Introducing

Roamey,

the KPhA Gnome

July 2013

THE KENTUCKY PHARMACIST 2

Table of Contents

Table of Contents

Table of Contents— Oath— Mission Statement 2 President’s Perspective 3 135th KPhA Annual Meeting 4 Message from Your Executive Director 7 2013 KPERF Golf Scramble 8 2013 KPhA House of Delegates Report 9 Images of the 135th KPhA Annual Meeting 10 Relevance and Relationships Review 12 KPhA Emergency Preparedness 13 Pharmacy’s Future: Student Participation at KPhA Annual Meeting 14 Saving the Bowl of Hygeia 15 July 2013 CE: Pediatric OTC 16 July Pharmacist/Pharmacy Tech Quiz 30

August 2013 CE: COPD and CVD 31 August Pharmacist/Pharmacy Tech Quiz 38 Senior Care Corner 39 KPhA New and Returning Members 40 KPhA Government Affairs/Pharmacy Health Screenings 42 Cardinal Health 43 Sponsors/Exhibitors of the 135th KPhA Annual Meeting 44 New Directors of the KPhA Board of Directors 46 Pharmacy Law Brief 48 Technician Review 49 Pharmacy Policy Issues 50 Pharmacists Mutual 52 APSC 53 KPhA Board of Directors 54 50 Years Ago/Frequently Called and Contacted 55

Oath of a Pharmacist

At this time, I vow to devote my professional life to the service of all humankind through the profession of phar-

macy.

I will consider the welfare of humanity and relief of human suffering my primary concerns.

I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy out-

comes for the patients I serve.

I will keep abreast of developments and maintain professional competency in my profession of pharmacy.

I will embrace and advocate change in the profession of pharmacy that improves patient care.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.

Kentucky Pharmacists Association

The mission of the Kentucky Pharmacists Associa-

tion is to promote the profession of pharmacy, en-

hance the practice standards of the profession, and

demonstrate the value of pharmacist services within the

health care system.

Editorial Office:

© Copyright 2013 to the Kentucky Pharmacists Asso-ciation. The Kentucky Pharmacist is the official jour-nal of the Kentucky Pharmacists Association pub-lished bi-monthly. The Kentucky Pharmacist is dis-tributed to KPhA members, paid through allocations of membership dues. All views expressed in articles are those of the writer, and not necessarily the official position of the Kentucky Pharmacists Association.

Editorial, advertising and executive offices at 1228 US 127 South, Frankfort, KY 40601. Phone 502.227.2303 Fax 502.227.2258. Email [email protected]. Website http://www.kphanet.org.

The Kentucky Pharmacy Education and Research Foun-

dation (KPERF), established in 1980 as a non-profit sub-

sidiary corporation of the Kentucky Pharmacists Associa-

tion (KPhA), fosters educational activities and research

projects in the field of pharmacy including career coun-

seling, student assistance, post-graduate education, con-

tinuing and professional development and public health

education and assistance.

It is the goal of KPERF to ensure that pharmacy in Ken-

tucky and throughout the nation may sustain the continu-

ing need for sufficient and adequately trained pharma-

cists. KPERF will provide a minimum of 15 continuing

pharmacy education hours. In addition, KPERF will pro-

vide at least three educational interventions through oth-

er mediums — such as webinars — to continuously im-

prove healthcare for all. Programming will be determined

by assessing the gaps between actual practice and ideal

practice, with activities designed to narrow those gaps

using interaction, learning assessment, and evaluation.

Additionally, feedback from learners will be used to im-

prove the overall programming designed by KPERF.

July 2013


It’s a very humbling experience to be standing at this podi-

um as YOUR president. I’m so very honored. I would like to

thank each of our members and our Board for their faith in

bestowing this honor on me. I’d also like to thank Bob and

our hard-working staff, Kelli, Scott, Leah and Nancy for

their support to our Board and to our profession. Special

thanks to my family for allowing me to serve you. Thanks to

our sponsors and supporters and to the University of Ken-

tucky College of Pharmacy and Sullivan University College

of Pharmacy for all the support they provide as well.

I had the very valuable opportunity with Bob to attend the

annual meeting of the National Alliance of State Pharmacy

Associations (NASPA) in April. The primary conversation

for the meeting was the leadership responsibility for incom-

ing presidents for each state association and the role of

each Board they served. One of the topics that really in-

trigued both Bob and me was the Four Sights of the Board:

1.) Oversight, making sure the Board is true to its mission.

2.) Insight, asking the questions that are important.

3.) Foresight, looking at trends in the profession.

4.) Hindsight, evaluating what has been done in the past.

Foresight was particularly of importance. How do we get to

where we want to go?

Many of the sideline conversations we had with other state

associations centered on that. We heard a primary concern

from almost all state associations of how to work through

membership issues while trying to establish the relevancy

of our profession.

The mission of the Kentucky Pharmacists Association is to

promote the profession of pharmacy, enhance the practice

standards of the profession and demonstrate the value of

pharmacists’ services within the health care system. That’s

a very lofty and honorable mission statement. Over the

years, we’ve done a great job of promoting the profession

and enhancing practice standards. We have always strug-

gled with demonstrating the value of our services, NOT

with our patients. We have, however, not done a good job

of demonstrating the value of our services within the

healthcare system in order to attain provider status.

There are various reasons this has not happened to date.

A primary reason, I believe, is that we are not a very unified

profession. Pharmacy has many diverse pathways down

which we travel. That leads to different issues that are rele-

vant to different segments within the profession. What’s

important to some seems to have less relevancy to others.

We need to change that mindset. If it’s important to the

profession in any area, it needs to be important to the pro-

fession overall. We need to be unified in our approach.

That’s where KPhA can play a vital role. We need to be the

unifying leader for all issues that face the profession no

matter from which pathway they arise. There are very dis-

tinct advantages in speaking as a consolidated, unified

group representing large numbers with an even louder

voice.

That’s exactly why MEMBERSHIP MATTERS. It matters to

YOU. It matters to YOUR patients. It matters to YOUR pro-

fession.

Let’s focus on what matters to YOU. For YOU, membership

provides:

Legislative and Regulatory Advocacy

Networking with Colleagues

Access to State and National Resources on Pharmacy

Related Issues

Special Programs and Pricing on Insurance and Finan-

cial Services specifically designed for Pharmacists

through Pharmacists Mutual Companies

Special Pricing on Quality Improvement Programs to

meet the needs of Pharmacists offered by Pharmacy

Quality Commitment

Special discounts from Dell, Hertz and others

Free CE for members

Programs like Immunization Training for Pharmacists

PRESIDENT’S

PERSPECTIVE

Duane W. Parsons

KPhA President

2013-2014

Adapted from President

Parsons’s address at the

Ray Wirth Banquet at the 135th KPhA Annual

Meeting, June 8, 2013 in Louisville, KY

President’s Perspective

Continued on Page 6

July 2013


135th KPhA Annual Meeting

2013 KPhA Professional Awards

Leon Claywell, Bardstown, Bowl of Hygeia Award sponsored by the American Pharmacists Associa-

tion Foundation and the National Alliance of State Pharmacy Associations with support from

Boehringer Ingelheim. Pictured with outgoing KPhA Chair Lewis Wilkerson, outgoing President Kim-

berly Croley and Amy Nicholas, Associate Director, Health Economics and Outcomes Research at

Boehringer Ingelheim.

Catherine Hanna, Lexington,

KPhA Distinguished Service Award

Trish Freeman, Lexington,

KPhA Pharmacist of the Year

July 2013



Buddy Wheeler, Lexington, KPhA Excellence

in Innovation Award sponsored by Upsher-Smith

Laboratories, Inc.

Brooke Hudspeth, Lexington, KPhA Distin-

guished Young Pharmacist of the Year, spon-

sored by Pharmacists Mutual Insurance. Bruce

Lafferre presented for Pharmacists Mutual.

KPhA Professional

Promotion Award

Julie N. Burris,

Louisville

Walgreens Corporation,

Buddy McCaffery,

District Manager,

accepted for Walgreens.

Leslie Lochner and Robin Lillpop, Louisville,

KPhA Technician of the Year Representative Jeff Greer (D-Brandenburg),

KPhA Meritorious Service Award. KPhA Member

Jonathan Van Lahr assisted in the presentation.

Raymond Float, Danville (second from right), Cardinal Health

Generation Rx Award. KPhA Executive Director Robert McFalls,

President Duane Parsons, Todd Wright, Cardinal Health Retail

Sales Manager and David Kelly, Cardinal Health Pharmacy Busi-

ness Consultant presented the award.

July 2013


President’s Perspective

The Kentucky Pharmacist is

online!

Go to www.kphanet.org, click on Com-

munications and then on The Kentucky

Pharmacist link.

Would you rather receive the

journal electronically?

Email [email protected] to be placed

on the Green list for electronic delivery.

Once the journal is published, you will

receive an email with a link to the

online version.

which allow members to enhance services offered

Opportunities to be engaged in making a difference

with your colleagues

How can each of us be engaged? Engagement doesn’t

necessarily mean that you need to serve on our Board,

although we should all give consideration to that. There are

various ways that we can all serve our profession through

KPhA that are less time consuming. Not all have the time

for a Board level commitment. We CAN, however, be en-

gaged in other ways.

We can help draft legislative priorities that affect us by

serving on a committee such as our Government Affairs

Committee.

We can serve as members of other committees as well.

Some of those are Organizational Affairs, Professional/

Public Affairs, New Practitioners, or Membership Engage-

ment.

We can be engaged in work groups such as Health Infor-

mation Technology (HIT) or Emergency Preparedness

when called upon.

We can serve as mentors to other members of the profes-

sion to help them understand the importance of becoming

KPhA members and getting involved themselves.

We can educate our legislators to help them understand

how important and valuable our services are to their con-

stituents.

We can engage in grassroots efforts involving issues that

affect our profession.

We can educate our patients on how important and benefi-

cial our services are to their personal health.

We can serve as ambassadors in our own areas to help

recruit and retain members.

We can actively promote KPhA membership to other mem-

bers of our profession.

If we are to attain provider status and expand patient ac-

cess to pharmacists’ services and receive reimbursement

for these services, we all need to be engaged. We need to

strengthen our membership numbers in order to speak with

a much louder voice. We need to present a more unified

appearance within our profession.

That will be a primary role as I serve as your President in

the upcoming year. Many of you will see Bob and me in

your workplaces throughout the coming year. We’ll be ac-

tively promoting membership benefits and membership

services as we travel. We challenge each of you to be

more actively engaged in this role and to get others actively

engaged. And, if you look close enough and follow us on

social media, you will be seeing our new KPhA Member-

ship Matters friend, Roamey the KPhA Gnome!

Continued from

Introducing!

Roamey the

KPhA Gnome!

Membership

Matters

Roamey, the KPhA

Gnome, visits

Wheeler Pharmacy in

Lexington

President Duane Parsons

accompanied Roamey on

a tour of several Lexington

pharmacies in July. Watch

the KPhA Facebook page

and the KPhA Website for

the adventures of Roamey

and Duane.

July 2013


From Your Executive Director

MESSAGE FROM YOUR

EXECUTIVE DIRECTOR

Robert “Bob” McFalls

I hope and trust that your Summer is going really well.

From our perspective, it has been a great Summer thus far.

To all who attended and supported KPhA’s 135th Annual

Meeting & Convention in Louisville, I want to thank you for

your engagement and participation. We especially want to

thank all of our sponsors and exhibitors for your participa-

tion and financial support. By all accounts, it was a great

meeting that was filled with informative CE, recognition of

pharmacists and pharmacy technicians with great peer

awards and presentations, engaged networking opportuni-

ties and a golf scramble that refused to be rained out.

Along these lines, be sure to mark your calendar and save

the date for 2014 when the 136th KPhA Annual Meeting

and Convention will be held on June 5-8, 2014 at the Mar-

riott Griffin Gate in Lexington!

Another exciting development at this year’s Annual Meeting

was the appearance of, uh…, a new little colleague, sup-

porter and almost humanoid creature. Gartenzwerg!

Through the pages of this edition of The Kentucky Pharma-

cist, you are being introduced to Roamey, the KPhA Mem-

bership Matters Gnome. Roamey began his journey with

KPhA in Louisville at the Annual Meeting and will be travel-

ing throughout the Commonwealth in the coming days,

months and years. Not all that different from “GNOME” —

that desktop environment and graphical user interface that

runs on top of a computer operating system — Roamey’s

intention is to serve YOU by promoting the profession of

pharmacy and membership engagement with YOUR KPhA.

Roamey the KPhA Gnome’s heartfelt message is simple

but incredibly powerful:

Membership Matters:

To YOU! To YOUR Patients! To YOUR Profession!

When you engage with KPhA, YOUR voice matters as an

active member. You add the power of YOUR voice to ad-

vance the profession of pharmacy with your peers in terms

of other engaged pharmacists and pharmacy technicians

who are working in all practice settings.

YOUR membership helps YOUR KPhA to be stronger

as an Association that represents and informs others

about the myriad ways that YOU help YOUR patients

with their healthcare needs.

YOUR active membership helps promote the visibility

of the profession as well as YOUR KPhA’s involvement

in pharmacy and related health issues throughout Ken-

tucky and on a national level.

YOUR profession is strengthened through the collec-

tive power of being united in YOUR KPhA to advance

the role of pharmacy with other health professions, the

media and the general public.

YOUR concerns matter — YOUR KPhA brings phar-

macists and partners together to advance legislative

priorities and to safeguard the profession from unfair or

unnecessary regulations and actions.

YOUR financial support matters. Membership dues are

the lifeblood for YOUR KPhA, providing the Association

with the flexibility of being able to use funds where they

are most needed in terms of addressing urgent legisla-

tive issues and other critical priorities.

YOUR active engagement as a grassroots advocate

matters. Whether you talk with an elected official, write

a letter or speak at a community forum, YOUR efforts

are making a difference.

YOU matter — and YOUR involvement is making a

difference as evidenced by our legislative successes

for the profession during the past two state legislative

sessions.

Thank YOU for being an active member and participant in

the KPhA Family. We hope that you will welcome Roamey,

the KPhA Gnome, and support his efforts in spreading the

message that MEMBERSHIP MATTERS with YOUR KPhA!

P.S. Did you know that there are currently an estimated 25

million garden gnomes in Germany, but that there is only

one Roamey, the KPhA Gnome? Hmmm. Or could there be

more?

July 2013


2013 KPERF Golf Scramble

2013

KPERF

Golf

Scramble

First Place: Duane Parsons, Lewis Wilkerson,

Jeff Mills, Joel Thornbury

Second Place: Nevin Goebel, Keith Stinson,

Josh Pitts, Eric Pitts

Last Place:

Jan Gould,

Cheryl Gould,

Gay Dwyer,

Joe Carr

Closest to the Pin:

Chris Stewart

Longest Drive: Kyle Carver

July 2013


2013 House of Delegates

2013 Actions of the KPhA House of Delegates

Louisville, KY, June 7-9, 2013

Matt Martin , PharmD, 2013 Speaker of the House

Cassandra Beyerle, PharmD, 2013 Vice-Speaker and Chair of the Reference Committee

Kim Croley, PharmD, CGP, FASCP, FAPhA- 2013 Parliamentarian

At the 2013 KPhA House of Delegates, members from

throughout the Commonwealth gathered to discuss, debate

and make recommendations to not only shape the organi-

zation, but also to push forward our beloved profession.

Opening Session

The opening session was on Friday morning. Delegates

were slated and committee reports presented. Nominations

were requested for Vice-Speaker; none were presented.

Therefore, the nomination process was postponed until the

final session of the House to allow time for Delegates to

make nominations for Vice-Speaker.

Reference Committee

The Reference Committee met Saturday morning, bright

and early to discuss resolutions and make recommenda-

tions to the House. The meeting was open to all KPhA

members and chaired by Vice-Chair Beyerle. The members

of the committee were Barry Eadens, Judy Minogue, Lance

Murphy, Chris Clifton, Joe Carr and Kim Croley

(Parliamentarian).

Closing Session

The closing session took place Saturday afternoon. During

this session, recommendations of the Reference Commit-

tee were discussed and nominations for Vice-Speaker were

announced and voted upon. Adoption of committee reports

also took place at the closing session of the House.

Bylaw Changes

2013.01 Subsection 5.51 (amended)

Address ballots for election and the way they will be sent to

members. This was changed to solely electronic, unless

the member requests a paper ballot.

2013.02 Subsection 6.57 (added)

This addition allows Board meetings to be held telephoni-

cally or by video conference. This is to address the issue of

inclement weather or when a Board meeting may be called

on short notice to address an urgent issue.

2013.03 Subsection 11.2 (added)

This addition addresses indemnification and insurance for

Board members and it will now be provided for their ser-

vice.

Committee Reports

Adoption of the following committee reports:

Public and Professional Affairs

Policy Review

Government Affairs

Resolution Adoption

Submitted by Gloria Doughty, recognizing the ef-

forts of UK student pharmacists in the packing of

memorabilia from the Pharmacy Museum during

this time of transition.

The House also approved five candidates to be submitted

to the Governor for consideration for appointment to the

Board of Pharmacy. The five names submitted were: Debo-

rah Brewer (Morgan), Joseph Carr (Daviess), Scott Green-

well (Jefferson), Christopher Killmeier (Jefferson) and Don-

ald Kupper (Oldham).

Two nominations were made for Vice-Speaker: Ethan Klein

and Barry Eadens. A vote via paper ballots was held, and

Ethan Klein, PharmD, was officially elected and appropri-

ately sworn in as Vice-Speaker of the House of Delegates.

The 2013 House of Delegates, once again, was a time for

discussion and debate. This is when we decide the next

steps of YOUR KPhA and look forward to more involve-

ment and discussion in the House as we push our profes-

sion forward. To become more involved, step up, serve on

a committee, become a delegate in the House, voice

YOUR stance. KPhA is here for YOU!

-The KPhA House of Delegates will meet at the Mid-Year

Conference on Legislative Priorities in November.

July 2013



Images from Louisville

July 2013



July 2013


Relevance and Relationships Review

I know the Agenda says this is a President’s Report, but I

will leave the listing of our accomplishments by Your KPhA

this year to our Executive Director. There have been many,

some small, some large, all well-deserved and all were the

result of a group effort.

Relevance and Relationships

This was the theme for my second Presidential year. I

chose this theme because it embodies everything that

pharmacists do. We are not purveyors of drugs; we are

providers of healthcare and most importantly, health infor-

mation about safe, effective medication use. Our patients

come to the pharmacy looking for answers; they pick the

pharmacy because they believe answers can be found

there. More than 186,000 people enter a pharmacy each

week and that cannot be by coincidence.

I have spent much of my time this year talking to other

pharmacists about the importance of what we do. Pharma-

cists tend to be humble, introverted, self-effacing individu-

als that do not draw attention to the wonderful things we do

for our patients. We tend to sit on the sidelines and wait for

recognition when instead we should be talking to everyone

about the positive patient outcomes we affect through our

daily work.

We struggle with anything controversial and try to fly under

the radar most of the time. If you had told me in November

when we had our Legislative Conference that we would be

able to affect change and achieve SB 107 which calls for

transparency by PBMs, I would have probably told you that

was a pipe dream. Everyone told us it could not be done,

yet we did. How do we build on this success, what is our

next hurdle to jump? In my part of the state, methampheta-

mine manufacture is a cash cow, much as marijuana pro-

duction used to be a cash crop. Should the healthcare pro-

fessional charged with safe, effective medication use revisit

again moving pseudoephedrine back to prescription status?

Should we push harder for a pharmacist-only class of drugs

which falls in the middle of the current prescription and non-

prescription classes? I don’t have any answers; I just have

the questions.

Can we unite as pharmacists and quit describing ourselves

based on practice site but on our place as the medication

experts to achieve provider status under the law? Of all the

questions, this one is my most challenging. I don’t care if

anyone calls me “doctor”, I just want them to call me

“pharmacist’ and know that the title comes with respect and

even awe of my ability to improve my patients’ quality of

life.

I attended my first KPhA convention here in Louisville in

June of 1984. This year marks my 29th consecutive annual

meeting. Next year as I finish my tenure as Chairman of the

Board, it will be my 30th anniversary. I have driven to

Frankfort an untold number of times in the last 29 years. I

have driven in rain, ice, snow and occasionally sunshine! I

have taken my daughter in her carrier to Budget meetings

and signed checks while she slept. My children have both

spent many nights at home with their father while I was

away at meetings representing KPhA. They also got to go

to places they probably would not have if I hadn’t been at-

tending yet another meeting.

One of our funny stories tells about Rachel staying at

friends of mine one evening while I was at a meeting. She

was about 4 years old and had her Barbie doll with her.

She asked my friend Darrell to help snap the clothes on the

doll because she was struggling with getting them on. Dar-

rell asked Rachel where “Barbie” was going and thought

she would say shopping but instead Rachel said “she has

to go to a meeting!” Both of my children are active in

groups that help other people. Rachel has volunteered hun-

dreds of hours while at UofL helping others, even tutoring

at a neighborhood center on 17th street. My son Rob is

working on his Eagle Scout project this summer and just

finished a week of teaching Bible School at church. I like to

believe that my work as a volunteer leader for KPhA has

set a good example for my children and for other pharma-

cists, and I would not trade a minute of it.

As a registrant for this Annual Meeting you each received a

ribbon attached to your nametag that says “Membership

Matters” I would declare to you that being a Member of

the Pharmacy Profession means YOU Matter. Stand up tall

YOU are a pharmacist!

I want to thank Bob McFalls, Scott Sisco, Kelli Sheets and

Nancy Baldwin for their dedicated service to Your KPhA.

They have made my job very easy this year. I want to thank

Lewis Wilkerson for his leadership and all the members of

the Board of Directors for their faithful service. Most of all I

want to thank you for the honor and privilege of serving as

President of Your KPhA for a second time. It has been my

pleasure.

RELEVANCE AND RELATIONSHIPS REVIEW Adapted from presentation at House of Delegates Opening Session, June 7, 2013 by outgoing President Kim Croley

July 2013


KPhA Pharmacy Emergency Preparedness

For more information on how you can be involved in the KPhA Pharmacy Emergency Preparedness

Initiative, contact Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness at 502-227-

2303 or by email at [email protected]. KPhA is a partner with the Kentucky Department of Public

Health for emergency preparedness and disaster response.

For more resources, visit YOUR www.kphanet.org and

click on Resources—Emergency Preparedness.

KPhA Pharmacy Emergency Preparedness Initiative

Interest Form

Name: _____________________________________ QS/1 Experience: Yes____ No _____

Status (Pharmacist, Technician, Other): ___________________________

Email: ______________________________ Phone: ___________________________

For Pharmacists: Interest in serving as a volunteer: Yes____ No _____

If yes, please go to KHELPS link on KPhA Website to register (www.kphanet.org under Resources)

____ I would like to serve as pharmacy district coordinator (PDC). PDCs will serve as a point of contact

in their respective county and may assist in dispensing activities on the mobile pharmacy if deployed in

the event of a disaster.

Please send this information to Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness via

email at [email protected], fax to 502-227-2258 or mail at KPhA, 1228 US 127 South, Frankfort, KY

40601.

The Emergency Preparedness program is moving along

nicely!

Here are the latest accomplishments as well as next steps

that will involve all of you around the state:

The destruction of Tamiflu Suspension and the transport of

the antivirals to a central warehouse for storage has been

complete.

The mobile pharmacy's functionality including water, gener-

ator and utilities is being tested this month. KPhA hopes to

have it fully operational for deployment by August 15th.

Pharmacy district meetings for the fall are being sched-

uled. An emergency preparedness program has been ap-

proved for 1.25 hours of continuing education that can be

provided. KPhA is working with KDPH to possibly have the

mobile pharmacy available for touring at the district meet-

ings.

We are looking for volunteers to coordinate a meeting for

eastern and southern Kentucky.

July 2013



PHARMACY’S

FUTURE: Student pharmacist

involvement

Team CHAOS, winners of the 2013 NASPA-NMA Student Pharmacist Self-Care Championship, Ryan P. Hickson – UK,

Mallory Megee – UK, Sharlonda Nunn – Sullivan, Clarissa Morey – Sullivan. Pictured with 2013 Host Brent Simpkins.

(Right) Lance Murphy (Sullivan) and Brooke Herndon (UK), members of Team Reigning Champs, discuss an answer.

Members of Kappa Psi were recognized for their ef-

forts in helping Gloria Doughty and other volunteers

pack the contents of the Kentucky Pharmacy Renais-

sance Museum. The museum’s contents will be stored

at KPhA headquarters until a permanent location is

established.

July 2013


Bowl of Hygeia

Saving the Bowl of Hygeia The Bowl of Hygeia has a rich history within pharma-cy, and we need to step up and make sure this history continues. Given that this is an award presented at the state lev-el, the State Pharmacy Associations — including YOUR KPhA — along with NASPA, are working to-gether to help make sure this award we hold so dear-ly is never at risk of being extinguished. In order to sustain the award, each state association is working to build an endowment sufficient to generate divi-dends that will fund the program in perpetuity. The APhA Foundation, a national nonprofit 501 (c) (3), has agreed to be the home of the endowment ac-count, and to date we are almost half way to our goal of $600,000.

Our goal is to raise $5,000 as a collective gift from members of the Ken-tucky Pharmacists As-sociation. At the 135th KPhA Annual Meeting, 2013 Bowl of Hygeia recipient Leon Claywell pledged to match contributions to the fund from Ken-tucky up to $5,000. As of March 2013, we have collected $900. Won’t you please help by making a contribu-tion? Let’s earn that pledge and make Ken-tucky proud by dobling our participation! There are two ways to give:

Online at: http://www.aphafoundation.org and choose the Bowl of Hygeia endowment button. Kentucky will get credit by your address.

Or, you can send your check to:

APhA Foundation – Bowl of Hygeia 2215 Constitution Ave., NW

Washington, DC 20037-2985 Be sure to mark Kentucky on the memo section of your check. Thank you in advance for joining YOUR KPhA in this effort. September 16, 2013

University Club of Kentucky

Kentucky Pharmacy Law Review at 9 a.m.*

Golf Registration begins at 10 a.m.

Lunch available at 11 a.m.

Shotgun Start at Noon

Dinner, Awards Ceremony & Auction start at 5:30 p.m.

*This activity is eligible for ACPE credit; see final CPE activity announcement for specific details.

Registration available at www.ukalumni.net/pharmgolf2013

Long-time KPhA Member Gloria Doughty was granted

Honorary Membership status by the KPhA House of Dele-

gates at the 135th KPhA Annual Meeting.

http://www.ukalumni.net/pharmgolf2013

July 2013


July 2013 CE—Pediatric OTC

Pediatric Over-the-Counter Medication Refresher for Pharmacists

There are no financial relationships that could be perceived as real or apparent conflicts of interest.

By: Ashley S. Crumby, PharmD, Assistant Clinical Professor, Purdue University and Clinical

Pharmacist, Pediatric Infectious Disease, Riley Hospital for Children at IU Health

(Indianapolis); Rachel E. Bohard, 2013 PharmD Candidate, Purdue University; and Andrea J.

Bittner, 2013 PharmD Candidate, Purdue University.

Original article published by the Indiana Pharmacists Alliance (IPA). This activity may appear

in other state pharmacy association journals. Reprinted with permission. Copyright

© 2012 Indiana Pharmacists Alliance.

Universal Activity # 0143-9999-13-007-H01-P&T

1.5 Contact Hours (0.15 CEU)

Goal

The goals of this article include increasing pharmacist awareness of barriers to appropriate pediatric OTC medication mis-use, identifying methods to address these barriers, defining appropriate use of over-the-counter pharmacologic and non-pharmacologic treatment options for pediatric cough and/or cold and identifying situations in which physician referral is ap-propriate.

Objectives

At the conclusion of this article, the reader should be able to:

1. Identify challenges associated with over-the-counter (OTC) medication use in children.*

2. Identify situations in which physician referral is appropriate for pediatric patients with cough/cold and fever symptoms.*

3. Design a treatment plan, including specific counseling points for parents, for a pediatric patient with cough/cold symp-toms and/or fever.

*Pharmacy Technician Objectives

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Introduction:

Many over-the-counter (OTC) cough and cold product la-

bels may contain complex instructions and misleading

graphics which may guide caregivers toward administration

of inappropriate products to children. Due to low literary or

numeracy skills, some caregivers are at increased risk for

inappropriate administration of pediatric OTC products. A

recent study showed 85 percent of parents in the United

States treat their children with OTC medications prior to

seeking professional care. This makes addressing situa-

tions in which physician referral is necessary an important

role of the pharmacist.1 Misuse of OTC products can be the

direct result of incorrect indication, selection of an inappro-

priate product or incorrect dosing. Although rare, an esti-

mated 85 percent of pediatric fatalities caused by OTC

medications involved inappropriately dosed cough and/or

cold products.2 Factors leading to overdose of these prod-

ucts included administration of more than two medications

containing the same ingredients, inappropriate utilization of

measuring devices, use of adult products in situations

where pediatric products were indicated, selection of a

product which was not indicated and involvement of more

than two caregivers in the treatment or selection of the

OTC product.2 Pharmacists can play an important role in

the selection of appropriate OTC products (non-

pharmacologic and pharmacologic) as well as during the

provision of counseling regarding dosing, adverse effects

and administration techniques. It is essential for pharma-

cists to be aware of current OTC product labeling as well

as recommendations in order to assist caregivers with the

selection and use of OTC medications in children. It also is

beneficial for pharmacy technicians to understand when a

pharmacist consultation is appropriate when dealing with

caregivers of pediatric patients.

The Common Cold: A Brief Overview

The common cold is typically a self-limited viral infection

which can be caused by more than 200 viruses. The most

common virus seen in children is rhinovirus. On average,

most children will experience between six and eight colds

per year, each lasting between 10 and 14 days per epi-

sode.3 Following onset, cold symptoms tend to peak

July 2013



around day three or four and begin to diminish on or after

day seven.3 These symptoms may include stuffy or runny

nose, frequent sneezing, accumulation of mucus in the

back of the throat (often referred to as postnasal drip), sore

throat, cough and water eyes. Other symptoms such as low

-grade fever, decreased appetite and mild head or body

aches can also occur.4,5

Mucus production during a cold is

common and can be clear, white, yellow or even green in

color.4 Historically, caregivers thought the color of the mu-

cus was an indicator of illness severity, but it has been

shown that the colors merely represent the body’s produc-

tion of antibodies and have no significance in determining

whether antibiotic therapy is indicated.4 Because the major-

ity of cold cases are viral in nature, antibiotics are often

unnecessary and should generally be avoided. Communi-

cating this to caregivers is important and can often prevent

unnecessary physician visits. An important rule of thumb to

remember is “green snot doesn’t mean squat.”

Rest, increased fluid intake and the use of non-

pharmacologic as well as pharmacologic therapy can be

used for symptomatic relief during episodes of the common

cold.6 These methods will help to alleviate the cold symp-

toms, but will not shorten the length of illness.6 Although

the common cold is typically a self-limiting and mild viral

infection, it can sometimes lead to more serious complica-

tions including secondary bacterial infections.7 In some in-

stances, physician referral of seriously ill infants and chil-

dren is necessary, and pharmacists can play a vital role in

this referral process due to their increased accessibility and

contact with caregivers.

Non-pharmacologic therapy

Non-pharmacologic therapy can include a variety of ap-

proaches and should generally be considered “first-line”

for symptom relief as well as immune system support dur-

ing the common cold. Some recommendations include the

use of humidifiers to improve the environment as well as

increasing fluid intake to keep the body well hydrated. Be-

low you will find specific instructions regarding a variety of

non-pharmacologic options.

Symptomatic relief6,8

Humidifiers or cool mist vapors

In general, cold air humidifiers are recommended when

compared to warm air humidifiers due to safety concerns

with regard to children. Also, regular cleaning of humidifiers

and other treatment products is recommended due to the

increased risk of bacterial growth and mold which may oc-

cur. If these instruments are not cleaned regularly, they

may emit microorganisms into the environment and cause

serious illness due to pathogen inhalation.8

Bulb syringe with or without saline nasal drops

This approach is considered the treatment of choice for

nasal symptoms in infants. Nasal bulb syringes can be

used to clear the nose every 3 to 4 hours.6

Head elevation

Elevating the head of the bed can promote better drainage

of the sinus and nasal passages. A large wedge-shaped

pillow that raises the upper body by 6 to 8 inches is best if

the patient is experiencing significant drainage.9,10

Increased water ingestion

Water is considered the best expectorant for children.

Proper hydration thins the mucus which can ease the

child’s efforts to expel it and prevent dehydration.

Immune System Support5

The common cold is caused by a viral infection and re-

quires the body’s immune system for proper eradication.

General ways to promote immune system function include:5

Avoiding secondhand smoke or other air pollutants5

Avoiding unnecessary antibiotics5

Antibiotics can breed resistance, thus increasing the

chance of becoming ill with antibiotic-resistant infections.

Breastfeeding5

Breast milk contains antibodies which can be passed from

mother to child. These antibodies can provide protection

against infection even after breastfeeding is stopped.

Increasing fluid intake5

Drinking plenty of fluids during the common cold is im-

portant. Healthcare providers should always recommend

pediatric-specific fluids such as Pedialyte® because these

products contain the proper amount of fluid and electrolytes

and can help prevent electrolyte imbalances.

Eating yogurt

Active cultures present in certain yogurts and probiotics

contain beneficial bacteria which can aid in preventing

colds.5

Yogurts and probiotics containing Lactobacillus acidophilus

with Bifidobacterium animales were shown to reduce both

the incidence and duration of rhinorrhea, cough and fever

symptoms in children 3 to 5 years old.11

Although sufficient efficacy evidence is lacking, the CDC

considers Lactobacillus safe for use in children and infants

but does caution regarding the use of probiotics in patients

on concomitant immunosuppressive therapy.12

Yogurts containing live active cultures include(but are not

limited to):

Yoplait YoPlus, Stonyfield, Dannon Activia.13

Check labeling on individual products for specific infor-

mation.

Receiving adequate amounts of sleep

Adequate sleep promotes immune system function. 14

July 2013



Younger children require more sleep than older children

but in general, “adequate sleep” includes at least 10 to 12

hours.14

Pharmacologic Therapy

Although not always recommended in pediatric patients,

various pharmacologic agents can be used to treat the

symptoms of the common cold. In general, these options

include antihistamines, nasal decongestants, antitussives,

expectorants and analgesics. Other therapeutic options

include complementary or alternative medicine such as

chicken soup, vitamin C, zinc, Echinacea, Airborne Jr®

and honey. Below are recommendations for the use of

these products in pediatric patients.

Antihistamines

Antihistamines competitively bind, but do not activate the

H1 receptor and prevent histamine from binding.15

First

generation antihistamines are considered nonselective and

provide mostly sedative effects. This class of antihista-

mines includes diphenhydramine, clemastine and chlor-

pheniramine.15

Second generation antihistamines are pe-

ripherally selective and therefore provide less sedation due

to an inability to cross the blood brain barrier.15

Second

generation oral OTC antihistamines include loratidine,

fexofenadine and cetirizine.15

First generation antihista-

mines often are utilized during the common cold because

they are associated with anticholinergic properties such as

drying of mucus membranes. This association results in a

reduction of nasal, lacrimal gland and salivary hypersecre-

tion, thus decreasing the amount of mucus and drainage

present.15

When compared to first generation antihista-

mines, the second generation products are not considered

to be as beneficial due to reduced anticholinergic proper-

ties.

A Cochrane systematic review evaluating the use of anti-

histamines either alone or in combination with a decon-

gestant concluded antihistamine use as monotherapy did

not provide any clinically significant effects on general re-

covery in the course of the common cold in either children

or adults.16

First generation antihistamines were associated

with a small decrease in sneezing and rhinorrhea, but also

were associated with a significantly higher incidence of

side effects such as sedation.16

Many caregivers expect antihistamines to decrease nasal

symptoms because they provide this effect in the setting of

allergic rhinitis. The general population does not under-

stand the pathophysiology of allergic rhinitis and the com-

mon cold differ greatly. 16, 17

During allergic rhinitis, large

amounts of histamine are released in response to an aller-

gen while a common cold uses bradykinin as the major

cytokine mediator.16,17

Bradykinin can induce vasodilation

and lead to congestion, but this mechanism is unaffected

by antihistamines. Sedation of a sick child is the most likely

benefit seen with the use of antihistamines although the

use of these products for sedative effects alone is not cur-

rently recommended.18

Although safety and efficacy data regarding antihistamine

Agent Dose Available dosage forms

ADEs Drug Interactions Administration Recommendation

Antihistamines

Diphenhydra-mine3,15,19,45

2-6 yo: 6.25 mg q 4-6 h (max 37.5mg/d) 6-<12 yo: 12.5-25 mg q 4-6 h (max 150 mg/d) ≥12 yo: 25-50 mg q 4-6 h (max 300 mg/d)

Solution/syrup/elixir (typically 12.5mg/5mL)*, orally disinte-grating strip, orally disinte-grating tablet, caplet, capsule, tablet, gelcaps, fastmelt tablets

Mild: Seda-tion, dizziness, dry nasal/pharyngeal mucosa, som-nolence; Se-vere: hyper-sensitivity (anaphylaxis) Idiosyncratic: paradoxical excitement in young chil-dren, nervous-ness, restless-ness

Moderate inhibi-tion of CYP2D6; cumulative effects with con-comitant CNS depressants and anticholinergics

With food to avoid GI upset

Consult physician if patient <2 yo; monotherapy not recommended in pediatrics for common cold;3,16,19 combi-nation therapy with decongest-ant may be bene-ficial in adoles-cent patients; chewable tablet contains phenya-lanine-caution in phenylketonurics; caution in peptic ulcer disease, urinary obstruc-tion

July 2013



use in pediatric patients is sparse and somewhat conflict-

ing, the general consensus is that antihistamine use as

monotherapy provides no real benefit in terms of nasal

symptom relief and should be avoided in pediatric pa-

tients.3, 16, 19

Combination therapy including antihistamines

and decongestants has been shown to be ineffective in

small children, but may provide limited benefit in older chil-

dren and adults by relieving nasal symptoms such as runny

nose and post-nasal drip.3, 16, 17, 19

Nasal decongestants

Topical and systemic decongestants produce vasocon-

striction in the nasal mucosa, therefore reducing inflamma-

tion and swelling while improving ventilation.15

OTC decon-

gestants for oral use can be found in a variety of products

and include pseudoephedrine (immediate and sustained

release) as well as phenylephrine.15

These oral options

have a slower onset of action when compared to topical

decongestants, but often are associated with longer decon-

gestive effects and less local irritation.15

Of the oral options,

pseudoephedrine is the most frequently used oral decon-

gestant, and although considered safe, has been associat-

ed with the potential for increased blood pressure and heart

rate.15

Additionally, use of pseudoephedrine in patients with

a history of hypertension, vasospasm and/or cardiovascular

disease should be avoided due to increased risk for stroke

or heart attack.15

Use of pseudoephedrine also should be

avoided in the treatment of patients taking monoamine oxi-

dase inhibitors such as linezolid due to the risk of severe

hypertensive reactions.15

At this time, insufficient data exist to support the safety and

efficacy of phenylephrine as an oral decongestant in any

age. However, it is suggested that phenylephrine has mini-

mal effect on blood pressure even when taken at higher

than recommended doses, making it seem like a safer al-

ternative to pseudoephedrine.20

Although data is conflict-

ing, phenylephrine is “generally recognized as safe” and

may be an appropriate alternative for patients unable to

tolerate the adverse effects associated with pseudoephed-

rine.20

Topical OTC nasal decongestants are an option in patients

unable to take oral medications and include phenylephrine,

naphazoline, tetrahydrozoline, oxymetazoline and xylomet-

azoline.15

These topical products are extremely effective at

relieving nasal congestion and produce less systemic ad-

verse effects than oral decongestants, but may produce

burning, sneezing, stinging and dryness of the nasal muco-

sa.15

Additionally, prolonged use (>3 to 5 days) can result

in severe rebound congestion.15

Patients should be coun-

seled to discontinue the use of topical decongestants after

three days and to contact his/her doctor.

At this time, studies evaluating the safety and/or efficacy of

nasal decongestants in pediatric patients have not been

completed, making the use of these agents inappropriate in

children due to lack of sufficient data.16, 19

Some studies

have shown potential benefit, including relief from nasal

congestion, from oral or topical nasal decongestants in the

adolescent and adult populations, making recommenda-

tions for these groups more appropriate.16, 19

Antitussives

Cough is one of the most common and troublesome pre-

senting symptoms in children.21

This symptom is not only

troublesome for the child but, it also can be one of the most

intolerable symptoms for caregivers because it often pre-

vents sick children from getting enough sleep at night.21

The Slone Survey identified that in any given week, about 1

in 10 children in the U.S. receives some form of cough and/

or cold products.22

With these results, it is important to ad-

dress the high prevalence of medication use in children,

especially given the lack of efficacy data and potential for

adverse effects.22

Various review articles have helped to

characterize the use of cough and/or cold products in chil-

dren, but evidence to support the effectiveness of the

agents in the pediatric population remains inconclusive.23

One agent utilized in the treatment of cough is dextrome-

thorphan. This cough suppressant is used to depress the

cough center activity in the medulla and inhibits the

reuptake of serotonin in the presynaptic cleft.24

This sup-

pressive action can be harmful because it puts the patient

at potential risk for severe respiratory depression and sero-

tonin syndrome.24

These risks are especially dangerous in

the pediatric population due to a lack of sufficient data, thus

making the use of dextromethorphan for treatment of acute

cough an inappropriate recommendation in children.3, 23

Topical antitussive options also are available for use in chil-

dren to treat the symptoms commonly associated with

cough and cold. These products use medicated vapors to

relieve symptoms such as cough without causing the sys-

temic side effects (i.e., drowsiness or jittery feelings) that

have been associated with other cough and cold relief

products.25

One of the most commonly used topical antitus-

sives is Vicks VapoRub® which includes camphor, eucalyp-

tus oil and menthol. Vicks VapoRub® is approved for use in

children 2 years of age and older and can be applied to the

neck and chest up to 3 times per day.26, 27

This product is

not intended for use in children less than 2 years old due to

the camphor component, and also should not be applied in

the nostrils or under the nose.25-27

Side effects associated

with the use of Vicks VapoRub® include increased mucus

production, obstruction of small airways and rebound con-

July 2013



gestion.26,27

Another formulation, Vicks BabyRub®, does not include

camphor and is regarded as safe for children less than 2

years old when used as directed.28

This product is a combi-

nation of petrolatum, aloe extract, eucalyptus oil, lavender

oil and rosemary oil. Because it is marketed as

“unmedicated,” very little safety and efficacy data is availa-

ble regarding its use in the pediatric population.26,27

Expectorants

Expectorants, specifically guaifenesin, are used to reduce

the viscosity of respiratory tract fluid secretions and in-

crease sputum volume.29

These actions are thought to im-

prove the efficacy of the cough reflex as well as the action

of the ciliary in the trachea and bronchi, making it easier for

patients to expel bronchial drainage.29

However, like other

cough and cold products, limited evidence is available to

support the efficacy of guaifenesin for acute cough and up-

per respiratory tract infections.19

Water is considered the safest and most efficacious expec-

torant for children with an acute cough.30, 31

Little data sup-

ports the use of mucolytics or pharmacological expecto-

rants, but it is clearly understood that ample water intake

will promote thinning and loosening of the mucus and pro-

mote coughing.30, 31

Complementary and Alternative Medicine (CAM)

All use of herbal supplementation in children under the

age of 2, as well as in pregnancy and lactation, should be

done with extreme caution.32

Many CAM therapies are

associated with little clinical data regarding efficacy and

safety, especially in the pediatric population. Non-

pharmacologic therapy is the safest way to manage symp-

toms of the common cold in pediatric patients, and should



Decongestants

Pseudoephedrine46,47 <4 yo: 1 mg/kg/dose q 6 h (max 15 mg/dose) 4-5 yo: 15 mg q 4-6 h, max 60 mg/24 h 6-12 yo: 30 mg q 4-6 h, max 120 mg/24 h >12 yo (adolescents and adults): IR formula-tion: 60 mg q 4-6 h, max 240 mg/day ER formu-lation: 120 mg q 12 h or 240 mg once daily

Syrup, caplet, ER caplet, tablet, ER tablet

Agitation, irrita-bility, hyperten-sion, tremor, dizziness, nerv-ousness, tachy-cardia, dysrhyth-mia, anorexia, nausea, vom-iting, seizure, insomnia, dys-tonic reactions, headache

Antacids (other than Al(OH)3; ↓ excretion of pseudoephed-rine), sympatho-mimetics (enhance ADEs; tachycardia, tox-icity), SNRIs (enhances tachy-cardia) canna-binoids (enhances tachycardia)

Oral formula-tions: water or milk can ↓ GI distress Do not crush ER tablet or capsule

No studies in chil-dren; adolescents and adults may benefit; FDA approved in ages >4 yo for symptomatic re-lief of nasal con-gestion associat-ed with the com-mon cold, sinusi-tis, upper respira-tory allergies(ER formulations ap-proved in >12 yo); Do NOT use >72 hours due to risk of rebound con-gestion (esp. with topical nasal for-mulation)

July 2013



be used prior to pharmacologic therapy and CAM.

Vitamin C – Vitamin C is the most commonly used CAM

product associated with the common cold. 3 Vitamin C

should not be used for treatment, but limited evidence sug-

gests that prophylactic use may decrease the severity and

duration of symptoms.3 However, excessively high doses of

vitamin C should be avoided as they have been correlated

with adverse effects including headaches, intestinal and

urinary complications, kidney stones and significant interac-

tions with anticoagulants.3

Oral Zinc: 33

Oral zinc formulations have demonstrated a

dose-related reduction in the duration of the common cold

in adults; however, studies in children did not reveal the

same reduction when compared to placebo. This lack of

reduction could be attributed to differences in formulation,

dosing and frequency of administration. Differences in host

inflammatory responses, virus etiology and susceptibility

and even the lack of reliable third-party symptom reporting

also could account for the lack of evidence. If oral zinc ther-

apy is used in the pediatric population, it is important to use


ADEs Drug Interactions

Administration Recommendation

Antitussives

Dextromethorphan48 <4 yo: not for OTC

use

4-6 yo: Oral: 2.5-

7.5 mg q 4-8 hrs

ER formu-lation: 15 mg twice daily, max

30 mg/day

6-12 yo:

Oral: 5-10 mg q 4 h OR 15 mg q 6-8 hrs

ER formu-lation: 30 mg twice daily, max

60 mg/day

>12 yo:

Oral: 10-20 mg q 4 h OR 30 mg q 6-8

h ER formu-

lation: 60 mg

twice dai-ly, max

120 mg/day

Tablet, ER cap-sule, liquid cap-sule, lozenge,

solution/syrup/suspension, oral disinte-

grating strip, ER suspension

Confusion, excite-ment, irritability, nervousness, ser-otonin syndrome

Antipsychotics, CYP2D6 inhibi-

tors, da-runavir, MAO

Inhibitors, metoclo-pramide,

peginterfeon alfa-2b, quini-dine, selective

serontonin reuptake inhib-itors, serotonin

modulators, tocilizumab

Do not use with-in 14 days of stopping an

MAO inhibitor

No proven effica-cy in children.

July 2013



a recommended dose and to counsel patients regarding

common side effects such as nausea or bad (metallic)

taste.

Echinacea:5, 32, 34

This product is believed to act as a non-

specific immune stimulant and is used to stimulate white

blood cell function and cell-mediated immunity. It also is

reported to have broad-spectrum antimicrobial activity

against bacteria, fungi and viruses.32

Root preparations

may be effective in lessening the severity of cold symp-

toms, but clinical data is inconclusive. 5,34

The use of

echinacea also can trigger allergic reactions and should be

avoided in patients with allergies to ragweed, daisy, aster

and chrysanthemum.5, 34

Also, many tinctures have high

alcohol concentrations (15-90 percent), which should be

considered when evaluating the use of echinacea in pedi-

atric patients. 32

Use for greater than 10 days in any popu-

lation is not recommended.32

Airborne Jr®35,36

- This product is marketed for children

ages 4 to 10 as an herbal supplement designed to “boost

your immune system to help your body combat germs.”35

The primary ingredients listed are vitamin C (835 percent

of the daily recommended value), vitamin E, zinc and man-

ganese.35

This product has not been evaluated by the FDA

and has not been proven to be clinically effective for the

prevention or treatment of cough or cold.35

Airborne Jr® is

classified as an herbal supplement, holding a similar place

in therapy to vitamins with the same ingredients.36

Honey37

- Data supporting the effectiveness of honey for

the treatment of acute cough in children (minimum age of

12 months) due to upper respiratory infections is limited.37

A review of two trials containing a total of 268 patients, ag-

es 2-18, showed treatment with honey to be potentially su-

perior to treatment with diphenhydramine but these results

were consistent with “low to moderate quality evidence.”37

Chicken Soup – Limited clinically significant data is availa-

ble with relation to the use of chicken soup for the common

cold.3,30

Some individuals believe the hot steam from the

soup may help relieve sinus pressure and inflammatory

symptoms. This action is similar to the moistening of oral

and nasal passage seen with other hot beverages or warm

air humidifiers.3, 30

Individuals also like the use of chicken

soup during the common cold because it is one of the few

non-pharmacologic options that is safe for the pediatric

population and is not associated with adverse effects.

Prevention of the Common Cold: Disinfection and

Hand Washing

In general, viruses often spread via hand-to-hand contact

as well as through large-particle aerosolization.34

Avoiding

close contact with people who have colds or other upper


ADEs Drug Interactions

Administration Recommendation

Expectorants

Guaifenesin49 6 mos – 2 yo: 25-50 mg q 4 h, max 300mg/

day

2-5 yo: 5-100 mg

q 4 h, max 600 mg/day

6-11 yo: 100-200 mg q 4 h, max 1.2 g/day

>12 yo: 200-400 mg q 4 h, max 2.4 g/day

Caplet, oral granules, syrup,

tablet, ER tablet

Dizziness, drowsi-ness, headache, rash, decreased uric acid levels,

nausea, stomach pain, vomiting,

kidney stone for-mation

No known significant

drug interac-tions

Take with a full glass of water; Do not crush,

chew, or break tablet

No proven efficacy in children.

July 2013



respiratory tract infections (URTIs) can help prevent viral

exposure.4 Infected persons are most contagious during

the first three days of symptom onset and will likely no

longer be contagious by about day seven of illness.5 Rou-

tine disinfection of commonly touched surfaces such as

door knobs, sink handles and light switches can decrease

the risk of viral spreading.39

This disinfection should be

done using an EPA-approved product such as Lysol® to

ensure appropriate killing of the virus.39

Proper hand hy-

giene in both children and adults also may prove beneficial

in preventing illness and stopping the spread of the virus.4

Intermittent and frequent hand washing is recommended

for all ages and should be done using antibacterial soap or

hand sanitizers containing organic acids such as salicyclic

acid. Recent studies have demonstrated increased efficacy

at prevention of rhinovirus infection when using organic

acid-based when compared to ethanol-based hand sanitiz-

ers. This difference is thought to be the product of extend-

ed residual activity against rhinovirus seen with organic

acid products.39-41

These products can be found over-the-

counter and are generally considered safe for use in chil-

dren.40

Pain and Fever relief

One of the leading causes of parental concern with regard

to symptoms of illness is fever.38

The common belief chil-



Analgesics and Antipyretics

Aspirin50 10-15mg/

kg/dose Max: 4g/

day

Caplet, tablet, chewable

tablet

GI bleeding; platelet inhibi-

tion; Reyes syn-drome

NSAIDs, anticoag-ulants, antithrom-

botics

Administer with food or full glass of water to mini-mize GI disturb-

ances

NEVER use for fever or viral symptoms

in children; product is only available as a

solid dosage form

Acetaminophen51 10-15mg/

kg/dose every 4-6 hours

Max: 5

doses in 24 hours

Caplet, ER caplet, capsule,

elixir, gelcap, solution/

suspension/syrup, supposi-

tory, tablet, chewable tab-

let, oral disinte-grating tablet

GI hepatotoxicity (in case of over-

dose)

Anticholinergics Shake suspen-sion well before

pouring dose; take with food or milk; report

any unusual bleeding or

bruising

One concentration 160mg/5mL; drops are no longer avail-

able

Ibuprofen52 OTC an-algesic

dose: 4-10mg/

kg/dose every 6-8 hours

Max:

40mg/kg/day

OTC fe-

ver dose: 5-10mg/kg/dose every 6-8 hours

Max:

40mg/kg/day

Caplet, capsule, solution injec-tion, suspen-sion, tablet,

chewable tab-let

Cardiovascular edema; drowsi-

ness; GI bleeding or intolerance; platelet inhibi-

tion; acute renal failure

GI irritants; can decrease efficacy of some antihy-

pertensives

Administer with food

Only approved for patients >6 months; keep children well hydrated; multiple

concentrations (40mg/mL and

100mg/5mL); avoid in patients with renal disease or congenital heart

disease; may blunt sings/symptoms of

serious infection

July 2013



dren must maintain a “normal” temperature leads to the

misuse of antipyretics on a daily basis.38

Many parents are

not aware of the beneficial effects associated with fever

including slowing of bacterial and viral growth which in turn

helps the body recover more quickly from an infection.38

Due to this beneficial effect, the primary treatment goal for

a febrile child should not be normalization of body tempera-

ture but should actually include improvement of the child’s

general well-being including adequate fluid intake and pre-

vention of more serious symptoms.38

Another common misconception in the pediatric population

is with regard to the treatment of pain. In previous decades,

pain management for infants and children was not consid-

ered a significant priority due to the assumption that these

patients did not experience pain due to an “inadequately

developed neuroendocrine system and nerve pathways.”10

However, many clinical studies have since proven the pedi-

atric population may actually be more sensitive and poten-

tially experience more intense pain than adults.10

As a re-

sult, effective practices to appropriately manage pain in

children have become standard in the clinical setting, in-

cluding using pain assessment as the fifth vital sign.10

Like

adults, children can experience pain in a variety of situa-

tions including immunizations, acute illness (i.e. otitis me-

dia), chronic disease, injury and medical procedures, thus

making pain management an important part of treatment in

this population.10,32

Treatment of both fever and pain contain both non-

pharmacologic and pharmacologic options. Safe and effec-

tive OTC medication options for the treatment of pain and/

or fever include ibuprofen and acetaminophen.42,43

Either

choice, when used in appropriate doses, may be consid-

ered first line therapy when the patient requires an analge-

sic or antipyretic.42,43

Non-pharmacologic therapy

Fever10, 42

Environmental Control

Adjust room temperature to avoid extremes in heat or cold.

Remove excess clothing and/or use lightweight clothing.

Sponge baths with lukewarm water

Do not use cold water which can induce shivering thus fur-

ther increasing body temperature.

Do not use rubbing alcohol which can be systematically

absorbed and cause fume inhalation, both of which have

hazardous CNS side effects (i.e. increased heart rate,

headaches, dizziness and nausea).

Pain4, 23

Hot/Cold Packs

Use cold packs if pain is associated with inflammation and

swelling.

Use heating pad if patient is experiencing stiffness or

chronic pain.

Distraction

Consider using an enjoyable activity or item such as TV,

board games, ice cream, etc. as a distraction for children in

pain.

Massage/physical therapy

Make the child more comfortable and relaxed to positively

contribute to general well-being and allow the body to natu-

rally overcome the acute situation.

Pharmacologic therapy

Acetaminophen

The current recommendation for pharmacologic treatment

of fever and pain in children is the use of acetaminophen.

In the past, recommendations included the use of aspirin in

these situations, but due to a confirmed association be-

tween salicylates and Reyes syndrome in children, aspirin

is no longer considered a treatment option for this popula-

tion.42,43

The recommended dose of acetaminophen in chil-

dren is 10 to 15 mg/kg/day every 4 to 6 hours with a maxi-

mum dose of 75 mg/kg/day (or 5 doses) in 24 hours.42,43

OTC acetaminophen formulations for children include a

standard liquid concentration of 160mg/5mL as well as

chewable tablets and Meltaways®.42-44

The generally ac-

ceptable safe and effective duration of OTC use is five days

or less.42,43

Hepatotoxicity is a severe adverse reaction of

acetaminophen use and is seen in situations of suprathera-

peutic dosing (greater than 15 mg/kg/dose) or in prolonged

overdose situations in which appropriate single doses were

given at intervals shorter than four hours.42

Ibuprofen

Ibuprofen is another option for fever and pain in the pediat-

ric population and has been associated with a faster onset

and duration of action than acetaminophen. However, data

do not currently support a significant difference in safety or

effectiveness between the two agents, making them both

appropriate options in children. 42

Dosing recommendations

in children are different for the treatment of fever versus

pain. For children greater than 6 months of age, the dose

for treatment of fever is 7.5 mg/kg/dose given every 6 hours

with a maximum dose of 30 mg/kg/day. This is slightly dif-

July 2013



ferent than the dose for treatment of pain which is 5 to 10

mg/kg/dose given every 6 to 8 hours with a maximum dose

of 4 doses in 24 hours.42,43

Dosage forms for ibuprofen in

children include liquid preparations in concentrations of 40

mg/mL as well as 100 mg/5 mL.42

The variety of concentra-

tions makes selection of the appropriate product even more

important due to the risk of overdose if the wrong product is

used. Ibuprofen also is available as a chewable tablet .45

One critically important point to remember in this population

is the maintenance of adequate hydration while taking ibu-

profen or other non-steroidal anti-inflammatory agents.42

Although only limited case reports exist, renal insufficiency

has been directly correlated with the use of ibuprofen as a

result of prostaglandin inhibition that ultimately disrupts re-

nal blood flow.42

It is recommended to avoid the use of ibu-

profen in children who are dehydrated, have a history of

cardiovascular disease, have preexisting renal disease or

also are using other nephrotoxic agents.42

When to refer10, 19, 43, 46, 47

In general, non-pharmacologic therapy should be consid-

ered first line for treatment of cough and cold in pediatric

patients. If pharmacologic therapy is used to alleviate

symptoms, it is important for the caregiver to use OTC

medications only for the amount of time recommended.47

If

symptoms persist beyond the recommended amount of

time, the caregiver should be instructed to follow-up with

the primary care physician.

Here are some general situations in which physician refer-

ral is recommended:

Cough/cold symptoms6, 10, 31

Persistent cough >4 weeks31

Children <2 years old with cough31

Cough indicative of another disease state such as pertus-

sis, croup, bronchiolitis, asthma, GERD10,31

Symptoms lasting > 10 days6

Pain symptoms10, 43

Swelling or erythema at the site of pain

No relief, no improvement, or worsening of pain despite

adequate treatment

Fever10, 42, 43

Age > 6 months and temperature ≥103oF

Age > 2 months and rectal temperature ≥100.2oF

Age 3 to 6 months and temperature ≥101oF

No fever relief or improvement despite adequate treatment

Development of seizures or unusual drowsiness in addition

to looking more “ill”

Development of additional symptoms such as stiff neck,

inconsolable irritability, vomiting/diarrhea, rash, headache

or severe pain in throat or ear

Fever in an immunocompromised child such as one with

cancer, HIV or history of transplant

Barriers to Appropriate OTC Use in Children

Inappropriate dosing is one of the most important barriers

to proper OTC use in children and plays a significant role in

OTC-associated fatalities in this population.2 Dosing in-

structions on these products are often confusing and result

in both overdosing and underdosing situations. Because

pharmacists are such an accessible healthcare provider, it

is important they feel comfortable providing dosing recom-

mendations with regard to use of these products in chil-

dren.

Another barrier to appropriate OTC use in children is the

selection of combination products containing the same ac-

tive ingredients. Many caregivers unknowingly administer 2

-3 times the daily recommended amount of medications

such as acetaminophen because they are not aware of its

inclusion in multiple products used in cough and cold. For

this reason, single ingredient products should be recom-

mended in order to avoid an unintentional overdose of any

one ingredient.2

Selection of an inappropriate product is also a common

barrier to proper OTC use in pediatric patients.2 In some

instances, caregivers may select products not indicated for

a child’s symptoms or even substitute adult products when

pediatric formulations are indicated.2

Finally, improper utilization of measuring devices also con-

tributes to inappropriate OTC use.2 Although many caregiv-

ers are tempted to use household teaspoons and table-

spoons for medication dosing, these devices are not con-

sidered appropriate because the amount of medication de-

livered can vary greatly. In these situations, pharmacists

should offer to explain how to use the devices appropriately

or provide measuring tools which will provide the recom-

mended dose of medication with less difficulty.2

Putting it all together

Medication adherence is an important part of medication

use in children and can be negatively impacted by a variety

of factors including:10

Poor communication between the provider and the caregiv-

er and/or patient.

Lack of understanding regarding the severity of the illness.

Lack of interest regarding taking medication (especially in

adolescents).

Poor taste of drug formulations.

Uncertainty or anxiety regarding potential medication relat-

July 2013


ed adverse effects.

Inconvenient dosage forms and dosing schedules (i.e. ad-

ministration three or more times daily).

Failure of the caregiver to remember to administer the

drugs.

Medication safety is another very important part of media-

tion use. Administration errors may result from the following

scenarios:10

Incorrect or inappropriate medication.

Incorrect or inappropriate dose.

Inappropriate medication administration technique.

Inappropriate dosing instrument.2

Administration of more than two medications containing the

same ingredients.2

Two or more caregivers contributing to the treatment and

selection of the OTC product.2

To avoid life-threatening events, pharmacists can remind

caregivers to keep all medications (OTC and prescription)

out of the reach of children. They also should keep all med-

ications in the original bottles or containers with the lids

tightly sealed.6

Recognizing and understanding common flaws in the medi-

cation-use process can help providers, caregivers and pa-

tients create strategies to prevent problems before they

arise.10

Clinical Pearls for Pharmacists

1. Not all OTC products are approved for use in children.

The FDA recommends against the use of cough and

cold products, such as pseudoephedrine, phe-

nylephrine, diphenhydramine, brompheniramine and

chlorpheniramine, in children younger than 2 years of

age. 57

Additionally, manufacturers of these products

voluntarily changed their labels to state: “do not use in

children under 4 years of age.” 57

Paying close attention

to product labeling, ingredients and instructions for use

allows pharmacists to provide appropriate recommen-

dations and guidance for patients.6

2. Although vitamin C is often used in the adult population

for prophylaxis of the common cold, it should not be

used as active treatment in adults or children.3

3. Antibiotic therapy is not appropriate for treatment of the

common cold in adults and children. Therapy directed

toward symptom relief is a more appropriate recom-

mendation.3

4. Antihistamines should not be recommended for the

treatment of nasal symptom relief in children.3,16,19

5. Currently, nasal decongestants are not recommended

in children due to limited safety and efficacy data. This

drug class should be reserved for adolescent and adult

populations.16,19

6. Dextromethorphan is not an appropriate treatment for

cough in pediatric children.3

7. Ibuprofen is an appropriate analgesic and/or antipyretic

for children greater than 6 months old.6, 42, 43

8. Aspirin should NEVER be given to children due to the

rare, but very serious, risk of Reyes syndrome. 6, 42, 43

9. Avoid cough and cold medications with multiple active

ingredients. Use single ingredient products to reduce

the risk of overdose.48

10. Pharmacists are the most accessible healthcare pro-

fessionals: it is critical to select the appropriate prod-

ucts based on the individual pediatric patient, screen

each patient for potential drug-drug interactions or con-

traindications, and thoroughly educate caregivers about

proper dosing and administration.

References

1. OTC Medicines/Dietary Facts and Figures. Consumer

Healthcare Products Association. Available at: http://

www.chpa-info.org/pressroom/

OTC_FactsFigures.aspx. Accessed June 10, 2012.

2. Dart RC, Paul IM, Bond GR, et al. Pediatric Fatalities

Associated With Over the Counter (Nonprescription)

Cough and Cold Medications. Ann Emerg Med. 2009;

53(4)411-7.

3. Simasek M, Blandino DA. Treatment of the Common

Cold. Am Fam Physician. 2007; 75(4):515-520.

4. Centers for Disease Control and Prevention. Get

Smart: Know When Antibiotics Work: Common Cold

and Runny Nose. Available at http://www.cdc.gov/

getsmart/antibiotic-use/URI/colds.html. Accessed May

14, 2012.

5. National Institutes of Health. MedlinePlus. Common

cold. Available at http://www.nlm.nih.gov/medlineplus/

ency/article/000678.htm. Accessed May 14, 2012.

6. Centers for Disease Control and Prevention. Get

Smart: Know When Antibiotics Work: Symptom Relief.

Available at http://www.cdc.gov/getsmart/antibiotic-use/

symptom-relief.html.

7. Aguilera L. Pediatric OTC Cough and Cold Product

Safety. US Pharm. 2009;34(7):39-41.

8. Humidifier Health. What is the Source of the problem?

Available at http://www.humidifierhealth.org/?

go=health. Accessed May 14, 2012.

9. Smith SM, Schroeder K, Fahey T. Over-the-counter

medications for acute cough in children and adults in

ambulatory settings. Cochrane Database of Systemat-

ic Reviews 2008; 1 :CD001831.

10. Nahata MC, Taketomo C. Pediatrics. In: Pharma-

cotherapy: A Pathophysiologic Approach. 7th ed. DiPiro

JT, Talbert RL, Yee GC, et al., eds. New York, NY:


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http://www.cdc.gov/getsmart/antibiotic-use/URI/colds.html

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July 2013


McGraw-Hill; 2008.

11. Lever GJ, Li S, Mubasher ME, et al. Probiotic effects

on cold and influenza-like symptom incidence and du-

ration in children. Pediatrics. 2009 Aug;124(2):e172-9.

12. National Institutes of Health. MedlinePlus Supple-

ments. Lactobacillus. Available at http://

www.nlm.nih.gov/medlineplus/druginfo/

natural/790.html. Accessed July 8, 2012.

13. Tyson A. Yogurt Brands Containing Probiotics.

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article/281319-yogurt-brands-containing-probiotics/.

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15. May JR, Smith PH. Allergic Rhinitis.

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mines for the common cold. Cochrane Database Syst

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17. What is the Common Cold? New-Medical. Available at

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Common-Cold.aspx. Accessed May 14, 2012.

18. Consumer Healthcare Products Association. Statement

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children's cough and cold medicines. www.chpa-

info.org/10_07_08_PedCC.aspx. Accessed July 8,

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19. Isbister GK, Prior F, Kilham HA. Restricting cough and

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view and meta-analysis. Ann Pharmacother.

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21. Paul, Ian M. Therapeutic Options for Acute Cough Due

to Upper Respiratory Infections in Children. Lung 2012;

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22. Vernacchio L, Kelly JP, Kaufman DW, et al. Cough and

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24. Dextromethorphan. Respiratory Agents. Facts & Com-

parisons eAnswers. Wolters Kluwer Health, Inc. St.

Louis, MO. Available at: http://

factsandcomparisons.com. Accessed June 7, 2012.

25. VICKS®. VapoRub

® Topical Ointment. Available at:

http://www.vicks.com/products/vapo-family/vaporub-

topical-ointment. Accessed October 2012.

26. OTC cough and cold medication: keeping children safe.

Pharmacist’s Letter/Prescriber’s Letter 2011;27

(1):270105.

27. Vicks Vapo-Rub – How dangerous for children? Child

Health Alert. 2009 Feb;27:2.

28. VICKS®. BabyRub

® Soothing Ointment. Available at:

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babyrub-ointment. Accessed October 2012.

29. Guaifenesin. Respiratory Agents. Facts & Compari-

sons eAnswers. Wolters Kluwer Health, Inc. St. Louis,

MO. Available at: http://

factsandcomparisons.com. Accessed June 7, 2012.

30. Aguilera L. Pediatric OTC Cough and Cold Product

Safety. US Pharm. 2009; 34(7):39-41.

31. Cold medicines for kids: What’s the risk? Children’s

Health. MayoClinic. Available at: http://

www.mayoclinic.com/health/cold-medicines/CC00083.

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32. Echinacea (Echinacea purpurea, Echinacea angustifo-

lia). Natural Products Database. Lexi-Comp Online.

Lexi-Comp, Inc. Hudson, OH. Available at: http://

online.lexi.com/crlonline. Accessed May 15, 2012.

33. Science M, Johnstone J, Roth DE, et al. Zinc for the

treatment of the common cold: a systematic review and

meta-analysis of randomized controlled trials. CMAJ.

2012. Available at www.cmaj.ca. Accessed May 14,

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34. Woelkart K, Linde K, Bauer R. Echinacea for Prevent-

ing and Treating the Common Cold. Planta Med. 2008;

74(6):633-7.

35. Airborne. Product Information. Airborne, Inc. Minneap-

olis, MN. Available at: http://www.airbornehealth.com/

product-information. Accessed on July 2012.

36. Airborne Jr. Effervescent Health Formula Grape. Die-

tary Supplements Labels Database. United States Na-

tional Library of Medicine. Available at: http://

dietarysupplements.nlm.nih.gov. Accessed July 2012.

37. Oduwole O, Meremikwu MM, Oyo-Ita A, et al. Honey

for acute cough in children. Cochrane Database Syst

Rev. 2012;3:CD007094.

38. Gwaltney JM Jr, Moskalski PB, Hendley JO. Hand-to-

hand transmission of rhinovirus colds. Ann Intern Med.

1978; 88:463-7.

39. Turner RB, Hendley JO. Virucidal hand treatments for

prevention of rhinovirus infection. Antimicrob Agents

Chemother. 2005; 56(5): 805-7.

40. Turner RB, Biedermann KA, Morgan JM, et al. Efficacy


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http://www.livestrong.com/article/281319-yogurt-brands-containing-probiotics/

http://www.livestrong.com/article/281319-yogurt-brands-containing-probiotics/

http://www.sleepforkids.org/html/sheet.html.%20Accessed%20July%208

http://www.sleepforkids.org/html/sheet.html.%20Accessed%20July%208

http://www.news-medical.net/health/What-is-the-Common-Cold.aspx

http://www.news-medical.net/health/What-is-the-Common-Cold.aspx

http://www.chpa-info.org/10_07_08_PedCC.aspx.%20Accessed%20July%208

http://www.chpa-info.org/10_07_08_PedCC.aspx.%20Accessed%20July%208

http://factsandcomparisons.com/




http://www.mayoclinic.com/health/cold-medicines/CC00083

http://www.mayoclinic.com/health/cold-medicines/CC00083

http://online.lexi.com/crlonline


http://www.cmaj.ca

http://www.airbornehealth.com/product-information

http://www.airbornehealth.com/product-information

http://dietarysupplements.nlm.nih.gov

http://dietarysupplements.nlm.nih.gov

July 2013



of Organic Acids in Hand Cleansers for Prevention of

Rhinovirus Infections. Antimicrob Agents Chemother.

2004; 48: 2595-8.

41. Turner RB, Fuls JL, Rodgers ND. Effectiveness of hand

sanitizers with and without organic acids for removal of

rhinovirus from hands. Antimicrob Agents Chemother.

2012; 54(3): 1363-4.

42. Sullivan JE, Farrar HC. Clinical report – fever and anti-

pyretic use in children. Pediatrics 2011; 127:580-587.

43. Berde CB, Sethna NF. Analgesics for the treatment of

pain in children. NEJM 2002;(347) 14:1094-1103.




ic Reviews 2008; 1 :CD001831.

45. Motrin®. McNeil Consumer Healthcare Division. Availa-

ble at: http://www.motrin.com. Accessed on July 2012.

46. Chang AB, Glomb WB. Guidelines for Evaluating

Chronic Cough in Pediatrics: ACCP Evidence-Based

Clinical Practice Guidelines. Chest 2006; 129: 260S-

283S.

47. Chang AB, Landau LI, Van Asperen PP, et al. Cough in

children: definitions and clinical evaluation. MJA 2006;

184: 398-403.

48. U.S. Food and Drug Administration. FDA Statement

Following CHPA’s Announcement on Nonprescription

Over-the-Counter Cough and Cold Medicines in Chil-

dren. Available at: http://www.fda.gov/NewsEvents/

Newsroom/PressAnnouncements/2008/

ucm116964.htm. Accessed on: July 2012.

49. Diphenhydramine. Lexi-Drugs Online. Lexi-Comp

Online. Lexi-Comp, Inc. Hudson, OH. Available at:

http://online.lexi.com/crlonline. Accessed July 2012.

50. Pseudoephedrine. Lexi-Drugs Online. Lexi-Comp


http://online.lexi.com/crlonline. Accessed May 14,

2012.

51. Pseudoephedrine. Pediatric and Neonatal Lexi-Drugs

Online. Lexi-Comp Online. Lexi-Comp, Inc. Hudson,

OH. Available at: http://online.lexi.com/crlonline. Ac-

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52. Dextromethorphan. Lexi-Drugs Online. Lexi-Comp


http://online.lexi.com/crlonline. Accessed June 7, 2012.

53. Guaifenesin. Lexi-Drugs Online. Lexi-Comp Online.


online.lexi.com/crlonline. Accessed June 7, 2012.

54. Aspirin. Lexi-Drugs Online. Lexi-Comp Online. Lexi-

Comp, Inc. Hudson, OH. Available at: http://

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56. Ibuprofen. Lexi-Drugs Online. Lexi-Comp Online. Lexi-

Comp, Inc. Hudson, OH. Available at: http://


57. An Important FDA Reminder for Parents: Do Not Give

Infants Cough and Cold Products Designed for Older

Children. U.S. Food and Drug Administration. Ac-

cessed 17 October 2012. Available at: http://

www.fda.gov/Drugs/ResourcesForYou/

SpecialFeatures/ucm263948.htm.

July 2013 — Pediatric Over-the-Counter Medication Refresher for Pharmacists

1. Which non-pharmacologic treatment is NOT RECOM-MENDED in a pediatric patient with a cough or cold? A. Increasing fluid intake with water B. Receiving at least 10 hours of sleep C. Using a warm air humidifier D. Use of nasal bulb syringes in infants with congestion 2. NK is a 12-year-old boy who presents to clinic with a runny nose, cough and nasal congestion. NK states that he has felt “really bad all over” for the past 2 days and hasn’t been able to sleep well because he can’t breathe through his nose. He has not had a fever. NK is not tak-ing any other medications, has NKDA and no significant PMH. Mom has not tried any form of therapy for his cold symptoms, but states she would like to get something to help him breathe at night so he can sleep. What would be the appropriate recommendation for NK?

A. Pseudoephedrine 30 mg q 4 to 6 hours; max 240 mg; appropriate counseling on all potential adverse effects

B. Diphenhydramine 12.5 mg q 4 hours; max 75 mg/day; appropriate counseling on all potential adverse effects

C. Phenylephrine 5 to 10 mg q 12 hours instead of pseudoephedrine; appropriate counseling on all potential adverse effects

D. Nonpharmacologic therapy including a cold air humidifier, head elevation, and increased fluid intake

3. Which is NOT a challenge associated with over-the-counter medication use in children? A. Administration by a single caregiver B. Inappropriate dosing C. Use of medications containing ≥2 active ingredients D. Use of an inappropriate measuring device

http://www.motrin.com













July 2013



4. A mom comes to your pharmacy with her 8 month old daughter, ML. She states ML has had a deep, non-productive cough for the last 5 days which is very bothersome and is even preventing her from getting enough sleep at night. Mom thinks it may be from something she picked up from her new daycare, espe-cially because she knows other kids have been sick recently. Mom wasn’t sure how she should treat the cough but states she was told to pick up some Chil-dren’s Tylenol Plus Cough and Sore Throat® (acetaminophen and dextromethorphan) by the mom of another kid. She has the product in her hand but wants to know what you would recommend for her daughter before she buys it. What would be your rec-ommendation? A. Nonpharmacologic therapy with increased fluid intake

using Pedialyte ®, adequate sleep, and use of cold air humidifier

B. Children’s Tylenol Plus Cough and Sore Throat®(acetaminophen 160 mg/5mL and dextromethorphan 5mg/mL); 5 mL q 4-6 h

C. Children’s Delsym® (dextromethorphan 30mg/5mL); 0.2 mL q 6 to 8 hours

D. Refer to physician 5. Which of the following statements is NOT true? A. Green mucous typically indicates a bacterial infection,

and most often requires physician referral B. Avoiding exposure to persons with cold symptoms and

proper hand hygiene may help prevent the common cold

C. Nonpharmacologic therapy should always be consid-ered as first line therapy in pediatric patients with mild cough/cold symptoms

D. Products including vitamin C or yogurt with active cul-tures can reduce the severity and duration of the com-mon cold in children

6. What is the MOST appropriate treatment for cough in a 10 year old boy with a sore throat and persistent, productive cough? A. Dextromethorphan 30mg every 4 hours as needed for

cough B. Increased water intake and elevation of the head of

the bed C. Guaifenesin 400mg every 4 hours as needed for

cough D. Ibuprofen 10mg/kg/dose every 4 hours as needed for

cough

7. JS is a 7 year old little girl who is complaining of a headache, cough, and lots of “drainage in her throat.” She says she has had the cough for about 24 hours without relief. JS confirms she does not have a history of allergies or sinus congestion. What is the best rec-ommendation for JS with regard to an expectorant? A. Acetaminophen 15mg/kg/dose every 4 to 6 hours as

needed for cough B. Drinking 8 to 10 glasses of water throughout the day C. Guaifenesin 50mg every 4 hours D. Dextromethorphan 10mg every 8 hours 8. NM is a 5 month old WM who just received three im-munizations. He is restless and will not stop crying. His mother suspects NM is experiencing lingering pain at the injection site. What is the best analgesic for NM at this time? A. Neonates do not experience pain. No treatment rec-

ommended. B. Ibuprofen 10mg/kg/dose x 1 dose C. Acetaminophen 15mg/kg/dose x 1 dose D. Aspirin 10mg/kg/dose x 1 dose 9. MR is a 4 month old female brought to your commu-nity pharmacy by her mother. MR is febrile with a tem-perature of 101.2ºF. Her mother is very concerned and asks you for the “quickest thing” to bring her daugh-ter’s fever down. What is your recommendation? A. MR should call her pediatrician or go to the emergency

room right away. B. Acetaminophen 30mg/kg as an initial loading dose,

followed by 10mg/kg/dose every 4 to 6 hours thereaf-ter until afebrile

C. Ibuprofen 10mg/kg/dose every 6 hours until afebrile D. No pharmacological therapy required. MR should be

taken home and given an ice bath. 10. Which is a common factor that positively affects pediatric medication adherence? A. A poorly tasting liquid formulation that does NOT in-

clude a sweetener or flavoring to mask the bitter taste B. A dosing schedule that requires administration every 6

hours C. A caregiver who doesn’t believe their child’s symptoms

or illness requires treatment D. Open and clear communication between the provider

and the caregiver

July 2013



PHARMACISTS ANSWER SHEET July 2013 — Pediatric Over-the-Counter Medication Refresher for Pharmacists Universal Activity # 0143-9999-13-007-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 7. A B C D 9. A B C D 2. A B C D 4. A B C D 6. A B C D 8. A B C D 10. A B C D Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________

NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD)

This activity is a FREE service to members of the Kentucky Pharmacists Association. The

fee for non-members is $30. Mail completed forms to: KPERF, 1228 US 127 South,

Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile.

The Kentucky Pharmacy Education & Research Foundation is

accredited by The Accreditation Council for Pharmacy

Education as a provider of continuing Pharmacy education.

Expiration Date: July 12, 2016 Successful Completion: Score of 80% will result in 1.5 contact hour or 0.15 CEU.

Participants who score less than 80% will be notified and permitted one re-examination.

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July 2013


August 2013 CE — COPD and CVD: Role of Beta-Blockers

COPD and CVD: Exploring the Role of Beta-Blockers and COPD Treatments in Comorbid Disease By: Allison Meyer, PharmD and Debbie Minor, PharmD, The University of Mississippi Medi-cal Center, Departments of Pharmacy and Medicine, Jackson, MS Reprinted with permission of the authors and the Mississippi Pharmacists Association where this article originally appeared. This activity may appear in other state pharmacy association journals. There are no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-9999-13-008-H01-P&T 1.0 Contact Hour (0.1 CEUs)

Goal: To review the role of beta-blocker (BB) therapy in the management of cardiovascular conditions and discuss the effects of these medications as well as treatments for chronic obstructive pulmonary disease (COPD) on associated mor-bidity and mortality.

Objectives: At the conclusion of this lesson, the reader should be able to:

1. Describe the role of BBs in the management of cardiovascular disease (CVD).

2. Discuss potential benefits as well as adverse effects associated with the use of BBs in patients with COPD.

3. Identify the association of inhaled COPD medication use and possible cardiovascular consequences.

KPERF offers all

CE articles to

members online at

www.kphanet.org

INTRODUCTION

COPD is a highly prevalent disease affecting approximately

15 million Americans.1 In 2007 it was the third leading

cause of death in the United States.2 Numerous observa-

tional studies propose that patients with COPD are more

likely to have coexisting cardiovascular conditions, includ-

ing hypertension (HTN), heart failure (HF) and coronary

artery disease (CAD), as well as diabetes and atherosclero-

sis, compared to patients without this lung disease.3-8

A

history of COPD also is associated with poor CVD out-

comes, including increased mortality and rehospitalization

in HF and post-myocardial infarction (MI) patients, when

compared to those without COPD.9-15

Whether these asso-

ciations are due to the disease process, smoking history or

other factors is unclear.3,5-6

BBs are indicated for many of the cardiovascular conditions

that often accompany COPD, including HF, CAD, atrial fi-

brillation (AF) and HTN. Screening and proper manage-

ment of CVD is vital to improving patient outcomes. While

evidence suggests that BBs are generally well-tolerated in

patients with COPD, many do not receive these lifesaving

medications due to historical concerns for bronchocon-

striction and worsening lung function.16-17

The role of BBs in

CVD management as well as recommendations for use in

patients with COPD are highlighted in Table 1. The purpose

of this review is to explore this role and discuss the effects

of these medications and COPD treatments on COPD and

cardiovascular morbidity and mortality.

BETA-BLOCKERS IN CARDIOVASCULAR DISEASE

Heart Failure

In several large clinical trials, metoprolol succinate, carve-

dilol and bisoprolol have demonstrated a reduction in mor-

bidity and mortality in patients with systolic HF when added

to baseline angiotensin converting enzyme inhibitor (ACEI)

therapy.18-22

These agents decrease sympathetic nervous

system effects on the heart, resulting in improved left ven-

tricular (LV) ejection fraction and diastolic function, which

are major determinants of the progressive clinical course of

HF.23

Current guidelines recommend that the majority of

patients with reduced LV systolic function be treated with

one of these BBs even in the presence of concomitant

COPD, diabetes or peripheral vascular disease.24-26

The

presence of COPD is the most significant reason for pa-

tients failing to receive adequate treatment.27

Coronary Artery Disease

BB therapy is considered standard of care post-MI.28-29

Most trials supporting this recommendation were published

July 2013



in the 1980s,

prior to the rou-

tine use of

ACEIs, thrombo-

lytics and percu-

taneous inter-

vention.30-31

More recent

studies have

demonstrated a

potential reduc-

tion in mortality,

reinfarction or

ventricular fibril-

lation post-MI

with use of car-

vedilol or

metoprolol suc-

cinate, though the primary endpoints were not significantly

reduced by allocation to a BB.20,32

Similarly, in a recent ob-

servational study, BB therapy did not reduce the primary

cardiovascular endpoint in patients with a remote MI histo-

ry, CAD without MI history or CAD risk factors only.33

Based

on previous affirmative evidence, a class I recommendation

remains for acute and long-term BB use in post-MI patients

with reduced LV function.28-29

In those with normal LV func-

tion, guidelines recommend using BBs for up to three years

after a cardiac event (class IB).29

BBs also are first-line

agents for symptomatic relief of stable angina, with an op-

tion of a calcium channel blocker (CCB) or long-acting ni-

trate in those intolerant to BBs.34

Treatment with selective

BBs is considered safe for patients with CAD and coexist-

ing COPD.27

Atrial Fibrillation

The most frequent cardiac arrhythmia is AF. Beta-blockers

are useful for rate control in patients with AF and were

shown to be more effective than CCB, both as monothera-

py and in combination with digoxin.35-36

They are recom-

mended as first-line initial therapy and may be used in com-

bination with a CCB and/or digoxin for patients with uncon-

trolled heart rate and persistent AF.35

While BBs will not

convert a patient from AF to normal sinus rhythm, they can

effectively maintain normal sinus rhythm. They also are

effective in maintaining sinus rhythm in post-cardiac sur-

gery patients.35

Patients with COPD have an increased inci-

dence of AF, and treatment can be challenging because of

the breathlessness and disability resulting from coexistence

of these disease states.27

Hypertension

Historically, BBs have been widely used as antihyperten-

sive agents, and

metoprolol and

atenolol remain in

the top 20 of the

200 most common-

ly prescribed medi-

cations.37

A meta-

analysis of 13 trials

comparing BBs to

other antihyperten-

sives or placebo

revealed a higher

risk of stroke and

no difference in MI

in patients taking

BB.38

With the

emergence of new-

er classes with

more favorable outcomes (i.e., diuretic, ACEI, angiotensin

receptor blocker [ARB], CCB), these medications are no

longer generally promoted as first-line therapy for treatment

of hypertension.39-40

The most prevalent cardiovascular

comorbidity in COPD is likely hypertension, which has im-

plications for COPD prognosis.27

BETA-BLOCKERS IN CHRONIC OBSTRUCTIVE PUL-

MONARY DISEASE

While no randomized controlled trials have been performed

to definitively prove the benefits of BBs in patients with

COPD, retrospective and observational data point to im-

proved survival and decreased hospitalizations with use of

these medications.38,41-43

In observational analyses, cardi-

oselective BBs appear to decrease mortality in COPD pa-

tients with CVD, including HTN, HF and atherosclerosis, as

well as those undergoing coronary artery bypass graft sur-

gery.9,44-46

However, these patients, especially those with

severe COPD, are less likely to receive a BB or may be

prescribed lower doses of BBs than those without

COPD.9,12-15,17

The benefits from BB use in patients with COPD may be

independent of their value in CVD. Contrary to previous

beliefs, the use of BBs does not appear to increase the rate

of COPD exacerbations.44-47

BBs may actually reduce the

incidence and severity of COPD exacerbations.47

Several

observational studies have demonstrated a mortality reduc-

tion with BB use during COPD exacerbations.41-43

Addition-

ally, patients with existing CVD and newly diagnosed

COPD have a higher mortality rate with BB discontinua-

tion.43

Most studies reviewing the use of BBs in COPD have been

conducted in patients with HF using carvedilol or bisoprolol.

Table 1: Recommendations for Use of BB in CVD and COPD

Condition Effects of BB Recommendations in COPD*

Heart Failure

Decrease sympathetic nervous system effects on

heart Reduce morbidity and mortality in systolic HF

Use in patients with systolic HF as tolerated

Coronary Artery Disease

Reduce morbidity and mortality acutely post-MI

Symptomatic relief of stable angina

Use in hemodynamically stable patients post-MI, as tolerated

May use BB, CCB, or nitrates for symptomatic angina

Atrial Fibrillation Rate control

Maintain sinus rhythm May use BB, CCB, or digoxin

Hypertension Potential increase in stroke,

no effect on MI risk No longer first-line agent

Use first-line agents (i.e. diuretics, CCB, ACEI, ARB)

before BB

*Cardioselective preferred in all conditions

July 2013



These medications,

particularly carve-

dilol, may acutely

decrease forced

expiratory volume

in one second

(FEV1) and cause

mild, transient

dyspnea and

wheezing; howev-

er, this typically

does not result in

the need for BB

discontinuation or

in a decrease in health-related quality of life.48-54

If respira-

tory side effects occur, a trial of another BB is warranted. In

a crossover study of patients with HF and COPD, switching

from a cardioselective BB, i.e. bisoprolol or metoprolol, to

carvedilol did not cause excess intolerance.55

The Global Initiative for Chronic Obstructive Lung Disease

(GOLD) guidelines specifically address CVD management

in patients with COPD (Table 1). These guidelines recom-

mend that patients with HF, ischemic heart disease, AF

and HTN be treated as usual per respective guidelines as

evidence does not suggest treating them differently.27

The

use of BBs in patients with ischemic heart disease or HF,

including those with severe COPD, is warranted as the

morbidity and mortality benefits outweigh the potential risk.

The GOLD guidelines also support the use of BBs in AF;

however, with the availability of other options, a trial of an-

other class of medication might be reasonable. Lastly, BBs

can be used in patients with HTN, as an adjunct to first-line

agents. In all cases, the use of cardioselective BBs is rec-

ommended over other BBs.27

COPD TREATMENTS AND CARDIOVASCULAR

DISEASE

The most commonly prescribed medications for COPD in-

clude the inhaled beta-agonists (IBA), anticholinergics

(IAC) and corticosteroids (ICS). While these medications

are generally well-tolerated, there is some concern for ex-

acerbation of CVD, especially with the use of IBAs (Table

2). Most supporting data for the risk of CVD stem from ob-

servational studies in which cardiovascular morbidity and

mortality are secondary outcomes.

In reference to CVD hospitalizations, several case-control

studies have suggested a potential increase with use of

ipratropium or IBA, while neither tiotropium nor ICS had an

effect. Additionally, ipratropium may increase and ICS may

decrease CV mortality. IBA use had no effect on mortality

in these studies;56-59

however, a recent case-control study

reported an in-

creased risk of cardi-

ovascular mortality

with initial use of

IBAs.60

Initial use of

IAC also was associ-

ated with increased

mortality.60

Risk of

overall death and

cardiovascular

events appears to be

lowest with the com-

bination of long-

acting beta-agonists

(LABA) and ICS.61-62

Though tolerance usually develops, a common side effect

of inhaled short-acting beta-agonists (SABA) is mild, dose-

dependent tachycardia.63

Arrhythmias, though rare, can

occur with initial use of SABA and LABA,63-65

potentially

due to a decrease in serum potassium seen with these

agents.66

Most of these reports do not reflect clinically sig-

nificant arrhythmias, and the risk decreases over time.58,63-

66 Additionally, it has been proposed that impaired lung

function is an independent predictor of arrhythmias.67

There is a potential association between IBA use and HF

hospitalization and mortality, especially with chronic thera-

py. This risk is highest in patients with excessive use of

SABAs, i.e. > 3 canisters per month.66,68-70

There is no cor-

relation, however, between IBA use and HF development.70

Conversely, these agents may improve HF exacerbations,

potentially due to decreased cardiac workload resulting

from the decreased work of breathing.66

Some patients ac-

tually have hemodynamic improvement with acute use of

an IBA. Other potential benefits of these medications in HF

patients include increased cardiac output, decreased pe-

ripheral vascular resistance and improved pulmonary capil-

lary wedge pressure.66

An increased risk of acute coronary syndrome (ACS) with

the use of IBAs also has been reported .71-72

Similar to the

risk of arrhythmias and with HF, this effect appears to be

dose-dependent, with the greatest risk in patients using > 6

canisters of a SABA per month.72

Many studies, however,

have found that IBA use does not worsen myocardial ische-

mia or increase the risk of ACS.66,73

While there may be an association between IBA use and

cardiovascular events, most cases are mild and transient

and are typically related to excessive use of these medica-

tions. Counseling patients on appropriate use of SABA and

ensuring use of controller medications, as appropriate, is

important for prevention of these negative cardiovascular

Table 2: Inhaled Beta-Agonists and Potential CVD Complications

Tachycardia/Arrhythmias Heart Failure Acute Coronary

Syndromes

Initial use

Mild, transient

Usually not clinically significant

Chronic use may increase HF hospitalizations and mortality

No correlation to HF development

May improve HF exacerbations – relieve dyspnea

May increase risk of ACS

Dose-dependent, highest risk with excessive use of SABA

July 2013


outcomes. Close follow-up is necessary, particularly with

severe disease.

The GOLD guidelines generally do not recommend altering

COPD treatment strategies with coexisting HF, ischemic

heart disease, AF or HTN as there is no direct evidence

that patients should be treated differently.27

For patients

with ischemic heart disease or AF, the guidelines state that

it is reasonable to avoid high doses of IBAs. Appropriate

heart rate control may be difficult in patients with AF using

high doses of IBAs. Patients with severe HF who are using

IBAs should receive close monitoring by their healthcare

providers due to the potential for an increased mortality and

hospitalization risk.27

CONCLUSION

BBs have established morbidity and mortality benefits in

many cardiovascular conditions that often coexist with

COPD. Additional research is needed to further define the

benefits and guide the treatment of patients with COPD

and CVD, and many of these patients may not receive BB

therapy due to concerns for bronchoconstriction. Evidence

suggests, however, that these agents are typically well-

tolerated in COPD patients and may reduce CVD and

COPD mortality as well as COPD exacerbations. Current

guidelines for COPD are consistent with those for CVD

management and support the role of BBs for treatment of

particular cardiovascular conditions, with preference for the

use of cardioselective agents. Additionally, proper educa-

tion and appropriate use of COPD medications, particularly

IBAs, will aid in the prevention of cardiovascular events.

Pharmacists encounter these patients on a daily basis. We

are in a unique position to influence patient care and deci-

sions, particularly in the areas of medication use and selec-

tion. By understanding current issues related to therapy, we

can effectively impact disease management and outcomes

for many patients with COPD.

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62. Calverley PMA, Anderson JA, Celli B, et al. Cardiovascular

events in patients with COPD: TORCH Study results. Thorax

2010;65:719-725.

63. Sears MR. Adverse effects of β-agonists. J Allergy Clin Im-

munol 2002;110:S322-S328.

64. Wilchesky M, Ernest P, Brophy JM, et al. Bronchodilator use

and the risk of arrhythmia in COPD: part 1: Saskatchewan

cohort study. Chest 2012;142:298-304.

65. Wilchesky M, Ernest P, Brophy JM, et al. Bronchodilator use

and the risk of arrhythmia in COPD: part 2: reassessment in

the larger Quebec cohort. Chest 2012;142:305-311.

66. Maak CA, Tabas JA, McClintock DE. Should acute treatment

with inhaled beta agonists be withheld from patients with

dyspnea who may have heart failure? J Emerg Med

2011;40:135-145.

67. Buch P, Friberg J, Scharling H, et al. Reduced lung function

and risk of atrial fibrillation in the Copenhagen city heart

study. Eur Respir J 2002;21:1012-1016.

68. Mentz RJ, Fiuzat M, Kraft M, et al. Bronchodilators in heart

failure patients with COPD: Is it time for a clinical trial? J Car-

diac Fail 2012;18:413-422.

69. Au DH, Udris EM, Fan VS, et al. Risk of mortality and heart

failure exacerbations associated with inhaled beta-adrenergic

agonists among patients with known left ventricular systolic

dysfunction. Chest 2003;123:1964-1969.

70. Au DH, Udris EM, Curtis JR, et al. Association between

chronic heart failure and inhaled β-2-adrenoceptor agonists.

Am Heart J 2004;148:915-920.

71. Au DH, Lemaitre RN, Curtis JR, et al. The risk of myocardial

infarction associated with inhaled β-adrenoceptor agonists.

Am J Resp Crit Care Med 2000;161:827-830.

72. Au DH, Curtis JR, Every NR, et al. Association between in-

haled β-agonists and the risk of unstable angina and myocar-

dial infarction. Chest 2002;121:846-851.

73. Suissa S, Assimes T, Ernst P. Inhaled short acting β agonist

use in COPD and the risk of acute myocardial infarction.

Thorax 2003;58:43-46.


July 2013


Nominate your peers for a new feature in

The Kentucky Pharmacist

We are looking for members to profile in coming editions of

The Kentucky Pharmacist who are making the world a better place. Do you know

someone who goes above and beyond the “above and beyond the call of duty”? Let

us know!

Email Scott Sisco at [email protected] with a brief description of the story or

to schedule a time to discuss.

August 2013 — COPD and CVD: Exploring the Role of Beta-Blockers and COPD Treatments in Comorbid Disease

1. Patients with COPD are more likely to have: A. coronary artery disease B. hypertension C. heart failure D. diabetes E. All of the above 2. Which of the following statements is FALSE regarding beta-blocker use in heart failure? A. BBs increase sympathetic nervous system effects on the

heart. B. Metoprolol succinate, carvedilol, and bisoprolol are rec-

ommended for use in systolic HF C. BBs reduce mortality and morbidity in systolic heart fail-

ure D. Cardioselective BBs are recommended by GOLD guide-

lines for use in HF with coexisting COPD 3. In patients with COPD and coexisting AF, BBs: A. are contraindicated B. decrease mortality and should be used in all patients C. can be used for rate control 4. According to the data presented, BBs may improve survival in COPD patients with all of the following coex-isting disease states EXCEPT? A. Hypertension B. Heart Failure C. Atrial fibrillation D. Atherosclerosis 5. BBs may: A. reduce the incidence and severity of COPD exacerba-

tions B. be inappropriately prescribed in lower doses in patients

with CVD and coexisting COPD C. increase the rate of COPD exacerbations D. Both a. and b

6. Studies of BB use in COPD patients with HF indicate that an initial increase in respiratory side effects may oc-cur most often with which of the following medications? A. Carvedilol B. Bisoprolol 7. Management of CVD with coexisting COPD, as dis-cussed in the GOLD guidelines, should include: A. altering therapy with all cardiovascular conditions, includ-

ing avoidance of BBs B. no differentiation between use of cardioselective and non-

selective BBs C. use of cardioselective BBs in HF patients, including those

with severe COPD 8. Changes in heart rhythms, including tachycardia and arrhythmias, with use of inhaled beta-agonists: A. are typically mild and transient B. can occur with initial use of both short- and long-acting

beta-agonists C. may be due to a decrease in serum potassium seen with

these agents D. All of the above 9. With regards to HF, use of inhaled beta-agonists: A. may improve HF exacerbations by decreasing cardiac

workload from decreased work of breathing B. may result in development of HF C. in excessive amounts (i.e. > 3 canisters of SABA per

month) may increase hospitalization and mortality D. Both a. and c E. Both b. and c 10. In treatment recommendations for patients with COPD and CVD, the GOLD guidelines suggest the follow-ing EXCEPT: A. generally no alteration of COPD treatment strategies B. avoiding high doses of IBAs in patients with ischemic

heart disease C. avoiding high doses of IBAs in patients with hypertension


July 2013


PHARMACISTS ANSWER SHEET August 2013 — COPD and CVD: Exploring the Role of Beta-Blockers and COPD Treatments in Comorbid Disease Universal Activity # 0143-9999-13-008-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D E 3. A B C 5. A B C D 7. A B C 9. A B C D E 2. A B C D 4. A B C D 6. A B 8. A B C D 10. A B C Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________


This activity is a FREE service to members of the Kentucky Pharmacists Association. The

fee for non-members is $30. Mail completed forms to: KPERF, 1228 US 127 South,

Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile.

The Kentucky Pharmacy Education & Research Foundation is

accredited by The Accreditation Council for Pharmacy

Education as a provider of continuing Pharmacy education.

Expiration Date: July 16, 2016 Successful Completion: Score of 80% will result in 1.0 contact hour or 0.10 CEU.

Participants who score less than 80% will be notified and permitted one re-examination.

TECHNICIANS ANSWER SHEET. August 2013 — COPD and CVD: Exploring the Role of Beta-Blockers and COPD Treatments in Comorbid Disease Universal Activity # 0143-9999-13-008-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D E 3. A B C 5. A B C D 7. A B C 9. A B C D E 2. A B C D 4. A B C D 6. A B 8. A B C D 10. A B C Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature _________________________________________________ Date _________________________________


Quizzes submitted without NABP eProfile

ID # and Birthdate will not be accepted.


July 2013


The Kentucky Renaissance Pharmacy Museum offers several ways way to show

support of the Museum, our state's leading preservation organization

for pharmacy.

While contributions of any size are greatly appreciated, the following levels

of annual giving have been established for your consideration.

Friend of the Museum $100 Proctor Society $250

Damien Society $500 Galen Society $1,000

Name______________________________________ Specify gift amount________________________

Address ____________________________________ City____________________Zip______________

Phone H____________________W________________ Email___________________________________

Employer name_____________________________________________________for possible matching gift.

Tributes in honor or memory of_____________________________________________________

Mail to: Kentucky Renaissance Pharmacy Museum, P.O.Box 910502, Lexington, KY 40591-0502 The Kentucky Renaissance Pharmacy Museum is a non-profit 501(c)(3) business entity and as such donations are tax deductible. A

notice of your tax deductible contributions will be mailed to you annually.

Questions: Contact Lynn Harrelson @ 502-425-8642 or [email protected]

Senior Care Corner from the KPhA Academy of Consultant Pharmacists

The Spring CE event took place on Saturday, April 20,

2013 at Sullivan University College of Pharmacy. We had

an excellent program offering 4 hours of CEU. Presenta-

tions included Long-Term Care Pharmacy Legislation and

Regulations in 2013 by Leah Tolliver, Medications as Risk

Factors for Dementia and Delirium by Noll Campbell, Geri-

atric Pharmacotherapy Principles: Not so obvious elements

leading to improved outcomes by Dee Antimisiaris, and

Speaker Panel: The Affordable Care Act & Accountable

Care Organizations: The changing face of pharmacy prac-

tice including BC Childress, Sean Jeffery, and Bonnie La-

zor. The president of ASCP, Sean Jeffery, was in attend-

ance to discuss national issues. Kim Croley represented

KPhA and the Academy in a promotional booth. Other pro-

motional booths included ASCP/KYASCP, SUCOP Drug

Information Center, KY Pharmacy Museum, and KHELPS.

The event was very successful. We are still waiting for the

final financial information to see what our profit will be.

The Academy met at the annual KPhA Annual Meeting at

the Louisville Downtown Marriott to discuss the LTC regula-

tions and put together a consensus statement. The primary

topic of discussion was the proposed regulations changing

and expanding the role of Automated Dispensing Machines

in LTC facilities as well as some changes in the roles of the

consultant pharmacist and pharmacist-in-charge that pro-

vide service to those LTC facilities. The lengthy discussion

centered around the potential of ADM use in place of the

current Emergency Box/First Dose Box that many pharma-

cy providers are utilizing in the facilities they serve. We

plan to elect new officers, and we currently have Peggy

Canler continuing as Academy Director of Government Af-

fairs. Chris Miles has been nominated as Chair, Joey Mat-

tingly as Vice Chair, Julie Owen as Academy Director of

Organizational Affairs, and an opening for Academy Direc-

tor of Public/Professional Affairs.

Respectfully,

Elisha Bischoff, PharmD, BCPS

Chair, KPhA Academy of Consultant Pharmacists

Senior Care Corner

July 2013


KPhA New and Returning Members

KPhA Welcomes New and Renewing Members

May-June 2013

Cathy Adams Pineville, KY John Adams Lebanon, KY Kasey Alford Smiths Grove, KY Sandra Foster Anderson Monticello, KY Michael Anneken Melbourne, KY Mark Antis South Portsmouth, KY Karen M Arlinghaus Ft. Wright, KY William M Ashby Cadiz, KY Rosana W Aydt Villa Hills, KY Jason K Baker Louisville, KY Jennifer Baker Louisville, KY James D Ball Elizabethtown, KY Ellen Barger Mount Washington, KY Christopher Lee Barker Morehead, KY Larry R Barnett South Williamson, KY Barbara C Batsel Madisonville, KY Margaret Beeler Lebanon Junction, KY John K Beville Louisville, KY Danny Biliter Richmond, KY Joseph H Blandford Louisville, KY Ralph E Bouvette Frankfort, KY

Billy R Bowling Lexington, KY Dianna Bryant Hartford, KY Robert W Buckner Campbellsville, KY William Bucy Bowling Green, KY John Garland Byassee Clinton, KY Margaret Christopher Winchester, KY Kenneth Clayton Elkton, KY Robert Clement Cadiz, KY Arica C Collins Albany, KY David E Collins Mayfield, KY Teresa Collison Summersville, KY Paul M Cooper Morehead, KY Kimberly Sasser Croley Corbin, KY Robert E Croley Corbin, KY Robert E Cull Owenton, KY Jeffrey W Danhauer Owensboro, KY Steven Dawson McDowell, KY Thomas Detraz Hopkinsville, KY Dave Dickerson Morehead, KY Steve Doom Elizabethtown, KY Barbara A Dorris Russellville, KY

Ben Doyle Nicholasville, KY Debra Dunaway Henderson, KY James Dunaway Henderson, KY Anna Lee Dupont Louisville, KY Margret Mae Easterling Jenkins, KY Michael Eastridge Lebanon, KY David Edmundson Bowling Green, KY Harold Ellis Frankfort, KY Kevin Emberton Edmonton, KY Chad Evans Maysville, KY Lorie Evans Quincy, KY Jaime Janielle Fields Hindman, KY Justin M Fink Fort Wright, KY Jamie C Fletcher Hazard, KY Celeste C Flick Crestview Hills, KY Raymond Float Danville, KY Veronica Foster Munfordville, KY Cathy N Francisco Pikeville, KY Sheila A Franklin Bimble, KY Lisa Freeman Paducah, KY Patricia Freeman Lexington, KY

Kenneth Glass Midway, KY Thomas P Glover Providence, KY Robert Goforth Somerset, KY Wayne P Gravitt Wheelwright, KY Dwaine K Green The Villages, FL Monte J Gross Stanton, KY Jennifer Grove Madison, IN Donald Gubser Melvin, KY David Guion Russellville, KY Larry Hadley Frankfort, KY Catherine Hanna Lexington, KY Melodie Hawkins Mt Sterling, KY Pamela Hays McKee, KY Gregory Hines Bowling Green, KY Tom Houchens London, KY Morgan Howard Scottsville, KY Reymonda Howard London, KY Robert Hughes Lexington, KY Michael Ingram Cynthiana, KY Kyla James Sellersburg, IN Daniel Jones Paducah, KY

July 2013


KPhA New and Returning Members

Donate online

to the

Kentucky

Pharmacists

Political

Advocacy

Council!

Go to

www.kphanet.org

and click on the

Advocacy tab for

more information

about KPPAC and

the donation form.

Melinda Joyce Bowling Green, KY Kyle Katterjohn Paducah, KY Amber Kayse Morning View, KY David Kelly Georgetown, KY Ann Keown Scottsville, KY Brian Key Pineville, KY Patricia Kinney Erlanger, KY Kristy Klebeck Maysville, KY Donald B Kupper Crestwood, KY Mike Leake Danville, KY Joe Lewis Hyden, KY Penny Liles Vanceburg, KY Michelle Lowe Paducah, KY Aleshea Martin Louisville, KY Matt Martin Louisville, KY Tamara Maynard Prestonsburg, KY Velda Mcdaniel Georgetown, KY John McFarland London, KY Aaron Mcintosh Midway, KY Roy Mckendree Murray, KY Lynita Mcwaters Paducah, KY Mark Meador Scottsville, KY Beverly Meeks Paducah, KY

Ross Melton Mount Sterling, KY Kelly Mink Lancaster, KY Bernardine Miracle Whitesburg, KY Jeffrey Moore Middlesboro, KY Sonya Muncy Russell, KY Ann Murphy Princeton, KY Frank Nicks Bowling Green, KY John F. Nie Independence, KY David O'Quinn West Liberty, KY Jamie Otte Florence, KY Eileen Palutis Richmond, KY Paul Patrick London, KY Kenneth Pearce Danville, KY Risa Perry Almo, KY Lavanya Wijeratne Peter Louisville, KY Brookes Pickard Louisville, KY Michael Pipkin Gilbertsville, KY Larry Powell Richmond, KY Elizabeth Prather Florence, KY Marcella Robinson Paducah, KY Donald Ruwe Fort Thomas, KY Denise Schickling Villa Hills, KY Lisa Schwartz Crestview Hills, KY

Ginger Scott Morgantown, WV Jan Scott Earlington, KY William Sewell Utica, KY Gina Sherrow Brodhead, KY David Shipley Henderson, KY John Simkins Somerset, KY Alan Simon Prospect, KY Sarah Slabaugh Louisville, KY Lisa Smith Dry Ridge, KY James Stallard Neon, KY Nancy Stanton Holmes Mill, KY Scott Stephens Cynthiana, KY Dan Stevenson Portsmouth, OH Jacquelyn Strickland Hopkinsville, KY David Bradley Stultz Flatwoods, KY Francis Britton Thompson London, KY Gene Thompson Lexington, KY Leah Tolliver Lexington, KY Earnest Watts Cornettsville, KY Lenville White Irvine, KY Thomas White Madisonville, KY Rodney Whittington Princeton, KY Gary Wientjes Morehead, KY

Charlsie Williams Paducah, KY Cindi Williams Hazard, KY James Wiseman Benton, KY Reginald David Woolf South Fulton, TN Whitney Wright Dixon, KY Mary Ann Wyant Finchville, KY Michael B Wyant Finchville, KY Jeanne Zeis Covington, KY

July 2013


KPhA Government Affairs Contribution Name: ______________________________________________________________

Pharmacy: ___________________________________________________________

Email: ______________________________________________________________

Address: _____________________________________________________________

City: _______________________________________________ State: _________ Zip: ____________

Phone: ________________ Fax: _________________ E-Mail: ______________________________

Contribution Amount: $_________ Check ____ (make checks payable to KPhA Government Affairs)

Credit Card (AMEX; Discover; MasterCard; VISA)

Account #: ____________________________________________________ Expiration date: _______

CVV: ______________

Billing address (if different from above)

___________________________________________________________________________________

Mail to: Kentucky Pharmacists Association, 1228 US Highway 127 South, Frankfort, KY 40601

Pharmacy Health Screening Provide state of the art health screenings to help improve

YOUR patients’ health and your bottom line.

Schedule a Health Screening Day at your pharmacy to offer YOUR patients a ser-

vice to improve their health and potentially catch dangerous issues early!

The health screenings offer multiple advantages for your business including imme-

diate profit from the screening process and the early recognition of diseases that are

usually treated with medications as well as increase the health and longevity of your

patients.

The process is a partnership between the Kentucky Pharmacists Association and Xcel Diag-

nostics and YOUR pharmacy to bring state of the art health screenings to your patients. The

net profit is divided among the partners, including your pharmacy.

Call Xcel Diagnostics today to schedule your screening day.

(606) 218-5483

KPhA Government Affairs/Pharmacy Health Screenings

July 2013


Cardinal Health

July 2013


Sponsors for the 135th KPhA Annual Meeting

Annual Meeting Supporter Rx Systems, Inc.

Cardinal Health Customers in Kentucky

Matt Carrico

Kim Croley

Brian Fingerson

Humana

Grant County Drugs and Custom

Compounding Centers, Dry Ridge,

Williamstown, Crittenden

Medica Pharmacy and Wellness Center,

Bardstown-Shepherdsville

National Association of Chain Drug Stores

Bob Oakley

Duane Parsons

Poole’s Pharmacy Care

Donnie Riley

Richard Slone

Tolliver Management Group

Wellcare of Kentucky

Sam Willett

Lewis Wilkerson

KPERF Golf Hole

Sponsors AmerisourceBergen

American Pharmacy Services Corp.

Booneville Discount Drug

Capital Pharmacy and Medical Equipment

Care More, Kimper & NOVA Pharmacies

Congratulations Leon Claywell,

Bowl of Hygeia Award Recipient

Flexible Pharmacy Staffing

George Hammons, Frankie Abner

& Tom Houchens



Pharmacists Mutual Companies

Poole’s Pharmacy Care

Republic Bank & Trust

Rite Aid

Rx Discount Pharmacy

The Save-Rite Family of Pharmacies

Tolliver Management Group

Wayne’s Pharmacy

Annual Meeting

Event Sponsors American Pharmacy Services Corporation

Humana

Jefferson County Academy of Pharmacists

KY Governor’s Office of Health Information

Exchange

KPhA District 1

Kroger Corporation

McWhorter College of Pharmacy

at Samford University



Northern Kentucky Pharmacists Association

Rx Therapy Management

Sullivan University College of Pharmacy

University of Kentucky College of Pharmacy

Sponsoring Pharmacy’s Future

Student Pharmacist Support


July 2013


AbbVie

American Pharmacy Cooperative, Inc.

AmerisourceBergen

American Pharmacy Services Corp.

Astrazeneca

Cardinal Health

Dr. Comfort

Eli Lilly & Co.

EPIC Pharmacies

HD Smith

iMedicare

Kentucky Cabinet for Health & Family

Services

Kentucky Renaissance Pharmacy Museum

KHELPS

KY Office of Health Information Exchange

Lifetime Financial

Growth Company

McKesson Corporation

Merck

Miami Luken

Morris & Dickson

Passport Health Plan

Pharmacists Mutual Companies

Pill Guard Medication Delivery Systems

QS/1

Rite Aid

RxMedic

Samuels Products, Inc.

ScriptPro

Smith Drug Company

SUCOP Student Organizations

TEC Laboratories

UK COP Experiential Ed/ CAPP

UK Student Organizations

UK Gerontology

Walgreens

Xcel Diagnostics

… and our 2013 Exhibitors

The outgoing members of the 2012-13 KPhA Board of Directors: outgoing President Kimberly Croley, Leah

Tolliver, Jeff Mills, Lance Murphy, Chris Clifton, Outgoing Chair Lewis Wilkerson, Trish Freeman and Molly

Trent.


July 2013


Sullivan University College of Phar-

macy Student Representative Heather

Bryan is originally from Louisville, and

now resides in Mt. Washington with her

husband and three-year-old daughter.

She is a graduate of Murray State Uni-

versity with her Bachelors in Science

and Nursing and is in her 2nd year at

Sullivan. She loves being involved, stay-

ing busy, and being active.

University of Kentucky College of Pharmacy Student

Representative Brooke Herndon is a third-year student

pharmacist at UK. She holds a B.S. in

Chemistry with a minor in Biology

from Bellarmine University. Brooke is

a native of Louisville and currently

lives in Lexington to attend school.

She serves as the President of the

American Pharmacists Association –

Academy of Student Pharmacists and

is an active member in Rho Chi, Phi

Lambda Sigma and Lambda Kappa

Sigma. When not studying or participating in extracurricular

activities, Brooke enjoys cheering on the CATS and attend-

ing sports games.

Director Chris Killmeier enjoys being a part of solutions

for the profession of pharmacy. He has been a pharmacist

for 22 years with Walgreens. Within Walgreens, he has

held positions from staff pharmacist up to district pharmacy

supervisor and is currently pharmacy manager at

Walgreens on Lime Kiln Lane in Louis-

ville. He currently serves as chair of

the Advisory Council to the Kentucky

Board of Pharmacy. He has been mar-

ried to his wife, Denise, for 19 years,

and they have two wonderful children,

Bayley Shea, 14 and Olivia Blaire, 11.

He was born and raised in Louisville,

where he resides today.

Vice Speaker of the House of Dele-

gates Ethan Klein was born and raised in Dallas, Texas,

and earned his BS in chemistry from

the University of Texas at Austin in

2004. In 2010, he graduated from the

University of Charleston School of

Pharmacy in Charleston, W.V. He

then moved to Chicago to complete

his PGY1 residency at the North Chi-

cago Veterans Affairs. After complet-

ing the residency, he moved to Louis-

ville, where he practices pharmacy in

the community setting.

Director Chris Palutis is originally from the northeast

Pennsylvania area. He attended the Philadelphia College of

Pharmacy & Science and earned his Bachelor of Science

Degree in Pharmacy in 1995. Chris has more than 17 years

of innovative pharmacy management experience, including

positions in retail and long term care. He began his career

in the retail pharmacy sector, where he quickly rose

through key areas of functional leadership responsibility

2013-14 KPhA Board of Directors

Welcome to the New Directors

July 2013


2013-14 KPhA Board of Directors

including operations, technology, cus-

tomer service, legal and regulatory

compliance, clinical services and sales.

He was promoted and led pharmacy

operations at national pharmacy chains

CVS and Rite Aid, as well as the na-

tion’s leading Long Term Care Phar-

macy provider, Omnicare. He successfully leveraged his

experience to maximize sales and profitability for these

premiere organizations.

After a successful stint with Omnicare, Chris decided to

venture out on his own. He and his wife, Consuelo (who is

also a pharmacist), decided to return to Kentucky and

open their own independent pharmacy in Lexington. The

pharmacy (C&C Pharmacy) opened in February 2009 and

has seen positive growth year after year. The pharmacy

now employs 2 additional full-time pharmacists (in addition

to Chris and Consuelo) as well as UK Interns and other

pharmacy technicians.

Chris and Consuelo reside in the Lexington area.

Past President Ron Poole was born in Covington, Ky.,

and raised in Williamstown, Ky. He married Lisa Wedding

in 1991 and they are the proud parents of Megan, Allie,

Evan and Emma.

He completed pre-pharmacy curriculum at Brescia Univer-

sity in Owensboro and graduated with a Bachelor’s De-

gree in Pharmacy from the University of Kentucky College

of Pharmacy in May 1990.

He started his career as a Staff Phar-

macist at Owensboro-Daviess County

Hospital before becoming owner and

pharmacist of Poole’s Pharmacy Care

in Central City, Livermore and Owens-

boro in October 1990. Ron is a Com-

munity Based Faculty Member for the

University of Kentucky College of

Pharmacy, Ohio Northern University- Raabe College of

Pharmacy, Samford College of Pharmacy and St. Louis

College of Pharmacy.

Director Mary Thacker, is a 1993 graduate of UK College

of Pharmacy. Having practiced community pharmacy for

17 years as both staff and pharmacy

management, she chose to pursue a

path in long-term care pharmacy and

has thoroughly enjoyed the challenge

the past two years. She lives in Louis-

ville with husband, Art, as well as kids

Jack (12) and Audrey (9). She enjoys

being a “soccer” mom, as well as a

roadie for her son’s band, and assis-

tant coach to both kids’ Quick Recall

teams. She loves music, gardening,

cooking, reading, watching NFL, visiting the Caribbean

and spending time with her newly adopted 11-year-old

Dachshund.

of the KPhA Board of Directors

Directors Chris Clifton and Jeff Mills were reelected to the KPhA

Board of Directors. Directors Trish Freeman and Chris Palutis were

appointed to fill unexpired terms.

2013-14 KPhA Executive Officers

Chair — Kimberly Sasser Croley

President — Duane Parsons

President-Elect — Bob Oakley

Secretary — Frankie Abner

Treasurer — Glenn Stark

July 2013


Question: I have read somewhere that the federal

government has ratcheted up its level of activity with regard

to excluding health professionals from health care pro-

grams that receive any federal funds, e.g., Medicare, Medi-

caid, TRICARE, programs for veterans, etc. What is that,

are there implications for pharmacists and pharmacy and

what can a practitioner who is “excluded” do to get reinstat-

ed?

Response: A number of federal statutes enacted over

the years starting in 1977 have created a legal prohibition

on payment by federal health care programs for items or

services either furnished by an “excluded person” or at the

request of such an individual, e.g., a prescription issued by

an excluded provider. This applies whether the federal pro-

gram is funded wholly (think TRICARE) or in part (think

Medicaid) with federal funds.

Program exclusion may be directed at any person who

submits false or fraudulent claims for payment. Thus, this

could include the owner of a pharmacy seeking reimburse-

ment or an employee pharmacist who initiated the claim.

There also are potential civil monetary penalties that can

be directed at entities, e.g., pharmacies, that employ indi-

viduals who are currently subject to exclusion. It has been

reported that as of April 2013, there were 51,000 individu-

als and 3,000 business entities under exclusion.

But the implications are even more expansive. No federal

health care program payment may be made for items or

services furnished on the prescription of an excluded prac-

titioner. So if a prescription were issued by an excluded

prescriber a pharmacy could not be reimbursed for that by

a federal health program.

Does that mean the pharmacist needs to verify that each

and every prescriber from whom prescriptions are received

are not under an exclusion order? Payment could certainly

be denied in such situations. One way to avoid liability for

honoring an order from an excluded prescriber is to double

check that the pharmacy’s computer system includes an

edit for excluded prescribers at the point of dispensing.

Looking at an inpatient scenario, if a hospital employed an

excluded pharmacist who dispensed medications to a Med-

icare beneficiary whose bill was covered under that pro-

gram’s diagnosis-related group payment system, that bill

would not be honored for payment. Moreover, that pharma-

cist would be open to penalties for violating his or her ex-

clusion by causing a claim to be submitted for federal reim-

bursement during the period of exclusion.

Well, could an excluded pharmacist get around this by

moving into an administrative or managerial role where,

say, no direct dispensing activities occur? The answer is

no. Excluded individuals are prohibited from furnishing

such services if payment comes from federal health care

programs. Nor could that excluded pharmacist limit his or

her activities to inputting billing information or reviewing

treatment plans. Those activities also would run afoul of the

exclusionary order.

This author has received inquiries from pharmacists who

have been subject to exclusion orders asking several ques-

tions. First is “what can I permissibly do while excluded?”

The answer is, unfortunately, not much in pharmacy. One

possibility might be a position with a poison control center

that receives no federal funds. The second question is

“What can I do to get out from under the five year exclusion

order?” The answer to that, also unfortunately, is not much.

Passage of time is pretty much the only remedy with the

hope that programmatic reinstatement to eligibility will fol-

low.

How can it be determined whether a particular individual is

currently under an exclusion order? The website of the

HHS Office of the Inspector General presents this infor-

mation at http://oig.hhs.gov/exclusions.

Pharmacy Law Brief

Pharmacy Law Brief: Exclusion of Practitioners from Federally Funded Health Programs Author: Joseph L. Fink III, B.S.Pharm., J.D., Professor of Pharmacy Law and Policy and Kentucky Pharmacists Associ-

ation Professor of Leadership, Department of Pharmacy Practice and Science, UK College of Pharmacy

Submit Questions: [email protected]

Disclaimer: The information in this column is intended for educational use and to stimulate professional discussion among col-

leagues. It should not be construed as legal advice. There is no way such a brief discussion of an issue or topic for educational or

discussion purposes can adequately and fully address the multifaceted and often complex issues that arise in the course of profes-

sional practice. It is always the best advice for a pharmacist to seek counsel from an attorney who can become thoroughly familiar

with the intricacies of a specific situation, and render advice in accordance with the full information.

July 2013


Technician Review

Technician Review From the KPhA Academy of Technicians

In April 2013, the Kentucky Pharmacists Association Board

of Directors voted in favor of the petition to found a new

KPhA Academy for Pharmacy Technicians. The Academy’s

approved mission statement is: To unite the pharmacy

technicians throughout the Commonwealth to have one

voice toward the advancement of our profession.

The founding 25 members have a wide footprint throughout

the state of Kentucky.

The selected officers for 2013-2014 are as follows:

Don Carpenter — Chair

Patricia Robinson — Vice Chair

Christen Schenkenfelder — 1st Director

Heather Daniels — 2nd Director

Kristina Blanton — 3rd Director

Raychel Stevens — 4th Director

The Academy plans to continue recruiting additional techni-

cians to become involved within our profes-

sion. Our objectives will be presented to the

KPhA Board of Directors and the Board of

Pharmacy Advisory Council.

We are excited about the changing environ-

ment in the pharmacy profession and look

forward to being a part of that change. If you

are a technician member of KPhA, you are

eligible to be a member of the Pharmacy

Technician Academy. There is no extra cost

involved or responsibility. Our goal is for the

role of the pharmacy technician to grow and

evolve as a profession. We want to invite eve-

ry technician to join the academy to have a

voice in guiding our profession.

For more information on how to join the Phar-

macy Technician Academy please email Don

Carpenter at [email protected].

Sincerely,

Don Carpenter, BS, CPhT III 222 Medical Circle Drive Morehead, KY 40351 606-783-6741 [email protected]

Check out resources

for Pharmacy

Technicians at the

KPhA Website:

www.kphanet.org

July 2013


Pharmacy Policy Issues

PHARMACY POLICY ISSUES:

Overcoming Barriers to Implementing Pharmacogenetic Services in Community Pharmacy Author: Jonathan Hughes is a third professional year Pharm.D. student at the UK College of Pharmacy. Jonathan re-

ceived his Bachelor of Science degree in Biology and Biochemistry at the University of Mississippi and is a native of

Madison, Miss.

Issue: Implementing pharmacogenetic services into community pharmacy practice promises to bring community practice

into the 21st century. However, many patients express fear that their insurance company or employer may use such

information to discriminate against them. What can pharmacists seeking to implement pharmacogenetic services do to

allay these fears?

Discussion: Of the several barriers existing to the imple-

mentation of pharmacogenetic services in community phar-

macy, one of the most prominent—and, as I hope to show,

most easily allayed—are fears regarding the use and priva-

cy of genetic information. As has been discussed exten-

sively in bioethical literature and such popular publications

as The Immortal Life of Henrietta Lacks, genetic infor-

mation is integral to who we are; indeed, it is our very blue

print. In the past decade, the biomedical sciences have

exploded in understanding how our genes affect our health,

from the progression of disease to variations in drug effica-

cy and toxicity. However, patients often shrink away from

even considering the potential benefit afforded by genetic

testing because of fear that entities such as their employer

or health insurance carrier may use such information to

discriminate against them.

In order to allay this fear and successfully incorporate phar-

macogenetic services into their practice, pharmacists need

to be familiar with and educate their patients regarding the

Genetic Information Nondiscrimination Act (GINA) of

2008;1 While protected health information is always held

confidential under HIPAA, a patient’s health insurance

company may receive a patient’s genetic information inci-

dental to data exchanges as part of its regular course of

business. Title I of GINA specifically prohibits insurance

companies from denying patients coverage2 or charging a

higher premium on the basis of a genetic test result.3 Title

II, on the other hand, focuses on employers, making it un-

lawful for them to make decisions on hiring, promoting or in

any way discriminating against an employee on the basis

of a genetic test4 or to even attempt to acquire such genet-

ic information5.

Ensuring patients that their genetic information can only

help them attain improved health outcomes without risk of

losing insurance coverage or discrimination from employ-

ers will certainly encourage them to use pharmacogenetic

services. Many community practitioners express concerns

that their patients will not embrace such services if offered

because of the fears posited above. Properly armed with

knowledge about GINA, pharmacists can help diminish or

remove this barrier between patients and improved health

outcomes.

Many direct-to-consumer (DTC) genetic testing companies

now exist and several are seeking partnership with commu-

nity pharmacies. In this model (see Fig 1), the pharmacist

would advertise the service and obtain buccal swabs from

the patient to send to the DTC company for testing. The

results of this test would then be sent back and incorpo-

rated into the patient’s health record to be consulted during

drug utilization review or medication therapy management.

To facilitate incorporation of this information, the partner

DTC lab often provides software that will automatically de-

tect gene-drug interactions when received.

= = =

Interested in finding out more about incorporating phar-

macogenetic services into your practice? Join the

CAPPNet listserv (http://pharmacy.mc.uky.edu/capp/

cappnet.php) and stay tuned for CPE from UK College of

Pharmacy on Implementing Pharmacogenetic Services in

Community Pharmacy Practice!

1. Pub.L. 110-233, 122 Stat. 881

2. 42 USC §300gg–53(a),(c)

3. 42 USC §300gg–53(b)

4. 42 U.S.C. §2000f-1(a)

5. 42 U.S.C. §2000f-1(b)

July 2013


Pharmacy Policy Issues

Have an Idea?: This column is designed to address timely and practical issues of interest to pharmacists, pharmacy interns and phar-

macy technicians with the goal being to encourage thought, reflection and exchange among practitioners. Suggestions

regarding topics for consideration are welcome. Please send them to [email protected].

Proposed Community Pharmacy Pharmacogenetic (PGx) Services Model

Figure 1. Proposed Pharmacogenetic Services Model in a Community Pharmacy.

Patient inquires about

new PGx services

PGx services advertised

through in-store signage,

patient leaflet inserts, or

targeted recommendation

Collect buccal swab to

obtain genetic sample

Consent

Direct-to-Consumer

(DTC) Genetic Testing

Laboratory Partner

Mail sample

Patient Genetic Information

Pharmacy electronic

health record (EHR)

Patient presents with

R.Ph. performs DUR Comprehensive Medication

Review (CMR) conducted as

part of Medication Therapy

Results returned to pharmacy

PGx interaction detected

during computer-assisted

DUR

R.Ph. Review and Assessment Prescriber

R.Ph. counsels patient on conse-

Patient health outcomes are im-

proved and patient-pharmacist

relationship is strengthened

Interprofessional consultation and recommendation

July 2013


Pharmacists Mutual

July 2013


APSC

July 2013


KPhA BOARD OF DIRECTORS

Kimberly Croley, Corbin Chair

[email protected] 606.304.1029

Duane Parsons, Richmond President


Bob Oakley, Louisville President-Elect


Frankie Hammons Abner, Barbourville Secretary


Glenn Stark, Frankfort Treasurer

[email protected]

Ron Poole, Central City Past President

[email protected]

Directors

Heather Bryan, Mt. Washington Student Representative

[email protected]

Matt Carrico, Louisville

[email protected]

Chris Clifton, Erlanger

[email protected]

Trish Freeman, Lexington

[email protected]

Brooke Herndon, Louisville Student Representative

[email protected]

Chris Killmeir, Louisville

[email protected]

Jeff Mills, Louisville*

[email protected]

Chris Palutis, Lexington

[email protected]

Richard Slone, Hindman

[email protected]

Mary Thacker, Louisville

[email protected]

Sam Willett, Mayfield

[email protected]

* At-Large Member to Executive Committee

HOUSE OF DELEGATES

Cassandra Beyerle, Louisville Speaker of the House

[email protected]

Ethan Klein, Louisville Vice Speaker of the House

[email protected]

KPERF ADVISORY COUNCIL

Kim Croley, Corbin

[email protected]

Ann Amerson, Lexington

[email protected]

KPhA/KPERF HEADQUARTERS

1228 US 127 South, Frankfort, KY 40601

502.227.2303 (Phone) 502.227.2258 (Fax)

www.kphanet.org

www.facebook.com/KyPharmAssoc

www.twitter.com/KyPharmAssoc

Robert McFalls, M.Div.

Executive Director

[email protected]

Scott Sisco, MA

Director of Communications & Continuing Education

[email protected]

Kelli Sheets

Office Manager

[email protected]

Leah Tolliver, PharmD

Director of Pharmacy Emergency Preparedness

[email protected]

Nancy Baldwin

Receptionist/Office Assistant

[email protected]

KPhA Board of Directors/Staff

KPhA sends email announcements

weekly. If you aren’t receiving: eNews,

Legislative Updates, Grassroots Alerts

and other important announcements,

send your email address to

[email protected] to get on the list.

July 2013


Kentucky Pharmacists Association 1228 US 127 South Frankfort, KY 40601 (502) 227-2303 www.kphanet.org Kentucky Board of Pharmacy State Office Building Annex, Ste. 300 125 Holmes Street Frankfort, KY 40601 (502) 564-7910 www.pharmacy.ky.gov Pharmacy Technician Certification Board 2215 Constitution Avenue Washington, DC 20037-2985 (800) 363-8012 www.ptcb.org

Kentucky Society of Health-System Pharmacists P.O. Box 4961 Louisville, KY 40204 (502) 456-1851 x2 (502) 456-1821 (fax) www.kshp.org [email protected]

American Pharmacists Association (APhA) 2215 Constitution Avenue NW Washington, DC 20037-2985 (800) 237-2742 www.aphanet.org

National Community Pharmacists Association (NCPA) 100 Daingerfield Road Alexandria, VA 22314 (703) 683-8200 [email protected]

Drug Information Center Sullivan University College of Phar-macy 2100 Gardiner Lane Louisville, KY 40205 (502) 413-8638 www.sullivan.edu Kentucky Regional Poison Center (800) 222-1222

Frequently Called and Contacted

50 Years Ago/Frequently Called and Contacted

KPhA Remembers KPhA desires to honor members who are no longer with us.

Please keep KPhA informed by sending this information to [email protected].

Deceased members for each year will be honored permanently at the KPhA office.

50 Years Ago at KPhA MEET THE BARBECUE CHAMPION

A.E. Tucker, RPh, Bowling Green, who owns a drug store and is a State Representative,

recently was featured in the Sunday Courier-Journal as a champion at cooking barbecue.

Here’s the story:

Pharmacist’s Barbecue Could Win Votes

Bowling Green residents who have sampled State Representative A.E. Tucker’s barbecue

dishes would be inclined to vote overwhelmingly for his cooking.

The Democrat, who’s a pharmacist and owner of a drugstore, learned his barbecueing “20 years ago camping, while

out hunting and fishing.”

He does some cooking indoors, but prefers outdoor barbecues for 12 to 20 guests.

For the past 10 years he has been using the same recipe for barbecue chicken. “I tried a number of others, but nev-

er found one I liked as well.”

- From The Kentucky Pharmacist, July 1963, Volume XXVI, Number 7.

July 2013


THE

Kentucky PHARMACIST

1228 US 127 South

Frankfort, KY 40601

SAVE THE DATES KPhA Mid-Year Conference

on Legislative Priorities

November 2013 (Time and place TBD)

136th KPhA Annual Meeting and

Convention

June 5-8, 2014

Marriott Griffin Gate Resort and Spa

Lexington, KY

the kentucky pharmacist vol. 8 no. 4

Documents

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