march/april 2014

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

Palmetto Pharmacist • Volume 54, Number 2 1

PharmacistPalmetto

The Official Journal of the South Carolina Pharmacy Association • Vol. 54, Num. 2

The Student Issue

• Convention • Student Board Review • Student Trivia • Student-Written Articles • And More!

2 Palmetto Pharmacist • Volume 54 Number 2

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SDC_collage_Final.indd 3 4/11/13 12:00 PM

Palmetto PharmacistVolume 54, Issue 2 March/April 2014The Palmetto Pharmacist, the official publication of the South Carolina Pharmacy Association, is distributed to association members as a membership service. Statements of fact and opinion are made by the authors alone and do no imply an opinion on the part of the officers or members of SCPhA. For advertising rates and other information, contact SCPhA.

What’s Inside...

5 Inspire Passion; Inspire Students President Steve McElmurray talks about how we can inspire students

7 One Profession. One License. One Voice. CEO Craig Burridge discusses unification in pharmacy

14 Palmetto Pharmacist Network Cecily DiPiro encourages members to get involved in the PPN

23 A Call to Action The What, Why, and How of Antimicrobial Stewardship

25 Transitioning the Role of the Pharmacist A look at the past, present, and future of pharmacy

Regular Columns 12 SCCP 13 PCSP 31 Financial Forum 33 Journal CE 43 Classifieds

Advertisers 2 Smith 4 Pharmacists Mutual 24 Display Options 24 Mutual Drug 26 PACE 43 JonWallace, AttorneyatLaw 44 QS/1


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

Board of Directors

President/Chairman of the Board

Steve McElmurray, RPh

Immediate Past President John Pugh, PharmD, RPh

President-Elect Bryan Amick, PharmD, RPh

Treasurer Pamela Whitmire, PharmD, RPh

Low Country Region Kristy Brittain, PharmD, RPh

Pee Dee Region Jarrod Tippins, PharmD, RPh

Midlands Region Patti Fabel, PharmD, RPh

Upstate Region Ed Vess, PharmD, RPh

At-Large DirectorWilliam Wynn, PharmD, RPh

Speaker, House of Delegates Michael Gleaton, PharmD, RPh

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

CEO Craig Burridge, MS, CAE

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

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

PALMETTO PHARMACIST STAFF

Jennifer Simmons Layout/Design/ContentCraig Burridge Managing Editor

What’s Inside...

5 Metathesiophobia President Steve McElmurray discusses the irrational fear of change

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

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

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

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

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

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

MeganMontgomery,PharmD,RPh

General CounselJonWallace,BSPharm,JD



Board of Directors


















What’s Inside...










Board of Directors


















What’s Inside...








LaurenPalkowski


EdVess,RPh


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Passion rebuilds the world for the youth. It makes all things alive and significant.

-Ralph Waldo EmersonRalphWaldoEmersonwasawiseman.Whenwehavepassionforwhatwedoandwhatwelove,wenotonlycreateabetterworldforourselves,wealsocreateabetterworldforfuturegenerations.

Severalofmypredecessors,includingKellyJonesandWayneWeart,toutedthissamemessage.Iwanttoemphasizethisaswell.Whatwedonowiswhatwillbuildafutureforgenerationsofpharmaciststocome.

OnethingthatI’mveryproudofisthefactthatoverthepastfewyearswehavetrulytakenstridestoengageourstudentmembers.WehaveseenahugeincreaseinattendanceatourAnnualConvention.WehaveseenmoreandmorestudentsinattendanceatHouseofDelegatesmeetings,Regionmeetings,andmore.

Thisincreasedengagementdidnothappenspontane-ously.Ithasbeenthroughagreatdealofhardworkanddedicationfromourmembers.ThroughoutmyservicetoSCPhA,I’veseenourleaderstimeandtimeagainreachouttohelpourfuturepharmacists.Fromformalprograms,suchastheJuniorBoardMemberprogram,toinformalhelpsuchasmerelynetworkingatevents,I’veseenourentiremember-shipstepupandreallyencouragestudentmemberstogetinvolved.

Whilewehaveallmadegreatstridestoencour-agestudentparticipationandengagement,Iknowthatwecanstilldomore!Firstofall,ifyouareapreceptor,encourageyourstudentstogetinvolved.BringstudentswithyoutoAssociationmeetingsandevents.Encouragethemtoattendwhenyoucan-not.Filltheminonthelatestissuesimpactingtheprofession.

Anotherwaythatyoucanhelpoutisbyfollowing

PRESIDENT’S PLATFORM

inthefootstepsoftheSCPharmacyFoundation.Recently,theFoundationdecidedthatprovidingad-ditionalfundsforstudentscholarshipstotheAnnualConventionwasapriority.TheFoundationagreedtohelpsendevenmorestudentstoConvention.

Youcanhelpaswell!WhiletheadditionalfundsfromtheFoundationwillhelptosendmorestudentstoConvention,wecouldalwaysuseadditionalsup-port.StudentsthatattendtheSCPhAconventionaremorelikelytobecomemembersofSCPhAaftergraduationandareoftenmorelikelytoenterintoleadershiproles.

Wehopethatyouwillconsidercontributingtoourstudentscholarshipstohelpshowyoursupportofthefutureofpharmacy.Itisagreatwaytoshareyourpassionofpharmacy,investinthefuture,andinspirestudentstocontinuetobuildthisprofession.


PRESIDENT’S PLATFORM

Inspire Passion; Inspire Students

SCCP


Thepublicdependsonpharmacistsfortheproductionofsafemedications,andsometimessuffertheconsequencesofunacceptableworkplaceconditions,inadequateatten-tiontostandardprocedureandpoorqualitycontroloverproducts.Theharmcausedbythecontaminatedmedica-tionsproducedbytheNewEnglandCompoundingCen-ter(NECC)wasadramaticexampleofhowtheseissuescanhavetragicconsequences.

Theprofession’sresponsehasbeenswiftandappropri-ate.UnsafesterilecompoundingtechniquewasattheheartoftheNECCoutbreak,inwhichtaintedsteroidinjectionsledtomorethan750fungalinfections,includ-ingafewcasesinSouthCarolina,and64deathsnation-wide.Intheaftermath,theInstituteforSafeMedicationPracticesissuedaclarioncallforadditionalmonitoringandregulationsofsterilecompounding--currentlybeingimplementedfollowingapprovaloftheDrugQualityandSecurityAct--andagreateremphasisonhands-ontraining.

Aspharmacyeducators,wehavetheresponsibilityofprovidingthattraining.Safesterilemedicationcom-poundingrequireshighlyspecifictraininginanenviron-mentnotreadilyavailabletomanypharmacists.Drugshortagesandspecializedmedicationshaveincreasedtheneedforcompoundedproducts,whichincreasestheneedforproperly-trainedpharmacistswhocansafelymakethemforpatients.

Lastmonth,theSouthCarolinaCollegeofPharmacy(SCCP)attheUniversityofSouthCarolinaopenedastate-of-the-artsterilemedicationcompoundingfacilitythatisoneofthefewofitskindinthecountry.

Createdtohelpassurethatpharmacistslearnthehigheststandardsforcompoundingofmedications,theAsepticCompoundingExperience(ACE)LaboratoryenablestheCollegetoofferoneofthenation’sfewUniversity-affiliatedsterilemedicationcompoundingprogramswithhands-ontraining,videotechnologies,coachingandendproduct-testing.

TheACELab,whichwilloffercontinuingeducation(CE)coursesaswellastrainingforourPharmDstudents,isinthelowerleveloftheCokerLifeSciencesBuildingontheuniversity’sColumbiacampus.“Whatmakesthislabuniqueisthecombinationofthesterilefacilitywiththewaytheeducationalmaterialispresented,usingtheoutreachandcapabilitiesofboththeKennedyPharmacyInnovationCenter(KPIC)andthe

College,”saidBobDavis,KennedyprofessoratUSC’sKPIC.“Thereareveryfewsterilecompoundinglabsatuniversitiesanywhereinthecountryandnoneweknowofofferingthiscompleteprogram.”

Aseptictechniquetrainingwillbethroughcorecur-riculumintheSCCPwhileadvancedtrainingwillbethroughKPICcontinuingeducationcoursesandelec-tives.Duringthenextfiveyears,morethan500phar-macystudentsandmorethan1,000pharmacistsandpharmacytechnicianswillgettrainingintheACELab.

“Thereisaprofoundlearningbenefittotraininginafa-cilitywhereyouproduceahands-onsterilecompound,incompliancewiththehigheststandards,thatyoucanthentest,”saidBryanZiegler,KPICexecutivedirec-torandSCCPassistantprofessorofclinicalpharmacyandoutcomessciences.“Theadvancedtechnologyalsoallowsustotrainlargergroupswithlivedemonstration,recordingandcoaching,andvideocaptureanddistribu-tion.Itwillrevolutionizesterilecompoundingtraining.”

AftertheNECCtragedy,industryandregulatoryagen-cieshavetohelprestorethepublic’sconfidencethatmedicationsarepreparedtothehigheststandards.Col-legesofpharmacycanhelprestorethattrustbyeducat-ingpharmacistswhoapplyproperstandardstotheirwork.

AstudyintheAmericanJournalofHealth-SystemPharmacistsfoundthatonly13percentofdeansatthenation’s130pharmacycollegesbelievedtheirstudentsgraduatedwithadequatetraininginsterilecompound-ing.

Ourgraduateshavealwaysreceivedtraininginsterileandnon-sterilecompounding.TheACELabenablesustoprovideasterilecompoundingexperienceonparwithanyinthecountrynotonlyforourstudents,butalsoforpracticingpharmacistsinSouthCarolinaandthroughoutthecountry.TheACELabiscompliantwiththehighestnationalindustrystandardsforsterilecompounding.

FormoreinformationonCEcourses,visittheKPICWebsiteatwww.kennedycenter.sc.edu.

“Weknowofnosimilartrainingprogramanywhereinthenation,”Davissaid.“TheultimatebenefitofthenewACELabisnotonlybettertrainingoffuturephar-macists,butalsoitsexponentialimpactonimprovedpatientsafetyandhigherqualityoflife.”

Sterile Compounding at SCCP

Whenspeakingtoapharmacist,weoftenask:“Wheredoyoupractice?”Theresponseisoften,I’mahospitalpharmacist,LongTermCarepharmacist,orIworkforachainorindependentpharmacyandthen,whotheyworkfor.Toooften,pharmacistsdefinetheirprofessionbythelimiteddefinitionofwheretheypractice.Isuspectthisiswhypharmacyhassomanynationalpharmacyorganizationsandamorelimitednumberofcompetingstatepharmacyorganizations.

FACT CHECK: Takeoutyourpharmacistregistrationandreadit.Doesitsayyouareregisteredasachainpharmacist?Maybeahospitalpharmacist?Or,doesitjustsayyou’rearegisteredpharmacistinthestatewhereyoupractice?I’mbettingonthelatter.Whydoyoudothis?Whathasfrustratedmeasapharmacyassociationexecutiveformorethan22yearsisthis‘we’and‘they’attitudeamongthislearnedprofessionwecallpharmacy.Itisn’tthefirsttimeIfacedthistypeofdivisionamongthesame.Istartedmyassociationmanagementcareer27yearsagoastheCEOoftheNYSAssociationofRenewalandHousingOfficials.Wetoohadfourcompetinggroupsinthestate.TheboardandIbroughtthesefourgroupstogethershortlyafterIjoinedtheorganization,andbecamethelargeststatehousingandrenewalassociationinthenation.Whenwedidthat,thestatepumpedoutmorepaper(meaninglettersofsupportoroppositiononfederalandstatelegislation)thanALLoftheotherstatescombined!ThisiswhatIsodesperatelywantforpharmacy.

Now,I’mnotsayingthatweeliminatesomeofthenationalorcompetingstatepharmacyorganizations.WhatIamsayingis:weallneedtogetonthesamepageandrealizeitisOneProfession,OneLicenseandmakeitOneVoiceforPharmacy.Ineachstate,youshouldestablishanAllPharmacyConferencethatmeetsthreetofourtimesayearaswedidhereinSouthCarolinaandwhatwasdoneinNewYork.Wemetwithallrepresentativesfromthevariouspharmacypracticeareas,including,Medicaid,BoardofPharma-cy,PhRMA,CMSRegional,DepartmentofHealth(PharmacyPolicy,NarcoticEnforcement),DEA,major

by:CraigM.Burridge,MS,CAECEO,SCPhA

Pharmacists

One Profession.

One License.

One Voice.


managedcareorganizations,independents,chains,LTC,compounding,clinical,hospitalandacademia.Alltoldmorethan60individualsateachofourmeet-ingssofarandgrowing.Theirpurpose:Toworktogetherasateamtoresolveissuesforsectorsofpharmacy,thestate,Medicaid,BoardofPharmacy,etc.Wealsorunlegislationandrulemakingchangesbythesegroupstomakesurewehaveconsensusforchangeandwedonotharmaparticularsectorofpharmacythroughregulatoryorlegislativeinitiatives.Weworkforthepurposeoftheprofession.Whybother?

Whatpharmacists,studentpharmacistsandpharmacytechniciansneedtounderstandisthatifonesectorofpharmacysneezes,everyoneinpharmacyissuscep-tibletoacold.Youcannotseparatethe‘business’ofpharmacyfromthe‘practice’ofpharmacy.Itisimperativethatpharmacyleadershipandacademiamakeitunderstoodhowallofpharmacyisinextrica-blylinkedtothenecessityofafinanciallysoundandvibrantbusinessofcommunitypharmacies,aswellas,thescopeofpractice.Weallknowthat90%ofpharmacistpositionsaretiedtoourcommunity-basedbrickandmortarpharmacies.Iftheyarefinanciallyfrailforwhateverreason,jobgrowthslowsorisnon-existent.Whenunemploymentincreasesamongourpharmacists,competitionforjobsdrivesalariesandbenefitsdownnomatterwhatsectorofpharmacyyouworkin.Forthosepharmacistsluckyenoughtobeemployed,badthingshappenwhenreimburse-mentscontinuetofreefall.WhatIseefirst,asanassociationCEO,arecutbacksintechnicianhours.Then,rollbacksinpharmacisthours.Longerdaysforpharmacistsasoverlappharmacisthoursareelimi-nated.Hasthishappenedtoyou?I’veseenhospitalpharmacistsstartingsalariesdropby15%becauseofcommunitypharmacyclosuresofmergers.Stilldon’tthinkthebusinessofpharmacyaffectsyou?Thinkagain.IamremindedofthisalmostweeklyasIfieldcallsandemailsfromangrypharmacistswhohadtheprescriptionfillbarraisedyetagaininordertogetmoretechnicianhoursortobringonanotherphar-macist.Or,whojustlostmoretechnicianhoursandnowhavetogettoworkearlierandstaylater(offthebooks)justtokeepupwiththedemand.I’veheardofseniorpharmacistshavingtheirweeklyhoursrolledbackfrom45to32.What’sthat,$1,300lessinyourpaycheckeverytwoweeks?Wouldthataffectyou?Howdoespharmacyexpectto‘use’theirexpandedscopeofpracticeauthorityiftherearenodollarsto

supportthesenewinitiatives?Everythingislinked.Nothingstandsalone.Everyoneinpharmacyisvul-nerable.Whattodo?Everystatepharmacyorgani-zationinthenationneedstostartanAllPharmacyConferenceandmakesureitmeetsonaregularbasis.Nationals–youneedtoencourageyourchaptersorstateassociationstoparticipateandsupporttheseefforts.Trustme,itwillimpressthemanagedcareentitieswhentheyseeyourpassionfortheprofes-sionandyourpatients.Itwillopendoorstopayerstoexpandpaymentsforpharmacyservicesasthesemeetingsareusedtoconductpresentationsofsomeofthegreatthingspharmacistsaredoingtosavethehealthcaresystemmoneywhileincreasingthequalityoflifeforyourpatients.SCPhAisusingthisforumatourMay22meetingtolaunchourseverementalhealthpatientstudyinitiativeinconcertwiththeSCDepartmentofMentalHealthandMedicaid.WhenthisstudywasmentionedbyMedicaidatourlastSCAllPharmacyConference,amanagedcareplanaskedtheDirectorofMedicaidPharmacyPolicyiftheycouldincludeprivatepaypatientsinthisstudy.Theyagreedtodiscussafterthemeeting.ThereasonhesaidwewereusingMedicaidonlypatientswasbecauseMedicaidhadaccesstoalltheDMHpa-tient’shealthcarecosts.

Doyouseehowthisworks?Whenallofpharmacysitsatthetable,anyregulatoryorstatutoryissuescanbediscussedand/oransweredduringthemeeting.Anyconcernsaboutaregulationorbillcanbemadeandadjustmentsmadeaccordingly.It’sameetingwhereyoucanrallyALLofpharmacy(eventhoughitmayonlybenefitoneortwosectors)tosupportthelegislationorregulatorychangesneeded.Itprovidesandavenueforstateandfederalregulatoryagenciestorunsomethingbytheprofessionbeforeintroduc-inganychanges.Whatitdoesisuniteallofphar-macyandstopthepublicairingofanydirtylaundry.Whenunited,legislatorsarehardpressedtouseonepharmacyorganizationagainstanothertodonoth-ing.Wehavealreadyhadsuccesswiththisapproachinthelegislaturewhereallpharmacyorganizationsstoodtalltodefeattwoverydamagingamendmentstoabillweallsupported.Thiscooperationiswhatisneededtomovepositivepharmacylegislationfor-warded.Remember,it’snotindependentpharmacy’sproblemorLTCpharmacy’sproblemorhealth-sys-tempharmacist’sissue;it’sPharmacy’sissue.

Pharmacy


FACT CHECK:Pharmacyisaprofessionthatisrelativelysmallinnumberscomparedtomostotherhealthrelatedprofessions.Thereare3.5millionnursesand1millionphysiciansnationallycomparedtosome290,000pharmacists.So,ifwejustusethe10%ruleofthose‘activists’withinanyprofession,thenonly10%ofnursescanoutnumber100%ofpharmacists.Thisis‘WHY’allpharmacists,techni-cians,owners,etc.needtofighthardforregulations(suchasCMS’2015AnyWillingPharmacyandMACPricingStandards),aswellas,FederalProviderstatus.Itaffectsyouall.Maybenottoday,ortomor-row,butsoonenough.

Iencourageallpharmacists,pharmaciststudentsandpharmacytechnicians,toworktogetheronallissuesimpactingthebusinessandpracticeofpharmacy,notjustthosethatbenefityoursector.Iencourageallofthenationalstocontinuetheirgreateffortstoworktogetherandtoencourageandsupportthestatesinbringingtheprofessiontogetherasonevoice.Helpeachotherforthebenefitofthewholeprofession.Ifyouarenotamemberofyournationalandstateas-

sociation,thenjointoday.Don’tthinkbecauseyou’reemployedtodaythatyouwillbetomorrow.Ihavesatdownwithtoomanypharmacistsintheirlate40’s,early50’swhoarewithoutapaycheckforthefirsttimeintheirlives.Therewasnotasectorofphar-macynotaffectedbylayoffsorcutbacksinstaffinghours.Ifyouarealreadyamemberofyourstateandnationalpharmacyassociations,thankyou!Now,getactive.Givebacktoyourprofessionwhichhasprovidedyouwithagoodlifewithnosmalleffortbyyourprofessionalassociations.

Free Vacation Voucher

Free Vacation Voucher


Time: 5-7pm Date: 05/12/2014

Location SCPhA Office

1350 Browning Road Columbia, SC 29210

Student Board Review

Trivia Night

What: Pharmacy history, general knowledge and OTC medications questions for a chance to win gift cards! (1st and 2nd place prizes)

Cost: FREE!!!

Who: Students (Guests are invited to watch)

Sign up today! Email Kit ([email protected]) or Stacie ([email protected]) for questions or

to submit your 3 person team!



Registration Type:

□ Full Registration without CE ($199) □ MPJE Only without CE ($89) □ NAPLEX Only without CE ($169) □ Full Registra�on with CE ($259) □ MPJE Only with CE ($109) □ NAPLEX Only with CE ($199)

Name_________________________________________ School____________________ Phone________________________ Email___________________________________________ NABP e‐ID________________ Birthdate_____________________ Address_______________________________________________________________________________________________ Payment Type: □ Check _________ Amount Due: $________________ Credit Card Type: □ MC □ Visa □ AMEX □ Discover Name on Card_____________________________________ Card #______________________________________________________ Exp. Date__________________ CVV____________ Billing Address__________________________________________________________________________________________

Cancellations will only be accepted if received more than 5 business days before the event. If applicable, a refund will be issued less a $25 processing fee.

MPJE/NAPLEX REVIEWMay 12‐14, 2014 USC Law School Auditorium Corner of Greens St. & Main St. Columbia, SC

Don’t Forget! • Parking is included with your registration. • There will be a short mid‐day break for lunch on your own each day. • Handouts will be available for printing prior to the course.

Schedule: Mon., May 12: MPJE Review, Dr. Jennifer Baker (7.5 hours) Tues.‐Wed., May 13‐14: NAPLEX review, Dr. Scott Sutton (7 hours per day)

Details will be sent out regarding parking and handouts closer to the date.

Register at www.scrx.orgor complete this form

and return, with payment, to: SC Pharmacy Association 1350 Browning Road Columbia, SC 29210 or 803.354.9207 (fax) or

[email protected]

New for 2014! If you don’t pass the NAPLEX after

taking this review, we will refund you $100!

Please refer to www.scrx.org for more information.


SCCP

MymostrecentcolumninthePalmettoPharma-cistannouncedthelaunchoftheWalkerPharmacyLeadershipScholarsEndowment,aninitiativemadepossiblebya$525,000giftfromUniversityofSouthCarolina(USC)pharmacyalumnaDonnaWalker’79.TheSouthCarolinaCollegeofPharmacy(SCCP)iscommittedtorecruitingandeducatingstudentswhohavetheattributesofleadership.

Pharmacistsoftenfillleadershiprolesintheircom-munities.Manypeoplewhogointocommunitypharmacy,pharmacyownersaswellasthoseinchainstores,refinetheirskillsasleadersandbecomeknownandtrustedbythepeopleoftheircommunity.Health-systempharmacistshavesimilarexperiencesworkingwithcolleaguesinmulti-disciplinaryenvi-ronments.

Ascommunityleaders,manypharmacistshavebeenelectedtopoliticaloffice,wheretheyhaveanoppor-tunitytoleadandhelptheircommunities.Whileinoffice,theyalsohavetheopportunitytoimprovethewell-beingofSouthCarolinacitizensthroughhealth-careadvocacy,educationandpolicycreation.Whenissuesarisethatrelatetothepharmacyprofessionoreducatingpharmacists,thesepolicymakersareinpositiontoprovideinsightandguidanceabouttheprofessiontolegislatorsandotherelectedofficials.Therewere46pharmacistsservinginstatelegisla-turesacrossthecountryenteringthe2012elections,accordingtotheAmericanPharmacistsAssociation(APhA).Aspharmacydeterminesitsplaceinanevolvinghealthcaresystem,havingexperiencedpro-fessionalsparticipateinpolicydiscussionsiscrucial.Inthelasttwoyears,twohighprofileexamplesofthosekindsofdiscussionsincluderesponsetothemeningitisscareand,inSouthCarolina,theadoptionofanewimmunizationprotocolforpharmacists.IntheSouthCarolinaLegislature,therearethreepharmacistscurrentlyserving,twoofwhomarealumniofSCCP’sfoundinginstitutionUSC:Sena-tor Ronnie Cromer USC ’73 (District 18), Senator Kevin Bryant (District 3), and Representative Kit Spires USC ’76 (District 96).

Sen.Cromer,whoownsLorexDrugsinNewberry,S.C.andisapartnerintheUnionFamilyPharmacyinUnion,S.C.,hasservedintheS.C.Senatesince2003.Heisco-orprimarysponsorof15bills,in-cludingthePharmacyPracticeAct(S.0183)toregu-

Updates at SCCP by Joseph DiPiro, Dean SCCP lateprescriptionbenefitsmanagersandacharitablefundsact(S.0250)toaddpublicschoolsasorganiza-tionsexemptfromfiling.HealsoservesontheSouthCarolinaCollegeofPharmacy(SCCP)LeadershipAdvisoryCouncil.

Rep.Spires,whoownsBigSDiscountDrugsinPelion,S.C.,hasservedintheS.C.HouseofRepre-sentativessince2007.Heisco-orprimarysponsorof10bills,includingthePharmacyPracticeAct(H.3161)tohelpestablishnewregulationsforcom-poundingpharmaciesandthePharmacyPatientPro-tectionAct(H.3151)toregulateprescriptionbenefitsmanagers.

Sen.Bryant,presidentofBryantPharmacyandSup-plyinAnderson,S.C.,isco-orprimarysponsorof13bills,includingthePrescriptionMonitoringProgramAct(S.0840)toamendlawsrelatedtosubmissionofinformationbydispensers.

AnumberofotherUSCandMedicalUniversityofSouthCarolina(MUSC)pharmacyalumnihavebeenelectedtolocaloffices.Asmallsamplingincludes:

•Frank Brunson MUSC ’76 isthemayorofForestAcres,S.C.Hebecamseinvolvedinpoliticsinjuniorhighschoolandwaselectedtohisfirstmayoraltermwith81percentofthevote.AftergraduationfromMUSC,hedidaresidencyatRichlandMemorialHospitalandstayedonasahospitalemployeeforthreeyearsbeforerunningaretailpharmacyfrom1979to1997.In1997,helaunchedInfusionCareofSouthCarolina.

•Mike Ross USC ’76waselectedmayorofBly-thewood,S.C.in2012.HestartedBlythewoodPhar-macyinSeptemberof1981andopeneditscurrentlocationin1986.Alongtimecommunityleader,hewaselectedpresidentoftheS.C.PharmacyAssocia-tion(SCPhA)forthe2000-01termandvotedPhar-macistoftheYearin2001.In2009,hereceivedtheBowlofHygeiaAward.HealsoservedaspresidentoftheUSCPharmacyAlumniSocietyLeadershipCouncil.

•Don Wall USC ’67,ownerofseveralpharmaciesinGreer,S.C.,MountainView,S.C.,Greenville,S.C.

continued on next page...


andTravelersRest,S.C.,servedasmayorofGreer,S.C.from1992-2000.Apracticingpharmacistfor45years,WallwashonoredwiththeBowlofHygeiain1993andthe2012OutstandingAlumnusoftheYearbytheUSCcampusoftheSCCP.

•Tom Rivers USC ’65 servedasmayorofWillis-ton,S.C.for20yearsbeforefinallysteppingdownin2013,sayingitwastimetopassthereinstoayoungergeneration.Firstelectedtotowncouncilin

OnMay10,2014,PresbyterianCollegeSchoolofPharmacywillholditsfirstgraduationofpharmacystudents.SeventysixstudentswillreceivetheirdiplomasforcompletingtheDoctorofPharmacydegreeatPresbyterianCollege.Morethanthreehun-dredundergraduateandgraduatestudentdegreeswillbeconferredthatSaturdaymorning.

Precedingthegraduation,theinauguralgraduat-ingclassofpharmacystudentswilltakepartintheSchool’sfirstDoctoralHoodingCeremony.Over400peopleareexpectedtobeinattendancewillbewelcomedbyPresidentClaudeC.LillyandDeanCliffFuhrman.ThekeynotespeakerwillbeDr.Lu-cindaMaine,ExecutiveVicePresidentandCEOoftheAmericanAssociationofCollegesofPharmacy.Graduatingstudentswillbepresentedwiththeirdoc-toralhoodbyDr.LauraFox,AssistantDeanofPro-fessionalandStudentAffairsandDr.Fuhrman,andwillreceiveanalumnipinfromDr.LewisMcKelvey,AssistantDeanofExperientialEducation.Severalstudents,facultyandpreceptorawardswillalsobepresentedattheceremony.

Asurveyofourgraduatesindicatedthat80%haveal-readyacceptedjoboffersorresidencyappointments.Wehada50%successrateforstudentsapplyingforresidencyprograms(8of16successfullymatchedinASHPprograms).Inaddition,onestudentwillattendtheUniversityofTexastopursueaPhDinPharmaceuticalOutcomes.

PCSP

1988,hehasbeeninthepharmacybusinesssince1970andistheownerofRiversPharmacyinWilliston.Thesearejustanillustrativefewofthemanyphar-macistsinleadershippositionsinSouthCarolina.TheCollegeisproudtohavecontributedtotheshapingoftheseleadersduringtheirpharmacyeducationsandweintendtocontinueemphasizingtheimportanceofleadershipaspartoftheCollegecurriculum.

ItseemssuchashorttimeagothattheClassof2014begantheiracademicjourneyatPCSP.Now,fouryearslater,theyeagerlyanticipatetheircareerpathsinthepharmacyprofession.Graduationdayhasandalwayswillbethebestdayoftheyear.Seeingtheproudandsmilingfacesonourgraduates’andtheirfamilies’isextremelygratifyingtoourfacultyandstaff.Weeagerlylookforwardtowatchingouralumniprovidequalityhealthcareandpublicservicetothecommunitiesinwhichtheyreside.

OnceaBlueHose…AlwaysaBlueHose!

An Inaugural Event at Presbyterian College by Cliff Fuhrman, Dean PCSP

continued from previous page...

ThePalmettoPharmacistNetwork(PPN)hasworkedwithSouthCarolinaemployerstoprovidediabetesself-managementservicessince2006.Ourdiabetesself-managementprogramwasorigi-nallyprovidedthroughtheDiabe-tesTenCityChallenge(DTCC)inpartnershipwiththeAmericanPharmacistsAssociationFounda-tion.TheprogramhascontinuedastheHealthMapRxProgramforDiabetes,ahealthcareinitiativethatfocusesonindividualswhohavebeendiagnosedwithdiabe-tes.

HealthMapRxworkswithemploy-erstoofferconsumerincentiveprogramsthatfocusonpatientself-managementeducationandtechniquestohelppatientswithchronicconditionsimprovehealthoutcomes.Theprogrammatcheshealthplanbeneficiarieswithcommunitypharmacist“coaches”whoprovidehands-oneducation,whilemonitoringandevaluatingtheemployees’healthimprove-ments.Throughone-on-onecoun-selingsessionswithpharmacists,employeescanlearnhowtobettermanagetheirchronicconditions

(diabetes,highbloodpressure,cholesterol)andreduceassociatedrisks.1

Thisinnovativeprograminvolvesthecollaborativeeffortsofem-ployers,localhealthcareprovid-ers--includingpharmacistsandphysicians,andhealthinsurerstoenableemployeestobetterman-agetheirdiabetes.Financialincen-tives,suchasreducedorwaivedmedicationco-pays,areofferedtoemployeesforparticipating.

Theprimaryelementsofthepro-graminclude:• Identifyingandenrollingemployeesandbeneficiarieswhohavediabetes,andarecoveredbytheemployer’shealthplan• ContractingwiththePal-mettoPharmacistNetworktopro-videtheappropriatepharmaceuti-calcare,coaching,andcounselingtohelppatientseffectivelymanagetheirdiabetes• Assessingeachpatient’sunderstandingofhis/herdiabetes• Conductinganeducationalandskillstrainingprogramtai-loredfortheneedsofeachpatient• Preliminarilyassessing

eachpatient’shealthandreinforc-ingthephysician’streatmentplan• Periodicevaluationofeachpatient’sknowledge,skills,andperformance• Establishingasecuredatacollectionmechanismandmain-tainingaconfidentialdatasourcethatcantrackandanalyzeaggre-gateoutcomedataforpurposesofdevelopingstatisticalcomparisonsofimprovedpatienthealthandtotalhealthcaresavingsfortheemployer• Evaluatingandreportingresultsofprogram.

Ourprogramispatient-focusedandsuccessoftheprogram,inlargepart,dependsonthepa-tient’sactiveparticipationinhis/herowncare.Theprogramisdesignedtohelppatientsmaintaingoodcontrolovertheirdiabetesbyhelpinghim/herlearnhowtobetterself-managetheircondition.Patientsmeetregularlywiththehealthcareteam–thephysician,pharmacist,andwhenneeded,otherspecialists.Thepharmacistworkswiththepatienttoidentifyknowledgedeficienciesandtodevelopaneducationsupportplan

The Palmetto Pharmacist Network by Cecily V. DiPiro, PharmD

Coordinator, Palmetto Pharmacist Network


that(a)meetshis/herindividualhealthcareneedsand(b)providestheeducationandskilltrainingthathe/sheneedstooptimallyself-managetheirdiabetes.OurprocessofcareismodeledaftertheAmericanDiabetesAssocia-tionGuidelines.

EachemployeeenrolledintheHealthMapRxprogramsignsareleaseofinformationformautho-rizingthepharmaciststoobtainlaboratorytestresults.Evaluationofclinicaloutcomeshasshownconsistentvaluesforkeyclinicalindicatorsindiabetesmanage-ment.AveragehemoglobinA1cresultsforemployeesofonePPNemployerhaverangedfrom7.1to7.39over3years(2009-2012;targetA1c≤7.0)andaverageLDLhasrangedfrom82to91duringthesametimeperiod(targetLDL≤100).

TheeconomicoutcomesfortheDTCCshowedareductionof$1,079inaveragetotalhealthcarecostsperpatientperyearascomparedwithprojectedcosts.2AnalysisofhealthcarecostsbyoneemployercontractedwithPPNhasshownconsistentlylowercostsperenrolleeperyear(2009–2013;nodataavail-ablefor2010)ascomparedtoanationalbenchmarkforaveragecostsforapatientwithdiabetes.

Weworkcloselywithourem-ployersandhaveworkedwiththeCityofCharlestonsinceimplementationoftheDTCC.JanPark,BSRN,EmployeeWellnessManagerfortheCityofCharlestonrecentlysum-marizedthebenefitstoCityemployeesasfollows:

“Theparticipantsinthisprogramaretaughttoself-managetheirdiabetes.Theylearnagreatdealaboutallaspectsofdiabetescareincludingglucosemonitoring,medicationmanagement,andtheimportanceofhealthynutri-tionandexercise.Thepharmacistcoachbecomesanimportantpartoftheircareteam.Ourparticipantsunderstandandcomplywiththeirmedicationregimensbetterwiththecounselingandtheyappreci-atebeingabletocalltheircoachiftheyareconfusedonanything.Ac-cordingtoourlastclinicalreport,theaverageA1cofparticipantsis7.2.Weareexcitedthatwecanofferthissupporttoourstaff.”

TherelationshipbetweentheenrolleeandthePPNcoachiskeytothecontinuedsuccessofthismodelofcare.WeareproudoftheworkdonebythepharmacistsworkingwithPPNandarework-

ingtoexpandtheHealthMapRxmodeltootheremployersintheStateofSouthCarolina.

References:1. http://www.healthmaprx.com/. Accessed March 6, 2014.2. Fera T, Bluml BM, Ellis WM. Diabetes Ten City Chal-lenge: Final economic and clini-cal results. J Am Pharm Assoc 2009;49:e52-e60.


PPN


SCPHA’S ANNUAL CONVENTION

IS RIGHT AROUND THE CORNER!

JUNE 19-22, 2014 MARRIOTT RESORT AND SPA

HILTON HEAD ISLAND, SC THEME: ROARING 20S

Journal Special! $10 off Full or VIP Registration

Promo Code: journal Offer good through May 28, 2014.

REGISTER AT WWW.SCRX.ORG

Scpha’s annual convention Marriott Resort and Spa

Hilton Head Island, SC June 19-22, 2014

Registration Types Full Registration • 15+ hours of Continuing Education available • Welcome Reception Thursday, Breakfast Friday-Sunday • Ticket to Foundation event (includes dinner) • Ticket to Exhibit Hall (includes lunch) • Event T-Shirt VIP Registration • All of the items listed above in the Basic Full package • Ticket to the Awards Dinner • Ticket to PC, South, MUSC or USC Alumni Luncheon Student Registration • Access to all CE programming (CE credit not included) • Student specific events, including student trivia night • Welcome Reception Thursday, Breakfast Friday-Sunday • Ticket to Foundation event (includes dinner) • Ticket to the Awards Dinner • Ticket to the Exhibit Hall (includes lunch) • Event T-Shirt STUDENT SCHOLARSHIPS ARE AVAILABLE! Apply today at www.scrx.org.

Guest Registration • Access to all CE programming (CE credit not included) • Welcome Reception Thursday, Breakfast Friday-Sunday • Ticket to Foundation event (includes dinner) • Ticket to the Awards Dinner • Ticket to Exhibit Hall (includes lunch) • Event T-Shirt Daily Registration • Credit for continuing education programs for the day(s) you attend • Breakfast for the day(s) you attend • Friday attendees receive ticket to Foundation event (includes dinner) • Saturday attendees receive ticket to Exhibit Hall (includes lunch)

Hotel Information Marriott Resort and Spa 1 Hotel Cir., Hilton Head Island, SC 29928

SCPhA’s group rate of $199 per night will be available until May 19 or until rooms sell out, whichever comes first.

Reserve your room today by calling 843.868.8400.

Questions? Call SCPhA at 803.354.9977.


Where would you prefer to have your HIPAA training?

Option A Option B

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

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

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

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

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









American Pharmacists Association Foundation

News Release FOR IMMEDIATE RELEASE CONTACT: Megan Lewis

March 25, 2014 202.558.2724; [email protected]

APhA Foundation and IQware Solutions announce partnership for new data integration and analytics

Expanded research capabilities will leverage the value of pharmacists’ patient care services

WASHINGTON, DC – The American Pharmacists Association (APhA) Foundation and software company IQware

Solutions announce a new partnership to create core components of an IMPACT Healthcare Innovation Hub, a new data

aggregation and reporting tool that will integrate clinical and economic data. The secure web-based platform will include

data collection, importing, analytics and reporting capabilities currently used in the Foundation’s successful research

projects. Using the hub, healthcare organizations will be able to produce a set of self-service reports using uploaded data

that demonstrate the value of pharmacists’ patient care services as an efficient, cost-effective healthcare solution.

The hub will enable the Foundation to build upon its rich history of research outcomes showing the value of pharmacists’

patient care services through a rapid, comprehensive analysis of data to collaborating stakeholders. “We are pleased to

have the opportunity to develop new tools to streamline data collection and reporting in a way that produces evidence of

the impact pharmacists’ patient care services have on healthcare delivery and ultimately, patient health outcomes,” said

Mindy Smith, APhA Foundation Executive Director.

“Privacy, confidentiality, reliability and security are of paramount importance to our research at the APhA Foundation and

to our collaborators,” said Benjamin Bluml, APhA Foundation Senior Vice President, Research and Innovation. “One of

the key reasons we selected IQware as our development partner is for the flexibility its secure, patented technology offers

in developing an infrastructure that allows us to adapt to a continuously evolving marketplace as we work to expand our

research and innovation enterprise to help invent a preferred future.”

Healthcare organizations who use the IMPACT Healthcare Information Hub will be able to collect, analyze, report and

aggregate data depending on their needs. The software will allow the option to enter data directly into the system if an

electronic medical record system (EMR) is not in place, convert non-standardized formats into standardized data, or

accommodate market standards for health information exchange if a standard EMR system is used.

“We are confident that the unique attributes of the IQware architecture will provide the APhA Foundation with the

information technology platform needed to lead the pharmacy profession into a new future and are proud to be a partner,”

said Donald L. Seddon, President of IQware Solutions, LLC.

About the American Pharmacists Association Foundation

The APhA Foundation, a nonprofit organization based in Washington, D.C., is a trusted source of research demonstrating

how pharmacists can improve health care. The APhA Foundation’s mission is to improve people’s health through

pharmacists’ patient care services. The APhA Foundation is affiliated with the American Pharmacists Association, the

national professional society of pharmacists in the U.S. For more information, please visit the APhA Foundation website

www.aphafoundation.org. Follow the APhA Foundation on Twitter and Facebook for the latest updates.

About IQware Solutions

Answering the call for an all-new method for software development, IQware created a patented (US #7,322,028, others

pending), revolutionary process that removed coding and scripting from the equation. Since its initial release in 2007, the

IQware Development Platform has evolved to include the necessary intelligence to deploy new applications in response to

events. Innovation continues to ensure IQware delivers solutions that enable healthcare organizations to capitalize on big

data by securing all data in motion against external and internal threats with 24x7 availability, and the ability to change

applications on the fly, adding/changing functionality even when systems are in use. For more information, please visit the

IQware website www.iqwaresolutions.com.

###

American Pharmacists Association Foundation ● 2215 Constitution Avenue, NW ● Washington, DC 20037-2985

P: 202.429.7565 ● F: 202-783-2351 ● www.aphafoundation.org


APhA

2014’s Convention Exhibitors & Sponsors Merck

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SC Medicaid/DHHS SCRIPTS

Smith Drug Company South University

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There are still a few booths available!For more information, please call 803.354.9977.

*This list was current at time of publishing and is subject to change.

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Bowl of Hygeia State Association Challenge 2.0 –

Help South Carolina Take the Lead!

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

How You Can Help:

• Save time: Make $10

quick donations by text - RxBowl to 52000

• We are encouraging all

former recipients to contribute!

Contact: Lynette Sappe-Watkins:

[email protected] or 202-429-7534

Prizes Funds for a Bowl of Hygeia Reception at

your next Annual Meeting

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

$5,000 before APhA2014*.

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

amount over $5,000 before APhA2014*.

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

amount over $5,000 before APhA2014*.

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

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


In Association with the South Carolina Chamber of Commerce,The 29th Annual Ranking of the State’s Largest Privately Owned Companies.

J M Smith Corporation Ranked 3rd

J M Smith Companies

1. Milliken & Company - Spartanburg 2. The Intertech Group, Inc. - North Charleston 3. J M Smith Corporation - Spartanburg4. United Sporting Companies, Inc. - Chapin5. Southeastern Freight Lines, Inc. - Lexington

R

We are proud to announce that


Student Article

WhenIregisteredforaclinicalpracticerotationinantimicrobialstewardship,itwasachallengetoascertainexactlywhatmyresponsibilitieswouldbe.Ittookseveraldaysofrotationformetotrulyrealizewhatantimicrobialstewardshipreallymeans.TheCentersforDiseaseControl&Prevention(CDC)definesantimicrobialstewardshipasusingtherightantibiotic,attherightdose,attherighttime,fortherightduration.1Thefirstrealizationisthatthe“right”answerisrarelytheobvious,simple,orstraight-forwardone.Thepracticeofstewardshiprequiresanintrinsiccuriosityandapropensityfortheartofproblemsolving.Onemustconsidereveryaspectofaparticularcasetoselecttheoptimalantimicrobialagent,includingsiteofinfection,drug-specificfac-torsincludingdosing,cost,potentialadverseevents,andahostofpatient-specificfactors.

Theimplementationofantimicrobialstewardshipprogramshasbeenshowntoreduceratesofresis-tance,infectionssecondarytomulti-drugresistantorganisms,riskofC.difficileinfection(CDI),andfinancialburdenonthehealthcaresystem.Antimi-crobialresistanceisescalatingatanalarmingrate.In2013,theCDCestimatedthatmorethan23,000Americansdieeveryyearfromantibiotic-resistantinfections,andantimicrobialresistanceleadsto$20billioninexcesshealthcarecosts.2Theleadingcontributortothisresistanceisprimarilyantibioticexposure.Often,theseexposuresaresecondarytoantibioticsprescribedinappropriately,inefficiently,orexcessively.Similarly,theprimarycauseofCDIisantibioticuse.Eachyear,C.difficileinfectionhasbeenassociatedwithover14,000Americandeathsandatleast$1billioninexcessmedicalcosts.2,3

Basicapplicationofantimicrobialprescribingprin-ciples,resultinginjudicioususeofantimicrobialagents,hasbeenshowntoreducebothclinicaland

A Call to Action: The What, Why, and How of Antimicrobial StewardshipMaggie K. Brilhart, PharmD Candidate, 2014 & P. Brandon Bookstaver, PharmD, BCPS (AQ-ID), AAHIVP

financialsequelaeassociatedwithCDIanddrug-resistantinfections.

Asfuturepharmacists,Iwouldencouragestudentstoapplyantimicrobialstewardshipprinciplesinallpracticesettings.Intheacutecaresetting,thisisfairlystraightforward.Determineifyourpatient’schoiceofantimicrobialtherapyisthemoststream-linedagent,coveringtheappropriateconfirmedorsuspectedbacteriawiththeleastamountofpatientriskandmakerecommendationstoprescribers.Fol-lowculturesandsensitivitiestoensurethattherapyisbeingappropriatelyadjusted.Confirmthatanti-microbialordersincludeappropriatedose,duration,androute.Addresstheavailabilityandrestrictionsofhigh-riskantibioticstotheprescribingteams.Thesepracticerecommendationshavebeenpre-sentedbytheInfectiousDiseasesSocietyofAmericawithafocusonbenefitsandmethodsofstewardshipimplementation.3Communitypracticemaypresentachallengeofinvolvement,buthasahighlevelofpotentialimpactwiththemajorityofantimicrobial

Student Articles


useintheoutpatientsetting.Thereareseveralwaystoensurequalitypatientcarebyminimizingriskandimprovingoutcomes.Spendingafewminuteswithapatientcanclarifyasituationandprovideopportunitytointerveneappropriately.Whatinfectionisbeingtreated?Whatarethemostlikelybacterialsources?Monitorpastantibioticexposures–isthepatientreceivingtheirthirdantibioticthismonth?IdentifyriskfactorsforCDI,andrecognizebarrierstoap-propriatetreatmentandclinicalsuccess.Similarly,providebriefpatientcounselingontheimportanceofcompletingtherapyandusingtheantimicrobialforonlytheintendedpurpose.Youshouldstresstheimportanceofnotsharingantibioticsandtodiscardunusedantibioticsforsafetyissues.Additionalcounselingpointsincludepotentialadverseeffectsandreconcilingmedicationallergies,whichcouldsavethepatientandhealthcaresystemconsiderabletimeandunduecost.Thesesmallstepsareacru-cialcomponentofpatientsafety,asallergiesareofparticularconcerninantimicrobialuse.Anticipationofcertaincommonadverseeventsmayputpatientsatease,whileawarenessofserioussideeffects,suchasprolongeddiarrhea,canfacilitateearlierdiscontinua-tionortreatment.

Whilepharmacistsplayacriticalroleineffectivelymanagingantimicrobialtreatmentregimens,otheravenuesofconcernincludecontinuedoveruseofantibioticsinlivestockandtherelativelackofanti-bioticsinthepipeline.Iencourageyoutoadvocateforlegislationthatwillhelptosupportbothantibioticdevelopmentandtargetedinterventionstoreducetheburdenofresistantorganisms.5,6Iurgeeachofyou,regardlessofpracticesetting,toadoptthehabitofactingasapatientadvocateinthecontextofanti-microbialuse.Itisaninvestmentinthesafetyandwell-beingofourglobalhealthcaresystemformanyyearstocome.

Maggie Brilhart is a fourth year pharmacy student at the SC College of Pharmacy at the University of South Carolina. Brandon Bookstaver is a faculty member at the SC College of Pharmacy at the Uni-versity of South Carolina and maintains a clinical practice site in infectious disease at Palmetto Health Richland.

References:

[1] Antibiotic resistance threats in the United States, 2013. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf. Published April 23, 2013. Accessed December 22, 2013.

[2] Get smart for healthcare: why inpatient steward-ship? Centers for Disease Control and Prevention Web site. http://www.cdc.gov/getsmart/healthcare/inpatient-stewardship.html. Published November 15, 2010. Accessed December 22, 2013.

[3] Dellit TH, Owens RC, McGowan JE, et al. Infec-tious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007; 44:159-77.

[4] Spellberg B, Blaser M, Guidos RJ, et al. Com-bating antimicrobial resistance: policy recommenda-tions to save lives. Clin Infect Dis. 2011; 52 (suppl 5): S397-S428. doi: 10.1093/cid/cir153.

[5] United States. Committee on Energy and Com-merce. Cong. Senate. Strategies to Address Antimi-crobial Resistance Act. 2013. Washington: GPO, 2013. Print.

[6] Spellberg B, Guidos R, Gilbert D, et al. The epi-demic of antibiotic-resistant infections: a call to ac-tion from the Infectious Diseases Society of America. Clin Infect Dis. 2008; 46:155-64.

Student Articles


Past:Theprofessionofpharmacyhasevolvedsubstantiallyoverthousandsofyears.Thefirst“pharmacies”,ordrugstores,wereestablishedinBaghdad,Iraqin754.TheMiddleEastmademanyadvancesinbotanyandchemistry,leadingtothemedicinaluseofchemicalcompoundsandthefirstpharmacopoediathatlistedvariousdrugsandremediesforailmentsin869.1 For centuries,theonlywayonecouldentertheprofes-sionwasthroughapprenticeship,orworkingside-by-sidewithan“apothecary”.Apothecarieswereknowntocompoundanddispensemedications,muchliketo-day’spharmacists,butalsoprovidedmedicaladviceandserviceswhichareperformedbyothermedicalspecialiststoday.

EdwardParrishoftheAmericanPharmaceuticalAs-sociationcoinedtheterm“pharmacist”nearly150yearsagoafterhesuccessfullyproposedthatallofthevariedpharmaceuticalprofessionalmembersbeconsidered“pharmacists.”2Oncethefieldofphar-macywasformalized,pharmacistsmade,prescribed,andcounseledpatientsuntiltheirrolechangedin1951.

The1951Durham-HumphreyamendmenttotheFederalFood,Drug,andCosmeticActof1938definedtwoseparatecategoriesformedications,overthecounter(OTC)andlegendproducts;andrequiredpharmaciststoobtainaprescriptionfromaphysi-ciantodispensemedications.3Thisrestrictionpushedpharmaciststofocustheirtimeondispensingandproductsafety.

Thepharmacist’srolechangedonceagaininthe1980’sasaprofessionalmovementurgingpharma-ciststoperformmoreclinicaldutiesgainedmo-mentum.However,legislationdidnotcatchupwiththemovementuntiltheMedicarePrescriptionDrugImprovementandModernizationActwaspassedin2003,whichmandatespatientstobecounseledbypharmacists.3ThislegislationalsoopeneddoorsforpharmacistsinregardstoMedicationTherapyManagement(MTM)whichisperformedbymanypharmaciststoday.

Present:TheWorldHealthOrganization(WHO)estimatesthereareatotalof2.5millionpharmacistsand

Transitioning Role of the Pharmacist:Past, Present,

and Future

Jessica T. Langdon, PharmD/MBA candidate 2014, SUSOPJenny Pope, PharmD Candidate 2014, SCCP, USC Campus

Student Articles


pharmacypersonnelworldwide.Manypeopleoutsidetheprofessiontypicallyviewapharmacistassome-onewhocountspillsandlabelsvials,butweknowtoday’spharmacistisresponsibleformuchmore.With129pharmacyschoolsintheUnitedStatesgraduatingthousandsofstudentseveryyearwithaDoctorateofPharmacy,PharmDdegree,pharmacistsaretransitioningtobecomeamoreclinicalhealthcareprofessional.2 Pharmacistspracticeinavarietyofsettingsincludingcommunity,hospital,industry,longtermcare,homeinfusion,academics,amongothers.Theirdutiesconsistofverifyingprescriptionorders,counselingpatients,administeringvaccines,interpretinglabval-ues,androundingwithhealthcareteamsinthehos-pital.Intheretailsetting,pharmacistsareprovidingMedicationTherapyManagement(MTM)servicesthatoptimizepatientspecificmedicationregimensandreducehealthcarecosts.Advancesintechnologylikeautomateddispensingmachines,refillsviasmartphoneapplications,drive-thrupharmacies,andtheelectronicpatientrecordallowpharmaciststospendmoreoftheirtimeonclinicaldutiesandworktothefullextentoftheirdegree.Thisleadsustowonderwhatthefutureholdsforpharmacistsasaprofession.

Future:Pharmacistshavebeenthemostaccessiblehealthcareprofessionalavailabletotheirpatientsovertime,whetheritisoverthephoneorinperson,atalmostanytimeofday,andarelationshipisformedfromthebeginningandmanycontinuetoremain!Throughtime,theserelationshipsallstartedwithapatientcomingtoapharmacyandgettinganewprescriptionthatthepharmacistcounseledthemon.Whenpa-tientsunderstoodtheknowledgebaseofthepharma-cist,theybegantotrustthemandaskmorequestionswitheveryvisittothepharmacy.Itisbecauseofthisrelationshipwiththepatientthattheroleofthephar-macistismovingtowardabroaderscopeofpracticetoallowformorefacetimewiththeirpatientsinthefuture.

Whatisbeingproposedforthefutureofpharmacyistobeabletodomoreofwhatistermedas“postdiagnosticcare.”“Onceadiagnosisismadebytheprimarycareprovider,pharmacistsmanagediseaseandprovidepatientcare.Pharmaciststhatperformintheserolesfunctionashealthcareproviders.”5Pharmacistsinsomestatesandfacilities-theIndian

HealthService,theVeteranAffairs,andtheDepart-mentofDefense–havealreadybeenmovinginthisdirectionbutuntilpharmacistsarerecognizedashealthcareprovidersthistransitiontoabroaderscopeofpracticewillbedifficulttoaccomplishnationwide.

Havingamedicalinformationdatabasewillalloweveryoneonthehealthcareteam-thephysician,thepharmacist,andanyotherspecialist-forapatient’scaretoeasilysharehealthinformationwitheachother.Thiswillhelppreventduplicationsincare,improveapatient’squalityoflife,assureeveryoneisintheknow,andreducehealthcarecostforboththepatientandtheinsuranceprovider.Pharmacieshaveanaddedbenefitsinceitisaeasyaccesspointtothepublicthatisfrequentlyuseddailywithextendedhoursofoperation;itmakesitmoreconvenientforpatientstogoaftertheygetoffwork.6 Pharmacists candeterminewhothehighriskpatientsarebasedontheirmedicationlistandcanofferneededvac-cinations,basedonusingthisdatabasetoensurethepatientisofferedtheopportunityiftheyhadnotreceivedthevaccinationyet.6

Currently,pharmacistserviceshavebeenincreasingincomplexitypertainingtospecificallyclinicalser-vicesbutthereisareductionintherevenuegenera-tionpotential.5Bypharmacistsbeingrecognizedashealthcareprovidersthisreimbursementofservicesisabletochange.

Thenextquestioniswhatclinicalserviceswillpharmacistbeabletoofferwiththisbroaderscopeofpractice?

References:1. Hadzovic, S (1997). “Pharmacy and the great contri-bution of Arab-Islamic science to its development”. Medicinski Arhiv (in Croatian) 51 (1-2): 47–502. Urdang G. Edward Parrish, a forgotten pharmaceuti-cal reformer. Am J Pharm Educ. 1950;14:223–32.3. Food and Drug Administration, Legislation,http://www.fda.gov/RegulatoryInformation/Legislation/default.htm4. AACP. Academic Pharmacy’s Vital Statistics. Available at: http://www.aacp.org/about/pages/vitalstats.aspx. 5. Gilberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S.Surgeon General. Office of the Chief Phar-macist. U.S. Public Health Service. Dec 2011.6. DHHS/CDC. Advisory Committee on Immunization Practices (ACIP).Summary Report, Atlanta, Georgia. June 19-20, 2013.

Fraud, Waste and Abuse Manual

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

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

Pricing:SCPhA Members $195

Non-Members $495

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

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

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

2013 South Carolina PAC Expenditures: SC Trucking Association: $121,750 SC Optometric Association: $90,400

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

Political Action

Committee

(PAC) Quick Facts

Julian Reynolds

Jessica Legge

John Pugh

Carolina Pharmacies Unlimited

SCPhA Foundation– 8th District

Pamela Whitmire

Dawn Devine

Eugene Sawyer

Marvin Hyatt

2013-2014 Contributors to SCPhA PAC Craig Harmon

Walter Hughes

Gregory Mayer

Lynn Connelly

Christopher James

Tom Simpson

Randy Todd

Davis Hook

Demetra Garvin

Pharmacy Partners

Regina Boswell

Tommy Simmons

Spartanburg Treatment Associates

Phillip Hall

Landrum Drug Company

James Shuler

Gordon Brown

Jamison’s Pharmacy

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

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

SC Pharmacy Association: $ 32,700

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FINANCIAL FORUM

MAKING RETIREMENT SAVINGS LAST Different ways to respond to the challenge

Asyouretire,therearevariablesyoucan’tcontrol;investmentperformanceandfatearecertainlyto-wardthetopofthelist.Yourapproachtowithdraw-ingandpreservingyourretirementsavings,however,maygiveyoumorecontroloveryourfinanciallife. Drawingretirementincomewithoutdrainingyoursavingsisachallenge,andtheresponsetoitvariesperindividual.Today’sretireeswilllikelyneedtobemoreflexibleandlookatdifferentwithdrawalmethodsandtaxandlifestylefactors. Shouldyougobythe4%rule?Fordecades,retireeswerecautionedtowithdrawnomorethan4%oftheirretirementbalancesannually(adjustednorthforinflationastheyearswentby).This“rule”stillhasmerit(althoughsometimesthepercentagemustbeincreasedoutofnecessity).T.RowePricehasesti-matedthatsomeoneretiringwithatypical60%/40%stock/bondratiointheirportfoliohasjusta13%chanceofdepletingretirementassetsacross30yearsifheorsheabidesbythe4%rule.A7%initialwith-drawalrateinvitesan81%chanceofoutlivingyourretirementassetsin30years.1

Thatsoundslikeaprettygoodargumentforthe4%ruleinitself.However,whilethe4%ruleregulatesyourwithdrawals,itdoesn’tregulateportfolioper-formance.Ifthemarketsdon’tdowell,yourportfo-liomayearnlessthan4%,andifyourinvestmentsrepeatedlycan’tmakebacktheequivalentofwhatyouwithdraw,youwillriskdepletingyournesteggovertime. Orperhapstheportfoliopercentagemethod?SomeretireeselecttowithdrawX%oftheirportfolioinayear,adjustingthepercentagebasedonhowwellorpoorlytheirinvestmentsperform.Asthiscanproducegreatlyvaryingannualincomeevenwithresponsiveadjustments,someretireestakeasecondstepandsetupperandlowerlimitsonthedollaramounttheywithdrawannually.Thisapproachismoreflexiblethanthe4%rule,andintheoryyouwillneveroutliveyourmoney. Ormaybethespendingfloorapproach?That’sanotherapproachthathasitsfans.Youestimatetheamountofmoneyyouwillneedtospendinayearandthenarrangeyourportfoliotogenerateit.Thisimpliesaladderedincomestrategy,withtheportfo-


lioheavilyweightedtowardsbondsandawayfromstocks.Thisisamoreconservativeapproachthanthetwomethodsabove:withalowequityallocationinyourportfolio,onlyaminorityofthoseassetsareexposedtostockmarketvolatility,andyettheycanstillcapturesomeupsidewithafootinthemarket.

Attentionhastobepaidtotaxefficiency.Manypeoplehaveamassedsizableretirementsavings,yetgivelittlethoughtastotheorderoftheirwithdraw-als.Generallyspeaking,thereiswisdomintakingmoneyoutoftaxableaccountsfirst,thentax-deferredaccountsandlastlytax-exemptaccounts.Thiswith-drawalordergivestheassetsinthetax-deferredandtax-exemptaccountssomeadditionaltimetogrow.Asmartlyconceivedwithdrawalsequencemayhelpyourretirementsavingstolastseveralyearslongerthantheywouldinitsabsence.2 Keepinghealthymighthelpyousavemoreintwoways.Increasingly,peoplewanttoworkuntilage70,orlonger.Manyassumetheycan,buttheirassump-tionmaybeflawed.The2012RetirementConfidenceSurveyfromtheEmployeeBenefitResearchInsti-tutefoundthat50%ofcurrentretireeshadlefttheworkforceearlierthantheyplanned,withpersonalorspousalhealthconcernsamajorfactor.3 Whenyoueatright,exerciseconsistentlyandseeadoctorregularly,youmaybebolsteringyourearn-ingpotentialaswellasyourconstitution.Healthproblemscanhurtyourincomestreamandreduceyourchancestogetajob,andmedicaltreatmentscaneatuptimethatyoucoulduseinotherways.GoodhealthcanmeanfewerERvisits,fewertreatmentsandfewerhospitalstays,allsavingyoumoneythatmightotherwisecomeoutofyourretirementfund.

Fidelityfiguresthatacoupleretiringnowatage65willspend$240,000(in2012dollars)onretirementhealthexpensesacrosstheirremainingyears.That$240,000doesn’tevenincludedental,over-the-coun-terdrugandlongtermcarecosts(andasareminder,manyeye,earanddentalcarecostsarenotevencoveredunderMedicareorbyMedigappolicies).Ev-eryyearyouworkmaymeananotheryearofhealthinsurancecoverageaswellasincome.4

Citations.1 individual.troweprice.com/staticFiles/Retail/Shared/PDFs/retPlanGuide.pdf [5/10]2 online.wsj.com/article/SB10001424052748703529004576160693310435366.html [3/7/11]3 www.dailyfinance.com/2012/09/03/postpon-ing-retirement-70-not-the-new-65/ [9/3/12]4 www.marketwatch.com/story/good-health-means-more-retirement-money-2012-12-06 [12/6/12]

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

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



Objectives1. Describeposttraumaticstressdisorder(PTSD)anditsassociatedsymptomsaccording toDSM-5diagnosticcriteria2. ReviewmedicationsthatmaybeusedtotreatPTSDbasedonNICEandVA/DoDtreatmentguide-lines3. Discussthemechanismofaction,dosing,andcommonsideeffectsofvariousmedicationsusedinthetreatmentofPTSDindetailalongwithspecificpatienteducationcounselingpoints

AbstractObjective: Afterreadingthisarticle,thereadershouldbeabletodescribesymptomsassociatedwithPTSD,listmedicationsusedintreatment,andbeabletoeducatepatientsonimportantcounselingpointswithregardtothesemedicationsinthetreatmentofPTSD.

Summary:Itisestimatedthatthelifetimeprevalenceofposttraumaticstressdisorder(PTSD)amongadultAmericansis6.8percent.Inveterans,thispercentageincreasesupto30percent.

TheDiagnosticandStatisticalManual,5thedition(DSM-5)discussesthesymptomclustersofPTSDwhichcanincludeintrusionsymptoms,avoid-ance,negativealterationsincognitionsandmood,andalterationsinarousalandreactivity.AccordingtoVA/DoDandNICEtreatmentguidelines,first-linetreatmentoptionsmayincludesertraline,fluoxetine,paroxetine,venlafaxine,mirtazapine,prazosinforPTSD-relatednightmares,andpsychotherapy.Otherpharmacologicoptionsthathaveshownsomebenefitincludephenelzine,nefazodone,andtricyclicantide-pressants(TCAs).Thereisinsufficientevidencetorecommenduseofothertreatmentssuchasanticon-vulsantsorantipsychoticsforadjunctivetherapyinPTSD.Finally,thereisevidenceagainsttheuseofbenzodiazepines(BZDs)inthetreatmentofPTSD.Withantidepressantmedications,severalsideeffectsmayoccursuchasanxiety,headache,nausea,diarrhea,antidepressantdiscontinuationsyndrome,andsexual

JOURNAL CEA Review of Pharmacotherapy for Posttraumatic Stress Disorder (PTSD) By Dr. Patricia H. Fabel, PharmD, BCPS, Clinical Assistant Professor in the Department of Clinical Pharmacy and Outcomes Sciences at the South Carolina College of Pharmacy (SCCP)

dysfunction.Itisimportantthatpatientsareeducatedonthesesideeffectsandthetreatmentstrategiestoalleviatethem.

Conclusion:ThetreatmentofPTSDcaninvolveavarietyofpharmacologicalandnon-pharmacologicalapproaches.Inorderfortreatmenttobemostsuccessful,patienteducationiskey.

Keywords: PTSD, antidepressant, prazosin, SSRI

Introduction Posttraumaticstressdisorder(PTSD)isoneofthemostcommonpsychiatricdisordersamongnationalmilitarypersonnel.Although50to90percentofthegeneralpopulationmaybeexposedtoatraumaticeventdur-inghisorherlifetime,mostindividualsdonotdevelopPTSD.1,2

TheNationalComorbiditySurveyReplication(NCS-R)estimatedthelifetimeprevalenceofPTSDamongadultAmericanstobe6.8percent.3Itisestimatedthatupto20percentofveteransoftheIraqandAfghanistanwars(OperationsIraqiandEnduringFreedom),10percentofGulfWar(DesertStorm)veterans,and30percentofVietnamveteranshavePTSD.1

ThereareseveralfactorsthatcanincreasetheriskofdevelopingPTSD.Someoftheseincludeifapersonwasdirectlyexposedtothetraumaasavictimorwitness,ifthetraumawasverysevereorlong-lasting,orifapersonhadaseverereactionduringtheevent,suchasshakingorfeelingapartfromthesurroundings.4,5TherearealsoseveralcomorbiditiesassociatedwithPTSDincludinggeneralizedanxietydisorder(GAD),majordepressivedisorder(MDD),substanceusedisorder,andalcoholabuseordependence.3Ithasbeenshownthat60to80percentofVietnamveteransseekingPTSDtreatmenthaveanalcoholuseproblem.6Thereasonforthishighpercentageislikelyduetothedepressanteffectsofalco-hol.AlthoughthepathophysiologyofPTSDisnotquiteunderstood,thereareseveraltheories.Theoriesinclude:alteredglutamatergicprocesseswithrespecttoinforma-


JOURNAL CEtionprocessing,alteredmemoryfunction,abnormalincreasesinsympatheticnervoussystemactivity,dys-regulationofthehypothalamic-pituitary-adrenalaxis(HPA),andabnormalserotonin(5-HT)activity.7

Symptoms of PTSDIntheUnitedStates,theDiagnosticandStatisti-calManual(DSM)servesasageneralguideforthediagnosisofpsychiatricdisorders.IthasrecentlybeenupdatedandwasreleasedinMay2013.8ThereweresomemajorchangeswithregardtothediagnosticcriteriaforPTSD.First,PTSDisnolongerconsideredananxietydisorder.Itisnowlistedunder“TraumaandStressor-RelatedDisorders.”InsteadofPTSDconsist-ingofthreesymptomclustersasitdidinDSM-IV,theupdatedDSM-5dividesitintofoursymptomclusters.Theseincludeintrusionsymptoms(e.g.distressingmemories,dreams,orflashbacks),avoidance(e.g.avoidingplacesorpeoplethatremindthepersonofthetraumaticevent),negativealterationsincognitionsandmood(e.g.inabilitytorememberanimportantaspectoftheevent,feelingdetachedfromothers,ornega-tivebeliefs),andalterationsinarousalandreactivity(e.g.irritablebehavior,hypervigilance,problemswithconcentration,recklessbehavior,orsleepdisturbance).Symptomsinthelastclustermaybesimilartosymp-tomsconsistentwithbipolardisorderorattention-deficit/hyperactivitydisorder(ADHD).Therefore,itisimportantthatthesediagnosesberuledoutbeforeadiagnosisofPTSDismade.

Inadditiontoassessingforsubjectivesymptomsasnotedabove,itcanalsobehelpfultoadministerthePTSDChecklist(PCL).9,10TherearedifferentversionsofthePCLincludingacivilianandamilitaryversion(PCL-CorPCL-M).Thisscaleisa17-item,standard-izedself-reportratingscalethattakesonlyfivetotenminutestocomplete.ItcanbeusedtodeterminetheseverityofPTSDoverallortodeterminewhichsymp-tomclustersaremostbothersome.Ifdesired,treatmentcanbeguidedbythepatient’sPCLscore.Overall,atento20pointchangefrombaselineisconsideredclini-callysignificant.Aclinicallysignificantchangemeansthatthetreatmentbeingutilizediseffective.

TreatmentThereareseveraltreatmentguidelinesforPTSD.TheseincludetheAmericanPsychiatricAssociation(APA)(2004),theBritishAssociationforPsychopharmacol-ogy(2005),CanadianPsychiatryAssociation(2006),WorldFederationofSocietiesofBiologicalPsychiatry(WFSBP)(2008),VeteransAssociationDepartmentof

Defense(VA/DoD)(2010),andtheNationalInstituteforHealthandClinicalExcellence(NICE)(2011)treatmentguidelines.TheremainderofthediscussionwillfocusontreatmentsforPTSDaccordingtoboththeVA/DoDandNICEguidelinesasthesearethemostcurrent.11,12

AntidepressantsMosttreatmentguidelineslistantidepressants,suchasselectiveserotoninreuptakeinhibitors(SSRIs),asfirst-linetreatmentconsideringtheseagentsareeffec-tiveforallsymptomclustersofPTSD.IntheVA/DoDguidelines,fluoxetine,sertraline,andparoxetinehavethelargestcollectionofevidencedemonstratingtheirefficacy.13Inaddition,venlafaxine,aserotonin-norepi-nephrinereuptakeinhibitor,isanotherfirst-lineagentandcanalsotreatallfoursymptomclusters.13,14 With regardtonon-pharmacologicaltreatment,psychotherapyisconsideredtobefirst-linealoneorinconjunctionwithpharmacotherapy.Theevidence-basedpsychotherapeu-ticoptionsforPTSDthataremoststronglysupportedbyrandomizedcontrolledtrialsincludeprolongedexpo-sure(PE),cognitiveprocessingtherapy(CPT),andeyemovementdesensitizationandreprocessing(EMDR)orstressinoculationtraining.11IfpatientsdonotrespondtoaspecificSSRIorvenlafaxine,theprovidershouldswitchtoanotheragent(e.g.,analternativeSSRIorven-lafaxine)and/oraddpsychotherapy.Ifthepatientfailstoclinicallyrespond,theprovidercanswitchtomirtazap-ineand/orpsychotherapy.Finally,ifthepatientisstillnotrespondingtotreatment,thelaststepistoswitchthepatienttophenelzine,nefazodone,oratricyclicantide-pressant(TCA)andaddpsychotherapy.Mirtazapine,phenelzine,nefazodone,andTCAshavebeenshowntobeeffectiveforallsymptomsclusterswiththeexceptionofavoidance.11

Interestingly,theNICEguidelinesdonotrecommendpharmacologicaltreatmentasfirst-linetherapyunlesstheindividualrefusestrauma-focusedpsychologicaltreatment(e.g.trauma-focusedcognitivebehavioraltherapy[CBT]orEMDR).Iftheindividualdecidestoproceedwithpharmacologicaltreatment,paroxetineormirtazapinearethepreferredagentsifprescribedbyageneralprovider.Amitriptylineorphenelzinemayalsobeanoption,buttheseagentsshouldonlybeprescribedbyamentalhealthspecialist.12 InitialandmaximumdosesoftheseagentsalongwiththeirtitrationschedulesarelistedinTable1.Patientsshouldbeeducatedonan-tidepressanttherapypriortoinitiation.Educationshouldincludepotentialsideeffectsandstrategiestoalleviatethesesideeffects,thedelayinonsetofactionandtheamountoftimeneededtoachievearesponse,andthe


JOURNAL CEriskofdiscontinuation/withdrawalsyndrome.

Mechanism of Action and Side Effects of Antide-pressants SSRIs/SNRIs15,16Selectiveserotoninreuptakeinhibitors(SSRIs)actontheserotonintransporter(SERT)pump.InhibitionoftheSERTresultsinanincreaseofserotonininthe

body.Serotonin-norepinephrinereuptakeinhibitors(SNRIs)actinasimilarfashion,howevertheyalsoinhibitthereuptakeofnorepinephrineinadditiontoserotonin.

ThemainsideeffectsofSSRIsandSNRIsincludenausea,diarrhea,headache,dizziness,sexualdys-

24

Table 1: Doses of Medications Commonly Used in the Treatment of PTSD11,12,16

Antidepressant Generic (Brand)

Initial dose (mg/day)

Titration Maximum dose (mg/day)

Fluoxetine (Prozac) 10 10– 20mg every2weeks 60

Sertraline (Zoloft) 25 Increase by 50mg within1week, thenby 25– 50mg every 1 – 2weeks

200

Paroxetine (Paxil) 10 10mg every 2weeks 60

Venlafaxine(Effexor or EffexorXR)

37.5 Increase to75mg within the first week,thenby 37.5 – 75 mg every 2 weeks

375(IR) 225 (XR)

Mirtazapine(Remeron) 15 15mg every 2weeks 60

Phenelzine(Nardil) 15 15mg every4days as tolerated 75

Nefazodone(Serzone) 200 100– 200mg (in2divideddoses) everyweek

600

Amitriptyline(Elavil) 25– 100 25– 50mgeveryweek 300

Desipramine(Norpramin) 100– 200 100mg everyweek 300

Nortriptyline(Pamelor) 50 25– 50mg everyweek 150

Prazosin(Minipress) 1 Days 1 – 3:1mg Days 4 – 7:2mg Week2: 4 mg Week3: 6 mg Week4: 10mg *After week4,thedose canbeincreasedby 5mg incrementsuntilsymptoms are resolved *Iftherapyisinterruptedfor3ormoredays,thenreinitiateatthelowestdoseandre-titrateaccordingtoschedule

20 (or higherif

needed/tolerated)

*IR=immediaterelease;XR=extendedrelease


JOURNAL CEfunction,and/orwhatisknownas“jitterinesssyn-drome.”JitterinesssyndromemayoccurwheninitiatingaSSRI/SNRIandincludesshakinessortremor,increasedanxiety,andinsomnia.17Somecommontreatmentstrate-giesforjitterinesssyndromeincludeusingalowerinitialdoseorslowertitration.

Therearespecificsideeffectsassociatedwitheachantidepressantmentionedpreviously.Fluoxetineiscon-sideredtobethemoststimulatingSSRI.Therefore,forsomepatients,thisagentcanpotentiallyworsenanxietyorirritability.Itisimportantthatfluoxetineisadminis-teredinthemorningasitcancauseinsomniaifdosedatbedtime.Inaddition,fluoxetineanditsmetabolitehavelonghalf-livesandtherefore,taperingisnotnecessarywhendiscontinuationofthisagentoccurs.Sertralinehasbeenshowntohaveahigherriskofgastrointestinaldiscomfort(e.g.,diarrhea/nausea)incomparisontootherSSRIs.Takingsertralinewithfoodmayhelpallevi-atethissideeffect.Paroxetinehasthehighestriskofsexualdysfunction,weightgain,andanticholinergicsideeffectssuchasdrymouthandconstipation.Italsohastheshortesthalf-lifeandcanleadtomorepronouncedwithdrawalsymptomsifthepatientmissesadose.TheSNRI,venlafaxine,mayalsobestimulatingforpatientsreceivinghigherdosesresultinginanxietyorirritabil-ity.Venlafaxinemayleadtoelevatedbloodpressureduetoanincreaseinnorepinephrine.Atlowerdoses(e.g.75mg/day),venlafaxineactsmostlyonserotonergicreceptorsversusadrenergicreceptorsandmaynotaffectbloodpressureascomparedtohigherdoses(e.g.150to225mg/day).Itisimportanttomonitorbloodpressureateachvisitifapatientisonvenlafaxine.Similartopar-oxetine,venlafaxinehasashorthalf-lifewhichcanleadtowithdrawalsymptomsuponabruptdiscontinuation.Therefore,thisantidepressantshouldbetaperedupondiscontinuation.

Sexualdysfunctionisaparticularlyconcerningsideef-fectthatcanoccurinupto70percentofpatientstakinganSSRI.18,19However,itisimportanttonotethatdepressionoranxietyitselfcancausesexualdysfunctionalongwithavarietyofotherhealthconditionsinclud-ingsmoking,alcoholuse,cardiovasculardisease,anddiabetes.Tohelpguidetreatment,aprovidershouldaskthepatienttodescribetheirsexualdysfunctioninmoredetail.Forexample,ifapatientishavingdifficultywithejaculation,phosphodiesterase-5(PDE-5)inhibitorswillnotbebeneficialastheseagentsareprimarilyeffectiveforerectiledysfunction(ED).Thesexualsideeffectsthatcanoccurwithantidepressanttherapyincludedelayedorgasm,anorgasmia,problemswithejaculation(e.g.,

delayedejaculation),anderectiledysfunction.Thereareseveralapproachestothetreatmentofsexualdysfunc-tion.18,19Oneapproachtotreatmentisthe‘watchandwait’strategy.Withinsixmonths,ithasbeenshownthatroughlytenpercentofpatientsreportremissionofsexualdysfunctionandimprovementmaybenotedinupto15to20percentofpatients.Loweringthedoseoftheantidepressantmaybeconsidered,althoughthereisariskofworseningPTSDand/ordepressivesymptoms.StudiesonPDE-5inhibitorsandbupropionareconflict-ing,however,aprovidermayaddeitherasanadjunc-tivetherapeuticoption.Anotherstrategytoconsiderisswitchingtheantidepressanttoonewithalowerriskofsexualdysfunction(e.g.,bupropion,mirtazapine,ornefazodone).Ofnote,bupropionisastimulatingantide-pressantthatmayleadtoworseningofPTSDsymptoms.Inaddition,thereisaninsufficientamountofliteraturesupportingitsuseinPTSD.Finally,sincethereisariskofseizureswithbupropion,itisnotrecommendedinpatientswithahistoryofseizuredisorder.AsummaryofantidepressantsideeffectsandtreatmentapproachescanbefoundinTable2.

Other Antidepressant Agents15,16

OtherantidepressantsthatcanbeusedinthetreatmentofPTSDincludemirtazapine,phenelzine,nefazodone,ortricyclicantidepressants(TCAs).Throughnegativefeedback,mirtazapineincreasesthelevelsofserotoninandnorepinephrinebyblockingpre-synapticalpha-2receptors.Mirtazapinealsoactsasanantagonistatserotonin-2Aand2C(5-HT2Aand5-HT2C),sero-tonin-3(5-HT3),andhistamine-1(H1)receptors.Duetotheblockadeof5-HT2and5-HT3receptors,5-HT1mediatedtransmissionisenhanced.MirtazapinehasalowerriskforsexualdysfunctionascomparedtoSSRIsandSNRIswhichisbelievedtobeattributedtoitsef-fectson5-HT1and5-HT2receptors.Inaddition,duetothepotentblockadeoftheH1and5-HT2Creceptors,mirtazapinecanbequitesedating,mayincreaseappe-tite,andcauseweightgain.Thisagentshouldbedosedatbedtime.Interestingly,whenmirtazapineisusedatlowerdoses(e.g.,7.5mg/day),itismorelikelytocausesedationandweightgaincomparedtohigherdoses(e.g.,15-30mg/day).Thehigherdosesofmirtazapinetendtobelesssedating,lesslikelytocauseweightgain,andmorelikelytobeefficaciousformood.Phenelzineisamonoamineoxidaseinhibitor(MAO-I).ThisagentinhibitstheactivityoftheMAOenzyme,whichbreaksdownmonoamineneurotransmittersincludingnorepinephrine,dopamine,andserotonin.IfapatientisinitiatedonaMAO-I,astrictdietmustbefollowedinwhichfoodshighintyraminecontentmust


JOURNAL CE

belimitedoravoidedaltogether(e.g.,agedcheese,processedmeats).Tyraminecantriggeracascadewhichmaycauseariseinnorepinephrineinthebody.There-fore,ifapatientdoesnotadheretothisdiet,thenahy-pertensivecrisiscanresult.Inaddition,priortostartinganMAO-I,awash-outperiodof14daysisusuallyrec-ommendedifapatientisbeingswitchedfromanotherantidepressant.Sincefluoxetinehasalongerhalf-life,itisrecommendedtowaitatleastfiveweeksafterstop-pingthisagentpriortoinitiatingaMAO-I.OthersideeffectsofMAO-Isincludedrymouth,constipation,orthostatichypotension,andinsomnia.Nefazodoneisanantidepressantthatissimilartotra-zodoneintermsofitsmechanismofaction,howeveritalsoactsuponnoradrenergicreceptors,hasaloweraffinityforalpha-1receptors,andlackshistamineactivity.Nefazodoneincreaseslevelsofserotoninandnorepinephrine,antagonizes5-HT2andslightlyantago-nizesalpha-1receptors.Asaresult,thereisalowerriskforbothsexualdysfunctionandposturalhypotension.Thereisablackboxwarningforhepatotoxicitywhich

warrantsthemonitoringofliverfunctionperiodicallythroughouttreatment.Nefazodoneisalsoapotentinhibi-torofCYP3A4,therefore,potentialdrug/druginterac-tionsshouldbemonitored.Tricyclicantidepressants(TCAs)includeagentssuchasamitriptyline,imipramine,nortriptyline,anddesipramine.Withregardtotheirmechanismofaction,theseagentsareverysimilartoSNRIsastheycanincreasebothsero-toninandnorepinephrinelevels.TheTCAsaremetabo-lizedtosecondaryandtertiaryamines.Thesecondaryamines(desipramineandnortriptyline)aremorepotentatnoradrenergicreceptorsandarethoughttohavealowerincidenceofsideeffectsascomparedtotertiaryamines.TCAsalsoactonseveralotherreceptorsincludingH1,alpha-1,andacetylcholinereceptors.Severalsideeffectscanresultfromthisreceptorbindingprofileincludingsedation,orthostatichypotension,blurredvision,drymouth,andconstipation.Inaddition,thereisawarningforpotentialcardiacsideeffectssuchasventricularar-rhythmiasandtachycardia.Duetothesevariousreasons,TCAshavethepotentialtobetoxicinoverdoseand

25

Table 2: Side Effects Associated with Antidepressants and Treatment Strategies17-19

Side Effect

Strategy

Anxiety Startwith a lowerdose and titrateslowly

Insomnia or sedation Adjusttimeof day that patient takesthemedication

Headache Take atbedtime.Ofnote,antidepressantsmay causeinsomniaif dosedatbedtime.

Nausea Take withfood

Diarrhea May go away withcontinuedtreatment;however,may needtoswitch to another antidepressant

Sexual dysfunction “Watch andwait” Reduce thedose ofthe antidepressant Switchtoanother antidepressant that haslower riskof

sexual dysfunction(e.g.,mirtazapine,bupropion,ornefazodone)

Adjunctivetherapy withaPDE-5inhibitorifthe issue iserectiledysfunction;adjunctivetherapy with bupropion


JOURNAL CEareusuallynotrecommendedinpatientswithsuicidalideation.

Time to Effect for AntidepressantsItisimportantthatpatientsareeducatedonthelengthoftimeitcantakeforanantidepressanttobeeffective.Contrarytothebeliefthattheseagentsworkimmedi-ately,itmaytakeuptofourtosixweeksatanadequatedosetoseemoodimprovement.15,16Anadequateantide-pressantdosecanbelooselydefinedastheminimallyeffectivetolerateddosethathasbeenshowntoimprovesymptomsinclinicaltrials.15Therefore,anadequatedoseofanantidepressantmaybedifferentforeachindividual.Theinitialdoseofanantidepressantisnotlikelytobeanadequatedoseandshouldbeincreasedifneeded/toler-ated.

Almostimmediatelyhowever,patientsmaynoticesideeffectssuchasdiarrhea,nausea,oranxiety.15,16Thesesideeffectsusuallydissipatewithinafewdaystoaweek.Thisisanimportantcounselingpointsincepatientswhostartanantidepressantmaydevelopsideeffectsearlyon,butshownoimprovement.Patientsmaydiscontinuetheirmedicationbecausetheybelieveitisnoteffective.WithdrawalsymptomsmayoccurandmayalsoleadtopoorcontrolofPTSD.

Antidepressant Discontinuation SyndromePatientsshouldbecounseledtoavoidabruptdiscon-tinuationofanantidepressantmedicationasitcanleadtowhatisknownasantidepressantdiscontinuationorwithdrawalsyndrome.Symptomsofthissyndromeincludenausea,flu-likesymptoms,tremor,anxiety,and/or“electricshock”sensationsthroughoutthebodyandhead.20Thissyndromeismostcommonwithantidepres-santsthathaveashorterhalf-lifesuchasparoxetineandvenlafaxineandleastlikelytooccurwithfluoxetinetherapy.Other Medications Used in the Treatment of PTSDOtherclassesofmedicationsthatarecommonlyusedinthetreatmentofPTSDincludeantipsychoticsandanti-convulsants.Ofnote,noneoftheagentsintheseclassesareFDAapprovedforthetreatmentofPTSD.

Second Generation Antipsychotics (SGAs)IntheVA/DoDtreatmentguidelines,secondgenerationantipsychotics(SGAs)asadjuncttherapiesarelistedas“unknownbenefit.”TheNICEguidelineslistrisperidoneandolanzapineashaving“limitedevidence”asadjuncttherapy.Therehavebeentenpublishedrandomizedcontrolledtrialsexaminingolanzapineandrisperidoneandtwotrialsexaminingquetiapineasadjuncttherapy

inPTSD.21-32Oneofthemaindrawbacksofthesetrialsisthesmallnumberofpatientsstudied(n=15to48).Inaddition,notallofthetrialsinvolvethecombatveteranpopulation.Insummary,theresultsofthesestudiesarevariableandthedetailscanbeviewedelsewhere.11,21-32

Onerandomized,multicenterdouble-blind,placebo-controlledVAstudyinvolvingnearly300patientswasperformedin2011.27ThiswasthelargestcontrolledtrialtodateexaminingaSGAasadjunctivetherapyinPTSD.Veteransreceivedrisperidoneupto4mgperdayasadjunctivetherapyversusplaceboforchronicmilitaryservice-relatedPTSD.TheprimaryendpointwasachangeinClinician-AdministeredPTSDScale(CAPS)scorefrombaselineto24weeks.Achangeof15pointsintheCAPSscorewasconsideredtobeclinicallysignificant.TheresultsofthisstudyfoundthatrisperidonewasnobetterthanplaceboinreducingPTSDsymptoms.Afterthisstudy,anupdatewasmadetotheVA/DoDtreatmentguidelineswhichnowspecificallylistrisperidoneas“nobenefit”versusotherSGAswhichstillarelistedas“unknownbenefit.”BothVA/DoDandNICEtreatmentguidelinesconcludethatthereisinsufficientevidencetorecommendtheuseofanySGAasadjuncttherapyinthetreatmentofPTSD.ItshouldalsobenotedthatpatientswithPTSDmayhavepsychoticfeaturesasapartofthissyndrome.Thereisalackofsufficientdatainthisarea.PsychoticsymptomsmustfirstbedifferentiatedaspartofPTSDorduetoacomorbidpsychoticdisorder.IfthesymptomsarethoughttobepartofPSTD,thetreatmentofchoiceisaSSRI.IfapatientfailstorespondtoSSRItherapy,aSGAmaybeusedtoaugmenttherapy.11Nodataareavailableontheuseoffirstgenerationanti-psychotics(FGAs)inthetreatmentofPTSD.IfPTSDisthoughttobeacomorbidconditionwithapsychoticdisorder,anantipsychotic(eitherSGAorFGA)shouldbeinitiated.11

TherearesomestudiesexaminingtheuseofSGAsforthetreatmentofinsomniaornightmaresinPTSD.How-ever,datasupportingtheuseofSGAsforthetreatmentofnightmaresinPTSDissparsecomparedtoprazosin.Onestudyexaminedprazosinversusquetiapine.33 This cohort studyinvolving237veteransfoundthatthetwodrugshadsimilarefficacywhichwasdefinedassymptomaticimprovementoverthecourseofsixmonths(61%versus62%,p=0.54).However,ahigherpercentageofpatientscontinuedonprazosinlong-term(threetosixyears)ver-susthosetakingquetiapine(48%versus24%,p<0.001).Patientsweremorelikelytodiscontinuequetiapineduetolackofefficacy(13%versus3%,p=0.03)andadverseeffects(35%versus18%,p=0.008)comparedtoprazosin.


Overall,thereareseveralrisksassociatedwithSGAs,includingweightgain,elevationsinlipidandbloodglu-coselevels,hypotension,cardiaceffects,andmovementdisorders.15,16Therefore,SGAsarereservedasalast-linetreatmentoptionforPTSDthathasnotrespondedtofirstlinetherapiesortotreatcomorbidpsychoticsymptomsinPTSD.

Anticonvulsants TheVA/DoDandNICEtreatmentguidelinesstatethereisinsufficientevidencetorecommendananticonvulsantasadjunctivetherapyforthetreatmentofPTSD.How-ever,moodstabilizersmayhaveapossibleroleinPTSDforpatientswhohavespecificintrusionsymptoms,suchasre-experiencingandhyperarousal,andmayevenhelptreataffectiveinstability.11,12Therehavebeenseveralopen-labelandrandomizedcontrolledtrialsexamin-ingdivalproex,carbamazepine,lamotrigine,topiramate,lithium,andphenytoinwhichhavedemonstratedmixedorlimitedefficacy.Itappearsthatdivalproexhasthemostliterature,althoughresultsarevaried.34,35Ameta-analysiswasperformedin2007whichexamineddivalproexasadjuncttherapyforthetreatmentofPTSD.Itinvolvedonesingle-blindedstudy,fouropen-labelstudies,andthreecasereports.Theanalysisdemonstratedthatdi-valproexcouldbebeneficialinreducinghyperarousal,improvingirritability,angeroutburstsandmood.36Un-fortunately,thesestudiesweresmallinnumberanddidnotincludeanydouble-blindtrials.Thedoserangedfrom1250–1400mgperday,butthedoseistypicallybasedonweight(target10-15mg/kg/day).Adverseeffectsmayincludesedation,nausea,weightgain,thrombocytopenia,alopecia,andpancreatitis.16

BenzodiazepinesAllguidelinesrecommendagainsttheuseofbenzodiaz-epines(BZDs)inPTSD.ThereisnoevidencethatBZDsreducecoresymptomsofPTSD.Theuseoftheseagentscaninterferewiththeextinctionoffearconditioningandworsenrecoveryfromtrauma.11Fearconditioningisabehavioralmodelinwhichpeoplelearntopredicthostileevents.PatientswhohavePTSDoftenhavealterationsinarousalandreactivity.Therefore,theymaymisinterprettheirsurroundingsasahostileenvironment.Benzodiaz-epinescaninterruptrestructuringofthisthoughtpro-cess.11Inaddition,thereisahighpercentageofpatientswithPTSDwhoalsohaveasubstanceusedisorderand/orhistoryofatraumaticbraininjury(TBI).3,6This is con-cerningbecauseanincreasedriskofrespiratorydepres-sionmayoccurwhencombiningBZDswithalcoholoropioids.InpatientswhohaveahistoryofTBI,BZDscancauseparadoxicalagitation/aggression.37IntheVA/DoD

treatmentguidelines,BZDsarelistedas“nobenefit/harm.”Unfortunately,ifapatientisalreadyonaBZD,itcanbedifficulttowithdrawtheagent.Thediscon-tinuationofaBZDcanresultinanxiety,sleepdistur-bances,rage,hyperalertness,increasednightmares,andintrusivethoughts.Thesewithdrawalsymptomshavebeenreportedafteraslittleasfiveweeksoftherapy.16ABZDshouldneverbediscontinuedabruptly.WhendiscontinuingaBZD,thetaperscheduledependsonthelengthoftimethepatientwasontheBZD.Forex-ample,ifapatientwaspreviouslyonaBZDforgreaterthanoneyear,thetapercanoccurovertwotofourmonths.Ageneralruleofthumbfordiscontinuationtoavoidwithdrawalistoreducethedoseby50percentthefirsttwotofourweeksandmaintainthatdoseforonetotwomonths.Then,reducethedoseby25percenteverytwoweeks.38

Prazosin for the Treatment of NightmaresPatientswhoexperiencetheintrusionsymptomofnightmareswithPTSDshouldbetriedonprazosinther-apy.Thisagentisconsideredtobethefirst-lineoptionforPTSD-relatednightmaresandhasbeenshowntobemoreeffectiveversusquetiapineasnotedabove.33Incombat,arushofadrenalineornorepinephrinecanoc-curandhelpsoldiersstayalert.Unfortunately,thismaybecomepersistentandmaladaptiveinnormalsituationsinwhichthisrushofadrenalineisnotneeded.Prazosincannormalizethearousalresponsetonorepinephrineinlowthreatenvironments.39Itisacentrallyactivealpha-1adrenergicantagonistthatisFDAapprovedforthetreatmentofhypertension.16Prazosinisthoughttobethemosteffectivealphaantagonistduetoitshighli-pophilicity.Ithastheabilitytopenetratethebloodbrainbarriertoagreaterextentthandoxazosinandterazosinwhichcrossthebloodbrainbarrierpoorly.40However,prazosinhasashorthalf-life(twotothreehours)anditsdurationofactionrangesfromsixtotwelvehours.16 As aresult,morefrequentdosingmaybeneededtoman-agehyperarousalsymptomsduringtheday.

PrazosinwasoriginallyexaminedbyDr.Raskindin1995.ItwasfirstthoughtthatPTSD-relatednightmaresweretheresultofageneraladrenergiceffect.However,itwasnotedthatwhenpropranololwasadministered,abeta-adrenergicantagonist,nightmaresbecameworse.Incontrast,whenprazosinwasadministered,itwasquiteeffective.41Intheopen-labelcasestudythatwasperformed,fourcombatveteranswithPTSDweretreatedfor8weekswithprazosin.42 NightmareseveritywasmeasuredusingthenightmareitemfromtheCAPSandClinicalGlobalImpressionofchange(CGI)scale.Twopatientsachievedadailydose

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of5mgperdayofprazosin.Thesepatientsmarkedlyimprovedandhadcompleteresolutionofnightmares.Theothertwopatientsreceived2mgdailyduetohavinglowbloodpressureatbaseline.Thepatientsthatreceivedthelowerdoseofprazosinmoderatelyimprovedandhadatleasta50percentreductioninnightmareseverity.Therehavebeenseveralstudiessinceinvolvingprazo-sinthathavedemonstratedbothsafetyandefficacyintrauma-relatednightmares,sleepdisturbances,andover-allPTSDseverityandfunction.43-45DespitethefactthatprazosinhasbeenshowntobehelpfulforglobalPTSDsymptoms,thegoalofthestudieswastoevaluatethetargetedsymptomsofnightmaresandsleepdisturbances.Therefore,theVA/DoDtreatmentguidelinescurrentlylistprazosinas“unknown”forthetreatmentofglobalPTSDsymptoms.

BasedonthestudiesfromRaskindetal.,theinitialdoseofprazosinshouldbe1mgatbedtime,andtheaveragedoserangesfrom9to13mgperday.Althoughthemaxi-mumdoseislistedas20mgperdayforhypertension,somepatientsmayrequireahigherdoseifneededandtolerated.Divideddosingofprazosintomanagedaytimehyperarousalsymptomsiscurrentlybeingstudied.Sideeffectsofprazosinincludehypotension,dizziness,andheadache.16Aslowtitrationcanhelptoreducetheseadverseeffects.Oncethedoseisincreasedupto6mgatbedtime,patientsareusuallyabletotoleratehigherdoseswhentitrated(seeTable1).Animportantcounsel-ingpointforpatientsistotakeprazosinonadailybasis,notasneeded.Ifpatientsdiscontinueprazosin,thenightmaresandhyperarousalsymptomsusuallyreturn.Finally,inorderforprazosintobemosteffective,thedreamsshouldbetraumanightmaresthatreenacttheeventandincludesympatheticarousal(e.g.,sweating,racingheart)versusnormalbizarredreams.Prazosinwillnoteliminatedreamsaltogether,butchangestraumaticnightmarestonormaldreams.41 Onemajordruginteractiontobeawareofisthecombi-nationofprazosinandanotheralphaantagonistsuchasterazosinordoxazosinoftenusedforbenignprostatichypertrophy(BPH).16,46Thiscombinationisconsideredtobeaduplicationintherapy.Tomanagethisdrug/druginteraction,itisrecommendedtoswitchfromterazosinordoxazosintoprazosinmonotherapy.Theconversionis1:1forterazosintoprazosin,and1:1fordoxazosintoprazosin(except4mgdoxazosin=5mgprazosin).However,fordosesgreaterthan4or5mg/dayfordoxa-zosinandterazosin,oneshouldstartwithprazosin5mgatbedtimeandtitrateupifneeded.16

Other Medications for the Treatment of PTSD-Relat-

ed Nightmares ThereareseveralothermedicationsthatmaybeusedinthetreatmentofPTSD-relatednightmares,butthedataarelowgradeandsparse.Potentialtreatmentsincludetrazodone,SGAs,topiramate,fluvoxamine,phenelzine,gabapentin,cyproheptadine,clonidine,andTCAs(LevelCevidence–assessmentissupportedbylowgradedatawithoutthevolumetorecommendmorehighlyandlikelysubjecttorevisionwithfurtherstudies).47 Withregardtocyproheptadine,afewopen-labeltrialssuggestthatthisantihistaminemaybeapotentialop-tionfornightmares.48,49CyproheptadineactsasaH1and5-HT2receptorantagonist.Ithasbeenshownthat5-HT2antagonistsincreasestagesofslow-wavesleepwithoutalteringtotalsleeptimeandcanimprovesleepout-comes.50,51Mostoftheothertrialsexaminingcyprohep-tadinearesmallandopen-label.52-54Thedosecanrangefrom4mgto24mgatbedtimeandresultsareusuallyseenwithinafewdaysoftreatment.Sideeffectsincludedizziness,increasedappetite,andsedation.Intheory,thereissomeconcernthatcyproheptadinecanreversetheeffectsofaSSRI,althoughthishasnotbeenclinicallydemonstratedinstudies.

Clonidineisanalpha-2agonistthatisthoughttoworkbydecreasingcentrallymediatedadrenergicactivitywhichmayhelpalleviatePTSDarousalsymptoms(LevelCevidence).47Inanopen-labeltrialperformedin2007,thedoseof0.2to0.6mgdailyimprovedintrusivesymptoms,startle,anger,vigilance,andnightmares.55Commonsideeffectsofclonidineincludelowbloodpressure,reboundhypertension,drymouth,andsedation.16

ConclusionInsummary,althoughthereisclearevidencefortheuseofcertainantidepressantsandprazosininthetreatmentofPTSDandPTSD-relatednightmares,respectively,thereislimitedevidencewithregardtootheragentsincludingantipsychoticsandanticonvulsants.PrazosinmaynotonlybehelpfulintreatingPTSD-relatednightmaresbutalsoforhypervigilanceduringthedayandimprovingoverallglobalPTSDsymptoms.Theroutineuseofprazo-sinforthelatterindicationswilldependonfuturestudies.Thereareseveralimportantcounselingpointswitheachmedicationthatpatientsshouldbemadeawareofifanyoftheseagentsareprescribed.Ifpatientsknowwhattoexpectwithvarioustreatments,theyaremorelikelytobeadherentwiththeirmedicationsandultimatelyimprovetheirhealth-relatedoutcomesforPTSD.

References1. Kessler, RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Post-traumatic stress disorder in the National Comorbidity Survey. Arch Gen

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Psychiatry. 1995;52(12):1048-60.2. Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry. 1998;55:626–32. 3. Kessler RC, Berglund P, Delmer O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disor-ders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.4. Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, Marmar CR, et al. Trauma and the Vietnam War Generation: Report of Find-ings from the National Vietnam Veterans Readjustment Study. J Trauma Stress. 1992;5(2):321-22.5. Tanielian T, Jaycox L. editors. Invisible Wounds of War: Psychologi-cal and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica: RAND Corporation; 2008.6. Evans K, Sullivan JM. Treating addicted survivors of trauma. New York: Guilford Press 1995. 7. 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Butterfield MI, Becker ME, Connor KM, Sutherland S, Churchill LE, Davidson JR. Olanzapine in the treatment of post-traumatic stress disorder: a pilot study. Int Clin Psychopharmacol. 2001;16(4):197-203.22. Petty F, Brannan S, Casada J, Davis LL, Gajewski V, Kramer GL, et al. Olanzapine treatment for post-traumatic stress disorder: an open-label study. Int Clin Psychopharmacol. 2001;16(6):331-7.23. Stein MB, Kline NA, Matloff JL. Adjunctive olanzapine for SSRI-resistant combat-related PTSD: a double-blind, placebo-controlled study. Am J Psychiatry. 2002;159(10):1777-9.24. Hamner MB, Deitsch SE, Brodrick PS, Ulmer HG, Lorberbaum JP. Quetiapine treatment in patients with posttraumatic stress disorder: an open trial of adjunctive therapy. J Clin Psychopharmacol. 2003b;23:15-20.25. Sokolski KN, Denson TF, Lee RT, Reist C. Quetiapine for treatment of refractory symptoms of combat-related post-traumatic stress disorder. Military Med. 2003;168(6):486-9.26. Bartzokis G, Lu PH, Turner J, Mintz J, Saunders CS. Adjunctive risperidone in the treatment of chronic combat-related posttraumatic stress disor-der. Biol Psychiatry. 2005;57:474-9.27. Krystal JH, Rosenheck RA, Cramer JA, Vessicchio JC, Jones KM, Vertrees JE, et al. Adjunctive risperidone treatment for antidepressant-resistant symptoms of chronic military service-related PTSD: a randomized trial. JAMA. 2011 Aug 3;306(5):493-502.28. Hamner MB, Faldowski RA, Ulmer HG, Frueh BC, Huber MG, Arana GW. Adjunctive risperidone treatment in post-traumatic stress disorder: A preliminary controlled trial of effects on comorbid psychotic symptoms. Int Clin Psychopharm. 2003a;18:1-8.

29. Monnelly EP, Ciraulo DA, Knapp C, Keane T. Low-dose risperidone as adjunctive therapy for irritable aggression in posttraumatic stress disorder. J Clin Psychopharmacol. 2003;23:193-6.30. Padala PR, Madison J, Monnahan M, Marcil W, Price P, Ramaswamy S, Din AU, Wilson DR, Petty F. Risperidone monotherapy for post-traumatic stress disorder related to sexual assault and domestic abuse in women. Int Clin Psychopharm. 2006;21:275-80.31. Reich DB, Winternitz S, Hennen J, Watts T, Stanculescu C. A prelimi-nary study of risperidone in the treatment of posttraumatic stress disorder related to childhood abuse in women. J Clin Psychiatry. 2004;65:1601-6. 32. Rothbaum BO, Killeen TK, Davidson JR, Brady KT, Connor KM, Heekin MH. Placebo-controlled trial of risperidone augmentation for selective serotonin reuptake inhibitor-resistant civilian posttraumatic stress disorder. J Clin Psychiatry. 2008;69:520-5.33. Byers MG, Allison KM, Wendel CS, Lee JK. Prazosin versus quetiap-ine for nighttime posttraumatic stress disorder symptoms in veterans: an assess-ment of long-term comparative effectiveness and safety. J Clin Psychopharmacol. 2010;30(3):225-9.34. Davis LL, Davidson JR, Ward JC, Bartolucci A, Bowden CL, Petty F. Divalproex in the treatment of posttraumatic stress disorder: a randomized, double-blind, placebo- controlled trial in a veteran population. J Clin Psycho-pharmacol. 2008 Feb;28(1):84-8.35. Hamner MB, Faldowski RA, Robert S, Ulmer HG, Horner MD, Lorberbaum JP. A preliminary controlled trial of divalproex in posttraumatic stress disorder. Ann Clin Psychiatry. 2009 Apr-Jun;21(2):89-94.36. Adamou M, Puchalska S, Plummer W, Hale AS. Valproate in the treatment of PTSD: systematic review and meta analysis. Curr Med Res Opin. 2007;23:1285-91. 37. Arciniegas DB, Anderson CA, Topkoff J, McAllister TW. Mild trau-matic brain injury: a neuropsychiatric approach to diagnosis, evaluation, and treatment. Neuropsychiatr Dis Treat. 2005 December;1(4):311–27. 38. Shelton RC. Steps following attainment in remission: discontinuation of antidepressant therapy. Prim Care Companion J Clin Psychiatry. 2001;3:168-74.39. Boehnlein JK, Kinzie JD. Pharmacologic reduction of CNS noradren-ergic activity in PTSD: the case for clonidine and prazosin. J Psychiatr Pract. 2007 Mar;13(2):72-8.40. Menkes DB, Baraban JM, Aghajanian GK. Prazosin selectively antag-onizes neuronal responses mediated by alpha1-adrenoceptors in brain. Naunyn Schmiedebergs Arch Pharmacol. 1981;317:273–5.41. Keller DM. Prazosin relieves nightmares and sleep disturbance in PTSD. EPA 2012: 20th European Congress of Psychiatry: Abstract P-1094. Presented March 6, 2012. Available from: http://www.medscape.com/viewarti-cle/760070. 42. Raskind MA, Dobie DJ, Kanter ED, Petrie EC, Thompson CE, Pes-kind ER. The alpha1-adrenergic antagonist prazosin ameliorates combat trauma nightmares in veterans with posttraumatic stress disorder: a report of 4 cases. J Clin Psychiatry. 2000;61(2):129–33.43. Raskind MA, Peskind ER, Kanter EV, Petrie EC, Radant A, Thompson CE, et al. Reduction of nightmares and other PTSD symptoms in combat veteran by prazosin: a placebo-controlled study. Am J Psychiatry. 2003;160:371-3.44. Raskind MA, Peskind ER, Hoff DJ, Hart KL, Holmes HA, Warren D, et al. A parallel group placebo controlled stud of prazosin for trauma nightmares and sleep disturbance in combat veterans with post-trauamtic stress disorder. Biol Psychiatry. 2007;61(8):928-34.45. Taylor FB, Martin P, Thompson C, Williams J, Mellman TA, Gross C, et al. Prazosin effects on objective sleep measures and clinical symptoms in civilian trauma posttraumatic stress disorder: a placebo-controlled study. Biol Psychiatry. 2008;63(6):629-32.46. VA Pharmacy Benefits Management Services, Medical Advisory Panel, and VISN Pharmacist Executives. Alpha-blocker combination therapy in PTSD and BPH: recommendations for use. June 2012. Available from: www.pbm.gov. 47. Aurora RN, Zak RS, Auerbach SH, Casey KR, Chowdhuri S, Karippot A, et al. Best Practice Guide for the Treatment of Nightmare Disorder in Adults. J Clin Sleep Med. 2010 Aug 15;6(4):389-401.48. Brophy MH. Cyproheptadine for combat nightmares in post-traumatic stress disorder and dream anxiety disorder. Mil Med. 1991;156:100–1.49. Harsch HH. Cyproheptadine for recurrent nightmares (letter). Am J Psychiatry. 1986;143:1491– 2.50. Idzikowski C, Mills F, Glennard R. 5-Hydroxytryptamine-2 antagonist increases human slow wave sleep. Brain Res. 1986;378:164–8.51. Adam K, Oswald I. Effects of repeated ritanserin on middle-aged poor sleepers. Psychopharmacology (Berl). 1989;99:219–21.52. Gupta S, Popli A, Bathurst E, Hennig L, Droney T, Keller P. Efficacy of cyproheptadine for nightmares associated with posttraumatic stress disorder. Compr Psychiatry. 1998 May-Jun;39(3):160-4.53. Ahmadzadeh G, Asadolahi G, Mahmodi G, Farhat A. Effect of cypro-heptadine on combat related PTSD nightmares. Ann Gen Psychiatry. 2006 Feb 5(Suppl 1):S159.54. Clark R, Canive J, Calais L, Qualls C, Brugger R, Vosburgh T. Cypo-heptadine treatment of nightmares associated with posttraumatic stress disorder. J Clin Psychopharmacol. 1999;19:486-7.55. Boehnlein JK, Kinzie JD. Pharmacologic reduction of CNS norad-renergic activity in PTSD: the case of clonidine and prazosin. J Psychiatr Pract. 2007;13(2):72-8.

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A Review of Pharmacotherapy for Posttraumatic Stress Disorder (PTSD)Correspondence Course Program Number: 0171-9999-14-047-H01-P 1.Completeandmailentirepage.SCPhAmemberscantaketheJournalCEforfree;$15fornon-members.Checkmustaccompanytest.Youmayalsocompletethetestandsubmitpaymentonlineatwww.scrx.org.2.Mailto:PalmettoPharmacistCE,1350BrowningRoad,Columbia,SC29210-6309.3.ContinuingEducationstatementsofcreditwillbeissuedwithin6weeksfromthedatethequiz,evaluationformandpaymentarereceived.4.Participantsscoring70%orgreaterandcompletingtheprogramevaluationformwillbeissuedCEcredit.Participantsreceivingafailinggradeonanyexaminationwillhavetheexaminationreturned.Theparticipantwillbepermittedtoretaketheexaminationonetimeatnoextracharge.

SouthCarolinaPharmacyAssociationisaccreditedbytheAccreditationCouncilforPharmacyEducationasprovidersforcontinuingphar-macyeducation.Thisarticleisapprovedfor1contacthourofcontinuingpharmacyeducationcredit(ACPEUPN0171-9999-14-047-H01-P).ThisCEcreditbegins5/05/2014;expiration5/05/2017CEcreditswillbeuploadedtotheCPEMonitorSystem.Thepublicdependsonpharmacistsfortheproductionofsafemedications,andsometimessuffertheconsequencesofunaccept-

ableworkplaceconditions,inadequateattentiontostandardprocedureandpoorqualitycontroloverproducts.TheharmcausedbythecontaminatedmedicationsproducedbytheNewEnglandCompoundingCenter(NECC)wasadramaticexampleofhowtheseissuescanhavetragicconsequences.Theprofession’sresponsehasbeenswiftandappropriate.UnsafesterilecompoundingtechniquewasattheheartoftheNECCout-break,inwhichtaintedsteroidinjectionsledtomorethan750fungalinfections,includingafewcasesinSouthCarolina,and64deathsnationwide.Intheaftermath,theInstituteforSafeMedicationPracticesissuedaclarioncallforadditionalmonitoringandregulationsofsterilecompounding--currentlybeingimplementedfollowingapprovaloftheDrugQualityandSecurityAct--andagreaterempha-sisonhands-ontraining.Aspharmacyeducators,wehavetheresponsibilityofprovidingthattraining.Safesterilemedicationcompoundingrequireshighlyspe-cifictraininginanenvironmentnotreadilyavailabletomanypharmacists.Drugshortagesandspecializedmedicationshaveincreasedtheneedforcompoundedproducts,whichincreasestheneedforproperly-trainedpharmacistswhocansafelymakethemforpatients.Lastmonth,theSouthCarolinaCollegeofPharmacy(SCCP)attheUniversityofSouthCarolinaopenedastate-of-the-artsterilemedi-cationcompoundingfacilitythatisoneofthefewofitskindinthecountry.Createdtohelpassurethatpharmacistslearnthehigheststandardsforcompoundingofmedications,theAsepticCompoundingEx-perience(ACE)LaboratoryenablestheCollegetoofferoneofthenation’sfewUniversity-affiliatedsterilemedicationcompoundingLEARNING ASSESSMENT QUESTIONS:

1.WhichofthefollowingisNOTasymptomclusterofPTSD?a.Intrusionsymptomsb.Avoidancec.Psychosisd.Negativealterationsincognitionsandmood

2.Allofthefollowingmedicationsareconsideredtobereason-ableoptionsasmonotherapyforthetreatmentofPTSDaccordingtoNICEandVA/DoDtreatmentguidelinesEXCEPT:a.Sertraline b.Bupropionc.Venlafaxine d.Mirtazapine

3.Youareapharmacistreviewingordersandrealizethatapro-viderenteredanorderforprazosin1mgQHSfornightmares,butthepatientisalreadytakingterazosin2mgQHSforBPH.Whatdoyourecommend?a. Discontinueprazosinasthisisduplicatetherapyanditcannotbeusedb. Startprazosinincombinationwithterazosinbutmonitorbloodpressurecloselyc. Discontinueprazosinandincreaseterazosinslowlyuntileffectivefornightmaresd. Switchterazosintoprazosinasa1:1conversionandtitrateprazosinasneeded/tolerated

4.Aprovidercomestoyouandsays,“IreallywouldliketotryanantipsychoticformypatientwhohasPTSDandishavingalotofdifficultywithirritabilityandre-experiencing.Whichoneisthebest?”Althoughthereislimitedevidencefortheuseofantipsy-choticsforthetreatmentofPTSD,whichagentshouldNOTberecommendedpertheVA/DoDtreatmentguidelinesduetoalargestudypublishedin2011?a.Risperidone b.Quetiapineec.Olanzapine d.Aripiprazole

5.Apatientistakingsertraline200mg/dayandisexperiencingsexualdysfunction.Theprovidercallsyouandaskswhatthebestoptionwouldbe.Yourespond:a. Ifirstneedtoknowwhatthepatientisactuallyexperi-encingasthiswillguidethetreatmentb. Increasethedoseto250mg/dayaslowerdosescancausemoresexualdysfunctionc. Addonsildenafil50mg/dayifneededforsexualdys-functiond. Switchthepatienttoparoxetine40mg/day

6.ApatientcallsyouandexplainsthatshemissedtwodosesofherantidepressantthatshetakesforPTSDbecauseshewentawayfortheweekend.Shedescribesthatshefeelsshock-likesensationsalloverherbody,isveryanxious,andistremulous.Whatdoyouthinksheisexperiencingandwhichantidepressantisthepatientmostlikelytaking?a.Allergicreaction,fluoxetineb.Allergicreaction,paroxetinec.Antidepressantdiscontinuationsyndrome,fluoxetined.Antidepressantdiscontinuationsyndrome,paroxetine

7.AdoctorcallsyouafterreadingasummaryoftheVA/DoDtreatmentguidelinesandisconcernedabouthispatientwhohasPTSDandhasbeentakingalprazolam1mgBIDforabout2years.Hewouldliketodiscontinuethismedicationandasksyouhowtodoso.Howwouldyoureply?a. Decreasethedoseofalprazolamby1mgeverydayandthendiscontinueb. Decreasethedoseto1mgQHSfor4–8weeks;de-creaseagain0.25mgTIDfor2weeks,then0.25mgBIDfor2weeks,then0.25mgQHSfor2weeks,thenstopc. SwitchalprazolamtoclonazepamasthisagentismoreeffectiveinPTSDd. Continuealprazolam1mgBID.TheNICEguidelinesstatethatbenzodiazepinesmaybeeffectiveinPTSD.

GAMECOCK/USC MERCHANDISEOfficial collegiate licensedmerchandise forsale.T-shirts,carflags,tailgategear.Allde-signedbyaSCPharmacist.PleaseemailDanielBundrickatgamecocktees@aol.comorcall/text803.603.8622.Originaldesigns,unique,edgynewdesignstoo.Alsolookforourtwomobilestores, our huge vans that go to events andfootballgames.Checkusoutonlineatwww.carolinagamecocktees.com STORE FIXTURES/PLANNING

Planning to expand, remodel or open a newpharmacy?Since1973DisplayOptions, Inc.has providedprofessional store planning, In-stallation,quality storefixturesandcustomerservice to Pharmacies across the Southeast.Pleaseallowus theopportunity to assistyouwithyourplans&dreams.Callustollfreeat(800)321-4344orvisitourweb siteatwww.displayoptions.com.

TRANSFORMING THE SOUL OF PHARMACY, BY MINISTERING TO THE

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FOR SALENEED HELP WITH MEDICATION

THERAPY MANAGEMENT?Contact:BryanZiegler,PharmD,MBA,PharmacyServiceConsulting,LLC Phone:(803)269-6333 Email:[email protected]:MTMeducation,Identifi-cationofMTMOpportunities,StaffTraining,WorkflowAnalysis,BusinessAnalysis

PHARMACY OPERATIONS CONSULTANTPharmacistsinterestedinchangingyouexistingdesign and operation of your pharmacy - letthebest in thebusinesshelpyoumake thosechanges.Contact:PaulJ.Hyer,Jr.,RPh,PDat843-814-2542orwriteto301S.MagnoliaSt.Summerville,SC29483.

PHARMACIST SEEKING EMPLOYMENTSouthCarolina Licensed Pharmacistwouldlike to work in an independent pharmacy,prefer small-town setting. TimMcKittrick704-585-6690

FOR SALE: MORTAR AND PESTLESSetof8ScheringPharmaceuticalCorporationcommemorativebronzed-likemetalmortarandpestles,datedfromthe late1960sand1970s.Theyhavebeenondisplayinourindependentpharmacy inFlorence,SC for over 40years.We know thosewho are familiarwith thesewill appreciate themandwant them for theircollections. They are all about 4 inches tallby4incheswide.Theyareingoodcondition.Call 843-992-0981withoffer, plus$30 ship-ping.Nightsandweekendscall843-669-7439oremailgalehdixon@sc.rr.com

RELIEF RPh

Services

RELIEF PHARMACIST AVAILABLEExperienced(retail,clinic,consulting,nursinghome)pharmacistavailableonPRNorregularbasis.Willtravel.CompetitiveRate.M-F,oc-casionalSat.JOHNW.OWEN,[email protected],(H)803-783-2979(C)803-466-4783

ETC.

Want to place an ad here? Mem-bers can post classified ads for free. Please visit www.scrx.org and fill out our online classified form to get your ad posted here!

FOR SALE: PRO ROBOTScript Pro Robot For SaleModel SP200, [email protected].

FOR SALE: OWENS ILLINOIS PROMOTIONAL CHINA

OwensIllinoisPromotionalChina,glasswareand“silver”cutlery.About85assortedpieces.Pleasee-mailmeatrxrrman@bellsouth.netifyouareinterested.Icansendyoualistifyouwish.RalphWilkie,843-884-5751

CLASSIFIEDS

BEACH HOME FOR SALE OR RENTPawley’s Island Beachhome - 5 Bedroomand 5 Baths. Beautiful view on the creekwith eleveator. For sale or rent. Checkout [email protected].

♦ South Carolina Board of Pharmacy/licensing matters

♦ Corporate legal counsel specific to pharmacies including purchase and sale

♦ OBRA-90 and South Carolina patient counseling requirements

♦ HIPAA and related privacy issues

♦ Third Party issues including pharmacy benefit managers

♦ Medicaid audits

♦ DHEC and DEA/controlled substances

♦ Risk management

♦ Pharmacy Technicians

♦ Federal compliance

Jon A. Wallace, B.S.Pharm., J.D.

602 Rutledge Avenue ♦ Charleston, SC 29403 ♦ (843) 266-2626 ♦ [email protected],Charleston,SC29403•DirectDial(843)266-2625•[email protected]


BOOKS FOR SALEChristianBookAvailableatAmazon,BarnesandNoble,andetc.ItisCalledChoices(ThesecrettoMakingWiseChoices)byCarolynGaultwifeofpharmacistHoraceGaultJr.Thebookisaboutourmomentsinhistoryaswefacechoicesthatareconfusing,inoutrapidlychangingculture.TheproceedswillgotoMissiontotheWorldtohelpmissionariesandtheirfamilies.

OXYGEN EQUIPMENT18-Portableoxygencylinders,1devilbissoxygenconservator,1-5literconcentratorinvacare,7-oxygenregulators,1-Salterlabsul-trsonicoxygenindicator.Call864-843-9207,libertyfamilypharmacy$500.00


“QS/1 always keeps us ahead of the curve as far as technology and the law, but it was their response when our store was decimated by Sandy that we really found invaluable. With four and a half to five feet of water in the store, we lost over 60 percent of our stock. We brought in a trailer as a temporary store and called QS/1. They responded immediately with someone onsite to get us back up and running. Thankfully, we used their off-site backup and disaster recovery system, so we had our data restored as it was before the storm.”Learn how QS/1’s products and services can help you. Call 866.994.1837 or visit www.qs1.com today.

“After Superstorm Sandy, QS/1® had us back up and running in no time.”

– Richard Longo

©2014, J M SMITH CORPORATION. QS/1 and RxCare Plus are registered trademarks of the J M Smith Corporation.

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march/april 2014

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