The Script A Publication of the Department of Pharmacy, Norman Regional Health System

The Script Spr ing 2 015 , Issue 6

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Lisa Mayer, Pharm.D., BCPS 901 N Porter Ave., Box 1308

Norman, OK 73070 lmayer@nrh-ok.com

Vitamin  K  Route  of  Administration  for  Reversal  of  Warfarin    .  .  .  .  .  .  .  .  .    1  

The  2014-­‐2015  NRHS    Pharmacy  Residents  .  .  .  .  .  .  .  .  .  .  .  .  .  2  

Pharmacy  and  Therapeutics  Committee  Update.  .  .  .  .  .  .  .  .  .  .  .  .  .    2  

Humulin®  R  U-­‐500  (Concentrated)  Added  to  NRHS  Formulary  .  .  .  .  .  .  .  .    3  

Critical  Medication  Shortages    .  .  .  .  .    3  

Prevention  and  Treatment  of  Extravasation    .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .      4  

In This Issue:

 

Vitamin K Route of Administration for Warfarin Reversal By Elizabeth Rathgeber, Pharm.D., Samantha Sepulveda, Pharm.D., Lysse Vadder, Pharm.D.

References  1. Ageno  W,  Gallus  AS,  Wittkowsky  A,  et  al.    Oral  Anticoagulant  Therapy.  Antithrombotic  Therapy  and  Prevention  of  Thrombosis,  9th  ed.  American  College  of  Chest  Physicians  Evidence-­‐Based  

Clinical  Practice  Guidelines.    CHEST  2012;  141(2)(Suppl):e44s–e88S.  2. Product  information.    Phytonadione  Injectable  Emulsion.  So.  El  Monte,  CA:  Amphastar  Pharmaceuticals  Company,  2013.  3. Garcia  DA,  Crowther  MA.    Reversal  of  warfarin:  case-­‐based  practice  recommendations.    Circulation  2012;125:2944-­‐7.  4. Kearney  TE.    Vitamin  K1  (phytonadione).    In:  Olson  KR,  ed.  Poisoning  and  drug  overdose.    6th  ed.    New  York,  NY:  McGraw-­‐Hill,  2012.  www.accessmedicine.com.    Accessed  January  12,  2015.  5. Holbrook  A,  Schulman  S,  Witt  DM,  et  al.  Evidence-­‐Based  Management  of  Anticoagulant  Therapy.    Antithrombotic  Therapy  and  Prevention  of  Thrombosis,  (9th  ed.)  American  College  of  

Chest  Physicians  Evidence-­‐Based  Clinical  Practice  Guidelines.  CHEST  Ansell  J,  Hirsh  J,  Hyle  KE,  et  al.    Oral  Anticoagulant  Therapy.  Antithrombotic  Therapy  and  Prevention  of  Thrombosis,                                        9th  ed.  American  College  of  Chest  Physicians  Evidence-­‐Based  Clinical  Practice  Guidelines.    CHEST  2012;  141(2)(Suppl):e44s–e88S.  

Warfarin  is  an  anticoagulant  that  works  by  inhibiting  the  synthesis  of  vitamin  K-­‐dependent  clotting  factors.     Excessive   anticoagulation   can   lead   to   an   elevated   international   normalized   ratio   (INR),  increasing  the  risk  of  bleeding  complications.      

Phytonadione   (vitamin   K1)   is   used   to   reverse   the   effects   of   warfarin   by   promoting   synthesis   of  clotting  factors.    Vitamin  K  is  available  for  several  routes  of  administration:  oral  (PO),   intravenous  (IV),  subcutaneous  (SC),  and  intramuscular  (IM).    The  low-­‐dose  (1  to  2.5  mg)  PO  formulation  should  be  used  in  patients  not  requiring  urgent  reversal,  which  takes  approximately  1.4  days  for  the  INR  to  reach  less  than  4.0  if  the  INR  is  between  6  and  10.    Vitamin  K  5  mg  PO  and  1  mg  IV  produce  similar  effects  at   twenty-­‐four  hours  after  administration.1  Higher  doses  of  vitamin  K  can   lead   to  warfarin  resistance  and  thrombosis.  The  IV  route  works  more  rapidly  than  PO  or  SC  administration  with  INR  reduction   beginning   within   2   hours   and   full   correction   occurring   within   24   hours.     However,   IV  administration   has   been   associated   with   a   small   risk   of   anaphylactic   reactions   and   is   not  recommended  unless  another  route  is  not  feasible  and  the  increased  risk  involved  is  justified.2    

The   SC   route   is   less   effective   and   less   predictable   than   oral   and   the   intravenous   formulations.    Studies  have  shown  less  than  50%  of  patients  with  an  INR  greater  than  4.0,  but  less  than  10.0  will  achieve   an   INR   between   1.8   and   4.0   within   24   hours   after   SC   administration   of   vitamin   K.3    Intramuscular   phytonadione   administration   is   not   recommended   due   to   the   risk   of   developing  hematomas.     For   this   reason,   SC   administration   is   preferred   over   IM   if   parenteral   therapy   is  required.4  

Choosing  the  appropriate  route  of  administration  for  vitamin  K  depends  on  several  factors.    While  SC   administration   has   been   associated  with   less   anaphylaxis,   it   has   also   shown   less   efficacy   and  predictability,  when  compared  to  IV  vitamin  K.    Intravenous  vitamin  K  has  the  quickest  onset,  but  is  associated  with  increased  risk  of  anaphylaxis,  thus  should  only  be  used  if  the  risk  is  justified.    Due  to  erratic  absorption  and  risk  for  hematomas,  IM  administration  of  vitamin  K  should  be  avoided.    Oral  is  the  preferred  route  of  administration   for  non-­‐urgent  reversal  of  vitamin  K  antagonists  due  to  its   predictable   pharmacokinetics   according   to   the  American   College   of   Chest   Physicians   (ACCP)  guidelines.  

ACCP  Recommendations  for  Vitamin  K  Administration5  

INR   Management  4.5  to  10.0,  

without  bleeding  ! Hold  warfarin    ! Recommend  against  routine  use  of  vitamin  K  

>  10.0,  without  bleeding  

! Hold  warfarin  and  give  vitamin  K  PO  (2  and  2.5  mg  doses  only  studied  and  demonstrated  low  rates  of  major  bleeding)  

! Allow  24-­‐48  hours  for  INR  reduction  

Serious  bleed,  any  elevated  INR  

! Hold  warfarin  and  give  vitamin  K  5  to  10  mg  IV  ! Administer  Factor  IX  complex  concentrate  (four-­‐factor  PCC)  ! May  repeat  vitamin  K  after  12  hours  

The Script Spring 2015 , Is sue 6

The 2014-2015 NRHS Pharmacy Residents By Kim Whitley, Pharm.D.

Pharmacy and Therapeutics Committee Update Drug   Indication   Usual  Dose   Dosage  and  

Strength  P&T  Action  

Canagliflozin  (Invokana®)  

Diabetes  mellitus,  type  2  -­‐  adjunct  therapy  

100  mg  PO  once  daily  prior  to  the  first  meal  of  the  day;  may  increase  to  300  mg  once  daily  (only  in  patients  with  eGFR  ≥60  mL/min/1.73m2)  

100  and  300  mg  tablets   Added  to  formulary  

Fidaxomicin  (Dificid®)  

Treatment  of  diarrhea  due  to  Clostridium  difficile  (CDAD)  

200  mg  PO  twice  daily  for  10  days   200  mg  tablet  Added  to  formulary  –  restricted  to  GI  and  ID  physicians  

Fluticasone/vilanterol  (Breo®  Ellipta®)   COPD   One  oral  inhalation  (fluticasone  100mcg/vilanterol  

25  mcg)  once  daily  (maximum  dose)  

Fluticasone  100  mcg/vilanterol  25  mcg  powder  for  inhalation  

Added  to  formulary    

Tbo-­‐filgrastim  (Granix®)  

Myelosuppressive  chemotherapy  recipients  with  nonmyeloid  malignancies  

5  mcg/kg/day  SC;  continue  until  anticipated  nadir  has  passed  and  neutrophil  count  has  recovered  to  normal  range  

Prefilled  syringe  of  300  mcg/0.5  mL  and  480  mcg/0.8  mL  

Added  to  formulary  

Tedizolid  (Sivextro®)  

Acute  bacterial  skin  and  skin  structure  infections     200  mg  IV/PO  once  daily  for  6  days  

200  mg  tablet  and  200  mg  solution  for  reconstitution  

Added  to  formulary  with  restrictions  –  see  Policy  Addendum  40700-­‐066.1  

Tobramycin  inhaled  (Bethkis®)   Cystic  fibrosis  

300  mg  inhaled  every  12  hours  (do  not  administer      <  6  hours  apart);  administer  in  repeated  cycles  of  28  days  on  drug  followed  by  28  days  off  drug  

300  mg/5  mL  nebulization  solution  

Added  to  formulary  

NRHS  offers  a  year-­‐long  accredited  Post  Graduate  Year  1  (PGY1)  Pharmacy  Residency  that  begins  each  year   in   July  and  ends  in  June  of   the   following  year.   It  allows  pharmacists  to  accelerate  their  growth  beyond  entry-­‐level  competencies,  to  refine  their  clinical  skills  in  a  broad  range  of  disease  states  and   to   provide   evidence-­‐based,   patient-­‐centered   medication   therapy.   Residents   are   also   cross-­‐trained   in   distribution   activities   and   can   be   found  staffing   at   the  HealthPlex  on  Monday   through   Thursday  evenings.   The  Pharmacy  department   is   proud   to  announce  our  pharmacy   residents   for   the  2014-­‐2015  year:  Elizabeth  Rathgeber,  Samantha  Sepulveda  and  Lysse  Vadder.    All  three  are  2014  graduates  of  The  University  of  Oklahoma  College  of  Pharmacy.  

Elizabeth  Rathgeber  was   born   in   Alva,  OK.  Her   current   pharmacy   interests  include   critical   care,   internal  medicine,   pediatrics,   diabetes,   and   especially  infectious   diseases   with   a   strong   focus   on   HIV   pharmacotherapy.   After  completion   of   her   residency,   Elizabeth   plans   to   pursue   a   clinical   pharmacy  position  in  an  inpatient  setting.  

Samantha   Sepulveda  was   born   in   Springfield,  MO,   raised   in   the   Southwest  United   States,   and   moved   to   Oklahoma   City,   OK   in   2009   from   Southern  Florida.   Her   pharmacy   interests   include   internal   medicine   and   infectious  disease.    She  plans  to  pursue  a  clinical  pharmacy  position  in  a  health  system  upon  completion  of  her  residency.      

Lysse   Vadder   was   born   in   the   town   of   Helena,   located   in   Northwest  Oklahoma.   Her   pharmacy   interests   include   infectious   diseases   and  gerontology/geriatrics.    Upon  completion  of  her  residency,  Lysse  plans  to  be  employed   as   a   clinical   pharmacist   at   Integris   Bass   Baptist   in   Enid,  OK.     She  plans   to   obtain   Board   Certified   Pharmacotherapy   Specialist   (BCPS)  certification  upon  completion  of  her  residency.  

Each  resident  undertakes  a  project  during  their  residency,  in  which  they  present  their  research  at  local  and  national  pharmacy  conferences.  Elizabeth’s  project  involves  evaluating  the  appropriate use  of  Visipaque®  and  Omnipaque®  in  catheterization  lab  patients,  taking  into  consideration  their  eGFR  and  procedure   type.   Lysse’s   project   involves   reducing   adverse   drug   events   associated  with   opioid   use   by   investigating   the   effectiveness   of   our   existing  protocols  and  evaluating  the  use  of  naloxone.    Samantha’s  project  focuses  on  evaluation  of  anticoagulant  reversal  agents.  

Please  take  a  moment  to  congratulate  our  residents  as  they  conclude  their  residency!  

2

 Left  to  right:    Elizabeth  Rathgeber,  Lysse  Vadder,  and  Samantha  Sepulveda  

The Script Spring 2015 , Is sue 6

Humulin® R U-500 (Concentrated) Added to NRHS Formulary

U-­‐500   (500  units/mL)   regular   insulin  contains  FIVE   times   as  much   insulin   in   1  mL   than  standard  U-­‐100   (100  units/mL)   regular   insulin.     It   is  useful   in  treating  patients  with  insulin  resistance  (requiring  doses  of  more  than  200  units/day)  because  it  allows  for  large  doses  of  insulin  to  be  given  in  smaller  volumes  and  less  frequently.    The  onset  of  action  for  U-­‐500  regular  insulin  is  30  minutes,  but  because  of  its  high  concentration  it  has  a  long  duration  of  action  (up  to  24  hours  following  a  single  subcutaneous  dose).    Based  on  its  unique  pharmacokinetic  properties,  U-­‐500  regular  insulin  should  be  dosed  with  2-­‐3  injections  per  day  and  NEVER  given  intravenously.  

There   are   several   safety   issues   that   arise   with   the   use   of   U-­‐500  regular  insulin.  

! Its   prolonged   duration   increases   the   risk   for   delayed  secondary  hypoglycemic  reactions  that  may  occur  18-­‐24  hours  after  injection.  

! There   are   no   U-­‐500   insulin   syringes   available;   therefore,  patients  are  usually   instructed  to   take  “XX  unit  marks  on  a  U-­‐100   syringe”   of   U-­‐500   regular   insulin.     This   can   lead   to  problems  upon  medication  reconciliation   if   that   same  patient  reports  “U-­‐500  regular  insulin  XX  units”   instead  of  “XX  unit  marks”  as  the  dose.    All  patients  who  report  U-­‐500  regular  insulin  should  be  asked:  what  type  of  syringe  is  used  at  home,  how  many  units  per  dose  and  what  measurement  unit  is  drawn  up  for  each  insulin  dose.      Good  patient  interview  questions  to  elicit  the  desired  response  include:  “How  do  you  administer  this  at  home?”  “Can  you  show  me?”  

! At   NRHS,   U-­‐500   regular   insulin   orders   must   be   written  with   both   the   actual   units   of  Humulin®  R  U-­‐500   and   the  volume   (in  mL)   to  be  measured  on  a  TB  syringe.     (eg.  50  units  of  U500  regular  insulin    =    0.1  mL)  

! Incomplete   orders   will   require   clarification   by   the  pharmacy.  

! Patients  may  NOT  use  their  own  U-­‐500  regular  insulin.    U-­‐500  regular  insulin  cannot  be  stored  on  the  nursing  unit  to  avoid  a  potential  error.  

! U-­‐500   regular   insulin   will   be   dispensed   from   pharmacy,  pre-­‐drawn   in   TB   syringes   with   a   needle   attached.     Each  dose  will  need  to  be  demanded  from  the  pharmacy  (include  FSBS  if  relevant).  

! U-­‐500  regular  insulin  doses  will  be  hand-­‐delivered  to  the  nursing  staff  by  the  pharmacy;  nursing  may  also  pick  up  the  doses  in  the  pharmacy.  

! U-­‐500  regular  insulin  doses  need  to  be  verified  by  a  second  licensed  healthcare  professional  prior  to  administration.  

 

  Critical Medication Shortages By Donna Wilk, CPhT

 

Medication   Action  Plan  Diltiazem  IV   Diltiazem  drips  have  been  changed  back  to  100mg/100mL  ADD-­‐Vantage  bag  and  loaded  back  into  Pyxis  machines.  Droperidol  IV   Out  of  stock  with  no  release  date.    Alternatives  include:  Metoclopramide,  Ondansetron,  Prochlorperazine,  and  Scopolamine.  Famotidine  IV   Product  is  available  again  and  has  been  loaded  back  into  Pyxis  machines.  Fomepizole  IV   Unavailable  with  a  release  date  of  April  2015.    We  currently  have  a  decent  supply  on  hand  at  this  time.  Indigo  Carmine  IV   Unavailable  with  no  release  date.    Alternatives  include:  Indocyanine  Green,  Methylene  Blue,  and  Isosulfan  Blue.  IV  Fluids   All  plain  IV  fluid  bags  (i.e.  Normal  Saline,  Lactated  Ringers  and  Dextrose)  are  currently  available  from  the  manufacturer.  Ketorolac  IV   Product  is  currently  being  allocated  by  the  manufacturer  with  no  release  date.    Pharmacy  is  able  to  maintain  stock  at  this  time.  

Piperacillin/  Tazobactam  (Zosyn®)  IV  

Unavailable  with  a  release  date  of  April  to  September  2015.    Alternatives  include:  Ampicillin/Sulbactam  IV,  Cefepime  IV,  Ceftazidime  IV,  and  Ciprofloxacin  IV/PO.    Metronidazole  is  required  in  addition  to  one  of  the  above  listed  alternatives  for  certain  indications.  

Prochlorperazine  IV   Unavailable  with   no   release   date.     Current   stock   is   reserved   for   use   in   OR   surgery   trays,   ER,   PACU   and   GYN/C-­‐Section   areas.    Alternatives  include:  Dexamethasone  IV,  Methylprednisolone  IV,  Ondansetron  IV/PO,  and  Promethazine  IVPB  or  topical  gel.  

Sincalide  IV   Product  is  available  again.    Pharmacy  is  mixing  IVPB  for  patient  specific  doses  again,  primarily  at  the  Porter  campus.  

TPN  Components   Due  to  a  nationwide  shortage  on  Dextrose  70%  and  Sterile  Water  used  to  compound  TPNs,  we  have  switched  to  a  premix  formulation  of  Clinimix  5/15  and  Clinimix  5/15  +  Electrolytes  for  adult  TPNs.    Baby  TPNs  are  not  affected.  

3

One  vial  of  Humulin®  R  U-­‐500  contains  as  many  units  of  insulin  as  10  vials  of  U-­‐100  

 (A  

Prevention and Treatment of Extravasation By Lisa Mayer, Pharm.D., BCPS, Jerri Cody, Pharm.D., and Fran Esfahani, Pharm.D., BCPS  

Extravasation  is  defined  as  escape  of  a  drug  into  the  extravascular  space  by  either  leakage  from  a  vessel  or  direct  infiltration.    While  many  drugs  are  irritating  upon  exposure  to  the  extravascular  tissues,  extravasation  of  a  vesicant  drug  can  potentially  cause  tissue  damage  with  severe  and/or  lasting  injury.    A  vesicant  is   an   agent   that   produces   blisters   and   causes   tissue   necrosis   if   it   escapes   from   the   intended   venous   system.   A vesicant   drug   can   be   a   cytotoxic  (chemotherapy)  or  non-­‐cytotoxic  agent. Infiltration  differs  from  extravasation  in  that  the  leakage  is  due  to  a  non-­‐vesicant  drug  rather  than  a  vesicant  drug.      

Risk  Factors  For  a  Peripheral  Vein   Risk  Factors  For  a  Central  Vein  ! Obesity  ! Multiple  previous  venipunctures  resulting  in  compromised  circulation  ! Disseminated  skin  disease  (e.g.  eczema,  psoriasis)  ! Large  gauge  cannula  relative  to  vein  size  ! Small  and/or  fragile  veins  AND  undesirable  cannula  sites  (e.g.  antecubital  fossa,  

dorsum  of  hand  or  wrist,  and  areas  of  joint  flexion)  ! Patient  movement  ! Peripheral  neuropathy  or  another  medical  condition  that  impairs  a  patient’s  

ability  to  detect  a  change  in  sensation  at  the  site  of  drug  administration  

! Catheter  migration  from  vein  to  tissue  ! Device  misplacement  with  the  catheter  tip  outside  of  the  venous  system  ! Difficult  catheter  insertion  ! Long  dwell  time  (six  months  or  longer)  ! Presence  of  a  fibrin  sheath  or  thrombus  at  the  catheter  tip  ! Deeply  implanted  port  

Signs  and  Symptoms  Early   signs   and   symptoms   of   extravasation   may   include   local   burning   or   tingling   at   the   injection   site,   mild   erythema,   pruritus   and   swelling.   More   extensive  extravasations  such  as  necrosis,  eschar  formation,  and  ulceration  may  develop  over  several  weeks.    If  left  untreated,  complications  can  include  development  of  nerve  compression  syndrome,  permanent  joint  stiffness,  contractures  and  neurologic  dysfunction.  

Prevention  of  Extravasation  ! Infusion  sites  in  order  of  preference:  forearm,  dorsum  of  hand,  wrist,  antecubital  fossae  ! Avoid  sites  with  thrombosis,  sclerosis  or  scar  formation  as  well  as  limbs  with  impaired  circulation  ! Avoid  previously  irradiated  areas  if  possible  ! A  clear  dressing  such  as  Tegaderm  should  cover  the  skin  entry  site  to  allow  for  examination  ! Educate  the  patient  to  notify  a  healthcare  professional  immediately  if  they  experience  any  pain,  leaking  or  changes  in  sensation  at  the  injection  site  ! Continuous  infusion  vesicants  or  vesicants  given  for  longer  than  1  hour  should  only  be  administered  via  a  central  line  

Initial  Management  of  Extravasation ! Stop  the  infusion  of  the  suspected  drug.    DO  NOT  flush  the  line  and  AVOID  applying  pressure  to  the  site.  ! Elevate  the  affected  extremity  ! Notify  the  physician  ! If  an  antidote  is  to  be  administered,  DO  NOT  remove  the  catheter/needle.  It  should  be  left  in  place  to  attempt  aspiration  of  the  extravasation  site  and  to  facilitate  

antidote  administration.  ! If  an  antidote  WILL  NOT  be  administered,  then  remove  the  catheter/needle  after  attempted  aspiration  of  the  drug  from  the  subcutaneous  tissues  

Treatment  of  Extravasation  Irritant/Vesicant  drug   Non-­‐Pharmacologic  Treatment   Pharmacologic  Treatment*  

Cytotoxic  Drugs    

Alkylating  Agents  (Irritants)  -­‐  Cyclophosphamide,  Dacarbazine,  Ifosfamide     Apply  cold  compresses  for  20  min  QID  Ifosfamide:    hyaluronidase.  Cyclophosphamide  and  Dacarbazine:    Sodium  thiosulfate  25%  

Anthracyclines  (Vesicant)  -­‐  DAUNOrubicin,  DOXOrubicin,  EPIrubicin,  IDArubicin   Apply  cold  compresses.      Withhold  cooling  15  min  before  and  after  dexrazoxane.  

Dexrazoxane  

Platin  Salts  (Irrirant)  -­‐  CARBOplatin,  CISplatin,  oxaliplatin*  Apply  cold  compresses.    *Conflicting  information  regarding  use  of  warm  or  cold  compresses  for  oxaliplatin  

Sodium  thiosulfate  25%  

Taxanes  (Vesicant)  -­‐  DOCEtaxel,  PACLitaxel   Conflicting  information  regarding  use  of  warm  or  cold  compresses  

Hyaluronidase

Vinca  alkaloids  (Vesicant)  -­‐  vinCRIStine,  vinBLAStine,  vindesine,  vinorelbine  Etoposide  

Apply  warm  compresses  for  20  min  QID.  Use  of  ice  is  contraindicated.   Hyaluronidase  

Non-­‐Cytotoxic  Drugs  Acidic  and  Alkaline  Agents  (amiodarone,  acyclovir,  conivaptan,  doxycycline,  phenytoin,  pentamidine,  promethazine,  sodium  thiopental,  vancomycin)   Apply  warm  compresses  for  20  min  QID   Hyaluronidase  

Hyper-­‐osmolar  Agents  (ampicillin,  Ca2+  solutions,  dextrose  ≥10%,  hypertonic  saline,  mannitol,  TPN,  K+  solutions,  radiocontrast  media,  sodium  bicarbonate)  

Apply  warm  or  cold  compresses  for  20  min  QID  

1.  Hyaluronidase  2.  Sodium  thiosulfate  25%        3.  NTG  paste  2%  (preferred  for  TPN)  

Hypo-­‐osmolar  Agents  (aminophylline,  nafcillin)   Apply  warm  or  cold  compresses   Hyaluronidase  Substances  containing  Propylene  glycol    (diazepam,  digoxin,  etomidate,  lorazepam,  nitroglycerin  (NTG),  phenytoin,  phenobarbital)  

Apply  warm  or  cold  compresses  for  20  min  QID   Hyaluronidase  

Vasopressors    (DOBUTamine,  DOPamine,  EPINEPHrine,  norepinephrine,  phenylephrine,  vasopressin)

Apply  warm  compresses  for  20  min  QID  1.  NTG  paste  2%  2.  NTG  patch  0.5  mg/hr    3.  Terbutaline  

*Consult  Lexi-­‐comp  or  another  drug  information  resource  for  preparation  and  dosage  of  pharmacologic  treatment;  a  laminated  reference  chart  will  soon  be  posted  in  the  medication  rooms  

Editor in Chief: Contributors: Lisa Mayer, Pharm.D., BCPS Jerri Cody, Pharm.D. Fran Esfahani, Pharm.D., BCPS Elizabeth Rathgeber, Pharm.D. Samantha Sepulveda, Pharm.D. Lysse Vadder, Pharm.D. Kim Whitley, Pharm.D. Donna Wilk, CPhT Clinical Pharmacy Specialist Clinical/Staff Pharmacist Clinical Pharmacy Specialist PGY1 Pharmacy Resident PGY1 Pharmacy Resident PGY1 Pharmacy Resident Clinical/Staff Pharmacist Clinical Pharmacy Technician  

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