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What Does Wellness Mean to You?
February 7 – 9, 2020
Sheraton Anchorage
Sheraton Anchorage
Registration Now Open!
"Pharmacy Wellness and Well-Being" 54th Annual AKPhA Convention & Tradeshow
Pharmacists Mutual Insurance Company808 Highway 18 W | PO Box 370 | Algona, Iowa 50511P. 800.247.5930 | F. 515.295.9306 | [email protected]
phmic.com
Apply at phmic.com/scholarship
2020 Community Pharmacy Scholarship
• Apply October 1 - December 2, 2019• Recipients selected will be awarded
$2,500 each• Up to $50,000 awarded annually
Board Members
Adele Davis, President
463-4031, [email protected]
Juneau
Ashley Schaber, President-Elect & Co-Treasurer
729-2154, [email protected]
Anchorage
Della Cutchins, Past President
729-2112, [email protected]
Anchorage
Michelle Locke, Secretary
729-2173, [email protected]
Chugiak
Sara Supe, Co-Treasurer
740-975-9656, [email protected]
Anchorage
Catherine Arnatt
443-243-6782, [email protected]
Anchorage
James Bunch
982-3864, [email protected]
Wasilla
Eric Burke
886-4748, [email protected]
Metlakatla
Nancy Frei
713-444-9885, [email protected]
Fairbanks
Gretchen Glaspy
405-761-2239, [email protected]
Juneau
Megan Myers
717-858-3965, [email protected]
Nome
Amy Paul
830-312-0525, [email protected]
Anchorage
Brennon Nelson, Appointed Technician
444-7379, [email protected]
Anchorage
Molly Gray, Executive Director
Alaska Pharmacists Association
203 W. 15th Avenue, Suite 100
Anchorage, AK 99501
563-8880 Phone, 563-7880 Fax
[email protected] , www.alaskapharmacy.org
Office Hours: Monday – Friday, 10:30 am – 3:00 pm
Alaska
Pharmacy
Newsletter
The Mission of the Alaska Pharmacists Association is to
preserve, promote and lead the profession of pharmacy in Alaska
2019 Calendar of Events
November 14-15 AK Board of Pharmacy Mtg
November 30 Scholarship Applications Due
December 1 Board Nominations Due
December 1 Award Nominations Due
December 31 Membership Renewals Due
February 7 – 9, 2020 AKPhA Annual Convention
Sheraton Anchorage
Upcoming Alaska CE Opportunities Courses below open to Pharmacists for CE Credit
Providence AK Medical Center Oncology Lectures
Noon - 1 pm, Cancer Center Media Room 2281
Providence Infusion Ctr, 3851 Piper Street, Anchorage
November 12 Pediatric Malignancies
December 17 Lymphomas
January 14 Leukemia, Acute
ANTHC Clinical ECHO Series
First Wednesday of the Month, 11:30am – 1:00 pm
ANTHC Internal Medicine Grand Rounds
Thursdays, Noon – 1:00 pm
Articles In This Issue
Interview with RADM Pamela Schweitzer
Emergency Pharmacy Preparedness
Billing and Coding: Disparities in Healthcare Provider
Training
Rx and the Law—A Pharmacist's Duty to an Unknown
Third Party
Continuing Education Home Study Article Series
Articles and information for future Alaska Pharmacy Newsletters can be
e-mailed to [email protected]
The Alaska Pharmacy Newsletter
3
PRESIDENT'S MESSAGE Adele Davis, USPHS, PharmD, NCPS
Greetings
AKPhA
Members!
I hope you all
had a wonderful
October, which
was American
Pharmacists
Month. It was a
great time to
celebrate the
accomplishments
of pharmacists
throughout the
year and also
celebrate our
pharmacy technicians. I salute you all!
Thank you to all those who were able to join us at
the 4th
Annual AKPhA Academy of Health-System
Pharmacy Fall CE Conference at Alyeska on
September 28th! Our Keynote Speaker was RADM
(Ret.) Pamela Schweitzer, PharmD and Former
Assistant Surgeon General who spoke about
“Leadership in the Pharmacy World”. She
presented to the group about potential changes in
the future of pharmacy. It was an original way of
thinking about new and old challenges in the
pharmacy world. I believe almost everyone in the
room was considering issues in the field of
pharmacy in a new way and we had a great
opportunity for questions and answers toward the
end. This one day meeting was jam packed with
CE and was a great networking opportunity.
Please plan for your continuing education needs and
meet us at the 54th
Annual Convention and
Tradeshow February 7-9, 2020 at the Sheraton
Anchorage. This meeting is surely going to be great
as the focus will be “Pharmacy Wellness and Well-
Being”.
Enjoy the fall season and please don’t forget to
encourage membership and its benefits to our
coworkers, fellow pharmacists and technicians. We
are only as strong as our members! As always, if
you have suggestions for continuing education
topics or programs that you are interested in seeing
through AKPhA, let the association or I know as we
would love to try new things and be as valuable as
we can be for you!
Alaska Board
of Pharmacy This update is not an official document of the AK Board of
Pharmacy. Please access the Board of Pharmacy website for
complete rules, regulations and minutes of proceedings.
Executive Administrator: Laura Carrillo
NEXT MEETING: November 14-15
Notice of Adopted Changes to the Regulations of the
Board of Pharmacy
On June 27, 2019, the Board of Pharmacy adopted
regulation changes in Title 12, Chapter 52 of the Alaska
Administrative Code. The regulations concern adding
new licensing categories (non-resident wholesale drug
distributor license, outsourcing facilities, and third-party
logistics providers), licensure and registration
requirements, etc.
The regulation changes were reviewed and approved by
the Department of Law, signed and filed by the
Lieutenant Governor on October 1, 2019, and will go
into effect on October 31, 2019. Please click HERE to
see the filed version of the regulations.
On June 3, 2019, the Department of Commerce,
Community, and Economic Development adopted
regulation changes in Title 12, Chapter 02 of the Alaska
Administrative Code. The regulations concern
occupational licensing fees for professions regulated by
the Board of Pharmacy.
The Alaska Pharmacy Newsletter
4
The regulation changes were reviewed and approved by
the Department of Law, signed and filed by the
Lieutenant Governor on October 1, 2019, and will go
into effect on October 31, 2019. Please click HERE to
see the filed version of the regulations.
The new regulation changes will be printed in
Register 232, January 2020 of the Alaska
Administrative Code.
https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing/BoardofPharmacy.aspx
NEW Online PDMP Application
The Prescription Drug Monitoring Program (PDMP) is
pleased to offer a new online application process for
registering with the database. This online registration
process takes the place of submitting the initial PDMP
registration paper application (form #08-4760) but does
not replace the requirement to first initiate the
registration process online at PDMP "AWARxE". The
application may be filed through your myAlaska account
and is submitted directly to our staff. As your application
is processed, you will be able to see real-time updates as
documents are received and reviewed by our staff. You
may opt-in for email notifications and will receive an
email notification each time your file is updated.
To register successfully, please refer to the Steps for
initial access to the PDMP. Delegates cannot sign up
through MyAlaska; please review the Delegate
Registration Instructions.
https://www.commerce.alaska.gov/web/cbpl/Profes
sionalLicensing/PrescriptionDrugMonitoringProgra
m.aspx
Congratulations Certified Pharmacy
Technicians, July – September 2019!
Ashley Bolyard—Juneau
Tiffany-Ann Eli—Palmer
McKenzie Haskins—Anchorage
Tessa Hopkins—Wasilla
Deanna Jenkins—Wasilla
Kelly Kazmierski—Palmer
Robin Kelly—Anchorage
Sherry LaRose—Sitka
Ty Miller—Anchorage
Naomi Tate—Anchorage
Hunter Taylor—Fairbanks
Alexis Valentine—Fairbanks
AKPhA Committee Chairs
Legislative Co-Chairs Barry Christensen, 225-6186
Dirk White, 738-6337
Continuing Education Michelle Locke, 729-2165
2020 Convention Katie McKillip
Academic/UAA Coleman Cutchins, 602-9085
Student Kellie Rasay
Academy of Health- Ursula Iha, 780-5889
System Pharmacy [email protected]
Community Affairs Kathryn Sawyer, 763-772-8559
Social Media [email protected]
Scholarship Catherine Arnatt, 443-243-6782
Membership James Bunch, 982-3864
Awards Melanie Gibson, 543-6992
Technician Advocacy Brennon Nelson, 444-7379
Board Nominations Della Cutchins, 729-2112
Newsletter Advertising Sara Supe, 740-975-9656
Treasurer's Report Balances as of 10/12/19
Checking $ 51,070.85
Jumbo Money Market $ 97,626.76
TOTAL $ 148,697.61
The Alaska Pharmacy Newsletter
5
Committee/Academy Reports
AKPhA Academy of
Health-System Pharmacy
Ursula Iha, Chair
The AKPhA Academy of Health-System Pharmacy is the
Alaska American Society of Health-System Pharmacists
(ASHP) Affiliate. The Mission of the Academy is to preserve,
promote and lead the profession of pharmacy in Alaska while
increasing AKPhA Health-System pharmacy membership and
promoting Health-System pharmacy education and initiatives
state-wide. The Academy has partnered with ASHP to meet
this mission since its formation in 2014.
4th
Annual Fall CE Conference
The Fourth Annual Fall CE Conference was held at
Hotel Alyeska in beautiful Girdwood on September 28th.
The fall colors and Octoberfest atmosphere made the trip
feel like a much-needed retreat to recharge after a
frenetic Alaska summer. Networking with colleagues
from around the state is not only beneficial
professionally, but it also brings us closer together and
develops a sense of community. This year we had
sponsorships from Bristol-Myers Squibb and UAA/ISU
Doctor of Pharmacy Program. Attendance was double
that of previous years and included 30 students! There
were eight speakers for 7.5 hours of continuing
education credit. All sessions were accredited for both
pharmacists and technicians.
Keynote speaker, Rear Admiral (RADM) Pamela
Schweitzer, has had a very distinguished career,
including experience at the national level as Assistant
Surgeon General and Chief Pharmacist Officer of the
United States Public Health Service. It was a privilege
to hear her presentation “Leadership in the Pharmacy
World” in such an intimate setting. Students were
fortunate to go on a hike with her on Winner Creek Trail
and continue discussions with her. She loves Alaska, is
very approachable, and is willing to help with our work
in advancing the practice of pharmacy.
Susan Jones, from the Alaska Section of Epidemiology,
used her wit and wisdom in updating us on trends,
services, and innovations relating to STDs and HIV
within the state. Did you know there is an epidemic of
syphilis in Alaska? Pharmacists Kylea Goff and Heather
Lefebvre shared “Protecting Lives, Once Vaccine at a
Time: The Advancement of the Pharmacist
Role in Vaccination Administration” about their
amazing work in increasing vaccination rates in the
Norton Sound Region. They show that through
persistent and consistent focus, pharmacists can make a
significant impact to the health of the area by increasing
vaccination rates. Kevin Cleveland joined us from the
UAA/ISU Doctor of Pharmacy Program to give a
pharmacy preceptor update. We enjoyed learning how
our generational differences affect the way we approach
our lives, communication preferences, and learning
styles. Ali Pryne showed us that “Special K” isn’t just
for breakfast anymore. She took a break from her
practice as an Emergency Department pharmacist at
Valley View Hospital in Glenwood Springs Colorado to
discuss the many uses of ketamine in the ED. Cara
Liday, an associate professor at UAA/ISU, is a clinical
pharmacist and certified diabetes educator with
experience in ambulatory pharmacy helping patients
manage diabetes. She taught us about options for
continuous glucose monitoring (CGM), what makes
some more appropriate for certain patients than others,
and how CGM can integrate with insulin pumps.
Gretchen Glaspy, an informatics pharmacist at Bartlett
Regional Hospital and the chair of the Fall CE
Conference, lead the AKConnect! session which focused
on the Pharmacy Advancement Initiative (PAI). Ideas
were discussed to further our organization’s efforts to
facilitate working together to help us make a meaningful
difference in healthcare in Alaska.
Two posters were presented. “Implementation of an
infusion center patient tracking board to enhance
efficiency and communication” was presented CDR
Ashley Schaber, PharmD, MBC, BCPS, with additional
authors CDR Ann Marie Bott, PharmD, BCPS, BCOP,
and Janelle Solbos, 2020 PharmD Candidate from
UAA/ISU College of Pharmacy. Megan Penner,
PharmD presented “Implementation of Pharmacy
Services in a Community Teaching Hospital Emergency
Department”.
During the Academy general membership meeting, we
reviewed the accomplishments which include the PAI
workshop, ASHP reaffiliation application, and city-wide
grand rounds. Goals of the organization include
maintaining full affiliation with ASHP, maintaining a
budget, increasing membership benefits and services,
maintaining a collaborative relationship with ASHP, and
increasing pharmacy student and resident involvement in
AKPhA and the Academy. Current projects include
supporting students and developing mentorship
The Alaska Pharmacy Newsletter
6
Dr. Pamela Schweitzer speaking with students during a hike on the
Winner Creek Trail in Alyeska (Photo Credit, Annie Enderle)
relationships by developing a CV review program.
Funding for residency programs is being threatened, and
we are reaching out to residency directors as well as
people interested in potential residency programs to
advocate for support. The Academy is working to bring
awareness of burnout in our profession and supports
educational efforts and research at the state level. There
are many opportunities to get involved in the Academy
from joining the executive committee, to work groups, to
CV review, or willingness to be chair-elect.
RADM Schweitzer said “Coming together is a
beginning. Keeping together is progress. Working
together is success.” We have a lot to be excited about.
We are coming together with talented speakers sharing
their work and projects in our state. We have a vibrant,
enthusiastic student contingent, and many dedicated
professionals in our state. Our Fourth Annual Fall CE
Conference shows that we are keeping together, and I
am very excited about the work we will do together to
achieve our goals for pharmacists in the State of Alaska.
The executive committee looks forward to seeing
everyone at the Alaska Pharmacists Association 54th
Annual Convention on February 7-9th, 2020.
Interested in expanding your role within the Academy? Please contact Chair Ursula Iha, [email protected],
or Chair-Elect Gretchen Glaspy,[email protected]
Interview with RADM Pamela Schweitzer
Daniel Enox, UAA/ISU Doctor of Pharmacy
Program, P3 Student
It was September 28th and despite the presence of gray
clouds, brisk temperature, and low sun, the weather at
Girdwood was pleasant. A steady stream of visitors from
abroad emerged from the Alyeska Resort Hotel, waiting
for their valets or family and friends to pick them up. It
was only eight in the morning but there was also a
steady stream of well-dressed individuals walking into
the hotel to begin their day at the annual fall CE
conference. The breakfast provided was pleasant. There
was a consistent hum of activity and conversations
before the clock struck eight and the conference began.
Proper etiquette was given as the keynote speaker began
an energetic lecture about leadership and the direction of
our profession. A simple trail of slides told the story of
her career with interesting anecdotes such as provider
status for pharmacists with CMS and the arduous task of
converting paper to electronic form during her time as
Technical Director. RADM Pamela Schweitzer’s career
covers a wide breadth of experience. Graduating in 1987
at the University of California, San Francisco, she
became a member of a small but growing group of
pharmacists becoming Doctors of Pharmacy. From there
Dr. Schweitzer earned her residency at the University of
California Irvine and became a Board Certified
Ambulatory Care Pharmacist. She was also the first
female Pharmacy and Assistant Surgeon General during
2014 to 2018, lauded by many in the United States
Public Health Service and more. Her career is enormous,
yet she is humble and always carrying a smile and kind
words with her everywhere.
The first several years of her career, Dr. Schweitzer
found numerous career opportunities along the way.
During the student hike at the conference, a student
asked how she got where she was. She explained that
many of these were offered unexpectedly, but she took
them on in her early career. Some positions lasted a
short time and others she felt less than ready in her
experience which helped her grow: “You get thrown in,
but you learn a lot about yourself. You ask yourself,
‘Okay, how can I make this situation better?’, and it’s
your attitude and you can control that.” Dr. Schweitzer
explained another important point in her life,
motherhood. "It changes when you have a kid,” she
added, and lifestyle and career choices were made.
In order to cut commute time, and adapt to her new
family, she applied at a local VA in South Dakota. She
called in, spoke with them and asked if they had a
position available and offered her CV and resume. Just
by asking they created a position for her, excited that she
had the clinical experience they were looking for. This
attitude of just asking and talking to people gave her
recognition and she would eventually transition up to
Department of Health and Human Services before finally
reaching Chief Professional Officer. Even though she is
retired, Dr. Schweitzer still has not slowed down and
shows no signs doing so.
The Alaska Pharmacy Newsletter
7
Dr. Schweitzer is more than just a pharmacist.
Another pillar in her life is work-life and
addressing the pressures of personal life and
career. In previous articles, Dr. Schweitzer
noticed that several of her colleagues were
feeling similar pressures. She held sessions with
other women during her CPO tenure that focused
on meaningful conversations balancing work and
family life. These gatherings helped to support
and encourage women to speak up and exchange
their views with one another.
By stepping forward at various points in her life,
Dr. Schweitzer grew to become a leader to many
students and pharmacists. The lessons seem
simple, but the results are powerful. There is a
common quote paraphrased that resonates: “Luck
is just opportunity and preparedness meeting,”
and Dr. Pamela Schweitzer exemplifies this.
The Alaska Pharmacy Newsletter
8
Committee Report, Community Affairs
AKPhA T-Shirt Design Contest Kathryn Sawyer, Chair
When: September 19, 2019 – November 15, 2019
Who: All Alaska Pharmacists Association Members, family of members and pharmacists or pharmacy technicians practicing are invited to participate. The winning t-shirt design will be produced by AKPhA’s vendor and sold at the Annual AKPhA Convention and via website sales.
Why: What does wellness mean to you? How do you stay well and help others achieve wellness? Wellness is the theme of this year’s 54th Annual Convention and Trade Show which takes place February 7th - 9th, 2020 and AKPhA is looking for a t-shirt design which encapsulates what wellness means. A picture is worth a thousand words and maintaining wellness is crucial for pharmacist, pharmacy technicians, students and patients! Create an original design that expresses what wellness means to you and submit it to AKPhA!
How does it work? Artistic Guidelines
1. Design does not need to include the AKPhA logo.
2. Design should be limited to no more than 3 colors.
Submission Guidelines 1. Designs must be original and submitted by or on behalf of the designer and with the designer’s
direct consent. Adults must submit on behalf of minors.
2. By entering the contest, the submitter certifies that the design is original and does not infringe oncopyright laws.
3. Designers must agree to the full Official Contest Rules (below) which includes assigning thecopyright to unrestricted public domain.
4. Designers must reside full-time in the United States or US territories.
5. Designs must be 300 dpi or better so they are suitable for print media as well as for use in onlinechannels. JPG, PDF, PNG files are accepted
6. Submit designs by email to [email protected] by midnight November 15, 2019 (local time
zone). You may submit more than one design. Artwork Submission form MUST accompany each
submission.
Official Contest Rules By signing below, I signify that I have read the OFFICIAL CONTEST RULES for the Alaska Pharmacists Association T -Shirt Design Contest and I agree to all the rules and regulations of the contest as outlined below:
1. The contest is open to all Alaska Pharmacists Association Members, family of members andpharmacists or pharmacy technicians practicing in the State of Alaska.
2. All entries must be original creations of the contestant that has never been published, and does notcontain profanity, trademarks, logos, or copyrighted works of any other person or business.
3. All entries become and remain the property of Alaska Pharmacists Association. We will not return any
entries to you. AKPhA may use the design of any entry at any time after the contest.
4. Contestants may display their own design(s) in a portfolio or personal collection, but may not sell or
reproduce the design(s) for any other purpose once submitted to the contest
5. A panel of judges representing AKPhA will choose the winning submission. 6. Designs may be modified slightly to accommodate graphics with all modifications
to be reviewed by AKPhA and the submitter.
7. The entries must be received by midnight, November 15, 2019. Designs may be submitted by
email at [email protected]
The Alaska Pharmacy Newsletter
9
FORM OF ENTRIES:
The entry may be drawn or printed on 8-1/2” x 11” paper or the entry may be any of the
following art file formats if submitted electronically:
.JPG, .PDF, .PNG.
The entry must be accompanied by the completed Artwork Submission form.
a. We reserve the right to pick one entry, more than one entry, or no entries as the winning
entry.
b. If we pick an entry as the winning entry, we may produce and sell t-shirts with the winningdesign but we are not obligated to do so.
c. We reserve the right to terminate this contest at any time, effective on the date of
issuing the termination notice. We do not need to give you notice prior to the date of
termination.
d. You agree that if you submit an entry, you will sign an assignment and release form
prepared by us acknowledging your acceptance and understanding of the complete contest
rules including that the design is the property of Alaska Pharmacists Association.
e. This contest is subject to all federal, state and local laws.
Acknowledgement and Assignment
I am submitting a contest entry with this form, and I hereby assign any and all rights in the intellectual
property of this entry to Alaska Pharmacists Association. I agree that the entry I submit becomes your
property and that the entry will not be returned to me.
I state that this entry is my own original creation and that I did not copy anyone else's work in creating
this contest entry. I agree that if I have copied anyone else’s work in preparing this entry, and if I win this
contest, I will defend, indemnify and hold harmless Alaska Pharmacists Association and its respective
officers, directors, employees, suppliers, licensors, contractors and agents against and from any loss,
debt, liability, damage, obligation, claim, demand, judgment or settlement of any nature or kind, known
or unknown, liquidated or unliquidated, including without limitation, all reasonable costs and expenses
incurred including all reasonable litigation costs and attorneys’ fees arising out of or relating to claims,
complaint, action, proceeding or suit of a third party, that arise or relate in whole or part to the
contestant’s entry.
I agree that if I win the contest, I authorize the use by you, without additional compensation, of my
name and likeness or photograph for promotional purposes in any manner and in any medium
(including without limitation the internet, written or email communications, brochures, videos,
slides, radio, television, film) that you deem appropriate.
If I submit more than one entry, I will submit an Entry Form with each entry.
Submission Deadline: November 15, 2019
All participants must read and agree to the Official Rules and Assignment. I have read, understand, and agree
to the Official Contest Rules and Assignment.
Person Submitting Design
First and Last Name:
Email Address:
Daytime Phone Number:
Signature of Person Submitting: ________________________________________ Date: _______________
The Alaska Pharmacy Newsletter
10
Emergency Pharmacy
Preparedness Talethia Bogart, PharmD Candidate
Renee Robinson, PharmD, MPH,
MSPharm
Elaine Nguyen, PharmD, MPH
Chris Owens, PharmD, MPH
Over the past decade, the number of extreme weather
events and natural disasters has increased (e.g.,
catastrophic bushfires, avalanches, mud slides, road
closures, and earthquakes). Based on Alaska’s limited
population density per capita, finding resources during
extreme weather events or emergencies is often
problematic. The key to successfully navigating and
supporting communities in these situations is disaster
preparedness (planning before events occur).
To determine what pharmacy-based emergency
preparedness programs exist we looked initially to the
peer-reviewed and grey literature; however, most
emergency preparedness protocols and standard
operating procedures (SOPs) did not pertain to
pharmacies, acknowledge the contribution of
pharmacists, and/or the role students may have in
emergency response/preparedness situations.
Recognizing a gap in disaster preparedness and an
opportunity for pharmacists, an emergency pharmacy
preparedness project (EPPP), an independent study, was
developed and through student/faculty collaboration.
The goal of the EPPP is to develop a framework that
utilizes the organizational structure of pharmacy student
leaders to collect and disseminate pertinent pharmacy
information (e.g. operational status, safe drug supply,
adequate staff, and environmental safety) during natural
disasters and unforeseen events. Vital information
collected by pharmacy student leaders will be distributed
to emergency preparedness officials, the media, and
community members in order to reduce inappropriate
healthcare system access and promote appropriate
utilization of local resources (i.e. acute and chronic life-
saving prescription medications from community
pharmacies).
Student leaders, including the APhA-ASP Patient Care
Vice President and three leaders in each APhA-ASP
operation (n=16) were identified to lead this Alaska
initiative. SOPs, flowcharts, telephone scripts, student
training materials, and talking points were created to
facilitate and streamline pharmacy-student interactions,
emergency contact information collection (e.g., cell
phone numbers and email addresses), and follow-up
communication strategies (bi-yearly check-ins and
emergency information communication plans). In the
case of a natural disaster or state of emergency pharmacy
students will contact pharmacies within the designated
area to collect vital information that patients may need to
know. Information will be disseminated to residents,
providers, and healthcare facilities.
Students at UAA/ISU are uniquely positioned to identify
community needs, support emergency efforts, and
expand pharmacy practice. Information collected has the
potential to improve utilization of healthcare resources
during natural disasters, promote, and preserve patient
health.
Billing and Coding:
Disparities in
Healthcare Provider
Training Brittany Romans, UAA/ISU
Additional Authors:
Michael Biddle, Elaine Nguyen,
Thomas Wadsworth, Renee Robinson
Knowledge on billing/coding is crucial to receive
payment for provided healthcare services and ensure
sustainability of such services; however, many providers
11
do not receive formal training on how to document and
bill for these services.
The purpose of the project is to identify any current
billing and coding training within the curriculum of five
discrete healthcare disciplines (pharmacy, social work,
dietetics, nursing, and medicine) and to identify
disparities. We administered a telephone survey to the
top 100 schools ranked by US News in each discipline.
Only 129 of the 493 schools contacted (29%) responded
to the survey, dietetic schools being the most responsive
(n=39) and most likely to respond with “yes” that they
taught billing (92%). No social work schools taught
billing (n=36, 0%) and one medical school reported
teaching billing (n=20, 5%). Nursing (n=21) and
pharmacy (n=13) schools reported 52% and 23% for
teaching billing, respectively. The majority of
responding schools were public institutions (72%).
Among the responding programs only 10% offer
medical billing/coding instruction of some kind within
their curriculums; however, even more interesting was
that significant disparity existed between the healthcare
disciplines. It is notable that responding medical schools
were one of the least likely to provide training within
curriculums, considering the high level of billable
services provided and number of claims submitted.
Although the survey did not explore the causes of the
disparities, the level of training within each profession
may indicate that training is taking place outside of the
school curriculum; during rotations or through
engagement with professional organizations (e.g., AMA,
AKPhA). AKPhA plans to offer billing/coding training
at their Annual Convention entitled “Alaska Pharmacy
Practice Transformation Workshop” to help address this
disparity.
Depicted here is a map of schools contacted that answered either “yes” or “no” to the survey. Social
work schools are pins that are red in color, dietetic schools are green, pharmacy schools are yellow,
nursing schools are purple, and medical schools are gray.
The Alaska Pharmacy Newsletter
12
ALASKA PHARMACISTS ASSOCIATION
54TH ANNUAL CONVENTION Sheraton Anchorage, 401 East 6th Avenue, February 7 – 9, 2020
First Name ____________________ Last Name___________________________ DOB:___________________
Address ________________________________________City _________________State ____Zip ___________
Place of Employment _________________________________________________________________________
Work Address _________________________________ City _________________ State ____ Zip ___________
Home/Cell phone ______________________Work phone _______________NABP e-profile ID _____________
AK Driver’s License # __________________ Email ________________________________________________
CONVENTION REGISTRATION Early bird pricing—register before January 15th to save $50! Registration includes Saturday Awards Reception. No
refunds issued after January 15th. A 50% refund may be requested prior to January 15th. To receive membership discount,
2020 dues must be paid. Registration also available online at www.alaskapharmacy.org
Pharmacist Associate Technician Student
Friday $ 60.00 $ 60.00 $ 40.00 $ 20.00
Saturday 140.00 140.00 90.00 45.00
Sunday 140.00 140.00 90.00 45.00
Non-Member Add 225.00 150.00 50.00 25.00
After Jan 15 Add 50.00 50.00 50.00 50.00
TOTAL FEES $ $ $ $
Please list any food allergies/dietary needs_________________________________________________________________________
AKPhA is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This activity is eligible for ACPE credit. See complete CPE activity announcement online. Target Audience: Pharmacists & Technicians.
HOTEL RESERVATIONS A group rate of $101 sgl/dbl occupancy is available at the Sheraton for the convention. Please reference Alaska
Pharmacists Association and book rooms by January 23, 2020 to ensure availability and receipt of group rate.
Reservations can be made by calling 800-325-3535 or visit the personalized webpage: https://www.marriott.com/event-reservations/reservation-link.mi?id=1570222206461&key=GRP&app=resvlink
ANNUAL MEMBERSHIP RENEWAL Memberships are valid January 1 – December 31. Dues and contributions are not deductible for income tax purposes,
but may be deductible as ordinary business expenses, subject to IRS restrictions. AKPhA estimates that 75% of your dues
dollar is non deductible because of AKPhA’s lobbying activities on behalf of its members. Renewal also available online.
Pharmacist $ 225.00
Pharmacist, 1st year graduate $ 125.00
Associate Member $ 150.00
Pharmacy Technician $ 50.00
Pharmacy Student $ 25.00
Business Membership $ 300.00 AKPhA Academy of Health-System
Pharmacy Membership*—ADD:
Pharmacist $ 25.00
Technician $ 10.00 *Must be a current member of AKPhA
Make checks payable and mail to AKPhA PHONE: 907-563-8880, FAX: 907-563-7880
203 West 15th Avenue, Ste 100, Anchorage, AK 99501 [email protected]
TOTAL FEES:
Convention Registration $_____________
Membership Dues $_____________
Donation (Scholarship/Legislative/General) $_____________
Extra Sat Reception Ticket (guest), $25 $_____________
OVERALL TOTAL $_____________
VS/MC/AMEX#:____________________________________________
Exp Date______________ Security Code____________
Signature:__________________________________________________
The Alaska Pharmacy Newsletter
13
Friday, February 7, 2020 8:00 am- 2:00pm
OPTIONAL Separate Registration
Required
Alaska Pharmacy Practice Transformation Workshop Trainers: Renee Robinson, Tom Wadsworth, Andrew Hibbard, Zach Rosko Program provided in partnership with the AK Dept of Health & Social Services
NOON AKPhA Convention Registration Open Howard Rock Ballroom Lobby, 2nd Floor
1:00 - 2:00 pm Suicide Prevention for Pharmacy Personnel Nancy Kavan
1:30 – 4:00 pm Exhibit Area Check-In and Set Up 2:15 - 3:15 pm Precepting Pharmacy Students and Residents
Anne Marie Bott & Courtney Klatt
3:15 – 3:30 pm Wellness / Coffee Break
3:30 – 4:30 pm AK Medicaid Update Erin Narus & Chuck Semling
Saturday, February 8, 2020 7:00 am Registration Open Howard Rock Ballroom Lobby, 2nd Floor
Scholarship Silent Auction Open* Staged at entrance to Ballroom B/C 7:00 -8:00 am
Ex
hib
it A
rea
Op
en
—H
ow
ard
Ro
ck A
& F
oy
er
Buffet Breakfast with Exhibitors Howard Rock Ballroom A & Foyer Sponsor:
8:00 - 9:30 am ASHP National Speaker Wilderness Medicine Deb Ajango
9:45 - 10:45 am Non-Opioid Pain Control Aimee Young
Partnership for Safe Medicines- Counterfeits in America Shabbir Safdar
Trends in Advanced Pharmacy Practice and Professional Development Through Board Certification Brian Lawson
10:45 – 11:00 am Wellness/Coffee Break Sponsor: Howard Rock A & Foyer
11:00 am - Noon Grassroots Training (Law CE) Heidi Ann Ecker
Podium Poster Presentations
Noon - 1:30 pm Lunch with Exhibitors Sponsor: Howard Rock A & Foyer
12:30 - 1:00 pm Poster Presentations Howard Rock Lobby
1:30 – 3:00 pm Adventures in Pharmacy Bill Altland
Waging a War Against Obesity with Fasting Protocols and Nutraceuticals Tim Schroeder
Demystifying the Hematology Alphabet Soup: AIHA, TTP/HUS, & ITP Katelyn Kammers & Ian Ingram
3:00 – 4:00 pm Practicing at the Peak of Your Pharmacist and Pharmacy Technician License Greg Sarchet & Weston Thompson
Review of New Oncology and Hematology Medications in 2019 Tyler Downey
4:00 – 4:30 pm Dessert Social & Coffee Break with Exhibitors Sponsor: Scholarship Silent Auction Closes* Howard Rock A & Foyer
4:30 pm Exhibit Area Teardown
Alaska Pharmacists Association 54th Annual Convention
"Pharmacy Wellness & Well-Being" February 7 – 9, 2020, Sheraton Anchorage
Schedule Updated: 10/25/19 All Sesssions Accredited for both Pharmacists and Technicians.
The Alaska Pharmacy Newsletter
14
4:30 – 5:30 pm New CAP Guidelines Angharad Ratliff
Technician Roles, Certification & Education (Tech Only) Tiffany Rudisill
Legislative Committee Update (Law CE) Barry Christensen, Dirk White, Tom Wadsworth
5:30 - 7:00 pm AKPhA Awards Reception and Pharmacy Game The Summit Room, 15th Floor Game provided in partnership with the UAA/ISU Doctor of Pharmacy Program Entertainment: Sponsor: WSPC (Western States Pharmacy Coalition)
Sunday, February 9, 2020 7:00 am Registration Open Howard Rock Ballroom Lobby, 2nd Floor
7:00 - 8:00 am Continental Breakfast Sponsor: Howard Rock A & Foyer
7:15 - 8:00 am Mindful Meditation Prayer Gathering AKPhA New Board Orientation
8:00 - 9:30 am
We
lln
ess
/ M
ind
ful
Me
dit
ati
on
Are
a
The Outward Mindset Howard Rock A & Foyer Jason Woo, Arbinger
9:45 – 10:45 am AKConnect! – Roundtable CE Session Howard Rock A & Foyer Michelle Locke & Ashley Schaber
10:45 – 11:00 am Wellness / Coffee Break Sponsor: Howard Rock A & Foyer 11:00 am - Noon PDMP/Board of Pharmacy Update (Law CE) Howard Rock A & Foyer
Noon - 1:15 pm Lunch—AKPhA Business Meeting & Committee Discussions Howard Rock A & Foyer
1:30 - 2:30 pm Pharmacogenomics Megan Penner
Opioid Use Disorder/ Medication Assisted Therapy Tess Larson, Haley Monolopolus
STDs in Alaska Susan Jones
2:45 - 3:45 pm Vaping, E-cigarettes, and Pulmonary Disease Nikolina Golob
USP 797 Roundtable Discussion Maria Terch, Carrie Lang
Malnutrition, TPNs, and Refeeding Syndrome Lisa Stewart
3:45 – 4:00 pm Wellness / Coffee Break Howard Rock A & Foyer
4:00 – 5:00 pm Women’s Health Paul Hardy & Colton Taylor
Hepatitis and Diabetes David Moore
5:15 - 6:00 pm AKPhA Board of Directors Meeting Yukon
*Scholarship Silent Auction
Proceeds from this event go toward funding our three annual
scholarships:
The Francis C. Bowden Memorial Scholarship—Students
who are Alaska residents and enrolled in a Professional
Pharmacy program at an ACPE accredited school of pharmacy
will be eligible to apply for this $1,500 award.
The Pre-Pharmacy Scholarship—Students who are enrolled
in a pre-pharmacy curriculum or equivalent who have a history
in Alaska will be eligible for this $1,000 award.
The Pharmacy Technician Scholarship—This $500
scholarship will be given to an Alaskan resident who is a high
school graduate or holds a GED certificate and is currently
enrolled in a pharmacy technology program, or to a current
Alaska Pharmacy Technician license holder who intends to
enroll in a pharmacy technology curriculum.
Applications were posted in September and have a November 30th
submission deadline. Recipients are notified mid-December
Donate an Auction Item
We hope you will consider donating an item or
service to help raise funds for our Scholarship
Program. Individuals and business donors are listed
on the silent auction bid sheets at Convention as well
as in our quarterly newsletter. We welcome any and
all donations. Please complete the form online:
https://alaskapharmacy.org/2019/10/call-
for-scholarship-silent-auction-items/
Items can be brought to the Association office
(email/call the office to coordinate drop-off) or
brought to convention. Thank you for your support
and participation with AKPhA!
Scholarship Chair: Cathy Arnatt,
Thank you Convention Chair Katie Jo McKillip
for scheduling our program!
The Alaska Pharmacy Newsletter
15
New
Awards
ALASKA PHARMACISTS ASSOCIATION
CALL FOR YEAR 2020 AWARD NOMINATIONS
Nominate an outstanding pharmacist and/or technician you know or work
with using online forms at www.alaskapharmacy.org
Distinguished Young Pharmacist Award Sponsored by Pharmacists Mutual
Presented to an Alaskan pharmacist with current
AKPhA membership who received an entry degree in
pharmacy less than 10 years ago (2009 graduation
date or later) practicing in a retail, institutional,
managed care or consulting pharmacy and who has
actively participated in national pharmacy
associations, professional programs, state association
activities and/or community service.
Pharmacy Technician Award Sponsored by AKPhA
This award was created in 2001 and presented by
the Alaska Pharmacists Association (AKPhA) to a
pharmacy technician currently employed in a
pharmacy in Alaska who has demonstrated
outstanding service. Preference is given to members
of AKPhA.
NASPA Excellence in Innovation Award Sponsored by Upsher-Smith Laboratories, Inc.
The Innovative Pharmacy Practice Award was first
introduced in 1993 by Elan Pharmaceuticals to
recognize pharmacists who meet the challenge of
providing quality, cost effective care in a rapidly
changing health care environment with creative new
solutions. A nominee should be a practicing
pharmacist in Alaska and should have demonstrated
innovative pharmacy practice resulting in improved
patient care.
Preceptor of the Year
AKPhA Fellow
Description and qualifications
will be announced at Convention.
Bowl of Hygeia Sponsored by the APhA Foundation and the
National Alliance of State Pharmacy Associations
(NASPA) with support from Boehringer-Ingelheim
Presented to a pharmacist who has compiled an
outstanding record of community service and civic
leadership, which, apart from his/her specific
identification as a pharmacist, reflects well on the
profession. The recipient must be a pharmacist
practicing in Alaska, must be living, must not have
been a previous recipient and is currently not serving,
nor has served within the immediate past two years as
an officer of AKPhA in other than an ex-officio
capacity or its Awards Committee.
Distinguished Alaskan Pharmacist Award Sponsored by AKPhA
This award was created in 1989 by the Alaska
Pharmacists Association to recognize an Alaskan
pharmacist who has worked in Alaska for over 10
years and devoted much of their career working
diligently to promote and support the profession of
pharmacy and community in which they live.
Furthermore they have served as a role model for
younger pharmacists to emulate through their
sustained contributions to the profession over time.
Please submit nominations
by December 1st. Additional narrative
can be sent (if needed) to:
Melanie Gibson, Awards Chair
Alaska Pharmacists Association
907-563-7880 Fax
Awards will be presented at the AKPhA Annual Convention Awards Reception,
Saturday, February 8, 2020, Sheraton Anchorage
The Alaska Pharmacy Newsletter
16
ALASKA PHARMACISTS ASSOCIATION
NOTICE
NOMINATIONS ARE OPEN
NOMINATIONS FOR PRESIDENT-ELECT AND THE FOLLOWING SEATS ARE OPEN FOR THE ALASKA PHARMACISTS ASSOCIATION 2020 BOARD OF DIRECTORS.
CONSIDER NOMINATING YOURSELF OR A COLLEAGUE!
PRESIDENT-ELECT: _____________________________________________________
Qualifications: Must be a member in good standing with at least one year past or present AKPhA Board experience.
BOARD OF DIRECTORS:
Qualifications: Must be a member in good standing.
The Following Seats are open:
1 Seat—SOUTHCENTRAL:______________________________________ (3 YEAR TERM)*
*Please note—Southcentral seats filled by members living in the Anchorage area may be asked to take on the roleof Co-Treasurer due to their proximity to the Association office.
1 Seat—SOUTHEAST: __________________________________________(3 YEAR TERM)
1 Seat—FOR TECHNICIAN (Appointed):____________________________(2 YEAR TERM)
The following are one year At Large Seats: President-Elect automatically assumes one seat as President. The other seat may be held in reserve for the new President-Elect.
SUBMIT NOMINATION FORMS TO THE AKPhA OFFICE
BY DECEMBER 1st
203 West 15th
Avenue, Suite 100, Anchorage, AK 99501
[email protected] or Fax 907-563-7880
Nominations can also be made online at www.alaskapharmacy.org
BALLOTS WILL BE DISTRIBUTED TO THE MEMBERSHIP BY DECEMBER 15
MARK YOUR CALENDARS, AKPhA 54th ANNUAL CONVENTION February 7 – 9, 2020, Sheraton Anchorage
The Alaska Pharmacy Newsletter
17
PHARMACY MARKETING GROUP, INC
AND THE LAWBy Don. R. McGuire Jr., R.Ph., J.D.
This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.
A PHARMACIST'S DUTY TO AN UNKNOWN THIRD PARTY
A recent court decision in Michigan re-examined an issue first discussed in this column about ten years ago. In the Sanchez case from Nevada in 2009, the patient, driving while under the influence of prescription medications, hit two men, killing one. The survivor and the decedent's family sued a number of parties, including eight pharmacies, for the injuries and wrongful death. The Nevada court cited Common Law principles that a person has no duty to control another's dangerous conduct, or to warn others of that dangerous conduct absent a special relationship and foreseeable harm. The court decided that there was no special relationship because the plaintiffs in that case were unidentifiable prior to the accident.
The Michigan decision dealt with a very similar situation. In this case, a patient's car crossed the centerline and collided with another car, killing two women and injuring another. The patient had received a number of prescriptions for controlled substances, including fentanyl patches, over the previous two years. On the day of the accident, the patient received a prescription for fentanyl patches. Upon leaving the pharmacy, he put a patch in his mouth and chewed it presumably in an attempt to bypass the time-release mechanism.
The decedents' families and the survivor filed suit against both the prescriber and the pharmacy alleging that a special relationship existed between the patient and the pharmacy and that it was foreseeable that the patient would drive while intoxicated. The pharmacy filed a
motion for Summary Judgment stating that no such relationship existed and that it was not foreseeable that the patient would misuse the patch. The trial court disagreed with the pharmacy’s position and denied their motion.
The pharmacy appealed the ruling to the Michigan Court of Appeals. The Court of Appeals reviewed a line of pharmacy cases in Michigan dating back to 1980. The existing rule in Michigan is that a pharmacist does not have a duty to warn a patient of possible adverse events when dispensing a drug pursuant to a facially valid prescription. Based on these cases, the Court concluded, ". . . it would be illogical to impose such a duty on the pharmacist with respect to a third party." The Court also concluded that the pharmacy had no duty to monitor the patient's use of fentanyl.
In a somewhat unusual circumstance, one judge filed a concurring opinion in which he agreed with the conclusion, but urged the Michigan Supreme Court to take up the case because he believed that Michigan case law was based on an incorrect interpretation of the law. He reviewed legislation and regulations from which he concluded that a pharmacist does have a duty to warn of possible adverse events and to monitor the patient's use of medications. The first of these was the Federal regulation under the Controlled Substances Act that created a pharmacist's corresponding responsibility to consider the validity of an order for a controlled substance. The conclusion was that the Michigan case law stating that a pharmacist has
The Alaska Pharmacy Newsletter
18
no legal duty to monitor the prescribing of controlled substances was at odds with Federal law. The judge also cited Michigan laws and regulations supporting the conclusion that pharmacists have a broader duty than the current case law outlines.
The judge urged the Michigan Supreme Court to take up the case because the Court of Appeals did not have the authority to overturn Michigan case law. However, in April 2019, the Supreme Court declined to hear the appeal and the Court of Appeals ruling stands.
While some states' case law still follows the concept of the Learned Intermediary (i.e., the pharmacist has no duty to warn the patient because of the involvement of the prescriber who is the Learned Intermediary). The concurring opinion in this case gives us a glimpse of where the law is likely to go. As pharmacists continue to expand the array of services that they can provide to patients and technological advances place more information into their hands, it seems unlikely that pharmacists will be able to continue to rely on the defense of filling a facially valid prescription. While this may not extend to a duty to unknown third parties, pharmacists should be prepared for future courts to impose a duty to warn patients of possible adverse events and to monitor their medication usage.
© Don R. McGuire Jr., R.Ph., J.D., is General Counsel, Senior Vice President, Risk Management & Compliance at Pharmacists Mutual Insurance Company.
This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly.
Please Renew
Your AKPhA
Membership
Before
December 31st!
AKPhA's memberships are valid
January 1 – December 31st (with
special offers or year-end joins
occasional differing from this cycle).
Please login to our website
and renew today! Our membership
system also has an auto-renewal option
which you can select when you access
your record.
Not sure of your status? Email
Thank you for your support and
participation with AKPhA!
The Alaska Pharmacy Newsletter
19
MIS
SIO
N
VIS
ION
P
rese
rve,
Pro
mo
te a
nd
Lea
d t
he
Pro
fess
ion
of
Ph
arm
acy
T
o b
e th
e re
sou
rce
for
an
d v
oic
e o
f p
ati
ent-
focu
sed
ph
arm
acy
ca
re i
n A
lask
a.
Str
ate
gic
Goal
#1
Pro
mote
an
d a
dvan
ce
ph
arm
acy
pra
ctic
e in
Ala
ska
Str
ate
gie
s:
1.
Act
ivel
y a
dvan
ce P
rovid
er S
tatu
s
for
ph
arm
acis
ts b
y c
oll
abo
rati
ng
wit
h s
takeh
old
ers
(com
mu
nit
y,
pat
ients
, pro
vid
ers
and l
egis
lato
rs).
2.
Su
pp
ort
the
Sust
ainab
le
Ed
uca
tion &
Tra
inin
g M
odel
un
der
Ph
arm
acis
t P
rovid
er R
eim
bu
rsem
ent
(SE
TM
uP
P)
dem
onst
rati
on p
roje
ct
via
th
e gra
nt
wit
h D
HS
S/C
DC
.
3.
Mai
nta
in a
nd s
tren
gth
en i
nte
r-
pro
fess
ional
rel
atio
nsh
ips
wit
h o
ther
hea
lth
care
ass
oci
atio
ns
by
par
tici
pat
ing i
n m
eeti
ngs
and
invit
ing t
hem
to A
KP
hA
even
ts.
4.
Cu
ltiv
ate
mem
ber
rel
atio
nsh
ips
wit
h r
egio
nal
leg
isla
tive
con
tact
s
and
mai
nta
in a
ctiv
e voic
e in
Ju
nea
u.
Str
ate
gic
Goal
#2
Att
ract
an
d r
etain
more
mem
ber
s, k
eep
th
em
in
form
ed,
an
d e
nco
ura
ge
engagem
ent.
Str
ate
gie
s:
1.
Per
sonal
outr
each
to i
nvolv
e new
and
no
n-r
enew
ed m
ember
s.
2.
Incr
ease
Ass
oci
atio
n m
ember
ship
over
all
by 5
%.
3.
Incr
ease
posi
tive
vis
ibil
ity o
f th
e
pro
fess
ion
of
phar
mac
y b
y w
ork
ing
wit
h v
ario
us
form
s of
med
ia o
n
curr
ent
new
s it
ems.
4.
Pu
bli
cize
mem
ber
ach
ievem
ents
inte
rnal
ly a
nd e
xte
rnal
ly i
ncl
udin
g
bo
ard
an
d t
echnic
ian c
erti
fica
tions.
5.
Co
nti
nue
to d
evel
op t
echnolo
gy
opti
on
s to
bet
ter
serv
e m
ember
s.
6.
En
gag
e T
echnic
ian m
ember
s.
Str
ate
gic
Goal
#3
Pro
vid
e ed
uca
tion
, p
rofe
ssio
nal
dev
elop
men
t re
sou
rce
s, a
nd
kn
ow
led
ge
for
ph
arm
acy i
n
Ala
ska.
Str
ate
gie
s:
1.
Uti
lize
web
inar
syst
em w
ith
UA
A/I
SU
Phar
mac
y P
rogra
m f
or
regio
nal
/sta
tew
ide
engag
em
ent
and
CE
acc
ess.
2.
Conti
nue
dev
elopin
g c
reat
ive
and
innovat
ive
net
work
ing s
essi
on
s at
Conven
tion.
3.
Pro
mote
join
t pro
vid
ersh
ip
opport
unit
ies
to H
ealt
h S
yst
ems.
4.
Cre
ate
more
res
ourc
es f
or
com
munit
y u
se.
Str
ate
gic
Goal
#4
Su
stain
org
an
izati
on
al
lead
ersh
ip a
nd
fin
an
cial
stab
ilit
y.
Str
ate
gie
s:
1.
Dev
elo
p a
nd
im
ple
men
t o
ther
adver
tisi
ng a
nd
pro
mo
tion
op
po
rtu
nit
ies.
2.
Ex
plo
re o
ther
rev
enu
e so
urc
es
and
mem
ber
even
ts.
3.
Co
nti
nu
ally
res
earc
h c
apit
al
imp
rovem
ent
pro
ject
s.
4.
Dev
elo
p l
eader
ship
an
d
net
wo
rkin
g o
pp
ort
un
itie
s w
ithin
our
asso
ciat
ion
an
d w
ith n
atio
nal
ph
arm
acy o
rgan
izat
ions.
The Alaska Pharmacy Newsletter
20
The
Ala
ska
Ph
arm
acis
ts A
sso
ciat
ion
is
accr
edit
ed b
y t
he
Acc
redit
atio
n
Co
un
cil
for
Phar
mac
y E
du
cati
on
as
a pro
vid
er o
f co
nti
nuin
g p
har
mac
y e
duca
tion.
ww
w.a
lask
ap
ha
rma
cy.o
rg
Leg
isla
tive
Pri
ori
ties
Mem
ber
Ben
efit
s
A
ctiv
ely a
dv
ance
Pro
vid
er S
tatu
s fo
r ph
arm
acis
ts
AK
PhA
is
her
e to
mak
e a
dif
fere
nce
. M
ember
ship
off
ers
a num
ber
of
ben
efit
s to
ass
ist
Phar
mac
ists
and T
echnic
ians
both
per
sonal
ly a
nd
pro
fess
ional
ly. T
oget
her
, w
e ca
n m
eet
the
chal
len
ges
of
hea
lth c
are
tom
orr
ow
. W
e off
er:
L
egis
lati
ve
Rep
rese
nta
tion
oA
pro
fess
ional
lobb
yis
t is
ret
ained
to r
epre
sent
the
inte
rest
s of
Phar
mac
y i
n A
lask
a an
d c
oord
inat
e ou
r
Annual
Leg
isla
tive
Fly
-In t
o J
unea
u.
A
Quar
terl
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rint/
E-N
ewsl
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-mai
l U
pdat
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Leg
isla
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Ale
rts
Jo
b O
pport
unit
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oP
ost
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nli
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at w
ww
.ala
skap
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mac
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rg
C
lass
ifie
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dver
tisi
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pport
unit
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oM
ember
rat
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n p
rint
new
slet
ter
and o
n w
ebsi
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C
onti
nuin
g P
har
mac
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duca
tion
oF
all
Hea
lth
-Syst
em P
har
mac
y C
E C
onfe
ren
ce
Sep
tem
ber
28, 2019
, A
lyes
ka
Hote
l
oA
nnual
Conven
tion, F
ebru
ary 7
-9, 2020
Sher
aton A
nch
ora
ge
oH
om
e S
tud
y C
ours
es
oC
erti
fica
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rogra
ms
A
Voic
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Your
Pro
fess
ion
& P
eer
Net
work
ing O
pport
unit
ies
W
ork
ing R
elat
ionsh
ips
wit
h S
tate
and N
atio
nal
Ass
oci
atio
ns
R
ecognit
ion o
f ex
cell
ence
thro
ugh
sch
ola
rship
s an
d a
war
ds
L
iais
on t
o B
oar
d o
f P
har
mac
y
2019 -
2020 B
oard
of
Dir
ecto
rs
Ad
ele
Da
vis,
Pre
sid
ent
Ca
ther
ine
Arn
att
M
ega
n M
yers
Jun
eau
A
nch
ora
ge
No
me
Ash
ley
Sch
ab
er,
Pre
sid
ent-
Ele
ct
Jam
es B
un
ch
Am
y P
au
l
& C
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nch
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The Alaska Pharmacy Newsletter
21
Program 0139-0000-19-201-H04-P/T Quarterly AKPhA Newsletter
Release Date 10/07/2019 Expiration Date 10/07/2022 CPE Hours: 2.0 (0.2 CEU)
This lesson is a knowledge-based CPE activity and is targeted to pharmacists and technicians in all practice settings.
Learning Objectives At the completion of this activity, the participant will be able to:
1. State two positive changes you can make toyour practice following participation in thisseries.
2. Summarize three practice updates or changesyou acquired while participating in this series.
Disclosure The author(s) and other individuals responsible for planning AKPhA continuing pharmacy education activities have no relevant financial relationships to disclose.
Fees CE processing is free for AKPhA members. Non-members must submit $20 per quiz at: https://alaskapharmacy.org/payments/
To Obtain CPE Credit for this lesson you must
complete the evaluation and quiz linked at the end and score a passing grade of 70% or higher. If you score less than 70%, you may repeat the quiz once. CPE credit for successfully completed quizzes will be uploaded to CPE Monitor within 60 days.
The Alaska Pharmacists Association is
accredited by the Accreditation Council for
Pharmacy Education as a provider of continuing
pharmacy education.
Genetic Mutations in
Cancer: BRCA1 and
BRCA2
Authors:
Danielle Hess, PharmD Candidate 2020
Anne Marie Bott, PharmD, BCOP, BCPS,
NCPS, Alaska Native Medical Center
Cancer is a genetic disease that results from an
accumulation of mutations in genes that normally
control cellular growth. This accumulation of mutations
can arise from either somatic or germinal tissue. While
the majority of mutations are somatic and result from
environmental exposures, lifestyle, the aging process, or
simply chance, germline mutations are inherited. These
inherited mutations in specific tumor suppressor genes
and DNA mismatch genes predispose individuals to
various hereditary cancer syndromes.1
Of the tumor suppressor genes associated with inherited
cancer syndromes, BRCA1 and BRCA2 play an
important role in the repair of damaged DNA and the
stability of genetic material within cells. However, when
these genes are mutated or altered, the DNA repair
process may not function properly, which causes cells to
be more prone to developing additional genetic
alterations that can lead to cancer. When an individual
carries a mutated BRCA1 or BRCA2 gene, their offspring
have a 50% chance of inheriting the mutation. Although
offspring may possess a normal second copy of the gene,
the effects of mutations in BRCA1 and BRCA2 remain
visible.2
In general, BRCA1 and BRCA2 gene mutations are the
leading genetic factors for breast and ovarian cancers.2
Most notably, these genes are the strongest susceptibility
genes for breast cancer, as they are responsible for 90%
of hereditary breast cancer cases. In addition, BRCA1
and BRCA2 are accountable for majority of hereditary
ovarian cancer.3 When inherited, individuals tend to
develop breast and ovarian cancer at younger ages than
those who do not possess these mutations.2
Across the general population, 12% of women will
develop breast cancer and 1.3% will develop ovarian
Continuing Education
Home Study Series
Alaska Pharmacists Association
22
cancer during their lifetime.4 In contrast, a recent study
aimed to estimate age-specific risks of breast, ovarian,
and contralateral breast cancer for mutation carriers to
evaluate risk modification by family cancer history and
mutation location. The resulting cohort of over 9,000
mutation carriers demonstrated that about 72% of
women who inherit a harmful BRCA1 mutation and
about 69% of women who inherit a harmful BRCA2
mutation will develop breast cancer by the age of 80,
while the cumulative ovarian cancer risk was 44% for
BRCA1 and 17% for BRCA2 carriers.5 Apart from breast
and ovarian cancers, BRCA1 and BRCA2 mutations have
been associated with fallopian tube and peritoneal
cancers. Likewise, men with BRCA2 mutations, and to a
lesser extent BRCA1 mutations, are at an increased risk
of breast and prostate cancers, while both men and
women are at an elevated risk of pancreatic cancer.2
Table 1: Cancer Risk in General Population
Compared to BRCA1/2 Carriers
In order to determine an individual’s BRCA1 and BRCA2
status, multigene (panel) testing is used to conduct next-
generation sequencing to detect harmful mutations.
However, the expert consensus argues for testing
individuals who do not have cancer only when the
individual’s personal or family history suggests the
probable incidence of a harmful mutation due to the
fairly infrequent incidence of harmful BRCA1 and
BRCA2 gene mutations in the general population. In
particular, the United States Preventive Services Task
Force recommends that women who have family
members with breast, ovarian, fallopian tube, or
peritoneal cancer be evaluated to determine if they have
a family history that is suggestive of an increased risk of
a harmful mutation in BRCA1 or BRCA2.2
When an individual’s family history is indicative of
BRCA1 or BRCA2 mutations, it is recommended to first
test the family member with cancer if possible. If this
individual is shown to have a harmful BRCA1 or BRCA2
mutation, other family members should then consider
genetic counseling to determine potential risks and the
need for genetic testing. If genetic testing is performed, a
positive test indicates that the individual has inherited a
known harmful mutation in BRCA1 or BRCA2; thus, an
increased risk of developing certain cancers is present.
However, a positive result does not determine whether
or not the individual will ultimately develop cancer, as
some individuals who inherit these mutations never
develop cancer. On the other hand, a negative result can
be more difficult to interpret, as it is dependent on an
individual’s family history of cancer and whether a
BRCA1 or BRCA2 mutation has been discovered in a
blood relative.2
Once an individual’s risk is determined, this risk is
managed through a number of methods. First, enhanced
screening, such as starting breast cancer screenings at a
younger age or more frequently is an option. Therefore,
experts typically recommend that BRCA1 or BRCA2
mutation carriers begin clinical breast examinations
starting at age 25 to 35 years old, along with a
mammogram every year. If detected at an early stage,
breast cancer may have a better probability of being
treated successfully. In contrast, ovarian cancer does not
have an established early screening method.2
Additionally, risk-reducing prophylactic surgery is
available to remove at-risk tissue, such as a bilateral
prophylactic mastectomy to reduce the risk of breast
cancer development. In regards to reducing ovarian
cancer risk, a woman’s ovaries and fallopian tubes can
be removed.2
Lastly, chemoprevention medications can be utilized to
reduce the risk of cancer. For example, tamoxifen or
raloxifene are FDA-approved to reduce the risk of breast
cancer in women at high risk of development. Similarly,
oral contraceptives are thought to reduce the risk of
ovarian cancer by around 50% in both the general
population and women with harmful BRCA1 and BRCA2
mutations.2
Overall, BRCA1 and BRCA2 mutations stand at the
forefront of genetic mutations leading to breast and
ovarian cancers. Therefore, knowledge of family history
and personal risk are significant factors necessary for
proper risk management. When risk is properly assessed,
risk management can result in early detection and a
higher probability of successful treatment.
References:
1. National Cancer Institute. The genetics of cancer. NCI at the NIH.
2019.
2. National Cancer Institute. BRCA mutations: cancer risk andgenetic testing. NCI at the NIH. 2019.
3. Mehrgou A, Akouchekian M. The importance of BRCA1 and
BRCA2 genes mutations in breast cancer development. Med J
Islam Repub Iran. 2016;30:369.
4. Howlader N, Noone AM, Krapcho M, Miller D, Brest A, Yu M,
Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ,Cronin KA (eds). SEER Cancer Statistics Review, 1975-2016,
National Cancer Institute. Bethesda, MD,
https://seer.cancer.gov/csr/1975_2016/, based on November 2018SEER data submission, posted to the SEER web site, April 2019.
5. Kuchenbaecker KB, Hopper JL, Barnes DR, et al. Risks of Breast,
Ovarian, and Contralateral Breast Cancer for BRCA1 and BRCA2Mutation Carriers. JAMA. 2017;317(23):2402-2416.
Cancer General
Population
Risk4
BRCA1
Carrier
Risk4
BRCA2
Carrier
Risk4
Breast 12% 46-87% 38-84%
Ovarian 1-2% 39-63% 16.5-27%
The Alaska Pharmacy Newsletter
23
Antiemesis Treatment
for Chemotherapy-
Induced Nausea and
Vomiting
Authors:
Janelle Solbos, PharmD Candidate 2020
Anne Marie Bott, PharmD, BCOP, BCPS
NCPS, Alaska Native Medical Center
Pharmacists in all roles and positions support patients
with knowledge and expertise. Here we discuss
medications that are recommended to prevent and/or
treat emesis in adult cancer patients, according to the
National Comprehensive Cancer Network (NCCN)1 and
American Society of Clinical Oncology (ASCO)
guidelines2.
Patients with cancer present in all healthcare settings;
therefore, pharmacists knowledgeable of the agents used
to manage different types of chemotherapy-induced
nausea and vomiting (CINV) are better able to provide
patient care. Acute CINV is defined as occurring within
24 hours of chemotherapy. Delayed CINV occurs more
than 24 hours after chemotherapy. Breakthrough CINV
occurs despite optimal antiemetic prophylaxis.
Anticipatory nausea and vomiting (ANV) occurs before
chemotherapy as a conditioned response, developed after
significant nausea and vomiting during previous
chemotherapy treatments.1
Acute and Delayed CINV
For management of acute and delayed emesis,
chemotherapy agents are classified into emetic risk
categories. Antiemetic regimens are selected based on
the highest emetic risk medication in the treatment plan.
Below is a review of the antiemetic medications used to
treat acute and delayed CINV.
Agents used in Acute and Delayed CINV prevention
Medication
Substance P/Neurokinin 1
Receptor Antagonists
(NK1 RA)
Aprepitant
Aprepitant injectable
emulsion
Fosaprepitant
Netupitant*
Fosnetupitant*
Rolapitant
5-HT3 Receptor
Antagonists (5-HT3 RA)
Dolasetron
Granisetron
Ondansetron
Palonosetron
Corticosteroid Dexamethasone
Atypical Antipsychotic Olanzapine
Typical Antipsychotic,
Phenothiazine Derivative
Prochlorperazine
5-HT4 Receptor Agonist Metoclopramide
*available in fixed combination with palonosetron only
Breakthrough Emesis Treatment
Breakthrough and anticipatory nausea can present when
the patient is not actively receiving chemotherapy.
Prevention of nausea and vomiting is ideal. If emesis
does occur, this can lead to anticipatory nausea and
vomiting in the future and/or discontinuation of
chemotherapy. 3 If patients experience emesis despite
optimal therapy, it is recommended to try an agent from
a different class than was used previously and
subsequent antiemetic regimens should be adjusted
accordingly.
Cornerstones of acute CINV management, 5-HT3 RAs,
NK1 RAs, dexamethasone, and olanzapine, are usually
utilized first. Dexamethasone and 5-HT3 RAs are
included in most antiemesis regimens so their use in
breakthrough CINV is limited. Olanzapine is becoming
more widely utilized as evidence emerges supporting its
safety and efficacy in CINV.4 It is often the last of the
four most-utilized antiemetics for acute and delayed
CINV prophylaxis, so it can usually be added as
breakthrough emesis treatment and to subsequent emesis
prevention plans. Concomitant use of olanzapine and
dopamine blocking agents such as metoclopramide and
haloperidol can increase the risk of extrapyramidal
symptoms (EPS).1 Benzodiazepines benefit patients who
experience anxiety before, during, or after
chemotherapy. Scopolamine has been shown to be
effective in CINV and dizziness associated with body
movement.5 Prochlorperazine is often preferred to
promethazine, because it has less histamine blocking
properties and so is less sedating.1 Cannabinoids have
shown some evidence of effectiveness but not more
effective than first line therapies, so it’s recommended
use is limited to second or third line for CINV.1,6
Haloperidol and metoclopramide use is limited to after
other therapies have failed because of their drug-drug
interactions and adverse effect profiles.
The Alaska Pharmacy Newsletter
24
Agents used in breakthrough emesis treatment Select a medication from a class not already utilized in
the antiemetic regimen
Anticipatory Emesis Management
Since ANV is a conditioned response to severe CINV
during or after previous chemotherapy, preventing
severe CINV is optimal. There is evidence the incidence
of ANV is decreasing compared to the 1980s, which is
suspected to be due to more effective antiemetic
medications becoming available.7 However, ANV
remains a challenge to treat as it can be resistant to many
pharmacological treatments.7 Evidence shows behavioral
therapies are more effective than pharmacologic
treatments likely due to ANV being a conditioned
response. 7 Most studies have focused on three general
behavioral therapy strategies: systemic desensitization
(SD), progressive muscle relaxation training (PMRT),
and hypnosis.8 SD involves counter-conditioning of a
developed response and was first utilized in the
treatment of learned fears and phobias. 7 PMRT, often
used with relaxation techniques, has been shown to
decrease the duration of CINV. 9 PMRT is performed
when the patient arrives at the clinic or sees the
chemotherapy nurse, as these are experiences which are
often associated with ANV. 10
These strategies and
relaxation training have shown to improve some
patients’ anxiety and quality of life when ANV is
controlled.11
Pharmacological treatments of ANV are
generally limited to a benzodiazepine, such as
lorazepam.
When assessing antiemetic therapy for patients,
pharmacists and other providers can improve patient
outcomes when cognizant of possible CINV and familiar
with effective therapies for the various types of nausea
and vomiting associated with chemotherapy.
Resources:
1. National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology. Antiemesis: version 1.2019.
NCCN Clin Pract Guidel Oncol.
https://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf. Accessed June 10th, 2019.
2. Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: American
Society of Clinical Oncology clinical practice guideline update. JClin Oncol. 2017;35(28):3240-3261.
https://www.asco.org/practice-guidelines/quality-
guidelines/guidelines/supportive-care-and-treatment-related-issues%20#/9796. Accessed June 10th, 2019.
3. Aapro M. CINV: still troubling patients after all these years.
Support Care Cancer. 2018;26(Suppl 1):5-9. 4. Chelkeba L, Gidey K, Mamo A, Yohannes B, Matso T, Melaku T.
Olanzapine for chemotherapy-induced nausea and vomiting:
systematic review and meta-analysis. Pharm Pract (Granada).2017;15(1):877.
5. LeGrand SB, Walsh D. Scopolamine for cancer-related nausea and
vomiting. J Pain Symptom Manage. 2010;40(1):136-41. 6. Schussel V, Kenzo L, Santos A, et al. Cannabinoids for nausea and
vomiting related to chemotherapy: Overview of systematic
reviews. Phytother Res. 2018;32(4):567-576. 7. Roscoe JA, Morrow GR, Aapro MS, Molassiotis A, Olver I.
Anticipatory nausea and vomiting. Support Care Cancer.
2011;19(10):1533-8. 8. Figueroa-Moseley C, Jean-Pierre P, Roscoe JA, et al. Behavioral
interventions in treating anticipatory nausea and vomiting. J NatlCompr Canc Netw. 2007;5(1):44-50.
9. Molassiotis A, Yung HP, Yam BMC, Chan FYS, Mok TS. The
effectiveness of progressive muscle relaxation training inmanaging chemotherapy-induced nausea and vomiting in Chinese
breast cancer patients: a randomized controlled trial. Support Care
Cancer. 2007;10:237–246.
10. Kamen C, Tejani MA, Chandwani K, Janelsins M, Peoples AR,
Roscoe JA, Morrow GR. Anticipatory nausea and vomiting due to
chemotherapy. Eur J Pharmacol. 2014;722:172-9.
11. Yoo HJ, Ahn SH, Kim SB, Kim WK, Han OS. Efficacy of progressive muscle relaxation training and guided imagery in
reducing chemotherapy side effects in patients with breast cancer
and in improving their quality of life. Support Care Cancer. 2005;13(10):826-33.
Understanding
Biosimilars Authors:
Jennifer Jabben, Pharm. D. Candidate 2020
Anne Marie Bott, Pharm. D., BCOP, BCPS
NCPS, Alaska Native Medical Center
Biologics are large, complex molecules that are
composed of live cells. They consist of thousands of
atoms to create highly specific molecules that are used to
treat more complex diseases/conditions. The first
biologic manufactured is referred to as the originator or
reference product. A biosimilar has no clinically
meaningful differences in safety, purity, and potency
from the reference product.1
Atypical Antipsychotic Olanzapine
Benzodiazepine Lorazepam
Cannabinoids Dronabinol
Nabilone Nabilone
Phenothiazines Prochlorperazine
Promethazine Promethazine
5-HT3 Receptor Antagonists (5-HT3
RA)
Dolasetron
Granisetron Granisetron
Ondansetron Ondansetron
Corticosteroid Dexamethasone
Other Haloperidol
Metoclopramide
Scopolamine
The Alaska Pharmacy Newsletter
25
Biosimilars differ mostly by the manufacturing process.
Once the patent on a biologic reference product expires,
the manufacturer does not have to release how they
formulated the original product. It then becomes a
backward twirl for others to try and “copy” the reference
product. While they are not identical to the reference
product, they are highly similar, hence the term
biosimilar. There are more patents on the manufacturing
process than the product itself.
The process involved in development initially entails
identifying the gene of interest to modify. Once
identified, manufacturers use a particular host cell for the
desired gene. The next measure is to increase the protein
expression after finding a way to replicate the cell line.
This is where biologics can vary as they are grown in
living systems that have their own unique cell line.2,3
Final steps involve harvesting the protein cells and
purifying the protein selected.4
Similar to the Food and Drug Administration (FDA)
351(a) biologic approval pathway, the FDA sets
regulations specific for the approval process for
biosimilar products, known as the 351(k) biosimilar
pathway. It is important to recognize the two differ. The
biosimilar pathway to approval is an entirely separate
and much shorter process than the biologic pathway.
Compared to a biologic reference product, once
approved, it goes through an extensive clinical studies
phase, strongly relying on clinical data for the
requirement of full reports on safety and efficacy in
investigations. A biosimilar relies on the existing
analytical data from the biologic reference product, in
addition to new data demonstrating its comparison to the
novel biologic. Biosimilars are provided a blanket
indication for the same indications as the reference
product once they can provide sufficient clinical
evidence there is no difference in efficacy.5
Both biologics and biosimilars that have gained FDA
approval can be found in the Purple Book. Much like the
Orange Book, which demonstrates which products are
therapeutically equivalent, the Purple Book displays the
biologics approved as well as the biosimilars that were
derived from the reference product.7
When making clinical decisions that can impact a
patient’s life and the cost for the pharmacy, it is crucial
to understand how biologic reference products and
biosimilars differ and what commonality they share.
Together they will share the exact same primary
structure. Both bioequivalences are comparative in
clinical trials. They both receive the same approval for
purity, safety, and potency from the FDA. As far as their
biologic activity goes, there is no clinically meaningful
difference. Both products will have the same mechanism
of action as well as indications.4,6
While the primary amino acid structure is the same,
biosimilars are produced from different cell lines and
have a different composition process. Biosimilars can
vary from reference product due to minor structural
variations causing a different formulation that can
include varying inactive ingredients. Due to this, the
stability of the product, storage requirements, and
expiration can vary from the biologic reference product.
Another factor is the price difference may vary
substantially.
Overall, biosimilars are highly comparable to their
original biologic reference product. With the expedited
FDA approval process, it allows for potentially more
affordable medications to be accessible with the same
safety, purity, and potency standards of all other FDA
approved medications.
References: 1. US Food and Drug Administration, Center for Drug Evaluation and
Research (CDER), Center for Biologics Evaluation and Research (CBER). Scientific Considerations in Demonstrating Biosimilarity to a Reference
Product. Guidance for Industry. April 2015.
https://www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm291128.pdf. Accessed August 5, 2019.
2. J.F. Lee, J.B. Litten, G.Grampp. Comparability and biosimilarity:
considerations for the healthcare provider. Curr Med Res Opin, 28 (2012), pp.1053-1058
3. H. Mellstedt, D. Niederwieser, H. Ludwig. The challenge of biosimilars.
Ann Oncol, 19 (2008), pp. 411-419 4. M. Schiestl, T. Stangler, C.Torella, T. Gepeljnik, H. Toll, R. Grau.
Acceptable changes in quality attributes of glycosylated biopharmaceuticals.
Nat Biotechnol, 29 (2011), pp. 310-312 5.https://www.fda.gov/drugs/biosimilars/prescribing-biosimilar-and-
interchangeable-products Accessed August 20, 2019
6. V. Strand, B. Cronstein. Biosimilars: how similar?. Intern Med J, 44 (2014), pp. 218-223
7. FDA Purple Book https://www.fda.gov/drugs/therapeutic-biologics-
applications-bla/purple-book-lists-licensed-biological-products-reference-
product-exclusivity-and-biosimilarity-or Accessed August 20, 2019
The Alaska Pharmacy Newsletter
26
Procalcitonin Utilization
Authors:
Jake Turin, PharmD Candidate
Daniel Beyer, PharmD Candidate
Kathryn Sawyer, PharmD
Norton Sound Health Corporation
Background:1,2
The Infectious Diseases Society of America (IDSA)
estimates that roughly 50% of inpatient antibiotic
utilization is inappropriate. One clinical scenario
included in this estimate is the inappropriate
administration of antibiotics to patients without bacterial
illness. For instance, approximately 90% of cases of
acute bronchitis are caused by viruses; however, roughly
two-thirds of all patients presenting with this illness in
the United States will receive antibiotics. Given this
trend, an increasing national interest has been taken in
diagnostic aids which may increase accuracy in the
diagnosis of acute bacterial illnesses in order to reduce
the unnecessary utilization of antibiotics and, thus,
minimize unintended consequences associated with their
use (i.e. adverse drug reactions, development of C.
difficile infection, development of resistance, etc.). This
review will describe how serum procalcitonin (PCT)
levels can be used in community healthcare to prevent
inappropriate use of antimicrobial agents.
What is procalcitonin?3-11
PCT is a precursor of calcitonin contained in many
tissues throughout the body. Normal physiologic PCT
levels are low at less than 0.1 mcg/L, but during periods
of severe infection PCT is released in large quantities,
providing a specific and sensitive identifier of bacterial
infections when serum levels rise above 0.25 mcg/L.
Advantages of obtaining serum PCT compared to lab
cultures and other biomarkers in infection diagnosis
include a strong correlation between the start of infection
and the elevation of PCT, the rapidity of turnaround time
for the results (obtainable within several hours of exam),
and it acts as a strong indicator of either bacterial or viral
infection. Serum PCT levels rise 2-4 hours after onset of
bacterial infections, with levels peaking 8-24 hours after
onset of infection. This is opposed to viral infections,
where PCT serum levels remain consistent with the pre-
infection levels. Studies suggest that the presence of
endotoxins and lipopolysaccharides upregulate the
production of PCT in bacterial infections. Contrary to
bacterial infections, the release of cytokines during the
host immune response to viral infections is known to
downregulate PCT synthesis through TNF-alpha
inhibition.
Figure 1.
Procalcitonin (PCT) algorithm in patients with respiratory tract infections in the emergency department. The clinical algorithm for antibiotic
stewardship in patients with respiratory tract infections in the emergency department encourages (>0.5 ng/ml or >0.25 ng/ml) or discourages
(<0.1 ng/ml or <0.25 ng/ml) initiation or continuation of antibiotic therapy more or less based on specific PCT cut-off ranges
The Alaska Pharmacy Newsletter
27
Additional Considerations
Certain subsets of patients should not undergo PCT
analysis. This includes but is not limited to patients who
are under the age of 18, pregnant or breastfeeding, with
poor kidney function, severe immunosuppression,
trauma, or who have other serious health conditions. In
addition, PCT can be elevated in situations other than
bacterial causes. False-positive elevated PCT readings
can be contributed to massive stress (severe trauma),
cytokine stimulating treatment, conditions allowing
translocation of bacteria, malaria and some fungal
infections, or prolonged cardiogenic shock. There are
also situations when PCT levels may be low when a true
bacterial infection exists. A false-negative can occur
early in the course of infection, when the infection is
localized, or with infections of Mycoplasma
pneumoniae or Chlamydiophila pneumoniae. When
using PCT levels, it is important to consider all of the
patient’s clinical data when diagnosing infection type
and treating with antibiotics.
How is procalcitonin used in clinical practice?12-14
Procalcitonin (PCT ) is used as a biomarker for early
detection of systemic bacterial infections. Other
inflammatory biomarker, such as C-reactive protein, lack
specificity in determining bacterial vs non-bacterial
infections. With a specificity of 79%, PCT is an
additional tool that clinicians can use to reduce the
overuse of antimicrobials and has proven to be a helpful
diagnostic tool in patients with lower respiratory tract
infections (LRTI). Furthermore, PCT can also be used in
the management of antimicrobial therapy in patients
with sepsis of unknown origin. While PCT should not be
used in the diagnostic criteria for sepsis, it can be used to
decrease the duration of antimicrobial therapy. Figure 2
contains a summary of evidence regarding procalcitonin
use in clinical practice.
Figure 2.
Summary of evidence regarding procalcitonin (PCT) for diagnosis and antibiotic stewardship in organ-
related infections. While for some infections, intervention studies have investigated benefit and harm of
using PCT for diagnosis and antibiotic stewardship (left side), for other infections only results from
diagnostic (observation) studies are available (right side). +: moderate evidence in favor of PCT; ++:
good evidence in favor of PCT; +++: strong evidence in favor of PCT; – no evidence in favor of PCT.
The Alaska Pharmacy Newsletter
28
Procalcitonin Use in LRTIs12-14
Multiple randomized controlled trials have yielded sufficient data to recommend the use of PCT in the management of
patients with LRTIs such as pneumonia, chronic bronchitis, and other assorted lower respiratory tract infections such as
acute exacerbations of chronic obstructive pulmonary disease (COPD). LRTIs are considered one of the most important
drivers for the over-use of antibiotics, contributing to the rise of multi-drug resistant pathogens. A 2012 Cochrane meta-
analysis found a strong reduction in the use of antibiotics when treatment duration was guided by biomarkers such as
procalcitonin. According to this meta-analysis, PCT monitoring resulted in a reduction in treatment time and exposure to
antibiotics. However, this is only based on community-acquired disease, and evidence suggests PCT levels should only
be used in patients with suspected community-acquired LRTIs. See the below Table 1 for recommended treatment and
interpretation of procalcitonin levels.
Table 1: Procalcitonin Utilization in LRTI.
INITIAL PROCALCITONIN LEVEL (DRAWN ON ADMISSION):
PCT Result: ≤0.1 ng/mL 0.1 - 0.25
ng/mL
>0.25 – 0.5 ng/mL >0.5 ng/mL
Antimicrobial
Recommendation:
Strongly
Discouraged Discouraged Encouraged
Strongly
Encouraged
Overruling the
Algorithm:
Consider Alternative Diagnosis
N/A N/A
Consider overruling algorithm and
initiating antimicrobials if patient is
clinically unstable (hemodynamic or
respiratory instability) or at
high risk for adverse outcomes (PSI class
IV-V, CURB-65 >3, or GOLD III-IV)
Follow-up/Other
Comments:
Reassess patient’s status and repeat PCT
in 6-24 hours if warranted.*
Recheck PCT level every 2-3 days to consider
early cessation of antibiotics using the above
breakpoints or, if initial values >5-10 ng/mL,
when a 90% reduction is seen from peak values.
If procalcitonin is rising or unchanged at repeat,
consider possibility of treatment failure and
workup need for expanded antimicrobial
coverage and/or further diagnostic evaluation.
PCT = Procalcitonin * Repeat procalcitonin levels should be considered in patients NOT started on antibiotics where no clinical
improvement is observed at 6-24 hours and in patients in whom the algorithm is overruled (i.e. initially with low procalcitonin levels
who are started on antimicrobials due to clinical instability or risk for adverse outcomes).
Procalcitonin Use in Sepsis12-14
Procalcitonin levels can also be used in the management of sepsis. It is NOT RECOMMENDED to be used in the
diagnosis of sepsis, due to the high mortality associated with delaying antimicrobial therapy. Procalcitonin levels should
be utilized by trending values in combination with patient specific clinical data to assess and guide clinical therapy. Table
2 below shows recommended utilization of antibiotics in patients with “sepsis of unknown origin”. Patients with sepsis of
known origin, however, are still recommended to follow treatment guideline duration of therapy.
Table 2: Utilization of FOLLOW-UP Procalcitonin Levels in Sepsis.
PCT Result: <0.25 ng/mL 0.25 – 0.49 ng/mL
-OR-
≥80% reduction from
peak value
>0.5 ng/mL
-AND-
<80% reduction from
peak value
>0.5 ng/mL
-AND-
Rising or stable when
compared with
previous value
Antimicrobial
Recommendation:
Antimicrobial
cessation strongly
encouraged
Antimicrobial
cessation encouraged
Antimicrobial
cessation discouraged
Antimicrobial
cessation strongly
discouraged
Overruling the Algorithm: Consider antimicrobial continuation if patient
clinically unstable. N/A
N/A
Other
Comments/Considerations:
A PCT value which is rising or not declining is a poor prognostic indicator and suggests infection is
not controlled. Consider further diagnostic evaluation.
The Alaska Pharmacy Newsletter
29
Program 0139-0000-19-201-H04-P/T Quarterly AKPhA Newsletter
Release Date 10/07/2019 Expiration Date 10/07/2022 CPE Hours: 2.0 (0.2 CEU)
Fees CE processing is free for AKPhA members. Non-members must submit $20 per quiz at: https://alaskapharmacy.org/payments/
To Obtain CPE Credit for this lesson you must complete the evaluation and quiz linked above and score a passing
grade of 70% or higher. If you score less than 70%, you may repeat the quiz once. CPE credit for successfully completed quizzes will be uploaded to CPE Monitor within 60 days.
The Alaska Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a
provider of continuing pharmacy education.
References
1. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious 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
2. Albert RH. Diagnosis and management of acute bronchitis. Am Fam Physician. 2010;82(11):1345-1350.
3. Procalcitonin (PCT) Guidance. (n.d.). Retrieved October 26, 2015,
from http://www.nebraskamed.com/careers/education-programs/asp/procalcitonin-pct-guidance
4. Schuetz P, Albrich W, Mueller B. Procalcitonin for diagnosis of
infection and guide to antibiotic decision: past, present, and future.BMC Medicine. 2011;9:107-15.
5. Kibe S, Adams K, Barlow G. Diagnostic and prognostic
biomarkers of sepsis in critical care. J Antimicrob Chemother.2011;66(2):ii33-ii40.
6. Simon L, et al. Serum procalcitonin and C-reactive protein levels
as markers of bacterial infection: a systematic review and meta-analysis. CID. 2004;39:206-17.
7. Grace E, Turner RM. Use of procalcitonin in patients with various
degrees of chronic kidney disease including renal replacementtherapy. CID. 2014;59(12):1761-7.
8. Zazula R, Prucha M, Tyll T, Kieslichova E. Induction of
procalcitonin in liver transplant patients treated with anti-thymocyte globulin. Critical Care. 2007;11(6):R131
9. Sager R, Kutz A, Mueller B, Schuetz P. Procalcitonin-guided
diagnosis and antibiotic stewardship revisited. BMC Medicine. 2017;15(1). doi:10.1186/s12916-017-0795-7.
10. Dandona P. Procalcitonin increase after endotoxin injection in
normal subjects. Journal of Clinical Endocrinology & Metabolism.1994;79(6):1605-1608. doi:10.1210/jc.79.6.1605.
11. Harbarth S, Holeckova K, Froidevaux C, et al. Diagnostic Value of
Procalcitonin, Interleukin-6, and Interleukin-8 in Critically Ill Patients Admitted with Suspected Sepsis. American Journal of
Respiratory and Critical Care Medicine. 2001;164(3):396-402.
doi:10.1164/ajrccm.164.3.2009052.12. Cleland DA, Eranki AP. Procalcitonin. [Updated 2019 May 17].
In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539794/
13. Lee H. Procalcitonin as a biomarker of infectious diseases. Korean
J Intern Med. 2013;28(3):285–291.doi:10.3904/kjim.2013.28.3.285
14. Rhee C. Using Procalcitonin to Guide Antibiotic Therapy. Open
Forum Infect Dis. 2016;4(1):ofw249. Published 2016 Dec 7. doi:10.1093/ofid/ofw249
Complete and submit the quiz and evaluation online at:
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Continuing Education
Quiz and Evaluation
The authors and the Alaska Pharmacists Association disclaim any liability to you or your patients
resulting from reliance solely upon the information contained herein.
The Alaska Pharmacy Newsletter
30
ALASKA PHARMACY NEWSLETTER FOURTH QUARTER 2019
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