georgia pharmacy journal april 2012

The Official Publication of the Georgia Pharmacy Association April 2012

Volume 34, Number 4 www.gpha.org

Spring CPE Conference in Atlanta

GPhA consolidates regional meetings and we’re opening the door for you to be there...page 4

April 2012 Journal 8.indd 1 4/5/2012 2:14:05 PM

*This is not a claims reporting site. You cannot electronically report a claim to us. To report a claim, call 800.247.5930.**Compensated endorsement.Not all products available in every state. The Pharmacists Life is licensed in the District of Columbia and all states except AK, FL, HI, MA, ME, NH, NJ, NY and VT. Check with your representative or the company for details on coverages and carriers.

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Life insurance solutions from The Pharmacists Life Insurance Company.

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*This is not a claims reporting site. You cannot electronically report a claim to us. To report a claim, call 800.247.5930.**Compensated endorsement.Not all products available in every state. The Pharmacists Life is licensed in the District of Columbia and all states except AK, FL, HI, MA, ME, NH, NJ, NY and VT. Check with your representative or the company for details on coverages and carriers.

For more information, contact your local representative:

www.phmic.com*

Guarantee a better

Quality of Life for your family.Life Insurance can provide for your loved ones by:

• Providing coverage for final medical and funeral expenses• Paying outstanding debts• Creating an estate for those you care about• Providing college funding

PO Box 370 • Algona Iowa 50511

Life insurance solutions from The Pharmacists Life Insurance Company.

Endorsed by:**

Hutton Madden800.247.5930 ext. 7149

678.714.9198

Th e Georgia Pharmacy Journal April 20123

Departments6 GPhA News10 Pharm PAC Members12 Pharm PAC Contribution Form13 GPhA Member News20 GPhA Pharmacy News31 GPhA Board of Directors

Advertisers2 Pharmacists Mutual Companies9 EC Retail Studio13 Melvin M. Goldstein, P.C.13 Logix, Inc.18 RxAllyTM

19 Meadowbrook Insurance Group20 Michael T. Tarrant32 UBS

Find GPhA’s up-to-date Calendar of Events at:www.gpha.org

CONTENT/FEATURES

5 Spring Forward with Our New CPE Conference

8 Be one in a Million HeartsTM

11 GPhA 2012 Awards Selection

15 Georgia Pharmacy Association 137th Annual

Conference

16 2012 Georgia General Assembly Wrap-Up

17 2012 Legislation Followed by GPhA

20 Timeline for GPhA 2012 Elections

21 Become a Pharmacy Based Immunizer

23 CE for Pharmacists: Restless Leg Syndrome

Management

30 CE Quiz

4 President’s Message

14 Executive Vice President’s Editorial

F E A T U R E A R T I C L E S

C O L U M N S

Georgia Pharmacy Association 137th Annual Convention

Hilton Head Marriott Resort & SpaHilton Head Island, SC

July 7 - 11, 2012



L ast year, while attending fall region meetings, the Executive Committee began hearing ideas

about improving our region meetings that are typically held annually in October and April. We learned that very few Regions hold additional meetings and these are the only two times the members in the Region come together. Region presidents cite the reduction in the number of meetings to the inability to obtain sponsorships for the meetings. Restrictions have been placed on drug companies prohibiting them from paying for a meal accompanied by a CPE presentation.

On several occasions, association members asked if GPhA would have a Spring Region CPE in Atlanta which would provide a good setting for networking, increased opportunities for continuing education and discussion about new ideas for change in our profession. Th e region presidents could incorporate their region meeting with the Spring Region CPE and bring association members up to date on legal changes and other activities on the horizon for our profession. It has always been a policy of GPhA to provide the association with two region meetings each year. One meeting would be in the spring prior to the convention and another region meeting would be held in the fall. As I stated earlier, aft er our fall region meetings, the Executive Committee decided to take this option to the region presidents for their input.

In January of 2012, at the GPhA Board Meeting, the idea of a convocation meeting of all Regions for this spring was discussed and approved as a one-time trial that would give the region presidents relief from

hosting the April meeting. Th is does not preclude the Region from having other meetings and GPhA will always be there to promote and handle registration.

Will we see you on April 21, 2012 at the Spring CPE Conference in Atlanta? I hope you will talk to your Region offi cers about your ideas for growing and improving your region meetings. Your ideas provide inspiration and growth for our association. Th e GPhA staff and the Executive Committee are here to support the programs you provide for your region. As Helen Keller stated, ‘When one door of happiness closes, another opens’. Please open the door to your profession and be active in your association. HOPE TO SEE YOU IN ATLANTA ON APRIL 21.

When one door of happiness closes, another opens; but oft en we look so long at the closed door that we do not see

the one which has been opened for us.

Helen Keller US blind & deaf educator (1880 - 1968)

L. Jack Dunn, Jr., R.Ph.President Georgia Pharmacy Association

Spring CPE Conference in Atlanta‘When one door of happiness closes...’

P R E S I D E N T ’ S M E S S A G E


hosting the April meeting. Th is does not preclude the Region from having other meetings and GPhA will always be there to promote and handle registration.

Will we see you on April 21, 2012 at the Spring CPE Conference in Atlanta? I hope you will talk to your Region offi cers about your ideas for growing and improving your region meetings. Your ideas provide inspiration and growth for our association. Th e GPhA staff and the Executive Committee are here to support the programs you provide for your region. As Helen Keller stated, ‘When one door of happiness closes, another opens’. Please open the door to your profession and be active in your association. HOPE TO SEE YOU IN ATLANTA ON APRIL 21.

When one door of happiness closes, another opens; but oft en we look so long at the closed door that we do not see

the one which has been opened for us.

Helen Keller US blind & deaf educator (1880 - 1968)


Spring forward with our new Spring CPE ConferenceSpring forward with our new Spring CPE Conference

In an effort to improve our CPE offerings, GPhA worked alongside Region Presidents to put a "new twist" on Spring Region Meetings. We hope that you will join us for this amazing CPE event at the Georgia Tech Hotel

and Conference Center!

This unique opportunity provides a total of 6 CPE hours over the course of one day.

CPE Topics include:

Federal and State Legislative Update Medication Therapy Management New Drug Update Law Update

Attendees of this conference will be able to:

Gain new knowledge that can be applied to everyday pharmacy best practices.

Review the current state of numerous state and national pieces of legislation that affect the practice of pharmacy.

Activity Types: Knowledge

Target Audience: Pharmacists and Pharmacist Technicians

Registration Fee: $99 for Members; $150 for Potential Members

Total CPE Contact Hours: 6

CPE Verification Process: Sign-in sheets and evaluations will be provided at each individual CPE opportunity. Both sheets must be legible, fully complete and turned in in order to receive CPE credit. No partial credits are offered as attendees must be present for the entire length of each CPE program. Statements of credit will be emailed within 6 weeks.

Additional information may be viewed by visiting the complete schedule located at www.gpha.org.

Hotel Room Rate: $109/night + applicable taxesHotel Room Rate: $109/night + applicable taxesHotel Room Rate: $109/night + applicable taxes

Reservations must be made on or before Thursday, March 22, 2012

After this date, reservation requests will be handled on a space and rate available basis. To make your reservation at the Georgia Tech Hotel & Conference Center, please call their Reservations department at: 404-838-2100 or 1-800-706-2899 and ask for the special "Georgia Pharmacy Association" rate. For your convenience, the hotel's main line is: 404-347-9440.

Consider bringing the family and taking advantage of a number of special discounts to Atlanta area attractions secured especially for attendees of this innovative conference. More details to come! Any Questions? If you have any questions about the conference, please contact Sarah Bigorowski at [email protected] or 404-419-8126.

800 Spring Street, NW| Atlanta, GA 30308 www.gatechhotel.com

Saturday, April 21, 2012 - 8AM - 5PM


6Th e Georgia Pharmacy Journal April 2012

G P H A N E W S

Former GPhA President Jonathan Marquess and wife Pam Marquess, First Vice President of GPhA, join Jack Dunn, GPhA President, at the head of the table. EVP Jim Bracewell is seated next to Robert Hatton, GPhA President-Elect, with Rick Marasco, GPhA member and APhA CPE presenter. All take a break to enjoy some of New Orleans’ fi ne food.

GPhA President, Jack Dunn, congratulates GPhA Member Monali N. Majmudar, Pharm.D., who received an Honorable Mention for the 2011 APhA Immunization Champion Award. GPhA EVP Jim Bracewell is pictured on the right.

GPhA President Jack Dunn poses with several studentswho attended the APhA Annual Meeting in New Orleans.

GPhA Delegates Carol Ludwig, Ken Eiland, 12th Region President, Bill Hopkins, Region President, and Pam Marquess, GPhA First Vice President, are pictured at the APhA House of Delegates. Not pictured is GPhA President Jack Dunn, also a delegate to



G P H A N E W S

APhA Trustee and former GPhA President Jonathan Marquess speaks to the GA Reception at the APhA Annual Meeting.

Th e Georgia reception at the APhA Annual Meeting had a record turn out.

GPhA President Jack Dunn has fun with some of the entertainers at the APhA Exhibit Hall.

GPhA President Jack Dunn poses with two GPhA winners of APhA Awards:Monali N. Majmudar, Pharm.D., winner of an Honorable Mention for the 2011 APhA Immunization Champion Award, and Dean Ted Matthews of Mercer University, winner of the APhA Outstanding Dean Award.


The Georgia Pharmacy Journal April 20128

G P H A N E W S

Be one in a Million Hearts™

Amanda Paisley, Pharm.D.Pharmacy Intern

Georgia Pharmacy Association

Attendees at the Million Hearts™ meeting from left to right: John O’Brien, GPhA President Jack Dunn, Anna Cohen, FACC Execu-tive Director Million Hearts™ Janet Wright, MD, Amanda Paisley and GPhA EVP Jim Bracewell.

On February 21, I joined Georgia Pharmacy Association President, Jack Dunn, and Executive Vice President, James Bracewell, for Grand Rounds at the Center for Disease Control and Prevention to discuss their exciting new initiative called Be one in a Million Hearts™.

Million Hearts™ is sponsored by Centers for Medicare and Medicaid Services (CMS), the Department of Health and Human Services (DHHS), CDC, and other public and private sponsors. The goal of the initiative is to prevent one million strokes and heart attacks in the next five years. In order to meet this goal, healthcare professionals are being asked to focus on the following ABCS:

Appropriate aspirin therapyBlood pressure controlCholesterol managementSmoking cessation

There were a number of ideas introduced at the meeting that will help us to accomplish the goal of preventing one million heart attacks and strokes. One of the ideas was to have pharmacists help with titrating blood pressure and cholesterol medication. What a great opportunity this could be! In order for us to make this a reality, we need to show our support and abilities for this initiative.


On February 21, I joined Georgia Pharmacy Association President, Jack Dunn, and Executive Vice President, James Bracewell, for Grand Rounds at the Center for Disease Control and Prevention to discuss their exciting new initiative called Be one in a Million Hearts™.

Million Hearts™ is sponsored by Centers for Medicare and Medicaid Services (CMS), the Department of Health and Human Services (DHHS), CDC, and other public and private sponsors. Th e goal of the initiative is to prevent one million strokes and heart attacks in the next fi ve years. In order to meet this goal, healthcare professionals are being asked to focus on the following ABCS:

Appropriate aspirin therapyBlood pressure controlCholesterol managementSmoking cessation

Th ere were a number of ideas introduced at the meeting that will help us to accomplish the goal of preventing one million heart attacks and strokes. One of the ideas was to have pharmacists help with titrating blood pressure and cholesterol medication. What a great opportunity this could be! In order for us to make this a reality, we need to show our support and abilities for this initiative.


G P H A N E W S

Some of the ways for pharmacists and student pharmacists to get involved include:

1) Sign the Million Hearts™ pledge at: http://millionhearts.hhs.gov/pharmacies.html

2) Talk with your patients about their risk for stroke and heart attack, and what they can do to prevent them

3) Contact your local pharmacy school’s chapter of APhA and off er your services as a supervisor for a blood pres-sure or cholesterol screening event

4) Keep track of your successes and interventions (ex: initiating prophylactic aspirin use in a diabetic patient, improving adherence to statin medications)

Eventually the Million Hearts™ website will be open for the sharing of success stories as well.

For more information, you can follow the Million Hearts™ Campaign online at http://millionhearts.hhs.gov; on Facebook at www.facebook.com/millionhearts and on Twitter at @MillionHeartsUS.


10The Georgia Pharmacy Journal April 2012

Titanium Level($2400 minimum pledge)T.M. Bridges, R.Ph.Ben Cravey, R.Ph.Michael E. Farmer, R.Ph.David B. Graves, R.Ph.Raymond G Hickman, R.Ph.Robert A. Ledbetter, R.Ph.Jeffrey L. Lurey, R.Ph.Marvin O. McCord, R.Ph.Scott Meeks, R.Ph.Judson Mullican, R.Ph.Mark Parris, Pharm.D.Fred F. Sharpe, R.Ph.Jeff Sikes, R.Ph.Dean Stone, R.Ph., CDM

Platinum Level($1200 minimum pledge)Ralph W. Balchin, R.Ph.Barry M. Bilbro, R.Ph.Robert Bowles, Jr., R.Ph., CDM, CftsJim R. BracewellLarry L. Braden, R.Ph.Thomas E. Bryan Jr., R.Ph.William G. Cagle, R.Ph.Hugh M. Chancy, R.Ph.Keith E. Chapman, R.Ph.Dale M. Coker, R.Ph., FIACPJack Dunn, Jr. R.Ph.Neal Florence, R.Ph.Andy FreemanMartin T. Grizzard, R.Ph.Robert M. Hatton, Pharm.D.Ted Hunt, R.Ph.Alan M. Jones, R.Ph.Ira Katz, R.Ph.Hal M. Kemp, Pharm.D.Brandall S. Lovvorn, Pharm.D.Eddie M. Madden, R.Ph.Jonathan Marquess, Pharm.D., CDE, CPTPam Marquess, Pharm.D.Kenneth A. McCarthy, R.Ph.Drew Miller, R.Ph., CDMLaird Miller, R.Ph.Cynthia K. MoonJay Mosley, R.Ph.

Allen Partridge, R.Ph.Houston Lee Rogers, Pharm.D., CDMTim Short, R.Ph.Benjamin Lake Stanley, Pharm.D.Danny Toth, R.Ph.Christopher Thurmond, Pharm.D.Tommy Whitworth, R.Ph., CDM

Gold Level($600 minimum pledge)James Bartling, Pharm.D., ADC, CACIILarry Batten, R.Ph.William F. Brewster, R.Ph.Bruce L. Broadrick, Sr., R.Ph.Liza G. Chapman, Pharm.D.J. Ernie Culpepper, R.Ph.Mahlon Davidson, R.Ph., CDMKevin M. Florence, Pharm.D.Kerry A. Griffin, R.Ph.Earl W. Marbut, R.Ph.Robert B. Moody, R.Ph.Sherri S. Moody, Pharm.D.William A. Moye, R.Ph.Anthony Boyd Ray, R.Ph.Jeffrey Grady Richardson, R.Ph.Andy Rogers, R.Ph.Daniel C. Royal, Jr., R.Ph.Michael T. Tarrant

Silver Level($300 minimum pledge)Renee D. Adamson, Pharm.D.Ed Stevens Dozier, R.Ph.Terry Dunn, R.Ph.Marshall L. Frost, Pharm.D.Johnathan Wyndell Hamrick, Pharm.D.Michael O. Iteogu, Pharm.D.Willie O. Latch, R.Ph.W. Lon Lewis, R.Ph.Kalen Porter Manasco, Pharm.D.Michael L. McGee, R.Ph.William J. McLeer, R.Ph.Sheri D. Mills, C.Ph.T.Albert B. Nichols, R.Ph.Richard Noell, R.Ph.Leslie Ernest Ponder, R.Ph.William Lee Prather, R.Ph.Sara W. Reece, Pharm.D., BC-ADM, CDE

Ola Reffell, R.Ph.Edward Franklin Reynolds, R.Ph.Sukhmani Kaur Sarao, Pharm.D.David J. Simpson, R.Ph.James N. Thomas, R.Ph.William H. Turner, R.Ph.Flynn W. Warren, M.S., R.Ph.Walter Alan White, R.Ph.William T. Wolfe, R.Ph.

Bronze Level($150 minimum pledge)Monica M. Ali-Warren, R.Ph.John R. Bowen, R.Ph.Michael A. Crooks, Pharm.D.William Crowley, R.Ph.Charles Alan Earnest, R.Ph.Randall W. Ellison, R.Ph.Mary Ashley Faulk, Pharm.D.Amanda R. Gaddy, R.Ph.Charles C. Gass, R.Ph.Ed KalvelageJohn D. KalvelageSteve D. KalvelageMarsha C. Kapiloff, R.Ph.Brenton Lake, R.Ph.Allison L. Layne, C.Ph.T.William E. Lee, R.Ph.Michael Lewis, Pharm.D.Ashley Sherwood LondonMax A. Mason, R.Ph.Amanda McCall, Pharm.D.Susan W. McLeer, R.Ph.Mary P. Meredith, R.Ph.Amanda Rose Paisley, Pharm.D.Rose Pinkstaff, R.Ph.Leslie Ernest Ponder, R.Ph.Kristy Lanford Pucylowski, Pharm.D.Sara W. Reece Pharm.D., BC-ADM, CDE Leonard Franklin Reynolds, R.Ph.Don K. Richie, R.Ph.Laurence Neil Ryan, Pharm.D.Richard Brian Smith, R.Ph.Charles Storey, III, R.Ph.Archie Thompson, Jr., R.Ph.Carrie-Anne WilsonSharon B. Zerillo, R.Ph.

Pharm PAC MembersGPhA is leading the way in influencing pharmacy-related legislation in Georgia

Thank you to all of our generous Pharm PAC supporters. To join Pharm PAC, see the form on the next page.

If you made a gift or pledge to Pharm PAC in the last 12 months and your name does not appear on this list, contact Andy Freeman at [email protected] or (404) 419-8118.

Pharm PAC donations are not charitable donations and are not tax deductible.


Ola Reffell, R.Ph.Edward Franklin Reynolds, R.Ph.Sukhmani Kaur Sarao, Pharm.D.David J. Simpson, R.Ph.James N. Thomas, R.Ph.William H. Turner, R.Ph.Flynn W. Warren, M.S., R.Ph.Walter Alan White, R.Ph.William T. Wolfe, R.Ph.

Bronze Level($150 minimum pledge)Monica M. Ali-Warren, R.Ph.John R. Bowen, R.Ph.Michael A. Crooks, Pharm.D.William Crowley, R.Ph.Charles Alan Earnest, R.Ph.Randall W. Ellison, R.Ph.Mary Ashley Faulk, Pharm.D.Amanda R. Gaddy, R.Ph.Charles C. Gass, R.Ph.Ed KalvelageJohn D. KalvelageSteve D. KalvelageMarsha C. Kapiloff, R.Ph.Brenton Lake, R.Ph.Allison L. Layne, C.Ph.T.William E. Lee, R.Ph.Michael Lewis, Pharm.D.Ashley Sherwood LondonMax A. Mason, R.Ph.Amanda McCall, Pharm.D.Susan W. McLeer, R.Ph.Mary P. Meredith, R.Ph.Amanda Rose Paisley, Pharm.D.Rose Pinkstaff, R.Ph.Leslie Ernest Ponder, R.Ph.Kristy Lanford Pucylowski, Pharm.D.Sara W. Reece Pharm.D., BC-ADM, CDE Leonard Franklin Reynolds, R.Ph.Don K. Richie, R.Ph.Laurence Neil Ryan, Pharm.D.Richard Brian Smith, R.Ph.Charles Storey, III, R.Ph.Archie Thompson, Jr., R.Ph.Carrie-Anne WilsonSharon B. Zerillo, R.Ph.


Pharm PAC Members Continued from previous page

Thank you to all of our generous Pharm PAC supporters. To join Pharm PAC, see the form on the next page.

If you made a gift or pledge to Pharm PAC in the last 12 months and your name does not appear on this list, contact Andy Freeman at [email protected] or (404) 419-8118.

Pharm PAC donations are not charitable donations and are not tax deductible.

Members(No minimum pledge)John J. Anderson, Sr., R.Ph.Fred W. Barber, R.Ph.Mark T. Barnes, R.Ph.Henry Cobb, III, R.Ph., CDMCarleton C. Crabill, R.Ph.Wendy A. Dorminey, Pharm.D., CDMBenjamin Keith Dupree, Sr., R.PhDavid M. Eldridge, Pharm.D.James Fetterman, Jr., Pharm.D.Charles A. Fulmer, R.Ph.Thomas Bagby Garner Jr., R.Ph. Christina Gonzalez

Kimberly Dawn Grubbs, R.Ph.Christopher Gurley, Pharm.D.Keith Herist, Pharm.D., AAHIVE, CPAJoel Andrew Hill, R.Ph.Carey B. Jones, R.Ph.Susan M Kane, R.Ph.Emily KrausCarroll Mack Lowrey, R.Ph.Tracie Lunde, Pharm.D.Ralph K. Marett, R.Ph.,M.S.Roy W. McClendon, R.Ph.Tom E. Menighan, R.Ph., MBA, ScD, FAPhADarby R. Norman, R.Ph.

Christopher Brown Painter, R.Ph.Whitney B. Pickette, R.Ph.Victor Serafy, R.Ph.Negin SovaidiJames E. Stowe, R.Ph.James R. Strickland, R.Ph.Celia M. Taylor, Pharm.D.Leonard E. Templeton, R.Ph.Erica Lynn Vesley, R.Ph.William D. Whitaker, R.Ph.Elizabeth Williams, R.Ph.Jonathon Williams, Pharm.D.Rogers W. Wood, R.Ph.

GPhA 2012 Awards Selection The GPhA Council of Presidents are charged with selecting the award recipients each year for our annual meeting and convention. This year the Council of Presidents will be meeting on Saturday, April 21, 2012 following the Spring CPE Conference. Nominations have been contributed by members across the state for each award and the Com-mittee will have their voice in making the 2012 selections. Following their annual spring meeting, the GPhA Execu-tive Committee will host a dinner for the former presidents and their spouses as an expression of gratitude for their service to GPhA as members of the Awards Committee, and their invaluable input and guidance throughout 2011-12.

Bentley Adams Jr.John Anderson Sr.James Bartling Robert Bowles Jr.Bruce Broadrick Sr.Hugh Chancy George Chapman Dale Coker W. Conley Jr.William Dunaway Michael Farmer John Glenn

David Graves Alton Greenway Buddy Harden Jr.Harold Jones Daniel Land Frances Lipscomb Jeffrey Lurey Eddie Madden Jonathan Marquess Jim Martin Max Mason Michael McGee

Isaac Mills Jr.Armon Neel Jr.Michael Reagan Robert Rogers John Sherrer Sharon Sherrer Brice Sikes Richard Smith Dean Stone Danny Toth Flynn Warren Steve Wilson



Welcome our new Pharm PAC members!

Th ank you for supporting Pharm PAC. Your gift allows GPhA to continue to advocate for improvements within the pharmacy profession.

Join Pharm PAC Today! GPhA is leading the way in infl uencing pharmacy-related legislation in Georgia

You have two Pharm PAC membership options:

1) A Monthly Contribution: (Please complete the following.)

Name: _________________________________________________________________________

Address: _______________________________________________________________________

Phone#: ________________________________________________________________________

Email Address: __________________________________________________________________

*You will be contacted for additional information to set up your monthly contribution.

Circle the level of monthly support you would like to provide: Titanium ($200/month) Platinum ($100/month) Gold ($50/month) Silver ($25/month) Bronze ($12.50/month)

2) A One-Time Gift :

To make a one-time contribution, simply write the amount you wish to contribute here:

$_________ and mail your check with this completed form.

To fi nalize your membership, complete and mail this form to: Pharm PAC, Georgia Pharmacy Association, 50 Lenox Pointe, NE, Atlanta, GA 30324

Pharm PAC is Georgia Pharmacy Association’s Political Action Committee.Your generous donations help GPhA to be able to

lobby and advocate on the behalf of Georgia pharmacy professionals.


Welcome our new Pharm PAC members!

You have two Pharm PAC membership options:

1) A Monthly Contribution: (Please complete the following.)

Name: _________________________________________________________________________

Address: _______________________________________________________________________

Phone#: ________________________________________________________________________

Email Address: __________________________________________________________________

*You will be contacted for additional information to set up your monthly contribution.

Circle the level of monthly support you would like to provide: Titanium ($200/month) Platinum ($100/month) Gold ($50/month) Silver ($25/month) Bronze ($12.50/month)

2) A One-Time Gift:

To make a one-time contribution, simply write the amount you wish to contribute here:

$_________ and mail your check with this completed form.

To finalize your membership, complete and mail this form to: Pharm PAC, Georgia Pharmacy Association, 50 Lenox Pointe, NE, Atlanta, GA 30324

Pharm PAC is Georgia Pharmacy Association’s Political Action Committee.Your generous donations help GPhA to be able to

lobby and advocate on the behalf of Georgia pharmacy professionals.


Individual Pharmacist Members:Jennifer M. Bennett, Pharm.D. - Alpharetta

Pharmacy School-Student Members:Charles Reid - WoodburyWhitney Reed - ConyersSorour Khaleghian - AthensSarah L. Peake - Marietta

Associate Members:Joseph Coyne, R.Ph. – Zion, IL

Pharmacy Technician Members:CKerry Glenn Ward, C.Ph.T. – Rincon Dana L. Baumgart, C.Ph.T. – Phenix City , AL

G P H A M E M B E R N E W S

Welcome New GPhA Members!GPhA is pleased to welcome the following new GPhA members:

If you, or someone you know, would like to join GPhA, Georgia’s premier professional pharmacy association, go to www.gpha.org and click

“Join” under the GPhA logo.

Melvin M. Goldstein, P.C.AT T O R N E Y AT L AW___

248 Roswell StreetMarietta, Georgia 30060

Telephone 770/427-7004Fax 770/426-9584

www.melvinmgoldstein.com

n Private practitioner with an emphasis on representing healthcare professionals in administrative cases as well as other legal matters

n Former Assistant Attorney General for the State of Georgia and Counsel for professional licensing boards including the Georgia Board of Pharmacy and the Georgia Drugs and Narcotics Agency

n Former Administrative Law Judge for the Office of State Administrative Hearings



N o, I am not about to try and sell you on investing in gold reserves or green industry stocks. I am going to remind you of the

best investment in your professional career and pharmacy practice and urge you today to block out time on your calendar to attend the GPhA Annual Meeting and Convention to be held at the Marriott Resort & Spa on Hilton Head Island, S.C., July 7-11.

Most of us readily affi rm the value of our college degree or advanced studies. It is a statistical fact that over a work career a college graduate will earn one to one and one half million dollars more than if they had stopped their educa-tion at high school graduation. With this basic knowledge about the value of education, especially for a profession like pharmacy, one would think that anyone who wants to earn more, deliver improved care and service would prioritize their continuing professional development.

At the GPhA offi ce, we encourage our staff to invest in their continuing education. Dan attends classes on latest tax changes, Sarah attends meetings to learn the latest in meeting venues and Andy attends classes to learn about PAC regulations. I am sure that is what you would want your staff at GPhA to be doing. You want us to know the latest information. You want us trained well in the skills to do our job for you, but are you investing in yourself? Th e GPhA meeting in July is an opportunity to hear from some of the best thinkersand speakers about pharmacy and provide you the knowledge you need to be a part of the today’s healthcare team.

What are you doing today to make absolutely sure that you are the Rx Expert of tomorrow, next year or the fol-lowing year?

One of my favorite stories is about the young Wall Street investor that buys a small farm in upstate Vermont. As winter is approaching the young investor fi nds himself with an axe, a chopping block and the need for sev-eral cords of fi rewood. As he worked in the midmorn-ing sun, he is now developing a full sweat; he was ex-periencing some self-doubt about owning a farm. Just then, this crusty old neighbor farmer stopped to watch the young man chop wood. Aft er a long spell of silence the old farmer suggested, “Son you might want to stop and sharpen that axe”, to which the irritated and frus-trated young investor replied harshly, “Old man, you obliviously don’t see that I don’t have time to do some-thing like that when I have all this wood to chop.“

July in Hilton Head is a great time to sharpen your axe and improve your pharmacy practice. You will learn a lot in the CE classes, you will learn a lot from the exhibit hall vendors, but most likely you will learn the most from a colleague of yours in GPhA. Go to the GPhA website and reserve your room today and enjoy some fun, fellowship and education with the best pharmacists in Georgia.

E X E C U T I V E V I C E P R E S I D E N T ’ S E D I T O R I A L

Jim BracewellExecutive Vice President / CEOGeorgia Pharmacy Association

I Have a Great Opportunity




Hilton Head Marriott Resort & Spa

Hilton Head Island, SCJuly 7 - 11, 2012

Mark Your Calendars!

Call (800) 228-9290 today to make your reservation!

Be sure to mention that you are part of the Georgia Pharmacy Association Room Block to receive

our special room rates.

Georgia Pharmacy Association 137th Annual ConventionSchedule At-a-Glance (preliminary)

Saturday, July 7, 2012

Morning CPE Sessions2011-2012 GPhA Board Meeting Aft ernoon CPE SessionsExhibit Hall OpenPharm PAC Contributors Reception--By Invitation Only

_________________________________

Sunday, July 8, 2012 Interfaith Sunrise ServiceGA Pharmacy Coalition Breakfast - By Invitation Only Morning CPE SessionsASA Luncheon & Business MeetingAIP LuncheonACP Luncheon & Business MeetingAEP Luncheon & Business MeetingAHP Luncheon & Business MeetingFIRST GENERAL SESSION Exhibit Hall Open

Monday, July 9, 2012

AIP Compounding Pharmacy Section Breakfast - By Invitation OnlyCouncil of President’s Breakfast & Meeting - By Invitation OnlyMorning CPE SessionsSECOND GENERAL SESSIONGA Pharmacy Foundation/Carlton Hen- derson Memorial Golf Tournament AEP Tennis TournamentAft ernoon CPE Sessions

_________________________________

Tuesday, July 10, 2012

Morning CPE SessionsTHIRD GENERAL SESSION Election Balloting ClosesAft ernoon CPE SessionsTellers Committee MeetingResolutions Committee MeetingPresident’s ReceptionPresident’s Inaugural Banquet & Offi cer InstallationDessert Reception & Dance _________________________________

Wednesday, July 11, 2012 FINAL GENERAL SESSION2012-2013 GPhA Board of Directors MeetingRegion Presidents Meeting

Please note this schedule is subject to change.



2012 Georgia General Assembly Wrap-Up

Andy FreemanDirector of Government Aff airsGeorgia Pharmacy Association

The 2012 session of the Georgia General Assembly was a good session for GPhA and Pharmacy. We were able to pass most of our

legislative agenda, but just as important we were also able to stop a lot of anti-pharmacy legislation.

Some of the legislation we were able to stop were laws that would have made generic substitution of certain prescriptions diffi cult, legislation that would have put the Composite Medical Board in charge of determining Continuing Education requirements for some pharmacists and another proposal that would have made pharmacists responsible for reporting and investigating potential child abuse or neglect of customers that come into their pharmacy. Probably the most important legislation we killed was the Georgia Secretary of State’s proposal that would have put non-pharmacists in charge of licensure, investigating and penalizing of pharmacists.

Our success at the Capitol comes not just through the lobbying team that GPhA has assembled, but also through the four pharmacists that are state legislators. Rep. Buddy Harden, Rep. Butch Parrish, Rep. Ron Stephens and Sen. Buddy Carter represent your profession well under the Gold Dome. GPhA is also very fortunate to have Eddie Madden, a former State Senator, to help develop and guide our legislative agenda. Just as important to our legislative program are people like Drew Miller, Jonathan Marquess, Liza Chapman and Mandy Reece who were willing to give their time to testify at the Capitol on various issues this session.

Also of importance are pharmacists like you that keep in constant communication throughout the session and the rest of the year with their legislators to ensure that they understand what issues the pharmacy industry faces every day as well as the 300+ pharmacists, students and friends that joined us at this year’s VIP Day.

Lastly, 2012 is an election year and we need to make sure that we are doing our part to have pharmacy friendly elected offi cials. We have several elected friends that have opposition that we need to help and there are some legislators that we need to help fi nd opponents for. I hope that you will join me in becoming a member of PharmPAC if you are not already one. PharmPAC registration forms can be found in this issue or online at our website.

Th anks again for all of your hard work. Together we can make 2013 another great year for pharmacists at the State Capitol.

G P H A N E W S

Past President and GPhA Govt. Aff airs Chairman, Eddie Madden (center), ad-vocated for GPhA issues with Senator Frank Ginn (left ) and Lt. Governor Casey Cagle (right).

G P H A N E W S

2012 Legislation Followed by GPhASB288 – Immunizations; allow pharmacists to give immunizations with physician’s protocol. Allows Pharmacists and nurses to give more immunizations. Passed out of the Senate 43-7 but died in House Health and Human Services when the Chair refused to let it come up for a vote.

SB346 - State Board of Pharmacy; prescription drugs by mail/other common carriers; Changes current state law to allow mail order from within the state with the same restrictions and patient safety precautions that Kaiser Permanente currently has. Also allows the Board of Pharmacy to develop rules to allow for a prescription to be fi lled at one pharmacy and sent to another pharmacy, which is commonly referred to as Central Fill. Language for the Board of Pharmacy to regulate remote entry access for hospital pharmacies was also added to the legislation. Passed out of the Senate and House and is on the Governor’s desk.

SB370 - Controlled Substances; Schedule I and V controlled substance; “dangerous drug”; Annual drug update bill. Passed the Senate and House and has already been signed by the Governor into law.

SB380 - Pharmacist and Pharmacies; change defi nition of security paper; State Board of Pharmacy; Fixes the problems regarding Pre-scription Pads that was inadvertently created with the passage of the Prescription Drug Monitoring legislation from last year. Th is bill will also allow for the licensing of pharmacies from other states that send prescriptions to Georgians. Georgia is one of the few states that do not currently license pharmacies in other sates. Passed the Senate but died on the fl oor of the House on the fi nal legislative day.

SB416 - Insurance Dept; authorize to develop exchange standards regarding electronic prior authorization drug requests with health care provider Allows for the national standards that are to be adopted by the National Council of Prescription Drug Programs govern-ing electronic prior approvals of prescriptions to be the standard followed here in Georgia. Passed the Senate and House and is await-ing the Governor’s signature.

SB445 - Secretary of State; create the position of director of professional licensing; provide powers, duties, and responsibilities Th is is the Secretary of State’s bill to reportedly streamline the process of getting professional licenses and renewals. Some of our main objec-tions to the legislation are that it takes away the Pharmacy board’s authority to issue emergency schedule controlled substances (lines 2220-2223), authorizes the 7 member Consumer Board to reschedule dangerous drugs and controlled substances (lines 2275-2278), gives the SOS authority to inspect pharmacies (line 2228) instead of the POST certifi ed licensed Pharmacists that work for GDNA. We do not like having the new Consumer Board appoint and control the GDNA Director (line 2394) either. GPhA successfully lobbied to kill this legislation along with some other groups.

HB964 - Th e Pharmacy Audit Bill of Rights; recoupment pursuant to an audit under certain circumstances; Currently when a Pharma-cy Benefi t Manager audits a pharmacy, they can recoup the cost of the drug for simple clerical or record keeping errors. Th is legisla-tion will correct this problem. Did not pass the House and is dead.

HB972 - Georgia Pain Management Clinic Act; Th is is the Attorney General’s legislation to continue regulating Pill Mills in Georgia. Died on the last day of the session as the House did not have time to approve the changes made by the Senate.

HB1069 - Pharmacists and pharmacies; revise defi nition of security paper Fixes the problems regarding Prescription Pads that was inadvertently created with the passage of the Prescription Drug Monitoring legislation from last year. Passed the House but died on the fl oor of the Senate the last day.

HB1125 - Th e Pharmacy Audit Bill of Rights; recoupment pursuant to an audit under certain circumstances; Does not allow PBM’s to recoup the costs of drugs in an audit if there was a technical or error such as spelling errors, etc. Did not pass the House and is dead.

HB1130 - Georgia State Board of Pharmacy; administratively attached to Department of Community Health; Moves the Board of Pharmacy out from underneath the Secretary of State and makes it an independent agency like the Composite Medical Board. Did not pass the House and is dead for this year. GPhA anticipates that this issue will be brought up again next year.

HB1149 - Physicians; administration of vaccines by pharmacists or nurses pursuant to vaccine protocol agreements; House version of SB 288 which allows pharmacists to give any immunization. Did not pass the House and is dead.


Past President and GPhA Govt. Aff airs Chairman, Eddie Madden (center), ad-vocated for GPhA issues with Senator Frank Ginn (left ) and Lt. Governor Casey Cagle (right).


G P H A N E W S

2012 Legislation Followed by GPhASB288 – Immunizations; allow pharmacists to give immunizations with physician’s protocol. Allows Pharmacists and nurses to give more immunizations. Passed out of the Senate 43-7 but died in House Health and Human Services when the Chair refused to let it come up for a vote.

SB346 - State Board of Pharmacy; prescription drugs by mail/other common carriers; Changes current state law to allow mail order from within the state with the same restrictions and patient safety precautions that Kaiser Permanente currently has. Also allows the Board of Pharmacy to develop rules to allow for a prescription to be fi lled at one pharmacy and sent to another pharmacy, which is commonly referred to as Central Fill. Language for the Board of Pharmacy to regulate remote entry access for hospital pharmacies was also added to the legislation. Passed out of the Senate and House and is on the Governor’s desk.

SB370 - Controlled Substances; Schedule I and V controlled substance; “dangerous drug”; Annual drug update bill. Passed the Senate and House and has already been signed by the Governor into law.

SB380 - Pharmacist and Pharmacies; change defi nition of security paper; State Board of Pharmacy; Fixes the problems regarding Pre-scription Pads that was inadvertently created with the passage of the Prescription Drug Monitoring legislation from last year. Th is bill will also allow for the licensing of pharmacies from other states that send prescriptions to Georgians. Georgia is one of the few states that do not currently license pharmacies in other sates. Passed the Senate but died on the fl oor of the House on the fi nal legislative day.

SB416 - Insurance Dept; authorize to develop exchange standards regarding electronic prior authorization drug requests with health care provider Allows for the national standards that are to be adopted by the National Council of Prescription Drug Programs govern-ing electronic prior approvals of prescriptions to be the standard followed here in Georgia. Passed the Senate and House and is await-ing the Governor’s signature.

SB445 - Secretary of State; create the position of director of professional licensing; provide powers, duties, and responsibilities Th is is the Secretary of State’s bill to reportedly streamline the process of getting professional licenses and renewals. Some of our main objec-tions to the legislation are that it takes away the Pharmacy board’s authority to issue emergency schedule controlled substances (lines 2220-2223), authorizes the 7 member Consumer Board to reschedule dangerous drugs and controlled substances (lines 2275-2278), gives the SOS authority to inspect pharmacies (line 2228) instead of the POST certifi ed licensed Pharmacists that work for GDNA. We do not like having the new Consumer Board appoint and control the GDNA Director (line 2394) either. GPhA successfully lobbied to kill this legislation along with some other groups.

HB964 - Th e Pharmacy Audit Bill of Rights; recoupment pursuant to an audit under certain circumstances; Currently when a Pharma-cy Benefi t Manager audits a pharmacy, they can recoup the cost of the drug for simple clerical or record keeping errors. Th is legisla-tion will correct this problem. Did not pass the House and is dead.

HB972 - Georgia Pain Management Clinic Act; Th is is the Attorney General’s legislation to continue regulating Pill Mills in Georgia. Died on the last day of the session as the House did not have time to approve the changes made by the Senate.

HB1069 - Pharmacists and pharmacies; revise defi nition of security paper Fixes the problems regarding Prescription Pads that was inadvertently created with the passage of the Prescription Drug Monitoring legislation from last year. Passed the House but died on the fl oor of the Senate the last day.

HB1125 - Th e Pharmacy Audit Bill of Rights; recoupment pursuant to an audit under certain circumstances; Does not allow PBM’s to recoup the costs of drugs in an audit if there was a technical or error such as spelling errors, etc. Did not pass the House and is dead.

HB1130 - Georgia State Board of Pharmacy; administratively attached to Department of Community Health; Moves the Board of Pharmacy out from underneath the Secretary of State and makes it an independent agency like the Composite Medical Board. Did not pass the House and is dead for this year. GPhA anticipates that this issue will be brought up again next year.

HB1149 - Physicians; administration of vaccines by pharmacists or nurses pursuant to vaccine protocol agreements; House version of SB 288 which allows pharmacists to give any immunization. Did not pass the House and is dead.



H o w t o r o c k

E n r o l lAt RxAlly, we believe that personalized pharmacist care can lead to better health outcomes. You are a pivotal player in the health of patients, particularly those facing chronic illnesses and taking multiple medications.

RxAlly offers you the opportunity to:

• Enhance your role as a health care provider • Access market opportunities through a

national network• Participate in clinical service programs • Expand into new patient care niches• Be compensated for an array of professional services • Transform pharmacy practice in the U.S.

RxAlly has brought together the nation’s leading independent pharmacy organizations, regional chains and Walgreens, to form a performance network of community pharmacies nationwide.

It’s good for your patients, and good for your business. Join the revolution today at www.rxAlly.com/enroll

How do I Enroll?• Go to www.rxAlly.com/enroll.• Enter your contact information.• Select your role as “Pharmacy owner/officer”.

Enter your NCPDP number.• Then, you will see another box with your affiliation(s)

listed. If you have more than one affiliation, select “AIP”.• Click “submit” button.• Review and confirm your acceptance of the Pharmacy

Network Agreement by checking the box at the bottom of the agreement and clicking the “confirm” button.

• You will see a Network Enrollment Confirmation screen indicating that you have successfully enrolled.

• Within a few days you will receive an enrollment confirmation email that includes your pharmacy name, NCPDP number and selected affiliation.

©2012 RxAlly, Inc. All rights reserved. RxAlly, the RxAlly logo, and other trademarks, service marks, and designs are registered or unregistered trademarks of RxAlly. 3/12

Visit RxAlly.com Email [email protected] Call 1-855-RxAlly-1



H o w t o r o c k

E n r o l lAt RxAlly, we believe that personalized pharmacist care can lead to better health outcomes. You are a pivotal player in the health of patients, particularly those facing chronic illnesses and taking multiple medications.

RxAlly offers you the opportunity to:

• Enhance your role as a health care provider • Access market opportunities through a

national network• Participate in clinical service programs • Expand into new patient care niches• Be compensated for an array of professional services • Transform pharmacy practice in the U.S.

RxAlly has brought together the nation’s leading independent pharmacy organizations, regional chains and Walgreens, to form a performance network of community pharmacies nationwide.

It’s good for your patients, and good for your business. Join the revolution today at www.rxAlly.com/enroll

How do I Enroll?• Go to www.rxAlly.com/enroll.• Enter your contact information.• Select your role as “Pharmacy owner/officer”.

Enter your NCPDP number.• Then, you will see another box with your affiliation(s)

listed. If you have more than one affiliation, select “AIP”.• Click “submit” button.• Review and confirm your acceptance of the Pharmacy

Network Agreement by checking the box at the bottom of the agreement and clicking the “confirm” button.

• You will see a Network Enrollment Confirmation screen indicating that you have successfully enrolled.

• Within a few days you will receive an enrollment confirmation email that includes your pharmacy name, NCPDP number and selected affiliation.

©2012 RxAlly, Inc. All rights reserved. RxAlly, the RxAlly logo, and other trademarks, service marks, and designs are registered or unregistered trademarks of RxAlly. 3/12

Visit RxAlly.com Email [email protected] Call 1-855-RxAlly-1


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For more information about this program, please contact James Taylor at:

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P H A R M A C Y N E W S

March 9, 2012 (No later than.)Nominating Committee must meet no later than this date.

April 10, 2012Th e First Vice President (at least one person) and Second Vice President (at least two people) nominations must be made.

May 10, 2012Th e petitions from additional nominees must be submitted to the Executive Vice President.

May 14, 2012 – Th e following data to be sent to the election service: 1) member last names/member ids/email addresses; and 2) candidate pictures/bios.

May 14, 2012Paper Ballot to be sent to the printer.

May 18, 2012Email sent to notify GPhA members of the log-in information that will be arriving in their email box on May 23, 2012 from the Association online

Voting with a reminder to unblock GPhA’s email address from SPAM.

May 23, 2012Log-in information to be emailed to GPhA members from the Association Online Voting.

May 23, 2012Paper ballots to be sent in the mail

May 25, 2012Th e election opens. Association Online Voting will email GPhA members the link to the voting site. Once each member has voted, he/she will receive no further reminder emails.

July 4, 2012Reminder emails will be sent to GPhA members who have not voted on a weekly basis.

June 25, 2012 Deadline for all mail-in ballots. (All mailed ballots must be post-marked by this date.)

July 5, 2012Mailed ballots to be retrieved and secured.

July 10, 2012 Polls close at Noon.

July 10, 2012Conduct Tellers Committee Meeting.

July 10, 2012Installation of new offi cers.

Timeline for GPhA 2012 Elections:First Vice President & Second Vice President

Your financial plan may need another look.

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Hilton Head Marriott Resort & SpaHilton Head Island, SC

July 7 - 11, 2012


Pharmacy-Based Immunization Delivery is an innovative and interactive practice-based educational program that provides pharmacists with the skills necessary to become primary sources for vaccine advocacy, education, and ad-ministration. Th e program reviews the basics of immunology, identifi es legal and regulatory issues pharmacists must consider before starting an immunization program, and focuses on practice implementation.

Th is program is priced as follows:

GPhA Members: $400GPhA Student Members: $175All GPhA Potential Members: $495

Faculty:Liza G. Chapman, Pharm.D.

2nd Faculty Member TBD

Th e purpose of this educational program is to:• Provide comprehensive immunization education and training.• Provide pharmacists with the knowledge, skills, and resources necessary to establish and promote a successful immunization service.• Teach pharmacists to identify at-risk patient populations needing immunizations.• Teach pharmacists to administer immunizations in compliance with legal and regulatory standards.

Pharmacy-Based Immunization Delivery is conducted in two parts: the self-study and the live training. To earn a Certifi cate of Achievement, participants must complete all components of the program including the self-study, the self-study assessment, the Pharmacy-Based Immunization

Delivery live training seminar, the fi nal examination, and the injection technique assessment. Statements of Credit and Certifi cates will be issued within 4-6 weeks of APhA’s receipt of program materials.

Aft er completing the live training seminar, participants will be able to:• Identify opportunities for pharmacists to become involved in immunization delivery.• Describe how vaccines evoke an immune response and provide immunity.• Identify the vaccines available on the U.S. market for each vaccine-preventable disease and classify each vac-cine as live attenuated or inactivated.• Evaluate a patient’s medical and immunization history and determine if the patient falls into the target groups for each vaccine based on the Advisory Committee for Immunization Practices (ACIP) recommendations. (continued on next page)



Pharmacy-Based Immunization Delivery is an innovative and interactive practice-based educational program that provides pharmacists with the skills necessary to become primary sources for vaccine advocacy, education, and ad-ministration. Th e program reviews the basics of immunology, identifi es legal and regulatory issues pharmacists must consider before starting an immunization program, and focuses on practice implementation.

Th is program is priced as follows:

GPhA Members: $400GPhA Student Members: $175All GPhA Potential Members: $495

Faculty:Liza G. Chapman, Pharm.D.

2nd Faculty Member TBD

Th e purpose of this educational program is to:• Provide comprehensive immunization education and training.• Provide pharmacists with the knowledge, skills, and resources necessary to establish and promote a successful immunization service.• Teach pharmacists to identify at-risk patient populations needing immunizations.• Teach pharmacists to administer immunizations in compliance with legal and regulatory standards.

Pharmacy-Based Immunization Delivery is conducted in two parts: the self-study and the live training. To earn a Certifi cate of Achievement, participants must complete all components of the program including the self-study, the self-study assessment, the Pharmacy-Based Immunization

Delivery live training seminar, the fi nal examination, and the injection technique assessment. Statements of Credit and Certifi cates will be issued within 4-6 weeks of APhA’s receipt of program materials.

Aft er completing the live training seminar, participants will be able to:• Identify opportunities for pharmacists to become involved in immunization delivery.• Describe how vaccines evoke an immune response and provide immunity.• Identify the vaccines available on the U.S. market for each vaccine-preventable disease and classify each vac-cine as live attenuated or inactivated.• Evaluate a patient’s medical and immunization history and determine if the patient falls into the target groups for each vaccine based on the Advisory Committee for Immunization Practices (ACIP) recommendations. (continued on next page)

Become a Pharmacy Based ImmunizerMacon, Georgia

Saturday, May 19, 20128:00am - 6:00pm

A CERTIFICATE PROGRAM FOR PHARMACISTS

Hosted by GPHA at the Hilton Garden inMacon / Mercer University

21


(continued from previous page) • Review a patient case and determine patient-specific vaccine recommendations based on the appropriate immunization schedule.• Discuss the legal, regulatory and liability issues involved with pharmacy-based immunization programs.• Describe the signs and symptoms of adverse reactions that can occur after vaccination• Describe the emergency procedures for management of patients with adverse reactions to vaccination.• List the steps for appropriate intranasal administration technique for the live attenuated influenza vaccine.• Demonstrate appropriate intramuscular and subcutaneous injection technique for adult Immunization.

Continuing Pharmacy Education (CPE) Credit:Release Date: 5/15/2011Successful completion of the live seminar component involves passing the final exam with a grade of 70% or higher and demonstrating competency in 2 intramuscular and 1 subcutaneous injection. Successful completion of this component will result in 8.0 contact hours of continuing pharmacy education credit (0.80 CEUs).ACPE UAN: 202-999-11-135-L01-P

Successful completion of the self study component involves passing the self-study assessment questions with a grade of 70% or higher and will result in 12.0 contact hours of continuing pharmacy education credit (1.2 CEUs).ACPE UAN: 202-999-11-136-H01-P

Pharmacy-Based Immunization Delivery: A Certificate Program for Pharmacists was developed by the American Pharmacists Association.

For all APhA education and accreditation information please visit www.pharmacist.com/education.

Your course book will be sent to you via UPS no later than three weeks prior to the course provided that complete payment has been received by GPhA. No refunds are available for this course. However, substi-tutions may be made but a course book will not be issued to the new participant. The participant who is canceling is responsible for transmitting the course book to the substituted participant. GPhA reserves the right to cancel the seminar should an inadequate number of seats be filled by 9 days prior to the program.

If you have questions about this program please contact Sarah Bigorowski at [email protected] or 404-419-8126.

To register for this event please visit www.gpha.org.

Thomas A. Gossel, R.Ph., Ph.D., Professor Emeritus, Ohio Northern University, Ada, Ohio andJ. Richard Wuest, R.Ph., PharmD, Professor Emeritus, University of Cincinnati, Cincinnati, Ohio

Gossel Wuest

continuing educat ion for pharmacists

Rest less Legs Syndrome and ManagementVolume XXX, No. 2

Dr. Thomas A. Gossel and Dr. J. Richard Wuest have no relevant financial relation-ships to disclose.

Goal. The goal of this lesson is to review restless legs syndrome, with emphasis on presenting key points of information to pass along to patients.

Objectives. At the completion of this activity, the participant will be able to:

1. demonstrate knowledge of restless legs syndrome including its causes and triggers, epidemiology and prevalence, pathogenesis, and clinical impressions;

2. explain the mechanism of action and major adverse events associated with the drugs used in treating restless legs syndrome;

3. select nonpharmacologic measures that are reported to modify symptoms of restless legs syndrome; and

4. demonstrate an understand-ing of information relative to restless legs syndrome to convey to patients and their caregivers.

Background Restless legs syndrome (RLS), also known as Ekbon’s syndrome, was named after Swedish neurolo-gist/physician Karl Ekbon. In the mid-1940s, Ekbon described the condition as a common and dis-tressing condition, but one that is readily treatable. Two to 15 per-cent of the general population of

the United States may experience RLS symptoms, although the exact prevalence may be much higher because it is generally held that many patients fail to discuss their symptoms with healthcare provid-ers. Patients may believe their condition is too insignificant with which to bother their physician, or they may not recognize that RLS can be symptomatic of more serious pathology that requires physician intervention. A sensorimotor (both sensory and motor) neurologic movement disorder, RLS causes patients to experience an almost irresistible urge to move their legs. Usually worse during periods of inactivity or rest, walking or other physical activity involving the legs can usually alleviate the sensa-tions. Often associated with a sleep complaint, the inability to rest can have a negative impact on the patient’s quality of life due to agita-tion, discomfort, frequent wak-ing, chronic sleep deprivation and stress. These conditions, in turn, can negatively affect job perfor-mance, social activities, and family life. Disturbed sleep and inability

to tolerate sedentary activities can lead to a compromised ability to enjoy life, and serious problems maintaining relationships.

RLS hardly receives the atten-tion it deserves. It has attracted lit-tle attention in medical textbooks until recently. A study conducted jointly in the United States and Europe suggests that the condi-tion is not only under-reported, but also greatly under-diagnosed and under-treated. A 1996 report described the outcome of a group of patients who delayed seeking medical help for many years, but even after they did receive help, ac-curate diagnosis frequently took a decade or more. The Restless Legs Syndrome Foundation has taken account of these observations and often reminds its constituency that RLS is “the most common disorder you have never heard of!”

This lesson describes RLS, including its clinical features and medical management. It stresses information that will be useful not only to pharmacists, but also to patients who experience the condi-tion.

Epidemiology and Prevalence RLS can affect persons of any race or ethnic group, but it is more com-mon in persons of Northern Euro-pean descent. African Americans are affected significantly less often than Caucasians. Its prevalence is distinctly lower in Asian popula-tions, ranging from 0.1 percent in


Singapore to 4.6 percent in elderly Japanese. Epidemiological studies in the general population of the United States and Europe show widely different prevalence rates, probably related to the variety of experimental design. Prevalence of RLS among patients in primary care settings has also been esti-mated. Results from a large survey of primary care centers in Europe and the United States reported that overall, 11.1 percent of pa-tients experienced any degree of RLS symptoms, while 9.6 percent reported symptoms at least once weekly.

RLS has a variable age of onset with prevalence increasing with advancing age. It can also occur in children. Studies confirm that in patients with severe RLS, one-third to two-fifths experienced their first symptoms before age 20 years, although a precise diagnosis of RLS was made much later. Women are twice as likely as men to develop RLS.

Etiology and Pathophysiology Although RLS is a disorder of the central nervous system, it is not a psychophysiologic pathology; how-ever, it may contribute to or be ex-acerbated by such conditions. RLS can generally be categorized into primary (idiopathic) and secondary forms. Primary RLS is not related to other identifiable abnormalities; secondary RLS is associated with an underlying pathology. When no specific cause can be identified for initiating RLS symptoms, it is considered a primary condition.

It is thought that RLS may be due to dysfunction of dopamine-producing cells in the nigrostriatal areas of the brain. Pharmacologic studies have shown a dramatic improvement in RLS symptoms with administration of levodopa, the precursor of dopamine, or with dopaminergic agonists that act on dopamine receptors in the brain. Conversely, dopamine antagonists will worsen symptoms in patients with RLS. Advanced brain imaging has revealed decreased dopamine D2 receptor binding in the striatum of patients with RLS. Hypoactive dopaminergic neurotransmission in RLS has recently been demon-strated and study results suggest that both striatal and extrastriatal brain regions are involved.

The high incidence (40 to 60 percent) of familial cases of RLS strongly suggests a genetic origin for primary RLS, especially if the condition onsets at an early age. Family and twin studies have proposed both autosomal-dominant as well as recessive modes of in-heritance. Genetic studies suggest several chromosomal loci associ-ated with RLS. At present, five loci have been mapped for RLS in single families, and three suscep-tibility loci have been identified in a genome-wide association study. Secondary causes of RLS are more common in persons who develop symptoms for the first time in later life; secondary RLS occurs in over 70 percent of persons with onset at age 65 years or more. It is impor-tant to rule out secondary RLS

when attempting to control symp-toms.

Secondary Causes. A number of secondary causes of RLS have been identified. For example, symp-toms of RLS may be associated with iron deficiency. A patient’s iron stores may be deficient with-out causing anemia. Studies have shown that decreased iron stores (i.e., ferritin levels below 50 µg/L) can exacerbate RLS symptoms. Iron is an essential cofactor for tyrosine hydroxylase, the rate-lim-iting enzyme for dopamine synthe-sis. Animal studies demonstrate that iron deficiency is associated with hypofunction of dopamine D2 receptors that is corrected by iron replacement. The fact that the extent of iron deficiency correlates well with symptoms and that iron is an effective therapy, at least in iron-deficient patients, provide strong support for the role of iron deficiency in the pathogenesis of some patients with RLS. Physi-cians often order serum ferritin levels in patients with newly diag-nosed RLS or RLS patients with a recent exacerbation of symptoms. Once iron levels are corrected (dis-cussed subsequently), symptoms are reduced.

RLS has been reported in per-sons with spinal cord and periph-eral nerve lesions, and in patients with vertebral disc disease. The exact pathological mechanism remains unknown.

RLS occurs in up to one-half of patients with end-stage renal fail-ure. Symptoms may be especially bothersome during dialysis when the patient is in a forced resting position. Improvement in RLS symptoms has been shown after renal transplantation.

One in five women experi-ence symptoms during pregnancy, especially in their last trimester. Some women, in fact, report RLS for the first time during pregnancy. Symptoms can be severe, but usu-ally subside within four weeks postpartum.

RLS symptoms may be wors-ened or unmasked by a variety of medications (Table 1). As a group,

Table 1Drugs reported to

exacerbate RLS

• Alcohol• Analgesics (NSAIDs, non-opioid)• Anesthetics (bupivacaine, mepivacaine)• Anticonvulsants (methsuximide, phenytoin, topiramate, zonisamide)• Antidepressants (mirtazapine, SSRIs, trazodone, tricyclics, venlafaxine)• Antihistamines (older)• Antipsychotics (clozapine, olanzapine, quetiapine, risperidone)• Beta-adrenergic blockers (pindolol)• Caffeine• Donepezil• Interferon-alfa/ pegylated interferon-alfa• Levothyroxine• Lithium• Methadone (withdrawal)• Metoclopramide• Nicotine• Sodium oxybate

G P H A W E B S I T E N E W S



antidepressants are the drugs most commonly implicated in secondary RLS with almost all classes report-ed to worsen symptoms. Persons with RLS who take one or more of the listed drugs are advised to discuss with their physician the possibility of changing medications to improve symptoms.

Clinical Assessment A diagnosis of RLS is based pri-marily on a careful patient history and detailed physical and neuro-logical examination. There is no laboratory test that can affirm the presence of RLS. The patient’s physical examination is often normal, except for those who have symptomatology suggestive of a secondary form of RLS or a comor-bid condition.

Symptoms may be described by patients as ranging from mild to intolerable. Due to the subjective nature of the disorder, however, patients often experience difficulty in describing their symptoms. Oftentimes their sensation defies description (Table 2). Confirmation of RLS is not easy. A population study showed that a large number of patients do not seek medical aid because of their motor condition, but rather because of the conse-quences of their disorder such as insomnia or decreased quality of life.

Most patients with RLS ex-perience the feelings in their

lower legs (calves); however the aggravating sensations may also occur any place in the legs or feet. They may also occur in the arms or elsewhere. The feelings seem to originate from deep within the limbs, rather than from the joints, or on the surface. The sensations are usually bilateral, but may oc-cur in one leg, move from one leg to the other, or affect one leg more than the other. The pain is more of an ache rather than sharp, jab-bing pain. Symptoms are generally worse in the evening and night, and less severe in the morning. Symptoms appear with rest, sitting or lying down. The more comfort-able the patient is, the more likely it is that RLS symptoms will occur. The reverse is also true – the less comfortable the patient is, the less likely it is that symptoms will on-set. As a result, some patients may prefer to sleep on a hard surface including the floor rather than in a comfortable bed. The condition should be distinguished from sleep-related disorders of the legs.

Periodic Limb Movements in Sleep. The presence of repeti-tive and highly stereotypic periodic limb movements in sleep (PLMS) supports, but does not confirm, a diagnosis of RLS. PLMS is also known as periodic limb move-ments and periodic limb movement disorder, and was formerly referred to as myoclonus. PLMS is noted as repetitive movements, typically in the lower limbs, that occur every 20 to 40 seconds. Symptoms can also occur in the arms. Hundreds of these involuntary, rhythmic muscular jerks in the lower limbs may occur, sometimes throughout the night. Affected persons are often not aware they are experienc-ing the movements. In a person with severe RLS, these involuntary kicking movements may also occur while awake. PLMS is common in older adults, even those without RLS, and doesn’t always disrupt sleep. Eighty percent of persons with RLS also experience PLMS, which correlates with RLS sever-ity, but less than half of those with PLMS also have RLS.

Essential Criteria that Con-firm RLS. The International Rest-less Legs Syndrome Study Group in collaboration with the National Institutes of Health has estab-lished criteria for diagnosis of RLS

Table 2Terms patients may use

when describing RLS symptoms

Aching Flowing waterBurning NumbBuzzing PainfulCramping PullingCrawling RestlessCreeping SearingDrawing TenseElectric current-like TinglingGnawing TuggingIndescribable UncomfortableItchingFeeling of worms or bugs crawling under my skin

Table 3Criteria for diagnosis

of RLS

Diagnostic criteria*

•Compelling urge to move the limbs, usually associated with paresthesias/dysesthesias•Motor restlessness as noted in activities such as floor pacing and rubbing the legs•Symptoms present or worse during rest, with temporary relief by activi-ties such as walking or stretching, at least as long as the activity continues•Symptoms worse in evening and at night than during the day, or occur only in the evening or night

Supportive clinical features± •Sleep disturbance and daytime fatigue•Normal neurological examination in primary RLS•Involuntary, repetitive, periodic, jerking limb movements during sleep or while awake•Positive family history of RLS•Positive response to dopaminergic therapy

Associated features§ •Natural clinical course: Onset age is variable, in patients with earlier onset (<50 years) the symptoms are insidious, while patients with later onset have a more aggressive course. RLS is usually a chronic disease with a progressive clinical course; in the mildest forms of RLS, the clinical course can be static or intermittent.•Sleep disturbances: disturbed sleep is usually associated with RLS.•Medical evaluation/Physical exami-nation: physical and neurological ex-amination is generally normal (except for secondary RLS). Medical evalua-tion should be addressed to identify possible causes for secondary RLS.

*Minimal criteria for positive diagnosis of RLS±Supportive clinical features common in RLS but not required for diagnosis§These features may provide additional information about the patient’s diagnosis



(Table 3). Four essential criteria must be present to establish a posi-tive diagnosis. A mnemonic to help remember these points is URGE: Urge to move, Rest induced, Gets better with activity, Evening and night accentuation. In the absence of the core clinical features of RLS, a positive diagnosis of RLS cannot be made, and other causes of PLMS or isolated periodic limb movement disorder must be considered. The relation between PLMS and RLS is unclear, but treatments used for RLS may also be effective in PLMS as well. The presence of supportive and associated clinical features as shown in Table 3 is not necessary for a positive diagnosis, but they are definitely helpful to the differ-ential diagnosis.

Differential Diagnosis. RLS should be differentiated from other conditions including:

•Nocturnal Leg Cramps. These typically include painful, palpable, involuntary muscle contractions, often focal, with a sudden onset. Nocturnal leg cramps are usually unilateral.

•Akathisia. This is a closely re-lated disorder, described as a condi-tion of motor restlessness, ranging from a sense of inner disquiet, to inability to sit or lie quietly or to sleep, with no sensory complaints. The restlessness is generalized and internal rather than localized to the limbs and associated with par-esthesias. Akathisia often does not correlate with rest or time of day, and often results as a side effect of medication such as neuroleptics or other dopamine blocking agents.

•Peripheral Neuropathy. This can cause leg symptoms that are different from RLS. Symptoms are usually neither associated with motor restlessness nor lessened by movement. The condition is not worse during the evening or night-time. Sensory complaints include numbness, tingling or pain. Small fiber sensory neuropathies such as those seen in diabetes mellitus may be confused with RLS. Patients with neuropathies may have both neuropathic and RLS symptoms.

•Vascular Disease. Conditions

such as deep vein thrombosis can be confused with RLS.

RLS in Children Although RLS is generally dis-cussed as a disease of adults, over the past 20 years there has been increasing recognition that it also occurs in children. Adults with the diagnosis often retrospectively recall having had symptoms during their childhood. Case series have described children as young as 18 months of age with features of RLS.

Diagnosing RLS in children is particularly difficult because clini-cians rely heavily on the patient’s description of symptoms. Even for adults with RLS, an accurate de-scription of its subjective symptoms may be difficult. Children may describe RLS symptoms differently than adults, using terms such as oowies, ouchies, tickle, spiders, twitchy, jerky, boo-boos, want to run, and a lot of energy in my legs. Or, children may have at least two of the following: sleep disturbance, a biological parent or sibling with RLS, or polysomnographic-docu-mented PLMS. Determining RLS in children can be aided using the same four criteria as for adults (see Table 3).

According to a recent survey of more than 10,000 families in the United States and the United Kingdom, RLS affects about 2 percent of children. A pediatric RLS prevalence of 5.9 percent was noted at one pediatric sleep disor-ders clinic. Another study found a prevalence of 1.3 percent in 12 pediatric practices, and another re-ported its occurrence in 6.1 percent of Canadian children ages 11 to 13 years. The U.S./U.K. study found a strong genetic component to RLS. More than 70 percent of children with RLS had at least one parent with the condition. There is also evidence suggesting that children with attention deficit hyperactiv-ity disorder (ADHD) and a family history of RLS are at risk for more severe ADHD.

Most children with RLS do not require pharmacologic treatment

and indeed, there are no FDA-approved drugs for use in children with RLS. Case histories and anecdotal reports suggest it is best to begin with good sleep hygiene measures, cognitive behavioral therapy and caffeine restriction (including restriction of caffeinated soft drinks). If these measures are ineffective, screening for anemia and checking the patient’s serum ferritin level makes sense. For children, elemental iron in doses of 3 mg/kg/day given for three months was shown to improve PLMS and clinical symptoms, but more data are needed to determine effective-ness in pediatric RLS. Dopaminer-gic drugs used “off-label” in chil-dren have been shown to improve RLS symptoms. In cases of associ-ated ADHD, dopaminergics may benefit ADHD symptoms as well.

Treatment in Adults There is no cure for primary RLS. Both nonpharmacologic measures and pharmacotherapy, however, are helpful in relieving symptoms in many patients. It is important to note that both severity and frequency of RLS are variable; therefore, nonpharmacologic thera-pies alone may be appropriate for milder forms of RLS and indeed, these measures should be consid-ered first in all but the most severe cases. It is also important to note that many pharmacologic agents are used in an “off-label” basis. Successful treatment for secondary RLS requires treating the underly-ing cause. Goals of treatment are to prevent or relieve symptoms, increase the amount and improve the quality of sleep, and treat or correct any underlying condition that may trigger or worsen RLS.

Lifestyle and Behavioral Changes. For those with mild-to-moderate symptoms, prevention is key to their control. In gen-eral, simple lifestyle changes that promote good health can play an important role in alleviating symp-toms of RLS. The measures listed in Table 4 may help reduce the discomfort and excessive leg move-ments. The websites listed in Table


(Table 3). Four essential criteria must be present to establish a posi-tive diagnosis. A mnemonic to help remember these points is URGE: Urge to move, Rest induced, Gets better with activity, Evening and night accentuation. In the absence of the core clinical features of RLS, a positive diagnosis of RLS cannot be made, and other causes of PLMS or isolated periodic limb movement disorder must be considered. The relation between PLMS and RLS is unclear, but treatments used for RLS may also be effective in PLMS as well. The presence of supportive and associated clinical features as shown in Table 3 is not necessary for a positive diagnosis, but they are definitely helpful to the differ-ential diagnosis.

Differential Diagnosis. RLS should be differentiated from other conditions including:

•Nocturnal Leg Cramps. These typically include painful, palpable, involuntary muscle contractions, often focal, with a sudden onset. Nocturnal leg cramps are usually unilateral.

•Akathisia. This is a closely re-lated disorder, described as a condi-tion of motor restlessness, ranging from a sense of inner disquiet, to inability to sit or lie quietly or to sleep, with no sensory complaints. The restlessness is generalized and internal rather than localized to the limbs and associated with par-esthesias. Akathisia often does not correlate with rest or time of day, and often results as a side effect of medication such as neuroleptics or other dopamine blocking agents.

•Peripheral Neuropathy. This can cause leg symptoms that are different from RLS. Symptoms are usually neither associated with motor restlessness nor lessened by movement. The condition is not worse during the evening or night-time. Sensory complaints include numbness, tingling or pain. Small fiber sensory neuropathies such as those seen in diabetes mellitus may be confused with RLS. Patients with neuropathies may have both neuropathic and RLS symptoms.

•Vascular Disease. Conditions

such as deep vein thrombosis can be confused with RLS.

RLS in Children Although RLS is generally dis-cussed as a disease of adults, over the past 20 years there has been increasing recognition that it also occurs in children. Adults with the diagnosis often retrospectively recall having had symptoms during their childhood. Case series have described children as young as 18 months of age with features of RLS.

Diagnosing RLS in children is particularly difficult because clini-cians rely heavily on the patient’s description of symptoms. Even for adults with RLS, an accurate de-scription of its subjective symptoms may be difficult. Children may describe RLS symptoms differently than adults, using terms such as oowies, ouchies, tickle, spiders, twitchy, jerky, boo-boos, want to run, and a lot of energy in my legs. Or, children may have at least two of the following: sleep disturbance, a biological parent or sibling with RLS, or polysomnographic-docu-mented PLMS. Determining RLS in children can be aided using the same four criteria as for adults (see Table 3).

According to a recent survey of more than 10,000 families in the United States and the United Kingdom, RLS affects about 2 percent of children. A pediatric RLS prevalence of 5.9 percent was noted at one pediatric sleep disor-ders clinic. Another study found a prevalence of 1.3 percent in 12 pediatric practices, and another re-ported its occurrence in 6.1 percent of Canadian children ages 11 to 13 years. The U.S./U.K. study found a strong genetic component to RLS. More than 70 percent of children with RLS had at least one parent with the condition. There is also evidence suggesting that children with attention deficit hyperactiv-ity disorder (ADHD) and a family history of RLS are at risk for more severe ADHD.

Most children with RLS do not require pharmacologic treatment

and indeed, there are no FDA-approved drugs for use in children with RLS. Case histories and anecdotal reports suggest it is best to begin with good sleep hygiene measures, cognitive behavioral therapy and caffeine restriction (including restriction of caffeinated soft drinks). If these measures are ineffective, screening for anemia and checking the patient’s serum ferritin level makes sense. For children, elemental iron in doses of 3 mg/kg/day given for three months was shown to improve PLMS and clinical symptoms, but more data are needed to determine effective-ness in pediatric RLS. Dopaminer-gic drugs used “off-label” in chil-dren have been shown to improve RLS symptoms. In cases of associ-ated ADHD, dopaminergics may benefit ADHD symptoms as well.

Treatment in Adults There is no cure for primary RLS. Both nonpharmacologic measures and pharmacotherapy, however, are helpful in relieving symptoms in many patients. It is important to note that both severity and frequency of RLS are variable; therefore, nonpharmacologic thera-pies alone may be appropriate for milder forms of RLS and indeed, these measures should be consid-ered first in all but the most severe cases. It is also important to note that many pharmacologic agents are used in an “off-label” basis. Successful treatment for secondary RLS requires treating the underly-ing cause. Goals of treatment are to prevent or relieve symptoms, increase the amount and improve the quality of sleep, and treat or correct any underlying condition that may trigger or worsen RLS.

Lifestyle and Behavioral Changes. For those with mild-to-moderate symptoms, prevention is key to their control. In gen-eral, simple lifestyle changes that promote good health can play an important role in alleviating symp-toms of RLS. The measures listed in Table 4 may help reduce the discomfort and excessive leg move-ments. The websites listed in Table


5 provide valuable information that can be passed along to patients.

Pharmacologic. Although nonpharmacologic strategies may work for some patients with milder symptoms, most individuals with mild-to-moderate symptoms will require medication to help make symptoms tolerable. Medical management of RLS is a rap-idly developing field. Large-scale multicenter trials in RLS became common only since the beginning of the 21st century. To date, only three drugs have earned FDA approval for RLS: ropinirole (Requip®) in May 2005, pramipexole (Mirapex®) in November 2006 and gabapentin enacarbil (Horizant™) in April 2011. Since symptom severity var-ies greatly between patients, no single medication or combination of drugs will work predictably for all

patients. Treatment must there-fore be individualized. Selection of pharmacologic agents is influenced by a number of factors, including:

•Patient Age. Benzodiazepines, for example, may cause cognitive impairment in elderly patients.

•Symptom Severity. Patients with mild symptoms may elect to forgo using medications due to cost, adverse effects or other reasons. Others may benefit from a dop-aminergic agent or a dopamine agonist. Severe symptoms may require a strong opioid.

•Symptom Frequency. Persons with infrequent symptoms may benefit greatly from a single dose of medication given on an as-needed basis, such as an opioid or levodo-pa.

•Pregnancy. Neither safety nor efficacy of medications for RLS has been assessed in clinical trials involving pregnant women.

•Renal Failure. Most pharma-cologic agents are generally safe in patients with renal failure, al-though dose frequency and quanti-ty may be modified if the drugs are excreted via the kidney. Moreover, for dialysis patients, some medica-tions are dialyzable (e.g., gabapen-tin) while others are not.

Dopaminergic Agents. Discovery that levodopa was ef-fective in RLS revolutionized its management. Every dopaminergic agent tested has been shown to be effective against RLS and PLMS. Levodopa/carbidopa (Sinemet®, and others) provides near-immediate relief from RLS. The response is so characteristic that a brief course of therapy may be considered in patients whose diagnosis of RLS is in doubt. Levodopa is also effec-tive in hemodialysis patients with RLS. In general, the drug is very well tolerated. Levodopa-induced dyskinesias have not been reported in RLS patients.

Two troublesome and common problems develop with prolonged use of levodopa, which limits the value of this otherwise almost ideal agent for RLS: rebound and aug-mentation. Rebound is an outcome of the drug’s short half-life; after

a while, patients start to awaken early in the morning with recur-rence of their RLS. Sustained-re-lease formulations can delay onset of rebound until later in the morn-ing, although the long-term efficacy of this approach remains unknown. Augmentation is more serious. It may shorten symptom-free periods at rest. Also, symptoms develop earlier in the day (morn-ing or afternoon instead of evening or night) and may become more severe; and symptoms may develop in parts of the body that were not previously involved. Augmenta-tion occurs in up to 80 percent of patients treated with levodopa as early as four weeks into treatment. Approximately one-third have sufficiently severe symptoms that warrant a change in therapy. The precise mechanisms contributing to augmentation are unknown. The need for higher doses of levodopa and development of more severe RLS may predict development of this complication. Levodopa is, therefore, no longer the treat-ment of choice for RLS, although it remains a therapy of choice for persons with only intermittently severe symptoms.

Dopamine Receptor Ago-nists. These are now regarded as the first-line treatment for RLS.

Table 4 Nonpharmacologic

management of RLS

•Identify any underlying disorders and treat, if feasible•Eliminate precipitants of RLS -Drugs (see Table 1) -Common stimulants and depres- sants: caffeine, alcohol, nicotine•Practice good sleep hygiene -Establish regular sleep and wake times -Restrict bed to sleep and intima- cy; remove TV, stereo -Avoid perturbing activities immediately before sleep -Avoid bright lights in late evening or night -Have a light snack before bedtime•Apply simple behavioral interventions -Brief walk before bedtime -Hot bath or cold shower -Massage limbs -Practice meditation and/or yoga -Avoid heavy meals within 3 hours of bedtime -Avoid excessive napping during daytime•Moderate exercise: neither inactivi-ty nor unusual and excessive exercise•Weight management: healthy diet and adequate activity•Information and support: use web-sites and patient support groups (see Table 5)

Table 5Support groups for RLS

•Restless Legs Syndrome Foundationwww.rls.org

•Worldwide Education and Aware-ness for Movement Disorders (WE MOVE)www.wemove.org

•National Sleep Foundationwww.sleepfoundation.org

•National Institute of Neurological Disorders and Stroke (NINDS)www.ninds.nih.gov/disorders/restless_legs/restless_legs.htm

•National Heart, Lung and Blood Institute (NHLBI)www.nhlbi.nih.gov/health/dci/Diseases/rls/rls.htm



The non-ergot agonists ropinirole and pramipexole have been shown to benefit RLS in randomized con-trolled trials. There is no indication based on the numerous compara-tive clinical trials reported for the dopamine receptor agonists that efficacy of one agent is better than another. The drugs are chemically distinct from dopamine, but their mechanism of action in the central nervous system is similar to that of the endogenous neurotransmitter.

Studies suggest that the drugs are well tolerated in patients with severe RLS who have failed other therapies and in those with aug-mentation. Augmentation and tolerance have been reported, although at a much lower inci-dence than seen with levodopa, and they seem more likely to occur in patients who previously developed similar problems with levodopa. Dose reduction may be required if augmentation or tolerance develop, but, unlike with levodopa, a change in medication is rarely needed. Several reports of unusual compul-sive behaviors occurring in persons taking dopamine receptor agonists include pathological gambling and increased sexuality.

Other Medications. The therapeutic effect of opioids is well known. Intermittent use of low-potency opioids or opioid recep-tor agonists, usually taken before bedtime, can be effective. Studies have shown positive short-term and long-term responses of various opioids. In severe disease, opioids may be considered a second-choice treatment after dopaminergic agents. There is a chance for de-pendence, and these drugs should be used with caution in persons with a history of addiction.

Benzodiazepines or benzo-diazepine receptor agonists, taken before sleep, may be use-ful. This is especially relevant if the patient has another cause of poor sleep in addition to RLS, such as psychophysiologic insom-nia. Most data have been derived with clonazepam (Klonopin®, and others). Some investigators have shown this drug to be well toler-

ated in older patients; however, its long duration of action may result in more adverse effects, such as an unsteadiness leading to falls during the night and drowsiness or cognitive impairment in the morn-ing.

Antiepileptics including carbamazepine (Tegretol®, and oth-ers) and gabapentin (Neurontin®, and others), have been reported to be efficacious in treating RLS, but are not commonly used in clinical practice due to their high incidence of adverse effects. Antiepileptics may be effective in patients with RLS who also suffer from painful paresthesias or underlying neur-opathy. The most recently ap-proved drug for RLS, gabapentin enacarbil (Horizant™) is a prodrug of gabapentin and accordingly, its therapeutic effects in RLS are at-tributable to gabapentin.

The management of RLS continues to evolve as new drugs become available. Cabergoline (Dostinex®, and others), a dop-amine agonist, is of interest be-cause of its long half-life (65 hours). This theoretically might produce less augmentation. Magnesium has been reported in a small open-label trial to be an effective therapy for RLS.

Selecting the Best Treat-ment for a Particular Patient. This usually proceeds in a “hit or miss” manner. Drugs should be used at their lowest effective dose, and only when necessary should the dose be slowly titrated upward. Medication should be taken early enough to permit absorption and action before the onset of sleep. Divided doses may be needed, often provided with the evening meal and later at night. If the first drug does not work, then a second agent with a different mode of action should be substituted. Sometimes a combination of medications works better than any single agent.

Iron Replacement in Sec-ondary RLS. As noted earlier, a serum ferritin concentration below 45 to 50 µg/L has been associated with increased severity of RLS. A common treatment regimen

is 325 mg ferrous sulfate three times daily along with 100 to 200 mg vitamin C with each dose to enhance absorption. Oral iron can cause constipation and abdominal discomfort, and the dose may need to be reduced in some patients. Oral iron should ideally be taken on an empty stomach to enhance absorption. If gastrointestinal symptoms develop, it should be taken with food. Follow-up ferri-tin determinations are indicated, initially after three to four months and then every three to six months until the serum ferritin level is greater than 50 µg/L. Iron therapy can then be discontinued. For patients with severe iron deficiency (ferritin ≤10 µg/L) and oral iron intolerance, intravenously admin-istered iron can be considered. Of note is that RLS does not always respond to an increasing serum fer-ritin concentration, even if it was low initially.

Prognosis RLS is usually a lifelong condi-tion that has no cure. Although it has a variable course, symptoms may gradually worsen with age, albeit more slowly for those with the primary form of RLS than for patients who also suffer from an associated medical condition. Nonetheless, current therapies can control RLS, minimizing symptoms and maximizing periods of restful sleep. Some patients experience remissions, periods during which symptoms decrease or disappear for days, weeks or months; how-ever, symptoms usually reappear. A diagnosis of RLS that onsets dur-ing adulthood does not indicate the onset of another neurologic disease. Individuals with RLS secondary to an underlying condition may note resolution of symptoms when their underlying condition is treated. Medication, when needed, usually provides relief of symptoms.

Summary and Conclusions RLS is a common but under-recog-nized disorder associated with dis-comfort in the legs that is hard to describe and a distressing urge to


The non-ergot agonists ropinirole and pramipexole have been shown to benefit RLS in randomized con-trolled trials. There is no indication based on the numerous compara-tive clinical trials reported for the dopamine receptor agonists that efficacy of one agent is better than another. The drugs are chemically distinct from dopamine, but their mechanism of action in the central nervous system is similar to that of the endogenous neurotransmitter.

Studies suggest that the drugs are well tolerated in patients with severe RLS who have failed other therapies and in those with aug-mentation. Augmentation and tolerance have been reported, although at a much lower inci-dence than seen with levodopa, and they seem more likely to occur in patients who previously developed similar problems with levodopa. Dose reduction may be required if augmentation or tolerance develop, but, unlike with levodopa, a change in medication is rarely needed. Several reports of unusual compul-sive behaviors occurring in persons taking dopamine receptor agonists include pathological gambling and increased sexuality.

Other Medications. The therapeutic effect of opioids is well known. Intermittent use of low-potency opioids or opioid recep-tor agonists, usually taken before bedtime, can be effective. Studies have shown positive short-term and long-term responses of various opioids. In severe disease, opioids may be considered a second-choice treatment after dopaminergic agents. There is a chance for de-pendence, and these drugs should be used with caution in persons with a history of addiction.

Benzodiazepines or benzo-diazepine receptor agonists, taken before sleep, may be use-ful. This is especially relevant if the patient has another cause of poor sleep in addition to RLS, such as psychophysiologic insom-nia. Most data have been derived with clonazepam (Klonopin®, and others). Some investigators have shown this drug to be well toler-

ated in older patients; however, its long duration of action may result in more adverse effects, such as an unsteadiness leading to falls during the night and drowsiness or cognitive impairment in the morn-ing.

Antiepileptics including carbamazepine (Tegretol®, and oth-ers) and gabapentin (Neurontin®, and others), have been reported to be efficacious in treating RLS, but are not commonly used in clinical practice due to their high incidence of adverse effects. Antiepileptics may be effective in patients with RLS who also suffer from painful paresthesias or underlying neur-opathy. The most recently ap-proved drug for RLS, gabapentin enacarbil (Horizant™) is a prodrug of gabapentin and accordingly, its therapeutic effects in RLS are at-tributable to gabapentin.

The management of RLS continues to evolve as new drugs become available. Cabergoline (Dostinex®, and others), a dop-amine agonist, is of interest be-cause of its long half-life (65 hours). This theoretically might produce less augmentation. Magnesium has been reported in a small open-label trial to be an effective therapy for RLS.

Selecting the Best Treat-ment for a Particular Patient. This usually proceeds in a “hit or miss” manner. Drugs should be used at their lowest effective dose, and only when necessary should the dose be slowly titrated upward. Medication should be taken early enough to permit absorption and action before the onset of sleep. Divided doses may be needed, often provided with the evening meal and later at night. If the first drug does not work, then a second agent with a different mode of action should be substituted. Sometimes a combination of medications works better than any single agent.

Iron Replacement in Sec-ondary RLS. As noted earlier, a serum ferritin concentration below 45 to 50 µg/L has been associated with increased severity of RLS. A common treatment regimen

is 325 mg ferrous sulfate three times daily along with 100 to 200 mg vitamin C with each dose to enhance absorption. Oral iron can cause constipation and abdominal discomfort, and the dose may need to be reduced in some patients. Oral iron should ideally be taken on an empty stomach to enhance absorption. If gastrointestinal symptoms develop, it should be taken with food. Follow-up ferri-tin determinations are indicated, initially after three to four months and then every three to six months until the serum ferritin level is greater than 50 µg/L. Iron therapy can then be discontinued. For patients with severe iron deficiency (ferritin ≤10 µg/L) and oral iron intolerance, intravenously admin-istered iron can be considered. Of note is that RLS does not always respond to an increasing serum fer-ritin concentration, even if it was low initially.

Prognosis RLS is usually a lifelong condi-tion that has no cure. Although it has a variable course, symptoms may gradually worsen with age, albeit more slowly for those with the primary form of RLS than for patients who also suffer from an associated medical condition. Nonetheless, current therapies can control RLS, minimizing symptoms and maximizing periods of restful sleep. Some patients experience remissions, periods during which symptoms decrease or disappear for days, weeks or months; how-ever, symptoms usually reappear. A diagnosis of RLS that onsets dur-ing adulthood does not indicate the onset of another neurologic disease. Individuals with RLS secondary to an underlying condition may note resolution of symptoms when their underlying condition is treated. Medication, when needed, usually provides relief of symptoms.

Summary and Conclusions RLS is a common but under-recog-nized disorder associated with dis-comfort in the legs that is hard to describe and a distressing urge to


Program 0129-0000-12-002-H01-PRelease date: 2-15-12

Expiration date: 2-15-15CE Hours: 1.5 (0.15 CEU)

The authors, the Ohio Pharmacists Foundation and the Ohio Pharmacists Association disclaim any liability to you or your patients resulting from reliance solely upon the information contained herein. Bibliography for ad-ditional reading and inquiry is avail-able upon request.

This lesson is a knowledge-based CE activity and is targeted to pharmacists in all practice settings.

The Ohio Pharmacists Foundation Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

move them. It increases in frequen-cy with aging, but is also found in children. Sleep disruption in RLS may impact daytime functioning and quality of life. For patients with mild symptoms, no drug treat-ment may be necessary; nonphar-macologic measures may be all that is needed. In patients with moder-ate to severe, troublesome symp-toms, a dopamine receptor agonist is the current treatment of choice, although it should be noted that there have been few satisfactory studies comparing different phar-macotherapies. If dopamine ago-nists are poorly tolerated or ineffec-tive, levodopa may be a satisfactory option for many people, especially for those with intermittent symp-toms, such as during a long trip or sitting through a boring lecture! It takes only 15 to 30 minutes to be-come effective, and augmentation is not a risk with intermittent use.


30The Georgia Pharmacy Journal April 201230 February 2012

continuing educat ion quiz Rest less Legs Syndrome and Management

Program 0129-0000-12-002-H01-P0.15 CEUPlease print.

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Completely fill in the lettered box corresponding to your answer.1. [a] [b] [c] [d] 6. [a] [b] 11. [a] [b] [c] [d]2. [a] [b] [c] [d] 7. [a] [b] [c] [d] 12. [a] [b] [c] [d] 3. [a] [b] 8. [a] [b] [c] [d] 13. [a] [b] 4. [a] [b] [c] [d] 9. [a] [b] 14. [a] [b] [c] [d] 5. [a] [b] [c] [d] 10. [a] [b] [c] [d] 15. [a] [b] [c] [d]

I am enclosing $5 for this month’s quiz made payable to: Ohio Pharmacists Association.1. Rate this lesson: (Excellent) 5 4 3 2 1 (Poor)2. Did it meet each of its objectives? yes no If no, list any unmet_______________________________3. Was the content balanced and without commercial bias? yes no4. Did the program meet your educational/practice needs? yes no5. How long did it take you to read this lesson and complete the quiz? ________________ 6. Comments/future topics welcome.

1. Restless Legs Syndrome (RLS) is: a. a motor disorder. b. a sensory disorder. c. both a motor and a sensory disorder. d. neither a motor nor a sensory disorder. 2. RLS is more common in which of the following groups of people? a. African Americans c. Asian Americans b. Northern Europeans d. Southern Europeans

3. RLS is NOT a psychophysiologic pathology. a. True b. False 4. An essential cofactor for tyrosine hydroxylase, the rate-limiting enzyme for dopamine synthesis, is: a. magnesium. c. calcium. b. iodine. d. iron.

5. The group of drugs most commonly implicated in secondary RLS is the: a. antidepressants. c. antipsychotics. b. antiepileptics. d. antirheumatics.

6. Diagnosis of RLS can be easily determined by a spe-cific laboratory test. a. True b. False 7. Periodic limb movement disorder was formerly re-ferred to as: a. dyskinesia. c. myoclonus. b. intermittent claudication. d. Raynaud’s disorder.

8. The condition characterized by symptoms that are usually neither associated with motor restlessness nor lessened by movement is: a. akathisia. b. intermittent claudication. c. nocturnal cramps. d. peripheral neuropathy.

9. Most children with RLS require pharmacologic treat-ment. a. True b. False 10. All of the following are considered to be good sleep hygiene management EXCEPT: a. avoid bright lights in late evening or night. b. establish regular sleep and wake times. c. avoid perturbing activities immediately before sleep. d. do not eat anything after the evening meal.

11. All of the following drugs have been approved for treating RLS EXCEPT: a. gabapentin. c. quinine. b. pramipexole. d. ropinirole.

12. Which of the following drugs is dialyzable? a. Gabapentin c. Quinine b. Pramipexole d. Ropinirole

13. The troublesome and common problem that develops with prolonged use of levodopa that is more serious is: a. augmentation. b. rebound. 14. Which of the following is regarded as first-line treat-ment for RLS? a. Benzodiazepines b. Dopamine receptor agonists c. Dopaminergic agents d. Opioids

15. Most data on the use of benzodiazepines to treat RLS have been derived with: a. alprazolam. c. clonazepam. b. chlordiazepoxide. d. diazepam.

To receive CE credit, your quiz must be postmarked no later than Feb-ruary 15, 2014. A passing grade of 80% must be attained. CE state-ments of credit are mailed February, April, June, August, October, and December until the CPE Monitor Program is fully operational. Send inquiries to [email protected].


The Georgia Pharmacy Journal April 2012 31

The Georgia Pharmacy Journal

Editor: Jim Bracewell [email protected]

Managing Editor Amy W. DeFaveri [email protected]

Writer & Designer: Amy W. DeFaveri [email protected]

The Georgia Pharmacy Journal® (GPJ) is the official publication of the Georgia Pharmacy Association, Inc. (GPhA). Copyright © 2012, Georgia Pharmacy Association, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including by photocopy, recording or information storage retrieval systems, without prior written permission from the publisher and managing editor.

All views expressed in bylined articles are the opinions of the author and do not necessarily express the views or policies of the editors, officers or members of the Georgia Pharmacy Association.

ARTICLES AND ARTWORKThose interested in writing for this publication are encouraged to request the official “GPJ Guidelines for Writers.” Artists or photographers wishing to submit artwork for use on the cover should call, write or email [email protected].

SUBSCRIPTIONS AND CHANGE OF ADDRESSThe Georgia Pharmacy Journal® (GPJ) (ISSN 1075-6965) is distributed as a regular membership service, paid for through allocation of membership dues. Subscription rate for non-members is $50.00 per year domestic and $10.00 per single copy; international rates $65.00 per year and $20.00 single copy. Subscriptions are not available for non-GPhA member pharmacists licensed and practicing in Georgia.

The Georgia Pharmacy Journal® (GPJ) (ISSN 1075-6965) is published monthly by the GPhA, 50 Lenox Pointe, NE, Atlanta, GA 30324. Periodicals postage paid at Atlanta, GA and additional offices.

POSTMASTER: Send address changes to The Georgia Pharmacy Journal®, 50 Lenox Pointe, NE, Atlanta, GA 30324.

ADVERTISINGAdvertising copy deadline and rates are available at www.gpha.org upon request. All advertising and production orders should be sent to the GPhA headquarters at [email protected].

GPhA HEADQUARTERS50 Lenox Pointe, NEAtlanta, Georgia 30324Office: (404) 231.5074Fax: (404) 237.8435 Power Marketing: (678) 990-3618

www.gpha.org

2011 - 2012 GPhA BOARD OF DIRECTORS

Name PositionDale Coker Chairman of the BoardJack Dunn PresidentRobert Hatton President-ElectPam Marquess First Vice PresidentBobby Moody Second Vice PresidentRobert Bowles State At LargeHugh Chancy State At LargeKeith Herist State At LargeEddie Madden State At LargeJonathan Marquess State At LargeTim Short State At LargeRichard Smith State At LargeChristine Somers 1st Region PresidentFred Sharpe 2nd Region PresidentRenee Adamson 3rd Region PresidentAmanda Gaddy 4th Region PresidentJulie Bierster 5th Region PresidentAshley Faulk 6th Region PresidentAmanda McCall 7th Region PresidentLarry Batten 8th Region PresidentKristy Pucylowski 9th Region President Christopher Thurmond 10th Region PresidentAshley London 11th Region President Ken Eiland 12th Region PresidentThomas Jeter ACP ChairmanJosh Kinsey AEP ChairmanSonny Rader AHP ChairmanIra Katz AIP ChairmanGail Lowney APT ChairmanChristina Gonzalez ASA ChairmanJohn T. Sherrer Foundation ChairmanMichael Farmer Insurance Trust ChairmanBill Prather Georgia State Board of Pharmacy RepresentativePatricia Knowles Georgia Society of Health Systems PharmacistsAmy Grimsley Mercer Faculty RepresentativeRusty Fetterman South Faculty RepresentativeSukh Sarao UGA Faculty Rep.Negin Sovaidi ASP Mercer University Rep.Annie Tran ASP South University Rep.David Bray ASP UGA Rep.Jim Bracewell Executive Vice President


Introducing the GPhA/UBS Wealth Management Program

UBS has agreed to provide all members of the Georgia Pharmacy Association with exclusive access to financial services resources through the Wile Consulting Group. This new group relationship enables members to leverage the vast scale of products and services at UBS.

With more than 100 years of financial services experience, The Wile Consulting Group at UBS has been recognized as one of Barron’s Top 1,000 Financial Advisors in the country. The Wile Consulting Group is the endorsed wealth management provider for the Georgia Dental Association and also PriceWaterhouseCoopers Southern Division. They will replicate these same offerings to the GPhA.

Harris Gignilliat, CRPS®

Vice President–Investments3455 Peachtree Road NE, Suite 1700Atlanta, GA [email protected]

ubs.com/team/wile

Member benefits include

– Complimentary financial planning (a $5k–10k value)

– Brand new 401(k) retirement savings plan designed exclusively for GPhA members at a group discount rate

– Advisory and investment program offered at group discount rate

– Retirement planning guidance, including a retirement income replacement system

– Lending capabilities with competitive interest rates

– Free access to UBS global investment research

Created

02/07/11

Last revision

July 18, 2011 4:08 PM

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8.5 x 8.75”cmykn/an/a––jgd/jt/jgd/lisajordan

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Chartered Retirement Plans SpecialistSM and CRPS® are registered service marks of the College for Financial Planning®. Neither UBS Financial Services Inc. nor any of its employees provides legal or tax advice. You should consult with your personal legal or tax advisor regarding your personal circumstances. As a firm providing wealth management services to clients, we offer both investment advisory and brokerage services. These services are separate and distinct, differ in material ways and are governed by different laws and separate contracts. For more information on the distinctions between our brokerage and investment advisory services, please speak with your Financial Advisor, the Wile Consulting Group, or visit our website at ubs.com/workingwithus. Financial Planning services are provided in our capacity as a registered investment adviser. As a firm providing wealth management services to clients in the U.S., we offer both investment advisory and brokerage services. These services are separate and distinct, differ in material ways and are governed by different laws and separate contracts. Note to the User: FINRA (NASD) requires that the prospectus offer legend (the first paragraph below) be in a font size that is at least the same size as that used in the main text of the marketing piece and in a different print style, such as bold or italic type. Once this disclosure (the prospectus offer legend) is used in any public facing materials, the materials are subject to filing with FINRA (NASD) by a Series 24 Principal. UBS Financial Services Inc. is a subsidiary of UBS AG. ©2011 UBS Financial Services Inc. All rights reserved. Member SIPC. 7.00_8.5x8.75_AX0712_GigH.2

Georgia Pharmacy Association50 Lenox Pointe, NEAtlanta, GA 30324


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