the georgia pharmacy journal: january 2011

The Georgia Pharmacy Journal January 20112

Let us be Your Insurance Resource

Join us in celebrating 30 years of serving the membersof the Georgia Pharmacy Association.

To learn more visit www.gpha.org.

Call or e-mail TODAY to schedule a time to discuss your health insurance needs.

Trevor Miller – Director of Insurance Services404.419.8107 or email at [email protected]

Celebrating 30 years of service to the Pharmacists of Georgia!

Georgia Pharmacy Association Members Take Advantage ofPremium Discounts Up to 30% on Individual Disability

Insurance

Have you protected your most valuable asset?Many people realize the need to insure personal belongings like carsand homes, but often they neglect to insure what provides their lifestyle and financial well-being - their income!

The risk of disability exists and the financial impact of a long-term disability (90 days or more) can have adevastating impact on individuals, families and businesses.During the course of your career, you are 3½ timesmore likely to be injured and need disability coverage than you are to die. (Health Insurance Association of America,2000)

As a member of the Georgia Pharmacy Association, you can help protect your most valuable asset and receivepremium discounts up to 30% on high-quality Individual Disability Income Insurance from Principal Life InsuranceCompany.

For more information visit www.gpha.org.

* Association Program subject to state approval. Policy forms HH 750, HH 702, HH 703. This is a general summary only. Additional guidelines apply. Disability insurance has limitations and exclusions. Forcosts and details of coverage, contact your Principal Life financial representative.


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

5 Welcome New GPhA Staff

12 2011 Pharmacy Based Immunization Certification Program Save the Date

15 GPhA Member News

19 NASPA 2011-2012 Executive Residency

21 Continuing Education for Pharmacists: Management of Pulmonary Artierial Hypertension

30 The 15th SE PRN Conference Held November 2-14, 2010

C O L U M N S

4 President’s Message

7 Editorial

11VIP Day Save the DateFebruary 23, 2011

Departments8 Pharm PAC 2010-201112 GPhA New Members31 GPhA Board of Directors

Advertisers2 The Insurance Trust2 Principal Financial Group7 PharmAssist Recovery Network5 Display Options, Inc.6 GPhA Career Center9 Logix, Inc.9 Michael T. Tarrant9 Toliver & Gainer10 Pharmacists Mutual Companies12 Melvin Goldstein, P.C.13 Sparkfly14 GoToMeeting/GoToWebinar17 Caribbean CPE Cruise18 GPhA Workers Compensation20 AIP32 The Insurance Trust

For an up-to-date calendarof events, log ontowww.gpha.org.

P R E S I D E N T ’ S M E S S A G E


By the time this publication hits the street, most of uswill have had ample time to break our new year’sresolutions. That being out of the way, we can get

on to more important business, like planning for the NewYear (we can always worry about losing that extra weightanother time, anyway, right?) There is always somethingrefreshing about the prospects of what may lie ahead whenthe calendar rolls over for yet another year. What newchallenges will create even greater opportunities? How weview the challenges will determine how we will respond.Irving Berlin said this about challenge: “The toughestthing about success is that you’ve got to keep on being asuccess.”

Before having the privilege of serving on the GPhAExecutive Committee, I had always heard it said thatGPhA was a leader among state pharmacy associations.Since that time, I have come to understand and appreciatethat this not just self-indulgent puffing up by our own, it istrue. There are many reasons for the success we haveenjoyed over the years, and much of that is owed to theresponse to challenge. The biggest challenge facingassociations today is dwindling membership. This is whyour five year strategic plan focuses first on membership.

So how do you go about increasing your membership inan environment where most associations are going in theopposite direction? I like this quote from Mark Twain,“The secret of getting ahead is getting started. The secret

of getting started is breaking your complex overwhelmingtasks into small manageable tasks, and then starting on thefirst one.” This quote exemplifies what has occurred sinceyour Board of Directors approved the five year strategicplan last year. We started with a list of directives formembership and advocacy and broke them down intomanageable tasks, beginning with redesigning our website,offering more member benefits (starting with freemembership to Sparkfly), and personally challenging allboard members to recruit at least three new members thisyear. These tasks will be evaluated each time there is ameeting, and new tasks will be identified and assigned tomeet the challenges of our strategic plan.

On the advocacy side of our plan, we have enjoyed somemajor successes the past two years, but keeping on being asuccess is not easy. It requires everyone pitching in. Thisis so critical in meeting the objectives set forth foradvocacy for the next five years. Making timely calls to ourelected representatives and participating in the politicalprocess through the giving of time and resources arecrucial to our success. I hope you will participate throughgiving to Pharm PAC, through being a personal advocatefor our profession, through developing relationships withyour elected officials, and participating in our politicalevents, such as VIP day on February 23 at the train depotdowntown. I hope you will go ahead and mark yourcalendar to be there. Here’s to our continued success!

Dale M. Coker, R.Ph., FIACPGPhA President

The Toughest Thing About

Success...

The secret of getting ahead is getting started. The secret of getting started is breaking yourcomplex overwhelming tasks into small manageable tasks, and then starting on the first one.

Andy FreemanGPhA Director of Government Affairs

5The Georgia Pharmacy Journal January 2011

G P H A S T A F F N E W S

Maggie PattersonGPhA Director of ContinuingEducation and Governance

Welcome New GPhA Staff Members

Caroline FieldsGPhA Director of Conferences and Events

Tei MuhammadGPhA Member Service Coordinator

Mr. Andy Freeman joins us as our Director of Government Affairs. Beforejoining GPhA, Mr. Freeman ran his own successful Governmental Affairsand Political Consulting Company. Although he has represented a diverse

group of clients before the Georgia General Assembly, Mr. Freeman began tospecialize in health care after his kidneys shut down in 2004 and receiving atransplant in 2006. Andy has been recognized by Georgia Trend Magazine in theirForty Under 40 list of the best and brightest Georgians in politics and business. Helives in Powder Springs with his wife and 2-year-old son.

Ms. Maggie Patterson is a native Georgian who holds a B.S. in Middle GradesEducation and Masters of Education in Leadership and Policy, both fromthe University of Georgia. Following school Ms. Patterson taught seventh

grade science in Gwinnett and Cobb Counties. With a relocation of her family toMemphis, Tennessee she was presented with the opportunity to enter the field ofassociation management and served as the Executive Director of the ApartmentAssociation of Greater Memphis for over four years. Ms. Patterson is thrilled to beback in Georgia and enjoys running, reading, and spending time with her husbandand daughter in her spare time.

Ms. Caroline Fields comes to us from Columbia, South Carolina and is agraduate of the University of South Carolina with a B.A. in Journalism &Mass Communications. Prior to relocating to Atlanta, Ms. Fields worked

at Capitol Consultants, Inc. (a lobbying and association management firm) where shemanaged multiple professional/trade associations. She also previously worked at theSouth Carolina Pharmacy Association in public affairs back in 2007 under theleadership of Jim Bracewell. In addition to her association management experience,Ms. Fields has also worked in sales and marketing. In her free time, she enjoyscooking, reading, spending time with friends and family, and traveling. And as a SCnative, she loves to pull for the Carolina Gamecocks!

Ms. Tei Muhammad is a native of Boston, Massachusetts and completedher undergraduate studies here at Clark Atlanta University. Her love forthe not-for-profit industry started at the age of 16. Since then, she has

played an intricate role in membership development, sustainability and liaises formission based organizations and trade associations. Ms. Muhammad has joinedthe GPhA team with a commitment to understand, support, and fulfill the needsof its members in any way she can. She currently resides in Covington, with hermost important love her beautiful daughter Giselle.

Find the best jobs and highly qualified pharmacists Georgia has to offer.

SUPPORTING PHARMACISTS.ADVANCING CAREERS.

Career Center

Members Save 20% on Job Postings

Use code MEMDIS001

www.gpha.org/jobs

Those words are perhaps some of the saddest wordsin Dickens’ “A Christmas Carol.” But, we read thatScrooge asks the Spirit if these things in the future

have to be, and the answer is that it will be the future if noone intervened.

Next month, on Wednesday, February 23, 2010, at theGeorgia Freight Depot, across the street from our StateCapitol, the GPhA will host our annual VIP Day at theCapitol in a new and improved format.

Your state legislator will be invited to come and enjoy abrief sit down breakfast with you at a reserved table for thatlegislator and the pharmacists from that House or SenateDistrict.

The most important question is, will the seat for thepharmacist from that district be empty or will you be thereto cultivate that important relationship between you andyour legislator?

What you say that morning to your representative will beheard and it will be important to that legislator and to yourprofession.

What you say with your empty seat will overshadow all yourGPhA legislative staff can do all year to advocate for yourprofession.

One Day + One Breakfast + One Legislator + Pharmacists= Legislative Success

A simple formula for success, but one that only you cancompound.

Your association has raised the money, reserved the room,paid for breakfast, and saved the morning for a great dayfor the pharmacy profession in Georgia.

I look forward to seeing you there at the best legislative dayever for pharmacy.

Register today at www.gpha.org. Your registrationguarantees you food and a name tag at this event.

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 / CEO


At the Table There Was an

Empty Seat...

PharmAssist Recovery NetworkThe PharmAssist Network continuesto provide advocacy, intervention and

assistance to the impairedpractitioners, students and techniciansin the state. If you or anyone youknow needs assistance, please call the

hotline number:

PharmAssist Hotline Number(24 hours / 7 days a week)

404-362-8185(All calls are confidential)


Titanium Level($2400 minimum pledge)Patrick Dunham, R.Ph.Michael E. Farmer, R.Ph.David Graves, R.Ph.Ann Hansford, R.Ph.Jeffrey L. Lurey, R.Ph.Robert A. Ledbetter, R.Ph.Marvin O. McCord, III, R.Ph.Judson L. Mullican, R.Ph.W.A. (Bill) Murray, R.Ph.Mark L. Parris, Pharm.D.Fred F. Sharpe, R.Ph.Jeff Sikes, R.Ph.

Platinum Level($1200 minimum pledge)Robert Bowles, Jr., R.Ph., CDM, CftsT.M. Bridges, R.Ph.Bruce L. Broadrick, Sr., R.Ph.Thomas E. Bryan, Jr., B.S.William G. Cagle, Jr., R.Ph.Keith Chapman, R.Ph.Hugh M. Chancy, R.Ph.Dale M. Coker, R.Ph., FIACPJ. Ashley Dukes, R.Ph.Stewart Flanagin, Jr., R.Ph.Martin T. Grizzard, R.Ph.Robert M. Hatton, Pharm.D.Alan M. Jones, R.Ph.Ira Katz, R.Ph.Harold M. Kemp, Pharm.D.Brandall S. Lovvorn, Pharm.D.Eddie M. Madden, R.Ph.

Jonathan Marquess, Pharm.D., CDE, CPTPam S. Marquess, Pharm.D.Kenneth A McCarthy, R.Ph.Scott Meeks, R.Ph.Drew Miller, R.Ph., CDMLaird Miller, R.Ph.Jay Mosley, R.Ph.Wallace Allen Partridge, Jr.Tim Short, R.Ph.Christopher Thurmond, R.Ph.

Gold Level($600 minimum pledge)James Bartling, Pharm.D., ADA, CAC IILiza G. Chapman, Pharm.D.Patrick M. Cook, Pharm.D.Mahlon Davidson, R.Ph., CDMJim Elrod, R.Ph.H. Neal Florence, R.Ph.J.Thomas Lindsey, R.Ph.Robert B. Moody, III, R.Ph.Sherri S. Moody, Pharm.D.Sharon M. Sherrer, Pharm.D.Michael T. TarrantJeffrey Richardson, R.Ph.Robert Anderson Rogers, R.Ph.Daniel C. Royal, R.Ph.Dean Stone, R.Ph., CDMThomas H. Whitworth, R.Ph., CDM

Silver Level($300 minimum pledge)Renee D. Adamson, Pharm.D.John L. Colvard, J. R.Ph.Chandler Conner, R.Ph.

F. Al Dixon, R.Ph.Jack Dunn, R.Ph.Marshall L. Frost, Pharm.D.Michael O. Iteogu, Pharm.D.Willie O. Latch, R.Ph.William J. McLeer, Sr., R.Ph.Kalen Beauchamp Porter, Pharm.D.Edward Franklin Reynolds, R.Ph.Houston L. Rogers, Jr., Pharm.D., CDMBrandon UllrichAlan M. Voges, Sr., R.Ph.Flynn W. Warren, M.S., R.Ph.Oliver C. Whipple, R.Ph.Walter Alan White, R.Ph.

Bronze Level($150 minimum pledge)Monica M. Ali-Warren, R.Ph.James R. Brown, R.Ph.Mark C. Cooper, R.Ph.Michael A. Crooks, Pharm.D.Charles Alan Earnest, R.Ph.Amanda R. Gaddy, R.Ph.Amy S. Galloway, R.Ph.Johnathan Hamrick, R.Ph.William E. Lee, R.Ph.Earl Marbut, R.Ph.Richard Brian Smith, R.Ph.Sharon B. Zerillo, R.Ph.

Members(no minimum pledge)Jill AugustineClaude W. Bates, B.S.Chad J. Brown, R.Ph.Max C. Brown, R.Ph.Lucinda F. Burroughs, R.Ph.Waymon M. Cannon, R.Ph.Walter A. Clark, Jr., R.Ph.

Pharm PAC Enrollment

Pledge Year 2010-2011

If you made a gift or pledge to Pharm PAC and your name does not appear above please, contact Kelly J. McLendon [email protected] or 404-419-8116.. Donations made Pharm PAC are not considered charitable donations and arenot tax deductible.


Lawyer and Pharmacist Leroy Toliver, Pharm.D., R.Ph., J.D.

• Professional LicensureDisciplinary Proceedings• Medicaid Recoupment Defense• Challenges in Medicaid Audits• OIG List Problems• SCX or Other Audits

Leroy Toliver has been a Georgia RegisteredPharmacist for 38 years. He has been a practicingattorney for 29 years and has represented numerouspharmacists and pharmacies in all types of cases.Collectively, he has saved his clients millions of

dollars.

Toliver and Gainer,LLP

942 Green Street, SWConyers, GA [email protected]

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An Independent Financial Planner since 1992

Focusing on Pharmacy since 2002

Securities, certain advisory services and insurance products are offered through INVEST Financial Corporation

(INVEST), member FINRA/SIPC, a federally registered Investment Adviser, and affiliated insurance agencies.

INVEST is not affiliated with Financial Network Associates, Inc. Other advisory services may be offered through

Financial Network Associates, Inc., a registered investment adviser.

Pharm PAC Contributors’ List ContinuedJean N. Courson, R.Ph.Carleton C. Crabill, R.Ph.Alton D. Greenway, R.Ph.J. Clarence Jackson, Jr., R.Ph.Gina R. Johnson, Pharm.D., BCPS, CDEAshley S. LondonTracie D. Lunde, Pharm.D.Randall Marett, R.Ph.Ralph K. Marett, M.S.

Whitney B. Pickett, Pharm.D.Rose Ann Pinkstaff, R.Ph.Michael Reagan, R.Ph.Leonard Franklin Reynolds, III, R.Ph.James Riggs, R.Ph.Victor Serafy, R.Ph.Harry A. Shurley, Jr., R.Ph.James Strickland, R.Ph.Leonard Templeton, R.Ph.

James. E. Stowe, Jr., R.Ph.William D. Whitaker, R.Ph.Jonathon A. Williams, Pharm.D.Michael R. Williams, R.Ph.

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

Pharmacy School Student MembersDebbra Bodah, Lawrenceville

Robert Boswell, RoswellLinh Cao, Morrow

Holly Lynn Dunham, MLT, AtlantaJoshua Ryan Erisman, Lawrenceville

Brett Hall, AthensYannolis Hernandez, Atlanta

Michael Kim, DuluthSy Le, LawrencevilleDavid Luc, Lilburn

Allison Renee’ Roehrs, B.S., LawrencevilleJohnny Sayarath, JonesboroKristina Yacob, Marietta

Individual Pharmacist MembersMartha M. Cardoso, R.Ph., CummingRonald B. Johnson, R.Ph., LithoniaGeorge C. Sanders, R.Ph., Toccoa

Nekia L. Austin, J.D., Pharm.D., FairburnHugh B. Cromer R.Ph., ForsythGary A. Payton, R.Ph., Suwanee

Tracey D. Martin, Pharm.D., Trion

First Year Graduate MembersJonathan Hamrick, Pharm.D., Atlanta

Amanda McCall, Pharm.D., Jefferson City, TNAdam Schnepp, Pharm.D., Chamblee

Retired MembersBenjamin W. Knight, R.Ph., Savannah

Joint MembershipMeredith C. Peckel, Pharm.D., Evans

Associate MembersMelissa Bishop-Murphy, J.D., MBA,

Washington, D.C.Jack S. Tonge, O.D., Winder

Welcome to GPhA!The following is a list of new members who have joined Georgia’s premier

professional pharmacy association!

The Georgia Pharmacy Journal December 201013

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Mercer University alumnus Herbert W. Hatton,R.Ph., received the Dean’s Award on Oct. 28 fromDr. H.W. “Ted” Matthews, dean of Mercer’s

College of Pharmacy and Health Sciences. The award was givenduring the College’s annual Honors Luncheon held onMercer’s Cecil B. Day Graduate and Professional Campus inAtlanta. The Dean’s Award annually recognizes an individualwho has contributed to the enhancement of the College as wellas the pharmacy profession.

Hatton, a 1967 graduate of the College, is a long-time residentof Carrollton and currently serves as pharmacy manager withPublix Super Markets. He is the immediate past president of theCollege of Pharmacy and Health Sciences Alumni Associationand now serves on the board of directors. In 2000, heestablished the Harriet Jean Hatton Endowed Scholarship inhonor of his sister, which is now the eighth-largest scholarshipat the College. Additionally, Hatton has been recognized for hismentoring and support of pharmacy students’ organizationaland professional efforts.

“The dedication he has shown to his profession is paralleled inhis commitment to his alma mater,” Dean Matthews saidduring the ceremony. “He is always on the lookout for youngpeople who would make outstanding pharmacists and is one ofthe most active and dedicated recruiters for the College.”


GPhA Member, Herbert Hatton, R.Ph., Receives Mercer

University Dean’s Award


GPhA Member, H. Truitt Smith, R.Ph., Passes Away

H. Truitt Smith, Jr., age 66, of Cornelia, Georgia passedaway on Wednesday, December 1, 2010.

Mr. Smith was born in Newnan, Georgia on March 20, 1944, tothe late Henry Truitt, Sr. and Mary Ruby Hicks Smith. He wasalso preceded in death by his sister, Bebe Thornton. Mr. Smithwas a Graduate of UGA receiving his Bachelors Degree inPharmacy. Mr. Smith was a United States Navy Veteran,serving during the Vietnam Conflict as a hospital corpsman. Heowned and operated Arnold Drug Company since 1983. Mr.Smith was an active member of the Georgia PharmacyAssociation and had served on the board of directors with theAcademy of Independent Pharmacy. He loved people, enjoyedbeing with his family, and was an avid follower of collegefootball. Mr. Smith was a lifelong stamp collector and a memberof the American Philatelic Society. He was a member of FirstBaptist Church of Dallas, Georgia where he had served as a

deacon and SundaySchool Teacher.

Survivors include his wife,Marianne Jackson Smith,Cornelia, GA; daughterand son-in-law, Melissaand Stacy Nichols,Winamac, Indiana;daughter, Jennifer SmithChastain, Mt. Airy, GA;son and daughter-in-law,James Truitt and TraceySmith, Woodstock, GA; and 11 grandchildren, Katie, Meredith,Sarah, Susanna, Gabby, Sam, Carrie Jane, and Mary HannahNichols, and Bobby, Luke, and Jonathan Powell.


Barney's Pharmacy in south Augusta prides itself onpatient interaction. Its focus on improving patient healththrough classes and individual attention has helped it

expand and attracted national attention.

This week, it also brought in visitors from half a world away tostudy the pharmacy's operations and programs.

A five-member group from Singapore pharmacy chain NTUCHealthcare visited Augusta, meeting with Barney's employeesand touring chain pharmacies such as Walgreens, Walmart andKroger.

"We have always had this dream of building a relationship withcustomers," said Chan Yiam Moi, NTUC's general manager ofthe 46-store chain. "Hopefully, we will bring back ideas and puttogether an action plan."

The Singapore group first heard about Barney's Pharmacy froman August New York Times article that highlighted the Augustabusiness's use of diabetes-management classes to engagepatients and improve health.

Those classes and other tools help Barney's Pharmacy reachpatients better, said owner Barry Bryant.

As part of the diabetes-management classes, known as "TheSweet Spot" courses, patients meet with diabetes educators atthe pharmacy who help them improve their diets and monitorblood sugar.

Chan said those classes resonated with her because 11 percentof her island nation has diabetes and many people don't knowhow to monitor their blood sugar levels properly.

"Diabetes affects such a large part of our population, here andaround the world," Bryant said.

Chan also said she liked the Barney's Pharmacy's ChampionsClub, which recognizes patients who have achieved theirdiabetes goals, and its weekly bingo games.

Pharmacies in Singapore and the U.S. have several keydifferences, Bryant said. Physicians also dispense medicine inthe southeast Asian country, so pharmacies mainly dispenseonly special medications that doctors don't stock. They alsohelp customers with herbs and vitamin supplements.

An independent pharmacy in the U.S. does most of its businessdispensing medicine, while a pharmacy in Singapore does mostof its business from products in the front of the store.

David Pope, a pharmacist and editor-in-chief of Barney'sPharmacy's educational Web site,www.creativepharmacist.com, said he hopes the Peach OrchardRoad business can continue to give feedback to NTUC'spharmacists after they return to Asia.

"We like to offer education wherever we can," he said.

Augusta Pharmacy is International ModelBy Erin Zureick Augusta Chronicle on December 7, 2010


UGA College of Pharmacy Team Ranked 4th in National

Competition

Two fourth-year students from the University of GeorgiaCollege of Pharmacy won Fourth Place at the 15thNational Clinical Skills Competition held this month

during the American Society of Health-System Pharmacist’s45th Midyear Clinical Meeting. Melissa Mahoney and JettaSartwell were able the compete against 108 other teams bywinning the preliminary competition held at the College.

During the national competition, which administered byASHP’s Pharmacy Student Forum and sponsored by the ASHPResearch and Education Foundation, students demonstrated

their skills by assessing patient information and current therapy,identifying and prioritizing drug therapy problems, identifyingtreatment goals, and recommending a pharmacist’s care plan.Other activities for pharmacy students included sessions oncareer planning, pursuing residency training, and opportunitiesfor involvement in ASHP and the ASHP Foundation’sPharmacy Practice Model Initiative.

In the College’s Clinical Skills Competition, Casey Allen-Hayesand Kim Ward took Second Place and Jake Galdo and ClarkLee placed Third.

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You are a future leader in pharmacy and understand thecontributions pharmacists can make to the future ofhealth care. You want to build a career beyond what is

currently available to you. You want a non-traditional, excitingjob with a limitless future, but you don’t want to leavepharmacy. Do you want to learn from, and be mentored byleaders in health care? The National Alliance of State PharmacyAssociations (NASPA) Executive Residency in AssociationManagement is the catalyst to jumpstart your career.

• You will learn first-hand how to lead an association duringone of the most tumultuous times in the history of Americanhealth care.• You will gain important skills that will help you be successfulin any setting.• During your tenure as the NASPA Executive Resident, youwill interact with influential leaders from national and statepharmacy associations, other provider and advocacyorganizations, government agencies, pharmaceuticalmanufacturers, and academia.• You will be exposed to and become well-versed in the mostpressing health care issues of the day.• You won’t read about it, you’ll be about it!

The NASPA Executive Residency offers opportunitiesunattainable elsewhere:• Launch your association and regulatory/policy career with asolid year of intense, hands-on training from the organization’stop executives.• Get an inside perspective into the mechanics of administeringan association.

o Budgets, Procedures, Consensus-building, Teamwork

• Surround yourself with, and learn from pharmacy’s foremostthought leaders in the nation.• Sharpen your communication and interpersonal skills.• Make valuable contacts that will last a lifetime.

Typical Resident Activities:• Get exposure to national issues as well at state and localissues.• Work on projects that transition the profession to the JCPP2015 Vision, with a focus on adherence, quality, and outcomes.• Work on safety and quality initiatives with the Alliance forPatient Medication Safety and Pharmacy Quality Alliance• Represent NASPA at various state and national meetings.• Manage ongoing state association projects (such as

Adherence Discovery Projects).• Create and edit a monthly newsletter.• Develop grant concepts and applications.• Network with other state/national executive residents• Be a resource-developer for the nation’s state pharmacyassociations.• Have the flexibility to tailor your experience to stateassociation management or public policy.• Work with state pharmacy executives who are knowledgeable,caring, supportive, and fun!

All applications must include the following:• A cover letter explaining your career goals and reason forinterest in the executive residency.• A résumé/curriculum vitae describing your work andprofessional experience.• Two letters of recommendation from the following: Statepharmacy association executive, faculty member, dean, recentemployer, or pharmacy mentor, one of which must be a statepharmacy association member.• An official copy of your most recent transcript from yourschool/college of pharmacy.

Mail applications to:National Alliance of State Pharmacy AssociationsExecutive Residency Selection Committee2530 Professional Road, Suite 202Richmond, VA 23235

Applications will be reviewed beginning January 15th, 2011.Select candidates will be granted a personal interview, whichwill be scheduled starting in February of 2011. The positionmay be filled at any time once the interview process begins.

Any interested candidate is encouraged to contact NASPAprior to applying to determine whether the position hasbeen filled.

For more information please contact:Jessica Baugh, Pharm. D.NASPA Executive Resident2530 Professional Road, Suite 202Richmond, VA 23235(804) 285-4431E-mail: [email protected]

Find out more about NASPA at www.naspa.us

National Alliance of State Pharmacy Associations 2011-

2012 Executive Residency

P H A R M A C Y I N D U S T R Y N E W S

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Goals.The goals of this article are to provide anoverview of pulmonary arterialhypertension, its pathophysiology, clinicalpresentation, diagnosis, and management,and to highlight the pharmacist’s role inthe management of this disease state.

Objectives.At the conclusion of this article, successfulparticipants should be able to:1) Define pulmonary arterialhypertension (PAH) and describe itspathophysiology. 2) Identify the signs, symptoms anddiagnostic tests utilized in the assessmentof PAH.3) Identify and describe thenonpharmacologic and pharmacologicmanagement of PAH.4) Determine appropriatepharmacotherapy and monitoringparameters for patients with PAH basedon WHO functional classification.

Introduction

Pulmonary arterial hypertension (PAH) isa disease state with an estimatedprevalence of about 15 cases per millionbased on recent evidence from a Frenchregistry.1 With modern therapy, theprognosis of PAH is poor with anapproximately 15 percent one yearmortality rate.2 PAH is a complexmultidisciplinary disorder and recentadvances in this field have led to newtherapies3 and with these, an increasedrole for pharmacists to aid in medicationtherapy management and patienteducation.

Pulmonary hypertension is the presenceof abnormally high pressures within thepulmonary vasculature and consists ofseveral subtypes, one of which is PAH.3

Table 1 highlights the World HealthOrganization (WHO) classification ofpulmonary hypertension.4 PAH occursdue to restricted blood flow through thepulmonary arterial circulation which leadsto increased pulmonary vascularresistance and eventually right heart

failure.3,5 Hemodynamically, PAH isdefined as a mean pulmonary arterypressure (mPAP) of 25 mmHg or greaterat rest with a pulmonary capillary wedgepressure (PCWP) of 15 mmHg or lessand a pulmonary vascular resistance ofgreater than 3 Wood units.6 A normalresting mPAP value is between 8 to 20mmHg.7 The pulmonary capillary wedgepressure (PCWP) is an estimation of theleft atrial pressure with a normal value of< 12 mmHg, while the pulmonaryvascular resistance (PVR) is the resistanceto the flow of blood offered by thepulmonary vessels.8

In a recent French registry, about half ofthe cases of PAH were either idiopathicPAH (no identifiable cause), heritablePAH (linked to a familial context) oranorexigen associated PAH, while theother half were associated with variousdisease states such as connective tissuediseases, congenital heart disease, portalhypertension, and HIV-associated PAH.1

Idiopathic pulmonary arterial

Continuing Education for PharmacistsManagement of Pulmonary Arterial HypertensionAngela O. Shogbon, PharmD, BCPSClinical Assistant Professor, Mercer University College of Pharmacy and Health Sciences


hypertension (IPAH) is the mostcommon type of PAH and affects morefemales than males with a ratio of about1.7:1 and a mean age at diagnosis of about37 years.9 However, more recent datasuggests that the incidence might beincreasing in older patients greater than70 years old.10 Heritable PAH (HPAH)has a hereditary component with about 50to 90 percent of patients with mutationsin the transforming growth factor betareceptor pathway, bone morphogenicprotein receptor-2 (BMPR2) which canlead to endothelial dysfunction.3 Drug andtoxins have also been associated withPAH with definite associations found withuse of toxic rapeseed oil and the appetitesuppressants aminorex, fenfluramine anddexfenfluramine.4 These anorexigens areno longer available in the United States.4

Likely associations have been reportedwith amphetamines, L-tryptophan andmethamphetamines and other possiblerisk factors are cocaine,phenylpropanolamine, St. John’s Wort,chemotherapeutic agents and the selectiveserotonin reuptake inhibitors.4

Pause and Reflect: What is PAH anddescribe its pathophysiology?

PathophysiologyPAH occurs as a result of changes in thestructure and function of the pulmonaryvasculature which leads to increasedpulmonary vascular resistance andeventually right heart failure.11 The causeof these changes has been proposed to bea multi-hit model such that patients havea predisposing state (e.g. geneticabnormalities) along with other genetic orenvironmental risk factors or comorbiditythat leads to the development of PAH.12

Multiple mechanisms are involved in thepathophysiology of PAH includingendothelial cell dysfunction, vascularconstriction, loss of relaxing factors,cellular proliferation, procoagulant stateand inflammation.13 In PAH levels ofendothelin-1 (ET-1), and thromboxaneA2 are increased and these substances arevasoconstrictors and promote smoothmuscle cell proliferation.14,15 In addition,thromboxane A2 promotes platelet

activation.3 On the other hand, the levelsof vasodilators such as prostacyclin(PGI2) and nitric oxide (NO) aredecreased and these agents possessantiproliferative properties and inhibitplatelet activation.3,14 The effects of NOare mediated by the production of cyclicguanosine monophosphate (cGMP)whose production is inhibited byphosphodiesterase type 5 enzymes.3

These changes leads to endothelialdysfunction in PAH. There is also aprocoagulant state in PAH with elevatedlevels of fibrinopeptide A, plasminogenactivator inhibitor-1, thromboxane A2and decreased levels of tissueplasminogen activator, NO and PGI2.

3,14

Evaluation and Diagnosis of PAH Evaluation for PAH is initiated byobtaining a clinical history includingsymptoms, risk factors, family history,physical exam, electrocardiogram andchest x-ray.16 If there is a suspicion of PAHbased on these findings, anechocardiography with dopplerultrasound would be an appropriatenoninvasive screening test to provideestimates of the pulmonary arterypressure and to assess the structure andfunction of the heart. 16 However, the goldstandard test to confirm a diagnosis ofPAH is right heart catheterization whichinvolves insertion of a catheter throughthe right side of the heart and into thepulmonary artery to obtain a moreaccurate measure of the pulmonarypressures. 16 Other screening tests toidentify underlying etiologies of the PAHshould also be performed such as HIVserology, pulmonary function tests, andliver function tests, among others.3

Clinical Presentation of PAH The symptoms of PAH are typically dueto impaired transport of oxygen andreduction in cardiac output.16 Early stagesof PAH may be asymptomatic, howeverexertional dyspnea is the most frequentpresenting symptom. 16 Other symptomsinclude, fatigue, weakness, anginal chestpain or syncope, and dyspnea at rest withdisease progression. 16 Symptoms related

to disease progression leading to rightventricular dysfunction and tricuspidvalve regurgitation include: leg swelling,abdominal bloating and distension,anorexia, plethora, profound fatigue. 16

The WHO functional classification ofPAH16 is used to classify the severity ofpatient’s symptoms and is useful indetermination of initial treatment optionsbased on disease severity and used tofollow up response to therapy (Table 2).Objective signs of PAH include signs ofincreased pulmonary artery pressureheard by auscultation, signs of advancedisease due to right-sided heart failureincluding hepatojugular reflux, pulsatileliver, right ventricular S3 gallop, jugularvenous distension, peripheral edema, lowblood pressure, cool extremities.3

Pause and Reflect: Describe some of thesymptoms of PAH. List common diagnostictests used to assess PAH.

Goals of TherapyThe goals of therapy in the managementof PAH are to alleviate symptoms,enhance WHO functional class andexercise capacity which is objectivelymeasured by the 6-minute walk distancetest, cardiopulmonary exercise test, tolower mPAP and normalize cardiacoutput, prevent disease progression andto improve survival.3

Nonpharmacologic Management ofPAHThe nonpharmacologic management ofPAH includes lifestyle modificationswhich involves low level graded aerobicexercise such as walking as tolerated, anda low Na+ diet of less than 2.4 g/day.3 It isalso recommended to avoid pregnancydue to the hemodynamic fluctuations thatoccur during pregnancy, labor, deliveryand postpartum3 which may increase therisk of maternal mortality by 30 – 50percent.17 Effective methods of birthcontrol are therefore very important inwomen of child bearing age. Influenza andpneumococcal vaccines are alsorecommended.3 In addition, supplementaloxygen is recommended in patients with apreflight pulse oximetry saturation of lessthan 92 percent to prevent hypoxic


pulmonary vasoconstriction with highaltitudes.3

Pharmacologic Management of PAH All patients with PAH should be evaluatedfor indications for general careinterventions which include oralanticoagulants, diuretics, oxygen, anddigoxin. Patients with PAH have anincreased risk of thrombosis due to areduction in pulmonary blood flow,dilated right heart chamber, venous stasisand a sedentary lifestyle.18 Studies haveevaluated the benefits of oralanticoagulants in patients with IPAH,HPAH and PAH associated withanorexigens.19,20,21 In recent randomizedcontrolled trials, the highest prevalence ofuse of oral anticoagulants were noted inpatients with IPAH and HPAH.22

Currently, oral anticoagulation therapywith warfarin is recommended based onexpert consensus for patients with IPAHand HPAH. 22 The INR goalrecommended is 1.5-2.5.3 There is not asmuch data with other types of PAH, butanticoagulation is recommended in thesepatients with more advanced disease suchas those on continuous intravenousprostacyclin therapy.3 Diuretics areutilized in patients with decompensatedright heart failure and associated volumeoverload presenting as abdominal organcongestion, peripheral edema and ascitesfor symptomatic relief. 22 Oxygen isrecommended in appropriate patients tomaintain oxygen saturation > 90 percentin order to avoid the pulmonaryvasoconstriction associated with

hypoxemia.3 Use of digoxin is based onclinical judgment22 and can be consideredfor use in patients with right sided heartfailure and a reduced cardiac output, or toslow ventricular rate in patients withconcomitant atrial arrhythmias.3

Pause and Reflect: Explain thenonpharmacologic and pharmacologicmanagement of PAH.

Specific therapy for PAH includesmedications that target the pathways inthe pathophysiology of PAH including theprostacyclin pathway, the nitric oxidepathway, and the endothelin pathwaywith the use of synthetic prostacyclin andprostacyclin analogs, phosphodiesterasetype-5 inhibitors and endothelin-1receptor antagonists respectively.22

Calcium channel blockers are alsoeffective in patients with a positiveresponse to acute vasodilator testing. 22

Acute Vasodilator Testing is utilized todetermine patients that will be candidatesfor use of calcium channel blockers and isusually performed at the time ofdiagnostic right heart catheterization.3 Itinvolves the use of inhaled nitric oxide(iNO), intravenous epoprostenol, orintravenous adenosine. The use of iNO ispreferred and the other two agents areacceptable alternatives.3 Patient’s baselinehemodynamics are obtained, then thepatient is administer 20 – 40 ppm of iNOfor 5 min and then hemodynamics arerepeated while on iNO.3 A positiveresponse is defined as a 10 mmHg or

greater decrease in the mPAP to less than40 mmHg, without a decrease in cardiacoutput6. If mPAP is less than 40 mmHg atbaseline, then a positive response may beconsidered if there is a greater than 20percent decrease in mPAP with a normalcardiac output.3 Acute responsivenessidentifies patients with a better prognosis;responders are more likely to have asustained beneficial response to oralcalcium channel blockers than non-responders and the drug of choice forthese patients with a positive response isthe calcium channel blockers.3

Calcium Channel Blockers. This class of medications blocks the influxof extracellular Ca+ leading tovasodilation.23 They are indicated only inpatients with favorable response to acutevasodilator testing.3 Even though IPAHand anorexigen-induced PAH patients aremost likely to respond to acutevasodilators and CCBs, vasoreactivitytesting is recommended in all patientswith PAH.22 Common agents utilized arelong-acting nifedipine, amlodipine ordiltiazem.7 Short-acting nifedipine shouldbe avoided due to increased risk forhypotension.18 Nifedipine is initiated at 30mg/day to a maximum of 240 mg/day24

and diltiazem doses of 120 mg to amaximum of 900 mg/day25 may beutilized. Verapamil should be avoided dueto its negative inotropic effects.7 Responseto therapy should be assessed after 3months of therapy with a goal ofimprovement to WHO Functional Class Ior II.7 If not at goal, consider additional or


alternative PAH therapy.7

Phosphodiesterase-5 (PDE-5)Inhibitors The currently available PDE-5 inhibitorsstudied and utilized in the management ofPAH are sildenafil (Revatio®) and tadalafil(Adcirca®). These agents are potent andhighly specific PDE-5 inhibitors thatincrease cGMP levels leading tovasorelaxation and antiproliferative effectson vascular smooth muscle cells.23

Sildenafil has been shown to improvehemodynamics, WHO functional classand exercise capacity measured by the 6-minute walking distance test andhemodynamics.26,27 Tadalafil has also beenshown to increase the 6-minute walkdistance and the time to clinicalworsening in patients with PAH.28

Synthetic Prostacyclin andProstacyclin Analogs Prostacyclin is produced by endothelialcells and is a potent vasodilator of vascularbeds, inhibits platelet activation andpossesses cytoprotective andantiproliferative properties,23 however theproduction of prostacyclin is reduced inpatients with PAH.3 Syntheticprostacyclin and prostacyclin analogsavailable are epoprostenol (Flolan®),treprostinil (Remodulin®, Tyvaso®) andiloprost (Ilomedin®, Ventavis®), andberaprost, non-FDA approved.Epoprostenol and treprostinil can beadministered by continuous intravenousinfusion via a central venous catheter anduse may be complicated by infection.3

Epoprostenol has been shown to improvefunctional class, exercise tolerance,hemodynamics, and survival in IPAH.3,29 Itis administered via continuousintravenous infusion and has a very shorthalf-life of 2.7 min, hence interruptions inthe infusion should be avoided to preventpotentially life-threatening rebound PAHsymptoms.30 Patients should have anaddition infusion pump and IV infusionsets to circumvent this problem.30

Treprostinil has a longer half-life of 4.5hours and while interruptions in theinfusion should also be avoided, it is not

as life-threatening as with epoprostenoltherapy.31 Treprostinil has been shown toimprove hemodynamic parameters,symptoms, and exercise capacity inpatients with PAH.32,33 Inhaled iloprost hasan advantage in targeting the lungvasculature and not requiring intravenousinfusion, however, it requires frequentadministration of up to 9 times per day.18

Iloprost has been shown to improveWHO functional class and 6-minute walktest in patients with PAH.34

Endothelin Receptor AntagonistsThis class of medications blockendothelin receptors on vascularendothelium and smooth muscle leadingto a lowering of systemic vascularresistance, pulmonary vascular resistance& mPAP.23 Medications in this classinclude: bosentan (Tracleer®),ambrisentan (Letairis®). Bosentan andambrisentan are only available throughaccess programs which requires that onlythe pharmacies and prescribers registeredthrough Tracleer Access Program, forbosentan, or LETAIRIS Education andAccess Program, for ambrisentan, mayprescribe and distribute these medicationsand they are dispensed only to patientsenrolled in and who meet all therequirements of the respective accessprograms.35,36 Liver enzyme tests shouldbe performed at baseline and monthly inall patients on bosentan and ambrisentan.35,36 In addition, in women of child bearingage, a pregnancy test should be performedat baseline to exclude pregnancy and thenmonthly in these patients. 35,36 Women ofchild bearing age must use two reliableforms of contraception during treatmentand for one month after stopping therapy.35,36 Since bosentan and ambrisentan mayreduce the efficacy of hormonalcontraceptives, an alternative non-hormonal method must also be used.35,36

In addition to hepatotoxicity andteratogenicity, anemia is another adverseeffect that requires routine monitoringwith these agents. 35,36 Bosentan is a non-selective endothelin receptor antagonistthat has been shown to improvesymptoms, the 6-minute walking distance

test and the WHO functional class inpatients with PAH.37 Ambrisentan is aselective type-A endothelin-1 receptorantagonists that have been shown toimprove exercise tolerance, WHOfunctional class, hemodynamics andquality of life in patients with PAH.38,39

Sitaxsentan is another medication in thisclass that was approved in severalcountries outside of the United States,however, the manufacturer recentlyannounced the voluntary withdrawal ofsitaxsentan from countries in which it wasmarketed due to a potentially fatalidiosyncratic risk of liver injury differentfrom the known risk of heptotoxicity withthis class of medication.44

Monitoring TherapyPatients with advanced symptoms, rightheart failure, poor hemodynamics, onparenteral or combination therapy shouldbe followed up every 3 months or morefrequently as indicated.3 Other patients onoral therapy or less ill can be followed upevery 3 to 6 months. Monitoringparameters included assessment offunctional class, exercise capacityincluding the 6 minute walk distance test,and graded treadmill test.3

Combination Therapy Combination therapy is aimed to targetthe different pathophysiologic pathwaysinvolved in PAH and may be consideredin patients with inadequate clinicalresponse to monotherapy.3

Inadequate clinical response to medicaltherapy would warrant consideration ofother nonpharmacologic invasiveapproaches such pulmonarythromboendarterectomy, atrialseptostomy, and lung or heart and lungtransplantation.3

The treatment algorithm for managementof PAH has been provided in Figure 1.For a specific WHO Functional Class, anyof the medications listed as a preferredtherapy can be used, but drug selectionmay depend on specific patient factorsthat may limit use of a specific agent infavor of another.22 For the alternative


agents, they are listed in order of thestrength of the recommendation (e.g.medications under (a) are graded higherthan medications under (b). For patientswith WHO Functional Class IV PAHwithout a positive vasodilator test,intravenous epoprostenol is the drug ofchoice.22

Pharmacist’s can play an active role in themanagement of PAH by counselingpatients on appropriate use of

medications and their adverse effects,evaluate drug therapy for druginteractions and potentialcontraindications to therapy. Pharmacistsshould also counsel women of childbearing age on appropriate methods ofcontraception and can assist withmonitoring of appropriate laboratoryparameters and tests with use of specificagents. In addition, pharmacists can helpwith appropriate dose calculations andwork with physicians on appropriate drug

selections based on potentialcontraindications to therapy.

Pause and Reflect: Can I determineappropriate pharmacotherapy andmonitoring parameters for patients withPAH based on WHO functionalclassification?


References1.Humbert M, Sitbon O, Chaouat A. Pulmonary arterial hypertension in France. Am J Respir Crit Care Med. 2006;173:1023-1030.2.Thenappan T, Shah SJ, Rich S, et al. A USA-based registry for pulmonary arterial hypertension: 1982-2006. Eur Respir J. 2007;30:1103-10.3.McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension. J Am Coll Cardiol.2009;53:1573-619.4.Simonneau G, Robbins IM, Beghetti M, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2009;54:S43-54.5.Ghofrani HA, Barst RJ, Benza RL et al. Future perspectives for the treatment of pulmonary arterial hypertension. J Am Coll Cardiol. 2009;54:S108-17.6.Badesch DB, Abman SH, Simonneau G, et al. Medical therapy for pulmonary arterial hypertension: Updated ACCP evidence-based clinical practiceguidelines. Chest 2007;131:1917-1928.7.Badesch DB, Champion HC, Gomez Sanchez MA et al. Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol. 2009;54:S55-66.8. Parker Robert B, Rodgers Jo E, Cavallari Larisa H, “Chapter 16. Heart Failure” (Chapter). Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary R.Matzke, Barbara G. Wells, L. Michael Posey: Pharmacotherapy: A Pathophysiologic Approach, 7e: http://www.accesspharmacy.com.9.Rich S, Dantzker DR, Ayres SM et a. Primary pulmonary hypertension. A national prospective study. Ann Intern Med. 1987;107:216-23.10.Yigla M, Kramer MR, Bendayan D, et al. Unexplained severe pulmonary hypertension in the elderly: report on 14 patients. Isr Med Assoc J. 2004;6:78-81.11.Morrell NW, Adnot S, Archer SL. Cellular and molecular basis of pulmonary arterial hypertension. J Am Coll Cardiol. 2009;54:S20-31.12.Yuan JX, Rubin LJ. Pathogenesis of pulmonary arterial hypertension: the need for multiple hits. Circulation. 2005;111:534-8.13.Murali S. Pulmonary arterial hypertension. Curr Opin Crit Care. 2006;12:228-234.14.Christman BW, McPherson CD, Newman JH. An imbalance between the excretion of thromboxane and prostacyclin metabolites in pulmonaryhypertension. N Engl J Med 1992;327:70-5.15.Giad A, Yanagisawa M, Langleben D, et al. Expression of endothelin-1 in the lunds of patients with pulmonary hypertension. N Engl J Med.1993;328:1732-9.16.McGoon, M, Gutterman D, Steen V, et al. Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinicalpractice guidelines. Chest. 2004;126:14S-34S.17. Weiss BM, Zemp L, Seifert B, et al. Outcome of pulmonary vascular disease in pregnancy: a systematic overview from 1978 through 1996. J Am CollCardiol. 1998;31:1650-7.18.Hopkins, W and Rubin LJ. Treatment of pulmonary hypertension. Accessed at www.utdol.com, April 8, 2010.19.Rich S, Kaufmann E, Levy P. The effect of high doses of calcium-channel blockers on survival in primary pulmonary hypertension. N Engl J Med. 1992;327:76-81.20.Fuster V, Steele PM, Edwards WD, et al. Primary pulmonary hypertension: natural history and the importance of thrombosis. Circulation. 1984;70:580-7.21.Frank H, Mlczoch J, Huber K, et al. The effect of anticoagulant therapy in primary and anorectic drug-induced pulmonary hypertension. Chest.1997;112:714-21.22.Barst RJ, Gibbs SR, Ghofrani HA et al. Updated evidence-based treatment algorithm in pulmonary arterial hypertension. J Am Coll Cardiol.2009;54(1):S78-84.23.Talbert Robert L, Boudreaux Rebecca, Owens Rebecca L, “Chapter 30. Pulmonary Hypertension” (Chapter). Joseph T. DiPiro, Robert L. Talbert, GaryC. Yee, Gary R. Matzke, Barbara G. Wells, L. Michael Posey: Pharmacotherapy: A Pathophysiologic Approach, 7e:http://www.accesspharmacy.com/content.24. Lexicomp Online. Accessed at http://online.lexi.com, November 1, 2010.25.Micromedex Healthcare Series. Accessed at www-thomsonhc-com, September 28, 2010.26.Prasad S, Wilkinson J, Gatzoulis, MA. Sildenafil in primary pulmonary hypertension. N Engl J Med 2000;343:1342.27.Galie N, Ghofrani HA, Torbicki et al. Sildenafil citrate therapy for pulmonary arterial hypertension. N Engl J Med 2005;353:2148-57.28.Galie N, Brundage BH, Ghofrani HA et al. Tadalafil therapy for pulmonary arterial hypertension. Circulation 2009;119:2894-2903.29.Barst RJ, Rubin LJ, Long WA, et al. A comparison of continuous epoprostenol (Prostacyclin) with conventional therapy for primary pulmonaryhypertension. The Primary Pulmonary Hypertension Study Group. N Engl J Med. 1996;334:296-302.30.GlaxoSmithKline. Flolan (epoprostenol) package insert. Research Triangle Park, NC; 2008.31.United Therapeutics Corp. Remodulin (treprostinil) package insert. Research Triangle Park, NC; 2010.32.Tapson VF, Gomberg-Maitland M, McLaughlin VV et al. Safety and efficacy of IV. treprostinil for pulmonary arterial hypertension: a prospective,multicenter,, open-label, 12-week trial. Chest 2006;129-683-688.33.Simonneau G, Barst RJ, Galie N et al. Continuous subcutaneous infusion of treprostinil, a Prostacyclin analogue, in patients with pulmonary arterialhypertension: a double-blind, randomized, placebo-controlled trial. Am J Respir Crit Care Med. 2002;165:800-4.34.Olschewski H, Simonneau G, Galie N et al. Inhaled iloprost for severe pulmonary hypertension. N Engl J Med 2002;347:322.35.Actelion Pharmaceuticals. Tracleer (bosentan) package insert. South San Francisco, CA; 2009.36.Gilead Sciences. Letairis (ambrisentan) package insert. Foster City, CA; 2010.37.Rubin LJ, Badesch DB, Barst RJ et al. Bosentan therapy for pulmonary arterial hypertension. N Engl J Med 2002;346:896-903.38.Galie N, Badesch D, Oudiz R et al. Ambrisentan therapy for pulmonary arterial hypertension. J Am Coll Cardiol 2005;46:529-35.39.Galie N, Olschewski H, Oudiz RJ et al. Ambrisentan for the treatment of pulmonary arterial hypertension: results of the ambrisentan in pulmonaryarterial hypertension, randomized, double-blind, placebo-controlled, multicenter, efficacy (ARIES) study 1 and 2. Circulation 2008;117:3010-3019.40. United Therapeutics Corp. Tyvaso (treprostinil) package insert. Research Triangle Park, NC; 2009.41Actelion Pharmaceuticals. Ventavis (iloprost) package insert. South San Francisco, CA; 2010.42. Pfizer Laboratories. Revatio (sildenafil) package insert. New York, NY; 2009.43. Eli Lilly and Company. Adcirca (tadalafil) package insert. Indianapolis, IN; 2009.44. Pfixer. Pfizer stops clinical trials of Thelin and initiates voluntary product withdrawal in the interest of patient safety [press release]. December 10, 2010.

Medication Dosage Significant Drug Interactions Warnings/Contraindications Common AdverseEvents

Prostanoids30Epoprostenol,IV (Flolan®)

Continuous IV infusion:Initiate at 2 ng/kg/min, andtitrate dose every 15 min orlonger by 2 ng/kg/min untildose-limiting effectsobserved or tolerance limitobtained

All prostanoids: -May cause an additive dropin blood pressure with other anti-hypertensives and vasodilators; May increaserisk of bleeding when used with otherantiplatelets or anticoagulantsEpoprostenol: May increase levels of digoxin

Contraindicated with significant leftventricular; systolic dysfunction; Avoidabrupt withdrawal; interruptions in drugdelivery, or large dose reductions due torisk for rebound symptoms of pulmonaryhypertension ; Aseptic techniqueimportant to prevent catheter associatedinfections

Flushing, headache,nausea, vomiting,hypotension, jaw-pain,flu-like symptoms,anxiety/nervousness,diarrhea, pain andinfection at injection site

31Treprostinil,SC/IV(Remodulin®)

Continuous infusion:Initiate at 1.25 ng/kg/min(or 0.625 ng/kg/min if nottolerated); dose may beincreased by 1.25 ng/kg/minper week for the first 4 weeksof treatment, and later by 2.5ng/kg/min per week up to40 ng/kg/min.

All formulations of treprostinil: CYP2C8substrate; inhibitors (e.g. gemfibrozil) mayincrease levels and inducers (e.g. rifampin)may reduce levels

Avoid abrupt withdrawal or dosereduction, may result in worsening of PAHsymptoms.

SC – infusion site painand reaction (erythema,induration, rash)IV/SC - diarrhea, jawpain, edema,vasodilatation , nausea,headache

40Treprostinil, oralinhalation(Tyvaso®)

Oral inhalation:Initiate with 18 mcg (3breaths) inhaled 4 timesdaily while awakeTarget dose: 54 mcg (9breaths) inhaled 4 timesdaily

Safety and efficacy not established inpatients with significant underlying lungdisease (e.g., asthma or chronic obstructivepulmonary disease [COPD]).

Inhaled: cough andthroat irritation;headache,gastrointestinal effects,muscle, jaw or bonepain, flushing andsyncope.

41Iloprost, oralinhalation(Ventavis®)

Oral inhalation: Initiate with2.5 mcg/dose, if welltolerated, titrate to 5mcg/dose.Maintenance dose: 5mcg/dose 6 – 9 times per day whileawake with a minimum of 2hours between doses

May induce bronchospasm especially inpatients with a history of hyperactiveairways. Not evaluated with Ventavis hasnot been evaluated in patients withCOPD, severe asthma or acute pulmonaryinfections

Flushing, cough,headache, jaw spasm

EndothelinReceptorAntagonists (ERA)35Bosentan, oral(Tracleer®)

Oral: 62.5 mg po twice dailyx 4 weeks, then increase to125 mg twice daily. Body weight < 40 kg,maintenance dose is 62.5 mgpo bid.

All ERA: -Reduces efficacy of hormonalcontraceptivesBosentan: -CYP2C9 and CYP3A4 substrateand inducer; Decreases levels of CYP3A4metabolized statins-Rifampin alters bosentan levels, monitorliver function weekly x 4 weeks, thenmonthly; Use with ritonavir: discontinue 36hours prior to initiation of ritonavir and inpatients on ritonavir for at least 10 days,initiate bosentan at 62.5 mg once daily orevery other day

All ERA-Boxed Warnings: Dispensed onlythrough restricted distribution program:Tracleer Access Program (T.A.P) forbosentan and LEITARIS Education andAccess Program (LEAP) for ambrisentandue to risks of liver injury and birthdefects.

Bosentan: Contraindicated in pregnancy,with cyclosporine (marked increased inbosentan concentrations) and withglyburide (increased risk of liver enzymeelevations)

Respiratory tractinfections, anemia,edema, hepatotoxicity

36Ambrisentan(Letairis®)

Initiate at 5 mg po once dailyand may increase to 10 mgpo once daily as tolerated.

Dose limited to 5 mg daily when used withcyclosporine due to up to 2-fold increase inambrisentan levels

Peripheral edema, nasalcongestion, anemia,hepatotoxicity

PhosphodiesteraseType-5 (PDE-5)Inhibitors42Sildenafil, oral,IV(Revatio®)

Oral: 20 mg three times aday, approximately 4-6 hoursapartIV bolus (used temporarily ifunable to take oralformulation): 10 mg three times a day

All PDE-5 Inhibitors: Use with caution withalpha-blockers due to potential for additiveblood pressure lowering Sildenafil: Major CYP3A4 substrate: Avoidconcomitant use with ritonavir and otherpotent CYP3A4 inhibitors

All PDE-5 Inhibitors: -Contraindicated inconcomitant use with organic nitrates dueto increased hypotensive effects-Seek immediate medical attention ifsudden loss of vision occurs or withsudden decrease or loss of hearing

Epistaxis, headache,dyspepsia, flushing,insomnia,erythema, dyspnea, andrhinitis

43Tadalafil(Adcrica®)

Oral: 40 mg once daily Tadalafil: Major CYP3A4 substrate. -Discontinue Tadalafil at least 24 hours prior toinitiation of ritonavir and resume at 20 mg oncedaily after at least one week after initiatingritonavir. May increase doe to 40 mg po dailybased on tolerabilit y. Avoid concomitant usewith other potent inhibitors of CYP3A4 such asketoconazole and with chronic use of potentinducers of CYP3A such as rifampin

Headache, myalgia,nasopharyngitis,flushing


Continuing Education for PharmacistsQuiz and Evaluation Management of Pulmonary Arterial Hypertension

1. Which of the following substances involved in thepathophysiology of PAH are increased in patients withthis disease?

a. Nitric oxideb. Endothelinc. Prostacyclind. Tissue plasminogen activator

2. Select the agent from the list that has been found tohave a definite association with causing PAH.

a. Fenfluramineb. Estrogenc. Amitriptyllined.Cigarette smoking

3. Which of the following is the gold standard test forconfirming a diagnosis of PAH?

a. Echocardiographyb. Electrocardiogramc. Right heart catheterizationd. Chest X-ray

4. All of the following are non-pharmacologic measuresrecommended in patients with PAH EXCEPT?

a. Avoiding pregnancyb. Hepatitis B vaccinec. Low graded aerobic exercised. Low Na+ diet < 2.4 g/day

5. Which of the following are general measuresrecommended in appropriate patients with PAH?

a. Warfarin anticoagulationb. Oxygen therapyc. Diureticsd. All of the above

6. Which of the following is drug of choice in a patientwith a positive vasodilator test response?

a. Sildenafilb. Amlodipinec. Bosentand. Iloprost

7. Which of the following is the most appropriate drug ofchoice in a patient with WHO Functional Class IV PAH?

a. Bosentanb. Inhaled iloprostc. Intravenous epoprostenold. Sildenafil

8. How often should liver enzyme tests be monitored inpatients on bosentan therapy?

a. Weeklyb. Monthlyc. Every 3 monthsd. Every 6 months

9. BJ is a 35 year old female with a recent diagnosis ofClass II IPAH with a negative vasodilator test response.The physician has decided to begin medication therapy inBJ. BJ has no significant PMH and only takes loestrin 1 podialy for contraception. Which of the following would bethe most appropriate initial option?

a. Diltiazemb. Bosentanc. Sildenafild. Intravenous epoprostenol

10. Which of the following medications is contraindicatedin a patient on tadalafil therapy?

a. Doxazosinb. Isosorbide mononitratec. Epoprostenold. Bosentan


J o u r n a l C P E A n s w e r S h e e t

The Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a providerof continuing pharmacy education. No financial support was received for this activity.

Management of Pulmonary Arterial HypertensionThis lesson is a knowledge-based CPE activity and is targeted to pharmacists.GPhA code: J11-1ACPE#: 0142-0000-10-0112-H01-PContact Hours: 1.0 (0.10 CEU)Release Date: 01/01/2011Expiration Date: 01/01/20131. Select one correct answer per question and circle the appropriate letter below using blue or black ink (no red ink or pencil.)2. Members submit $4.00, Non-members must include $10.00 to cover the cost of grading and issuing statements of credit/Please send check or money order only. Note: GPhA members will receive priority in processing CE. Statements of credit forGPhA members will be emailed or mailed within four weeks of receipt of the course quiz.

1. A B C D 6. A B C D2. A B C D 7. A B C D3. A B C D 8. A B C D4. A B C D 9. A B C D5. A B C D 10. A B C D

Activity Evaluation: must be completed for creditPlease rate the following items on a scale from 1 (poor) to 5 (excellent)as to how well the activity:

1. Relates to pharmacy practice: 1 2 3 4 5 2. Met my educational needs: 1 2 3 4 5 3. Achieves the stated learning objectives: 1 2 3 4 5 4. Faculty presented the information: 1 2 3 4 5 5. Made use of the educational material (article): 1 2 3 4 56. Teaching methods conveyed information (tables, figures, boxes): 1 2 3 4 5 7. Post-test aided in assessing my grasp of the information: 1 2 3 4 5 8. Met my expectations: 1 2 3 4 57. Avoided any bias: 1 2 3 4 5 8. How long did it take to complete this activity? _______________________

A passing grade of 70% is required for each examination. A person who fails the exam may resubmit the quiz only onceat no additional charge.

Please check here if you are indicating a change of address ___ Phone #: _______________________________

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Remove this page from the Journal and mail this completed quiz and evaluation to: GPhA, 50 Lenox Pointe NE,Atlanta, GA 30324.


The Georgia Pharmacy Foundation and GeorgiaPharmAssist Committee hosted the 15th AnnualSoutheastern PRN Conference on November 12-14 at

the beautiful Simpsonwood Conference Center in Norcross,Georgia, just north of Atlanta. This annual event owes itssuccess to two dedicated GPhA members, Jim Bartling,Pharm.D., ADC, CAC II, Intervention Coordinator, GeorgiaPharmAssist Program, and Richard B. Smith, R.Ph.,Chairman of the Georgia PharmAssist Program.

This “southeastern” meeting attracts individuals from across thecountry. A large number of the attendees have participated inthis conference almost every year, if not in fact every year.They always mention how they look forward to it. This year weheard many comments from these attendees that they thoughtthis was the best conference yet. We are privileged that one ofthe most well-known PRN websites across the country,www.usaprn.org, promotes this event.

Student pharmacists are motivated to attend this conference toenhance their knowledge about the disease of addiction. Inaddition to the pharmacy schools in Georgia participating, eachyear McWhorter School of Pharmacy has a large contingent ofstudent pharmacists in attendance. All participating studentsare awarded a certificate acknowledging their participation inthis two-day Conference.

Pharmacy Technicians are also encouraged to attend, and doreceive CPE credits for their participation. The conference isopen to anyone who wants to learn more about the disease ofaddiction. Always, there are comments from the participantsthey had no idea about the extensive information available andhow little they really knew about the disease.

Saturday’s program included a presentation by Dr. Paul H.Earley, the Medical Director at Talbott Recovery Campus. Histopic covered “The Neurobiology of Addiction and the Hope ofNew Medications.” Brian Fingerson, R.Ph. and President ofBrian Fingerson, Inc. dba KY Professionals Recovery Network -KYPRN, and frequent speaker, covered “Risk, Recognize,Resolve: Addiction in the Pharmacy Profession.” Tom House,President of Partnership for Professional Wellness /Professional Monitoring, presented “Drug Testing forHealthcare Professionals: A Positive Recovery Tool!” Apopular and emotionally moving portion of the program iswhen someone gives their “Personal Story” about theirrecovery. This year was no exception. (Name is not provided

in consideration for their privacy.) The last speaker of the daywas Steve Moore, MSW, LCSW, who is with the Alabama StateBoard of Pharmacy’s Committee on Rehabilitating ImpairedPharmacists. He gave a very engaging presentation titled “TheHistory of Addiction” and had the attendees laughing andthoroughly enjoying the session.

On Sunday Brian Fingerson delivered the spirituality portion ofthe meeting covering “12-Steps to Recovery and the Brain –How Spirituality Helps.” One of the Pharmacy RecoveryNetwork’s favorite speakers and a GPhA member, MerrillNorton, Pharm.D., D.Ph., ICCDP-D, and Clinical AssociateProfessor at UGA, made a presentation on “Beyond Sadness:The Neuroscience of Depression and Addiction.” Steve Mooredelivered the closing session with “Understanding Craving andDenial” and once again had the audience engaged.

We sincerely thank all of our speakers for all their hard wordand commitment to this program. We couldn’t do it withoutyou.

The Georgia Pharmacy Foundation and Georgia PharmAssistCommittee want to thank the following Exhibitors andSponsors for their support of this Conference:

Academy of Independent Pharmacy (AIP)MARR, Inc.QuestHouse, Inc.Ridgeview InstituteShands Vista – Florida Recovery CenterTalbott Recovery Campus

Their assistance helped make this Conference possible and isvery much appreciated. Each exhibitor provided door prizesthat added to the fun of the weekend. We also thank eachrepresentative who attended and for their contributions to itssuccess! We look forward to seeing you at next year’sConference.

Mark your 2011 Calendar!The 2011 SE PRN Conference will be

held at Simpsonwood on November 11-13, 2011

The 15th Southeastern PRN Conference

Held November 12-14, 2010

G E O R G I A P H A R M A C Y F O U N D A T I O N N E W S


The Georgia Pharmacy Journal

Editor: Jim [email protected]

Managing Editor & Designer: Kelly [email protected]

The Georgia Pharmacy Journal® (GPJ) is the official publication of theGeorgia Pharmacy Association, Inc. (GPhA). Copyright © 2011, GeorgiaPharmacy Association, Inc. All rights reserved. No part of this publicationmay be reproduced or transmitted in any form or by any means, electronicor mechanical including by photocopy, recording or information storageretrieval systems, without prior written permission from the publisher andmanaging editor.

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

ARTICLES AND ARTWORKThose who are interested in writing for this publication are encouraged torequest the official GPJ Guidelines for Writers. Artists or photographerswishing to submit artwork for use on the cover should call, write or e-mailthe editorial offices as listed above.

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

The Georgia Pharmacy Journal® (GPJ) (ISSN 1075-6965) is publishedmonthly 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 PharmacyJournal®, 50 Lenox Pointe, NE, Atlanta, GA 30324.

ADVERTISINGAdvertising copy deadline and rates are available at www.gpha.org uponrequest. All advertising and production orders should be sent to the GPhAheadquarters as listed above.

GPHA HEADQUARTERS50 Lenox Pointe, NEAtlanta, Georgia 30324Office: 404.231.5074Fax: 404.237.8435 www.gpha.org

Print: Star Printing - 770.974.6195

2010 - 2011 GPhA

BOARD OF DIRECTORS

Name PositionEddie Madden Chairman of the BoardDale Coker PresidentJack Dunn President-ElectRobert Hatton First Vice PresidentPamala Marquess Second Vice PresidentJim Bracewell Executive Vice President/CEOHugh Chancy State-at-LargeRobert Bowles State-at-LargeKeith Herist State-at-LargeJonathan Marquess State-at-LargeSharon Sherrer State-at-LargeLiza Chapman State-at-LargeMary Meredith State-at-LargeHeather DeBellis Region One PresidentFred Sharpe Region Two PresidentJohn Drew Region Three PresidentAmanda Gaddy Region Four PresidentShobhna Butler Region Five PresidentAshley Faulk Region Six PresidentMike Crooks Region Seven PresidentLarry Batten Region Eight PresidentDavid Gamadanis Region Nine PresidentChris Thurmond Region Ten PresidentMarshall Frost Region Eleven PresidentKen Eiland Region Twelve PresidentRenee Adamson ACP ChairmanJosh Kinsey AEP ChairmanDon Davis AHP ChairmanIra Katz AIP ChairmanDeAnna Flores APT ChairmanLance Faglie ASA ChairmanJohn T. Sherrer Foundation ChairmanMichael Farmer Insurance Trust ChairmanSteve Wilson Ex Officio - President, GA Board of

PharmacySonny Rader Ex Officio - Chairman, GSHPGina Ryan Johnson Ex Officio MercerJill Augustine Ex Officio Mercer ASPRusty Fetterman Ex Officio South Olivia Santoso Ex Officio South ASPSukh Sarao Ex Officio UGADavid Bray Ex Officio UGA ASP

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Main: (404) 231-5074 ext. 8107

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The GPhA Journal50 Lenox Pointe, N.E.Atlanta, Georgia 30324

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