Make a nomination for MPA and affiliated organization Boards and awards, including the Consultant and Specialty Pharmacists of Michigan (CSPM)! Look through the information below and visit the website pages indicated to make a nomination online. Indicate your interest in serving on the CSPM Board of Directors or MPA Executive Board, or nominate one of your colleagues for an award to recognize their professional accomplishments!

Board Nominations
Additional information and printable and electronic nomination forms are available online.

• CSPM Board of Directors: Nominations are due June 1. To learn more about CSPM, please visit www.MichiganPharmacists.org/cspm.

Award Nominations
Additional information and printable and electronic nomination forms are available online.

• CSPM Pharmacist of the Year Award: The CSPM Pharmacist of the Year Award is presented annually to a CSPM member who displays professional excellence and/or exemplary service to the profession toward advancing public health. The award is presented during the CSPM Annual Meeting and Luncheon at the MPA Annual Convention & Exposition the last weekend in February. Nominations are due Oct. 1.
• MPA Awards: MPA is accepting nominations for the following awards: Pharmacist of the Year, Bowl of Hygeia, Executive Board Medal, Excellence in Innovation, Distinguished New Pharmacist Practitioner, Generation Rx Champions, Fred W. Arnold Public Relations and Fellow of MPA. These awards are presented at the Annual Banquet & Awards Ceremony during the MPA Annual Convention & Exposition the last weekend in February. Nominations are due Oct. 1.

We received notice from the Michigan Dept. of Licensing & Regulatory Affairs (LARA) on April 1, 2016, related to the upcoming pharmacy technician licensure process. This is the latest update on how the Dept. is going to be enforcing the CE (continuing education) requirement.

The LARA document was created following a meeting MPA had with the Licensing Director several days ago. During the meeting, we specifically asked how LARA is planning to implement the newly approved Pharmacy Technician Continuing Education Administrative Rules. We asked for this clarification because it came to our attention that LARA was providing information different than what they had previously given us in writing. They supplied us with this document in order to assist in educating our members of their intended actions. MPA has highlighted the paragraph in the document that addresses this change.

The "new" news is that LARA is not going to be requiring any pharmacy technician CE until the licensure renewal period ending June 30, 2017.

The key change is that pharmacy technicians who have their licenses due on June 30, 2016, do not need to have CE completed.

Effective June 2017 if the pharmacy technician has had their license:

• Less than one year = No CE required
• Greater than 1 year, but less than 2 years = 10 hours
• For 2 years = 20 hours

We hope this information is helpful to you as we all go through the first pharmacy technician licensure renewal process.

If you have additional questions, please contact Eric Roath, MPA Director of Professional Practice, at (517) 484-1466 or Eric@MichiganPharmacists.org.

by Michelle Smith, Pharm.D. and Rebecca Tomich Pharm.D., CGP

The discovery of penicillin by Sir Alexander Fleming in the 1940s ushered in an era of undoubted medical advancement. It didn’t take long to recognize that this new life saving antibiotic would soon find resistance to its effect on the targeted organisms, elevating the concern for careful usage of these agents in order to preserve their effectiveness. On June 26, 1945, in a New York Times article, Sir Alexander Fleming would address this blow by stating, “… the microbes are educated to resist penicillin and a host of penicillin-fast organisms is bred out… In such cases the thoughtless person playing with penicillin is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism. I hope this evil can be averted.”

This struggle between bugs and drugs has continued without avail for the last 70 years. Our current pharmacological environment is plagued by low research and development of new agents and staggering rates of resistance. It is hard to believe that we are currently facing pathogens that we simply have no useful treatment tools to address. It will require a team approach comprised of several expert disciplines in order to implement a strategy that begins the process of reclaiming the viability of current antimicrobial agents and detects and prevents the spread of resistant isolates. With antimicrobial stewardship programs exists the opportunity to optimize antimicrobial use and achieve the best clinical outcomes while simultaneously minimizing adverse events and limiting selective pressures that drive the emergence of resistance. They may also reduce excessive costs related to suboptimal antimicrobial use and inappropriate durations.

The Principles of Antibiotic Stewardship are simple: The Right Drug at the Right Dose for the Right Duration and Down Regulate as soon as new information is available. As Long-Term Care Consultant pharmacists, we have an opportunity to impact care and be an integral aspect toward better outcomes with less collateral damage to the system. Implementing such a collaborative effort will decrease resistance rates with more appropriate empiric drug selection, minimize overuse of unnecessary antibiotics and early targeted therapy for true infections to reduce readmission rates.

Several barriers exist for consultant pharmacists to be effective in the long-term care arena. Advanced training in microbiology and infectious diseases will be necessary to provide concise recommendations for therapy. It is critical that pharmacists become experts on the most common drug-bug therapy options, the most appropriate drugs of choice for infections common in elderly populations and have a working knowledge of laboratory resistance data for the community. Limitations of pharmacist’s time, access to all necessary patient information and quick access to appropriate antibiotics may create barriers to an effective team approach that will impact resistance development and patient care outcomes. An effective Antibiotic Stewardship Program will need to be endorsed and supported by a champion physician who can drive therapy selection for any involved patients. The team will be most successful if it can also garner participation from the Director of Nursing, Infection Control nurse, Laboratory and a consultant pharmacist trained in infectious disease. Communication delays of culture results, antibiotic recommendations and time delays for antibiotic initiation will impact patient outcomes and represent a significant barrier to providing antibiotic stewardship, so it is essential to create a network of practitioners to promote increased patient care.

The stewardship team can develop protocols that help guide appropriate therapy for specific site infections such as UTI, pneumonia and skin. Such therapy pathways can significantly influence the principles of right drug, right dose and right duration for empiric therapy. As culture results are available, therapy can then be targeted to the offending organism based on its specific MIC data.

CMS requires more frequent chart reviews for any resident receiving antibiotics in the last month and has proposed more pharmacist involvement in the nursing facility as well as active involvement with infection control committees and antibiotic stewardship programs. SHEA, IDSA and PIDS recommend that the Centers for Medicare and Medicaid Services (CMS) require participating healthcare institutions to develop and implement antimicrobial stewardship programs. This can be modeled after the IDSA and SHEA “Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship.” Minimum requirements for the program can be found at Clinical Infectious Disease 2007; 44:159-177

References:

• Dellit T.H., Owens R.C., McGowan Jr., J.E., et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159–177.
• Federal Register. Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities. Office of the Federal Register. https://www.federalregister.gov/articles/2015/07/16/2015-17207/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities#h-26. Published July 16, 2015. Accessed April 20, 2016.
• National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination. Office of Disease Prevention and health Promotion. http://health.gov/hcq/prevent-hai.asp. Updated April 27, 2016. Accessed April 20, 2016.
• Penicillin finder assays its future. New York Times. 26 June 1945:21.
• Society for Healthcare Epidemilogy of America. Policy statement on antimicrobial Stewardship. Infection Control and Hospital Epidemiology 2012;33(4): 322–327.

by Kim Moon, Pharm.D., Blue Cross Blue Shield of Michigan, CSPM Member and Riham Kiston, Pharm.D. Candidate, Blue Cross Blue Shielf of Michigan Intern

The updated 2015 American Geriatrics Society (AGS) Beers Criteria was published to reflect changes made to the existing list of potentially inappropriate medications for patients 65 and older, as well as provide three new components: select drug-drug interactions, renal function dosing adjustments and an alternative medication list. The list is an update to the 2012 Beers criteria, and it aims to address drug related problems and adverse drug events in the geriatric population using new pieces of evidence. It is important to note that these recommendations do not pertain to patients who are receiving hospice or palliative care.

New to the list is the long-term use (greater than eight weeks) of proton-pump inhibitors (PPIs), due to increased risk of C. difficile infections, bone loss and fractures. The Beers criteria recommends avoiding PPI use for more than eight weeks unless the patient is high-risk (chronic use of NSAIDs or oral corticosteroids), has a hyper-secretory condition (erosive esophagitis, Barrett’s esophagus, etc.) or has a demonstrated need for maintenance treatment (trial and failure of H2 blockers, etc.).

Another shift in the criteria is the status change of zolpidem, zaleplon and eszopiclone. The evidence for potential harms of delirium, falls and fractures seems to outweigh the benefit of their use for any duration, in comparison to the 90-day limit previously suggested. If a patient must be on these medications, along with other CNS-active medications (psychiatric medications, opioids, etc.), the recommendation is to reduce the dose and/or frequency and avoid the use of three or more of these drugs concomitantly.

The 2015 Beers update also removes the previous recommendations against use of anti-arrhythmic drug classes Ia, Ic and III as first-line treatment for atrial fibrillation; however, amiodarone and dronedarone are not recommended as first line agents in the treatment of atrial fibrillation and disopyramide is to be avoided altogether. An anti-arrhythmic by another mechanism, digoxin has a few clarifications of its own. Adding to the recommendation of a 0.125mg daily dose maximum, the criteria now also says to avoid digoxin as first line therapy for both atrial fibrillation and heart failure, and to provide renal dose adjustments for stage four or five chronic kidney disease patients.

The following medications have been added to the 2015 Beers list as medications to be avoided due to high anticholinergic activity: dimenhydrinate, meclizine, atropine (excludes ophthalmic), belladonna alkaloids, clidinium-chlordiazepoxide, dicyclomine, hyoscyamine, propantheline, scopolamine, amoxapine, desipramine, nortriptyline, paroxetine and protriptyline.

It is worth noting that trimethobenzamide, an anti-cholinergic traditionally used to treat nausea and vomiting, has been removed from the new Beers criteria. Also, the creatinine clearance below which nitrofurantoin use should be avoided has been loosened from less than 60mL/min to less than 30mL/min. Long-term use of nitrofurantoin is still not recommended.

References:

• The American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63:2227-2246.