by Lindsey Ghiringhelli, Pharm.D., BCGP, consultant pharmacist, PharMerica 

An enthusiastic crowd of pharmacy students, pharmacy technicians and pharmacists gathered on Sept. 12 to hear opening remarks from Larry Wagenknecht, Michigan Pharmacists Association (MPA) chief executive officer and Eric Liu, MPA’s director of professional affairs, before the sea of crisp white lab coats headed over to the steps of the Capitol Building. The day’s mantra is, “Pharmacists Care,” and we’re here to engage our legislators and show them what we are capable of. We delivered legislative packets to 110 representatives, thirty-eight senators, as well as Governor Snyder himself, with information about current legislative opportunities and to invite them down to our event for free lunch, vaccinations and health screenings. A large pharmacy tent on the south lawn offered blood pressure, glucose and lipids screens, as well as information tables and lunch to legislators and volunteers. Ninety flu vaccines were given and many legislators sat down with us to discuss our profession’s value and specific proposals over lunch. A second tent housed the drug disposal event which received over 1,500 pounds of medication, compared to 592 pounds last year, in just a few hours’ time.

Additional pharmacy advocacy activities included a press conference held with MPA leadership, Shelly Edgerton, director of the Department of Licensing and Regulatory Affairs, Michigan’s Chief Medical Executive Dr. Eden Wells, MPA’s President Jim Lile and the Department of Environmental Quality Office of Environmental Assistant’s Chief, Jack Schinderle, to promote pharmacy day, the new controlled substance reporting system and naloxone access. Pharmacy students were invited to attend a Senate Health Policy Committee meeting at which Larry Wagenknecht testified in support of legislation protecting the pharmacist’s right to refuse a controlled substance prescription without threat of civil lawsuits. Senator Mike Shirkey acknowledged our commanding presence in the capitol by opening the committee meeting with the comment, “The white coats are coming!” These are experiences that we can all draw on in order to continue promoting pharmacy in our daily practices throughout the year. It was an exciting day for Michigan pharmacists, pharmacy technicians and pharmacy students as we sent a resounding message to the Capitol: Pharmacists Care!

Pharmacy day is a stunning example of what we can accomplish as a profession when we all come together. Mark your calendars for next year’s Pharmacy Day at the Capitol on Sept. 11, 2018.

By Natalie Pirkola, Pharm.D., M.B.A., BCACP, BCGP, BC-ADM, CDE, pharmacist, Oakland Southfield Physicians, Southfield

Sodium-glucose Co-transport Type-2 Inhibitors (SGLT2)
SGLT-2 inhibitors decrease reabsorption of filtered glucose in the kidney, thereby increasing urinary excretion of glucose. These oral agents lower both fasting and post prandial glucose levels, but the greatest interest has been generated due to the ability to lower blood pressure, as well as induce modest weight loss. Empagliflozin (Jardiance) is emerging as a preferred agent due to the EMPA-REG OUTCOME trial which showed improvements in cardiovascular mortality. Secondary analysis from this trial is generating further interest in potential renoprotective effects which merits further study. In contrast, canagliflozin (Invokana) studies have generated concerns about increased risk for amputations, acute kidney injury and bone fractures. Dose-dependent increases atypical fractures which seems a possible class effect. Concerns across the class include genital mycotic infections, urinary tract infections (including cases of urosepsis and pyelonephritis), ketoacidosis and hyperkalemia. Renal adjustment is required across the class and all should be taken before the first meal of the day.

Incretin Therapies - Dipeptidyl Deptidase-4 (DPP4) Inhibitors
DPP4-inhibitors reduce the breakdown of endogenous glucagon-like peptide-1 GLP-1 and glucose-dependent insulinotropic polypeptide (GIP). Early interest was generated as this class is weight neutral, available orally and may have a beta-cell sparing effect. Concerns have emerged due to serious hypersensitivity reactions, including skin and airways reactions. A1c reduction is small and the patient expense is still relatively high. Linagliptin (Tradjenta) is the lone agent that does not require renal dose adjustment. As post marketing use increased, concerns emerged regarding safety of these agents in patients with cardiovascular disease, particularly heart failure. Concerns continue regarding possible increased risk of heart failure hospitalization for saxagliptin (Onglyza); however, trials such as SAVOR-TIMI, EXAMINE and TECOS are demonstrating no increased risk for other agents in the class. Risk of pancreatitis seems small, however, but continues to remain a concern.

Incretin Therapies - Glucagon-Like Peptide-1 (GLP-1) Agonists
Glucagon-Like Peptide-1 (GLP-1) agonists are synthetic analogs of human GLP-1, which result in supra-endogenous levels. Weight loss, particularly with longer acting therapies, is a stand out feature of these medications. Injectable formulation, reconstitution for longer acting therapies and cost are still potential barriers for patients. Labelling concerns remain regarding medullary thyroid carcinoma. Risk of pancreatitis remains a concern; however, debate exists whether this is due to drug or underlying diabetes. Liraglutide (Victoza) stands out with evidence for macrovascular beneficial outcomes in very high-risk patients (LEADER). 

Combination
Studies have examined combining SGLT2 inhibitors with DPP4 inhibitors or GLP-1 agonists. Greater reductions in A1c, weight and blood pressure have been seen with SGLT2 in combination with GLP-1, than either agent alone. Similarly, overlapping risks regarding with renal impairment, worsening chronic renal failure, are also increased. Combination use is growing, therefore, pharmacists should support monitoring for reduced renal function, particularly in elderly patients and/or those with nausea, vomiting, diarrhea, or other risk factors for dehydration.

Taking it Further
1. Mora PF, Johnson EL. Cardiovascular Outcome Trials of the Incretin-Based Therapies. Endocr Pract. 2017;23(1):89-99. 
2. Pratley RE, Cersosimo E. Use of Canagliflozin in Combination With and Compared to Incretin-Based Therapies in Type 2 Diabetes. Clin Diabetes. 2017;35(3):141-153.
3. Heerspink HJ, Perkins BA, et al. Sodium Glucose Cotransporter 2 Inhibitors in the Treatment of Diabetes Mellitus: Cardiovascular and Kidney Effects, Potential Mechanisms, and Clinical Applications. Circulation. 2016;134(10):752-72. 

Robyn Parker, CPhT, manager, reporting and data analytics, Diplomat, Flint

We all have various similarities in this life. You look like your mother, your philosophies are comparable to your father’s and the family resemblance in character, personalities or mannerisms can be easily noticeable. But what about those similarities which stretch beyond our family tree? The similarities between all humans, like the inherent drive to be more, or the inner ambition to serve others, any maybe the satisfaction of making a difference on this Earth. Those similarities can be summed up in one word: volunteering. You want to feel good about yourself, be fulfilled life and stand as an outstanding individual? Then volunteer! What could the cost be? Just your talents and time! Volunteering is an expressive act of service in which you are paid by successfully making a difference on this Earth through your life.

But I don’t know where to volunteer? How do I find a place? Remember the beauty of volunteering is that you chose volunteer service according to your strengths and likes. How about volunteering within your career? Contact Michigan Pharmacist Association (MPA) for any of these opportunities: Michigan Society of Pharmacy Technicians (MSPT) Executive Committee tackles issues that impact pharmacy technicians’ careers. Get yourself involved with the Committee, and you could voice that key information that would secure a healthier opportunity for pharmacy technicians. Do you love politics? Pharmacy Day at the Capitol is a yearly advocacy event hosted by MPA that could easily be your place. The chance to speak with our elected officials regarding pharmacy technicians and the profession is available every September. Is writing your love? The Tech Connect newsletter always wants to hear from fellow technicians about their thoughts on the profession, ideas for the pharmacy, and suggestions about increasing efficiency in our practices. Or maybe use your career on a more public level like at your local free clinic helping to dispense medication. Patients and staff will think you are outstanding while you just want to be more fulfilled in life. Want something outside of your career? Revisit your likes and strengths and think outside the box. I enjoy cars and puzzles, and every year I volunteer as a parking attendant for the local museum auto fair fund raiser. I get to see all the admission cars while trying to figure out how to park participants within the designated area. Every year my car parking puzzle improves as I figure out what car puzzle piece fits within the layout. I’m fulfilled every time I fit that beautiful car into that perfect spot, and the car owner thinks I’m outstanding for taking such good care of their vehicle, which ultimately makes me feel good. Do you have a passion for the less fortunate? How about getting a group together and providing school clothes for children. The parents and school social worker would likely think that is outstanding, the group is fulfilled knowing you were a part of making the lives of those children easier.

If still unsure on how to find volunteer opportunities, do some internet searches. There are so many opportunities in all of our local communities to make a difference and enrich both our own lives and the lives of others. Whether you are volunteering within the profession you love so much, or spending some more time with the hobbies you get so much enjoyment out of, every act of volunteering helps and makes a difference. There’s more to explore when you steer to volunteer!!

By Adam King, B.S., C.Ph.T., R.Ph.T., PRS, billing, technology and regulation specialist, Keystone Pharmacy, Grand Rapids 

In all the frenzy that surrounded pharmacy technicians becoming licensed with the Department of Licensing and Regulatory Affairs, there are a couple of glaring notes about the laws surrounding your license. First, depending on your employer, you may not have to complete a certification exam to obtain full licensure by the State. Second, you are not required to remain certified to renew your license. Third, depending on your employer-based training program, you may not ever need to become licensed at all. With all that in mind, why do I need my certification? I’ll give you four good reasons to do just that!

First, your employer may require you to maintain active certification. This is particularly true with my employer. Our owner asks his technicians to remain licensed and certified. While this sounds like a cumbersome employment requirement, the continuing education requirements are similar and the same credits can count for your license and certification. Make sure you stay compliant with your employer’s requirements.

Second, your next employer may require active certification. This is particularly true in compounding pharmacies and hospital pharmacies. If you want to work for the federal government, Pharmacy Technician Certification Board (PTCB) certification is the only acceptable requirement. Obtaining and maintaining your certification might just help you make your next career move.

Third, due to the patchwork nature of pharmacy technician licenses between states, pharmacy technician licenses are not reciprocated from state to state like pharmacist licenses. If you plan to move or get involuntarily moved to another state, you will have to go through their license process, and in most states, that process is obtaining or possessing national certification. Additionally, if you plan to practice in Canada, PTCB certification is a pre-requisite to taking their licensing exams unless you have received a pharmacy technician degree from a college.

Fourth, licenses do not relate to professional competence. In a recent survey by PTCB, 85 percent of patients want the pharmacy technicians in their pharmacy to be certified. Many of our patients think that pharmacy technicians are already pharmacists, so proving you have taken an interest in your profession by remaining certified goes a long way earning the respect of your patients. Remember you once your certification lapses, you lose the ability to use the “CPhT” designation.

Maintaining your certification is important to your career. If you aren’t certified, get certified. If you are certified, maintain it. It helps your profession, your patients, your pharmacists and your career to have that demonstration of competence.

Robyn Parker, CPhT, manager, reporting and data analytics, Diplomat, Flint

At this year’s Pharmacy Day at the Capitol and Medication Disposal Event, technicians spoke about being the pharmacist’s ears and patient’s voice – we listen for the pharmacist and speak for the patient – to legislators visiting the Pharmacists Care tent on the south Capitol lawn in Lansing. As legislators and their staff made their way through the Pharmacists Care tent, technicians took this opportunity to explain their role as the ears of the pharmacist and the voice of the patient. Pharmacy technicians are the first line to patients, and patients tend to speak more on a personal level to that technician. Many times, information learned from casual conversations with a patient can impact their current therapy, and pharmacists should be aware of that information. For example, a patient diagnosed with high blood pressure may come into the pharmacy, casually speak to the pharmacy technicians about an increase of sinus pressure and headaches. The patient informs the technician they have been taking over-the-counter decongestants and NSAIDs for relief. Unbeknownst to the patient, decongestants should not be taken while being treated for high blood pressure. In addition, certain pain and anti-inflammatory medications can cause water retention, which in turn may increase blood pressure. This casual conversation with a pharmacy technician was an opportunity to be the ears for the pharmacist and to voice that information to the pharmacist to ensure the patient is receiving the best care. The relationship between the pharmacist and the pharmacy technician, and what makes it so effective, was the topic of many discussions with legislators in the Pharmacists Care tent throughout the day.

This year was also a year of records for the event! 2017 marks the largest number of volunteers for the event to date! A total of 492 pharmacy students and other pharmacy professionals made their way down to Lansing to show support for the profession. Of the 492 individuals volunteering their time, 417 were pharmacy students coming to learn more about what Michigan Pharmacists Association and Michigan Society of Pharmacy Technicians does for our members and profession. This year was also the largest amount of medications collected for the Medication Disposal Event. This year’s disposal event collected 1,527 pounds of unused, unwanted or expired medications. Of the 1,500 pounds, 20 pounds were controlled substances. Over the past eight years, the Medication Disposal Event has taken in nearly four tons of medications, keeping them off the streets and out of our environment, with a total value of more than $8.75 million.

Thank you to all who were involved in this year’s event, and to the City of Wyoming for assisting in the medication disposal. Save the date for next year – Tuesday, Sept. 11, 2018. We can’t wait to see you there!