Sepsis and Septic Shock Guidelines

One of the main guidelines in sepsis is the Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock from 2012 (updating the 2008 guidelines).

Pocket Guide

Key recommendations and suggestions:

• Early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C)
• Blood cultures before antibiotic therapy (1C)
• Imaging studies performed to confirm a potential source of infection (UG)
• Administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B)
• Infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C)
• Initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C)
• Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to acheive a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C)
• Fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG)
• Norepinephrine as the first-choice vasporessor to maintain mean arterial pressure >/= 65 mm Hg (1B)
• Epinephrine when an additional agent is needed to maintain adequate blood pressure (2B)
• Vasopression (0.03 U/min) can be added to NE to either raise MAP to target or to decrease NE dose but should not be used as the initial vasopressor (UG)
• Dopamine is not recommended except in highly selected circumstances (2C)
• Dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite acheiving adequate intravascular volume and adequate MAP (1C)
• Avoiding use of IV hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C)
• Hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B)
• Low tidal volume (1A) and limiation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS)
• Application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B)
• Higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C)
• Recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C)
• Prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of </= 100 mm Hg in facilities that have experience with such practicees (2C)
• Head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B)
• A conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C)
• Protocols for weaning and sedation (1A)
• Minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B)
• Avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C)
• A short course of neuromuscular blocker (no longer than 48 hours) for patients with early ARDS and a PaO2/FIO2 < 150 mm Hg (2C)
• A protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose </= 180 mg/dL (1A)
• Equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B)
• Prophylaxis for deep vein thrombosis (1B)
• Use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B)
• Oral or enteral (if necessary) feedings, as tolerated, rathern than either complete fasting or provision of only IV glucose with the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C)
• Addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hours of intesive care unit admission (2C). 

Board Certification After Awhile

Was it worth it? I know many wonder this same question, and I believe it is. It is expensive to keep current. There is a yearly fee due to BPS every year. The required approved continuing education is pricey and complicated. 

The reason I continue to believe it is worth it is because prior to obtaining this, I feel like I had something to prove. Many newer grads felt or assumed I was a BS Pharm even though I was a PharmD. Many assume that because I have been out of school over 15 years, I am behind the times. Experience is sometimes not as valued in every job culture no matter what field it is. Bright and eager new graduates come out feeling as though we are behind the times, and sometimes they are right. 

Prior to obtaining my BCPS, I had no residency to point to. Yes, we had residencies back then, but my debt load didn't endorse another year of the same at half the price. The return on investment didn't seem good enough. If I was graduating today, I would definitely do a residency. 

What happened to me after the board certification is that I quit trying to prove myself to peers. I refocused my efforts on the patients by doing a better job in going the extra mile and also by noticing the system issues that aren't being exposed. I also have stopped trying to make my career the thing I work on the most and have let it fall to a healthier place behind God and family. What will be will be.  

Should a job in pharmacy open up where I can do more of the things I enjoy: clinical decision making, brainstorming, patient advocacy, and writing, I will be moved. Until then I credit certification to validating competiveness with newer pharmacists while also solidifying my belief that experience is king. I am glad I invested in myself and hope you will too! 

Oncology Support

BCPS Oncology Support

Antiemetics

Acute onset: occurs within 24hr of chemotherapy, peaks 5-6hr, resolves within 24hr

Delayed onset: >24hr after chemo [cisplatin, carboplatin, cyclophosphamide, doxorubicin]

Anticipatory: conditioned response triggered by sights, smells; more likely to occur with delayed N/V is not controlled

Breakthrough: despite prophylaxis treatment and requires additional rescue meds

Refractory: occurs during treatment cycles when ppx and/or rescue has failed in previous cycles

Risk Factors: <50 yo, female, motion sickness, N/V pregnancy, N/V previous chemo [alcoholism decreases risk]

General Principles for Managing Chemo/Radiation N/V

1. PPx meds before moderate or high emetogenic agents

2. antiemetics should be scheduled for delayed N/V

3. most common: High- serotonin antag + dex (steroid increases efficacy by 10-20%)

4. may also add aprepitant to above regimen.  [metoclopramide + dex used to be the most common]

High (>90%): [doxorubicin/epirubicin + cyclophos], carmustine, cisplatin>50mg/m2, cyclophosphamide>1500mg/m2

Minimal (<10%): most ‘mabs, Vins, interferon alpha<5million/m2, methotrexate <50mg/m2

Treatment: Use ppx for all chemo high-low (not routine for minimal)

1. 5-HT3: all similar efficacy (except palonosetron)   AEs- HA, constipation

2. corticosteriods: dex more studied than methylpred   AEs- infrequent with short duration (insomnia, fluid retention)

3. neurokinin-1 antag: aprepitant (PO) fosaprepitant (IV)   DDI- CYP3A4(warfarin-decrease INR, oral dex- decrease dose 40%, OCs- another form)   AEs- asthenia, dizziness, hiccups

4. benzamide analogs (metoclopramide): AEs- mild sedation, EPS

5. phenothiazines (prochlorperazine, promethazine): AEs- EPS, drowsiness, HoTN

6. butyrophenones (haloperidol, droperidol): AEs- EPS, sedation, less HoTN than above

7. benzodiazepines (lorazepam): only in combo, can help manage EPS   AEs- amnesia (can be good with anticip)

8. Others: cannabinoids (dronabinol, nabilone); H2 blockers/PPI

Pain Management

General Principles for Cancer Pain Management

1.  oral route preferred- scheduled basis, not as needed (as needed for breakthrough pain); >2 doses may need modify

2. maximize one drug dose and schedule before adding another drug

3. provide medications for AEs: constipation, sedation

4. assess pain often- most important step!

Treatment

1. mild-mod (1-3): nonopiod- NSAIDs, ASA, APAP (platelets, SCr)

2. mod-severe (4-6): + weak opiod- codeine, hydrocodone (watch for APAP OD with combos)

3. persistent severe (7-10): change weak to strong opiod- morphine, oxycodone (constipation- stimulant laxatives, urinary retention, sedation- dextramphe, methylphen, N/V- meclizine, phenothiazines)

4. Bisphosphonates: Pamidronate or zoledronic acid for skeletal pain (spinal cord compression, fracture, bone mets) in breast CA and myeloma [SCr,elec]

5. Adjuvant: antidepressants, anticonvulsants, transdermal lidocaine, corticosteroids, benzos (spasms), strontium-89

Febrile Neutropenia: ANC<500, nadir usually day 10-14 [No chemo if WBC<3000, ANC<1500, or Plate<100]

Febrile= one temp 101 or 100.4 >1hr

Reassess all pts in 3-5 days after abx

CSFs may be given: similar in efficacy, should be initated in 24-72hr post-chemo, cont until post nadir ANC>10,000

Thrombocyotpenia (plate<100, no increased risk of bleeding until <20, transfuse plate when symptoms)

Oprelvekin (interleukin-11)- ppx, cont until post-nadir >50   AEs- edema, SOB, tachycardia, conjunctival redness

Anemia/Fatigue: epoetin/darbipoetin alfa

Chemoprotectants

1. Dexrazoxane: anthracyclines- cardiotox. May use in pts doxorubicin >300mg/m2 and may benefit from cont. use

2. Amifostine: cisplatin- nephrotox and head/neck radiation- xerostomia. AEs- HoTN, metallic taste, flush

3. Mesna: ifosfamide/cyclophosphamide- hemorrhagic cystitis (metabolite acrolein)

Oncology Emergency

1. hypercalcemia: thiazide and hormonal therapy can exacerbate

                Treat (cCa> 14):NS 3-4L in 24hr, loop (to prevent fluid overload), bisphosphonates, calcitonin, steroids

2. spinal cord compression- dexamethasone and radiation or surgery

3. tumor lysis syndrome (uric acid, K, P): hydration and allopurinol, rasburicase with uric acid> 10

Misc Pharmacotherapy

1. leucovorin rescue- MTX > 100mg/m2 [Also used in combo with 5-FU to enhance activity, NOT rescue]

2. Extravasation (vesicants): ACs (topical dimethyl sulfoxide, dexrazoxane, cold), Vins (hyaluronidase, heat),mechlorethamine (Na thiosulfate) oxaliplatin, paclitaxel

3. Diarrhea- loperamide (higher than usual doses)

4. Renal dose: MTX, carboplatin, cisplatin, etoposide, bleomycin, topotecan, lenalidomide

5. Hepatic dose: doxorubi, daunorubi, vincrist, vinblast, docetaxel, paclitaxel, sorafenib, pazopanib

6. Never administer Viscristine intrathecally

Osteoporosis: Topic of the Day

The National Osteoporosis Foundation released an update to its Clinician's Guide to the Prevention and Treatment of Osteoporosis last year (April 2014). 

The current version (2014) was released April 1, 2014. The 2014 version of the Clinician’s Guide stresses the importance of screening vertebral imaging to diagnose asymptomatic vertebral fractures; provides updated information on calcium, vitamin D and osteoporosis medications; addresses duration of treatment; and includes an expanded discussion on the utility of biochemical markers of bone turnover and an evaluation of secondary causes of osteoporosis.

Osteoporosis Guidelines

Postmenopausal women and men age 50 and older

National Osteoporosis Foundation (2014) U.S. Preventative Services Task Force among other organizations

Postmenopausal women

 American Association of Clinical Endocrinologists (2010) – North American Menopause Society (2010)

Men

Endocrine Society (2012)

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Review of the 2014 NOF Clinician's Guide

• Approach to the diagnosis and management of osteoporosis
• Universal Recommendations 
• Pharmacotherapy (Who) and FDA indications
• Sequential and combination therapy
• Duration of treatment

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Dual‐energy Absorptiometry (DXA) Bone Density Testing: Indications

• NOF guideline
  • Women > 65 years old and men > 70 years old
  • Younger postmenopausal women, women in the menopausal transition, and men age 50‐69 years old with clinical risk factors for fracture • e.g., current smoker, low body weight, history of osteoporosis, low trauma fracture in a first‐degree relative
  • Adults who have a fracture after age 50 years
  • Adults with specific conditions or medications associated with bone loss
• Other – Women 50‐ 64 years old with FRAX overall fracture risk > 9.3% (USPSTF) – 

WHO Definition of Osteoporosis Based on Bone Mineral Density testing results:

• Normal 
  • BMD within 1 SD of the mean level for a young-adult reference population
  • T-score at -1.0 and above
• Lone Bone Mass (Osteopenia)
  • BMD between 1.0 and 2.5 SD below that of the mean level for a young-adult reference population
  • T-score between -1.0 and -2.5
• Osteoporosis
  • BMD 2.5 SD or more below that of the mean level for a young adult reference population
  • T-score at or below -2.5
• Severe or Established Osteoporosis
  • BMD 2.5 SD or more below that of the mean level for a young adult reference population
  • T-score at or below -2.5 with one or more fractures

Imaging Recommendations

• Vertebral Imaging recommended for women age 70 and older and all men age 80 and older if BMD T-score at the spine, total hip or femoral neck is </= -1.0
• Women age 65-69 and men age 70-79 if BMD T-score at the spine, total hip or femoral neck is </= -1.5
• Postmenopausal women and men age 50 and older with specific risk factors: low trauma fracture during adulthood (age 50), historical height loss of 1.5 inches or more (4 cm), prospective height loss of 0.8 inches or more (2 cm), or recent or ongoing long-term glucocorticoid treatment.

FRAX was developed to calculate a 10-year probability of a hip fracture and the 10-year probability of a major osteoporotic fracture (defined as clinical vertebral, hip, forearm or proximal humerus fracture). FRAX algorithm available at www.nof.org as well as at www.shef.ac.uk/FRAX.

FRAX is for postmenopausal women and men age 50 and older. In patients being pharmacologically treated for osteoporosis, clinical judgment must be use in interpreting results. No treatment in 2 years could be interpreted as untreated. Femoral neck BMD is preferred in calculating FRAX.

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Diagnosis of Osteoporosis (WHO Criteria) (Postmenopausal women and men >/= 50 years of age)

• T‐score at ‐1.0 or above  (SD) Normal
• T‐score between ‐1.0  and ‐2.5 (SD) - Low bone mass (Osteopenia)
• T‐score at or below ‐2.5 (SD) - Osteoporosis
• T‐score at or below ‐2.5 (SD) with one or more fractures - Severe or established osteoporosis SD = standard deviation

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Diagnosis of Osteoporosis (International Society for Clinical Densitometry 2007 Guidelines)*

• Z‐score above ‐2.0 (SD) “Within the expected range for age”
• Z‐score at or below ‐2.0 (SD) “Low bone mineral density for chronological age” or “Below the expected range for age” SD = standard deviation Premenopausal Women, Men < 50 Years of Age, and Children * These criteria are never used alone to diagnose osteoporosis in these populations

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RECOMMENDATIONS IN ALL PATIENTS:

Several interventions to preserve bone strength can be recommended to the general population. These include an adequate intake of calcium and vitamin D, lifelong participation in regular weight-bearing and muscle-strengthening exercise, cessation of tobacco use, identification and treatment of alcoholism, and treatment of risk factors for falling. 

Bone‐Healthy Lifestyle:

• Calcium - Recommended elemental calcium intake should be obtained ideally through dietary sources + supplements
• Age Group Recommended Daily Intake Maximum Daily Intake
  • 19-50 years 1000 mg
  • 50-70 years 2000 mg Men = 1000 mg Women = 1200 mg
  • ≥ 71 years 1200 mg

According to the updated 2014 National Osteoporosis Foundation guideline, intakes of calcium in excess of 1200 to 1500 mg per day could place a patient at increased risk for kidney stones, cardiovascular disease (CVD), and stroke. (J Bone Metab 2014;29:531‐3; J Bone Metab 2014;21:21‐8; Am J Clin Nutr 2011;94:270‐277)

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Vitamin D: This is the amount needed to maintain the majority of healthy patients within the sufficient range

• Age Group Recommended Daily Intake
  • National Osteoporosis Foundation (2014)
    • <50 years 400-800 units (4000 units max daily intake) 
    • ≥ 50 years 800-1000 units (4000 units max daily intake)
• Institute of Medicine (2010)
  • ≥ 71 years 800 units (4000 units max daily intake)
  • 51-70 years 600 units (4000 units max daily intake)
  • 19-50 years 600 units (4000 units max daily intake)

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When to Consider Drug Treatment

• History of (low trauma) hip or vertebral fracture
• T‐score - ‐2.5 at femoral neck, hip, or spine by central DXA
• Postmenopausal women and men 50 years of age if T‐score between –1 and –2.5 and 10‐year hip fracture probability of 3% or a 10‐year all major osteoporosis‐related fracture probability of 20%

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Bisphosphonates:  inhibit osteoclastic bone resorption and reduce osteoclast activity and beneficial effect on osteoblasts.

• Drug holidays are being considered for bisphosphonates to prevent which serious long‐term adverse effects 
• Show residual effects after discontuation
• Evidence for efficacy beyond 5 years is limited, whereas rare safety concerns become more common beyond 5 years. 
• Reasonable to discontinue after 3-5 years in patients who have a modest risk of fracture after the initial treatment period, but in high risk, continued treatment or alternative treatment should be considered.

Non-Bisphosphonates: produce temporary effects that wane with discontinuation.

Duration of Treatment and Drug Holiday

• Alendronate: Duration of treatment 5 years. Assessment for reinitiation: 1-2 years
• Risedronate: Duration of treatment 5 years. Assessment for reinitiation: 1 year
• Zoledronic acid: Duration of treatment 3 years. Assessment for reinitiation: 2-3 years

Denosumab Role in Therapy

• FDA osteoporosis indications
  • Postmenopausal women and men with high fracture risk (Osteoporosis fracture, multiple risk factors, can’t use other meds)
  • Androgen deprivation therapy for nonmetastatic prostate cancer
  • Adjuvant aromatase inhibitor for breast cancer
• AACE guideline – first line
• Increases BMD for at least 8 years
• Vertebral, hip, & nonvertebral fracture prevention
• Quicker reversal with medication discontinuation
• Adverse effects: Common adverse reactions (> 5% and diff placebo)
  • Back, shoulder, leg, and musculoskeletal pain – Increased cholesterol – Cystitis
  • Cases of MRONJ and atypical fractures

Raloxifene Role in Therapy

• FDA indications
  • Osteoporosis prevention and treatment
  • Postmenopausal women with osteoporosis and/or at high risk for invasive breast cancer
• AACE guideline –Second‐ and third‐line therapy
• Dose ‐ 60 mg daily
• Contraindications ‐ active or past history venous thromboembolism
• Precaution – risk for stroke
• Adverse effects – Vasomotor symptoms (hot flushes) – Leg cramps – Breast tenderness – Spotting – Venous thromboembolism – Box warning – fatal stroke

Teriparatide Role in Therapy

• FDA indications
  • Postmenopausal women at high risk for fracture
  • Men with primary or hypogonadal osteoporosis at high risk for fracture
  • Glucocorticoid‐induced osteoporosis
  • High fracture risk
    • Previous fracture
    • Extremely low BMD (T‐score < ‐3.5)
    • Multiple risk factors for fracture
  • Teriparatide Dose, Selection, and Common Adverse Effects
    • 20 mcg subcutaneously daily for 24 months
    • Once weekly injection in trials – ? Start antiresorptive agent before end of therapy
    • Contraindications – Skeletal muscle radiation, bone cancer, hypercalcemia, Paget’s disease
    • Common adverse effects
      • Orthostasis – first doses
      • Nausea, arthralgia, leg cramps
      • Hypercalcemia (check calcium at baseline)
      • Box warning ‐ osteosarcoma (animal data)

Calcitonin: Role in Therapy, Efficacy, Dose, and Adverse Effects

• FDA indication – osteoporosis treatment for women   5 years post menopause with low bone mass
• AACE guideline – fourth‐line therapy
• Only vertebral fracture prevention
• Dosing –Intranasal ‐ 200 units daily alternating nares
• Adverse effects –Nasal – rhinitis, epistaxis, irritation –Subcutaneous – pain, redness –Other – nausea, allergic response, backache, headache –FDA post‐marketing analysis for cancer risk

References:

• National Osteoporosis Foundation (2014)

• U.S. Preventive Services Task Force – calcium vitamin D (2013)

• Ann Intern Med 2013;158:691‐696

• U.S. Preventive Services Task Force – screening (2011) – www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm

• International Society for Clinical Densitometry (2013) – www.iscd.org/documents/2013/07/2013‐iscd‐official‐ positions‐adult.pdf

• American Association of Clinical Endocrinologists(2010)

• Endocr Pract 2010;16(Suppl 3):1‐37

• North American Menopause Society (2010) – www.menopause.org/docs/default‐document‐ library/psosteo10.pdf?sfvrsn=2

• Endocrine Society (2012) – J Clin Endocrinol Metab 2012;97:1802‐1822

BCPS Mock Exam by Med Ed 101

Eric Christianson, PharmD, BCPS, CGP the founder of Med Ed 101 has created a BCPS mock exam that is full of valuable clinical content that will help prepare you to pass your BCPS exam.  There are numerous case studies that are similar in style and format to the actual BCPS exam.  There are also a bunch of statistics questions that will be excellent practice for anyone taking the exam.  Another part that many who’ve taken the practice exam like is that you get the answers, and also get a good explanation (when necessary) for why each answer is correct. 

For a limited time, Eric is offering a 20% discount to followers of this blog!  Use the discount code “blonde” when checking out.  This offer will expire May 8th, 2015. Here’s the link to check out more on the exam, and don’t forget to use the discount code:  blonde   -   https://www.meded101.com/downloads/bcps-practice-exam/

Here’s a few more details on the exam from the website:

“This BCPS practice exam was created to help you maximize your productivity by helping you identify weaknesses that you need to spend more time on.  If you enjoy the free content on meded101.com, you’ll love this exam.  The content is good, the explanations are solid, and compare it with the cost of ACCP mock exam at 100$.  The other neat thing is you get it as a PDF so you can refer back to it if necessary.

It is a 90 page PDF that includes 200 questions with the answers, an explanation for each answer, and lab values table.  In preparation for your BCPS exam, this practice exam will test your pharmacotherapy skills on the following topics:

•Pediatrics

•Geriatrics

•Gastrointestinal Disorders

•Oncology Supportive Care

•Endocrine and Metabolic Disorders

•Men’s and Women’s Health

•Ambulatory Care

•Neurology

•General Psychiatry

•Nephrology

•Infectious Diseases

•Pharmacokinetics: A Refresher

•Biostatistics: A Refresher

•Study Design

•Fluids, Electrolytes, and Nutrition

•Critical Care

•Cardiology

•Dermatology

•HIV/Infectious Diseases”

If you’d like a free 10 question trial, you can go here: https://www.meded101.com/bcps-practice-test-2/

Should Pharmacists Become Board Certified?

I enjoy brainstorming with other pharmacists on becoming board certified.

I remember back in 1998-1999, the assistant dean of my alma mater, the University of Tennessee at Memphis, stressed how important it was to consider residency and board certification. At the time, I was 25 years old and making decisions that would impact me for life.

I decided back then to decline that path. I only saw the dollars that were before me in retail pharmacy and the student loan debt approaching 6 figures. So, I quipped, "Why would I want to work for half pay or less for a whole year?" and "Why would I want to spend money and time to become board certified when there are no immediate financial rewards?"

Hindsight is 20/20. Fast forward to a 40-something in the profession for more than 14 years experiencing all sorts of different pharmacy experiences. After trying most, I have regrets regarding my earlier decisions. I regret not doing a rotation overseas. I regret not doing a residency. I regret that I dismissed it all for more money.

I know that not everyone feels like me, and that is understandable. Perhaps I am just a different sort who realized fairly quickly that I was falling behind. Whatever the reason, I decided to pursue a Board Certified Pharmacotherapy Specialist (BCPS) certification a couple of years ago. I work in a small community setting in a smaller city, and although it is nothing like Memphis in terms of clinical opportunities, such opportunities can be found with a little luck. Passing the test was probably up there with my other personal accomplishments.

Why should you become board certified?

1. According to the Board of Pharmacy Specialties (BPS) website, "From patient to provider, the value of the BPS-certified practitioner registers throughout the health care continuum. For pharmacy professionals, documentation of specialized experience and skills yields the additional benefits of personal satisfaction, financial rewards and career advancement." I definitely agree, but most BCPS-certified pharmacists I have spoken with did not receive a raise unless they changed jobs. While BCPS certification may have helped with landing a clinical job in the past, it might just be something to separate you from a PharmD without BCPS on any pharmacist job interview today.

2. If you have been out of school for more than 5 years, I bet you have already forgotten some of what you have learned. You can either depend on your local hospital's computer system to remind you of every little thing OR you can take charge of what you know and remain committed to being the best pharmacist you can be. Think of it like this: if you work in a hospital and are commanding larger salaries than new graduates with fresher knowledge, there comes a point at which you are replaceable. Remain competitive in your field, which means using continuing education to really learn something, rather than last-minute cramming to renew your state license.

3. A paper published in 2006 states that "Future Clinical Pharmacy Practitioners Should Be Board-Certified Specialists.” In the past, clinical pharmacists have not made board certification a priority, but this is changing rapidly in both clinical and staff positions. As pharmacists move in the direction of becoming reimbursed professionals for optimizing medications, there will be a trend toward licensing agencies requiring board certification in certain scenarios. Sure, that is not the case today, but if you would have told me in 2000 that the market would be in its current shape with oversaturation and residency demand, then I would have done things very differently in 1999-2002.

4. The PharmD curriculum is not enough to get you in sync with other health care professionals. Experience in dealing with physicians and their assistance along with board certification will take you to the next level in recommending appropriate treatment. Placing new graduates in clinical positions without experience and expecting them to build relationships with clinicians is not the best-case scenario for building pharmacist clinical teams. Requiring board certification ensures a higher level of expertise and is moving toward becoming a requirement in many hospitals. The benefits in just preparing and studying for the test are immense, in my experience.

5. Last, but not least, you should become board certified to give your patients the best care possible. This was my number 1 reason. I remember the day when I sat at my desk years ago and realized I had no idea about new practice guidelines and that order entry had essentially turned me into a robot dependent on the computer. I realized that it was time to make some personal changes that would cost me both dollar and time, yet result in amazing benefits for my patients.  

Most pharmacists are reluctant to pursue BCPS certification because no one wants to fail, much less fail twice. Although it is humbling to fail once, it is euphoric to pass, even the second time.

I hope to inspire more pharmacists to be their best in our profession. If you fail, realize that any amount of learning will significantly change how you practice pharmacy. 

The Anticoagulant and Antiplatelet Refresher

Anticoagulants and antiplatelets are the most common group of medications setting questioning in motion at my job.  Whether it is surgeons asking about washout periods or other colleagues admitting to not knowing the latest medications in the this category, I find myself constantly learning and relearning this topic.  I decided to put together a brief overview of what we have, how it is used and some of the nuances to remember.

1.        FACTOR Xa INHIBITORS (Anticoagulants):

• Rivaroxaban (Xarelto):  Deep vein thrombosis (DVT), pulmonary embolism (PE) treatment, Reduction in the risk of recurrent DVT/PE (in select patients), nonvalvular atrial fibrillation (to prevent stroke and systemic embolism), and postoperative DVT thromboprophylaxis.
  • Caution in pts w/moderate renal impairment (CrCl 30-50 mL/min)  and avoid in patients with severe renal impairment (CrCl <30 mL/min).
  • CYP3A4 substrate and P-gly transporters
  • No reversal agent
  • Discontinue at least 24 hours before any procedure in normal renal function.  If CrCl <50 and elderly, need 48 hours washout.
• Fondaparinux (Arixtra): Prophylaxis of DVT in patients undergoing surgery for hip replacement, knee replacement, hip fracture, or abdominal surgery, treatment of acute PE, treatment of acute DVT without PE.  Unlabeled: DVT prophylaxis with HIT
  • CrCl 30-50 mL/min: use caution.  Contraindicated in <30 mL/min.
• Apixaban (Eliquis): hip or knee replacement DVT, nonvalvular AFib, unlabeled initial tx of VTE
  • Nonvalvular atrial fibrillation 5 mg BID, adjust in serum creatinine >1.5 and either age >/=80 or body weight </=60 kg: 2.5 mg BID.

2.  DIRECT THROMBIN INHIBITORS (Anticoagulants):

• Bivalirudin (Angiomax):
  • Current recommendations are to adjust the dose for renal impairment in patients with a CrCl of 10–29 ml/min undergoing PCI and in patients with a CrCl<60 ml/min being treated for heparin-induced thrombocytopenia. Current manufacturer recommendations state that dosing modifications are not necessary in patients with hepatic impairment.
  •  No Reversal Agent.  Modified ultrafiltration and hemodialysis may facilitate removal (45-69% removal w/ultrafilt and 25% with HD).  Recombinant factor VII can be administered at a dose of 90 mcg/kg IV.  FFB, etc…
• Dabigatran (Pradaxa):
  • Dosed as a twice daily oral tablet, dabigatran reaches a peak plasma concentration after 1–2 h with a half-life of 12–17 h. Renal clearance accounts for 80–85% elimination of dabigatran. Doses should be reduced in patients with moderate renal impairment (defined as CrCl 30–50 ml/min) and should be avoided in patients with severe renal impairment (defined as CrCl 15–30 ml/min) and concomitant use of medications requiring use of P-glycoprotein). Current manufacturer recommendations state that dosing modifications are not necessary in patients with hepatic impairment.
  • No Antidote.  FFP can be tried.  HD can be effective in removing as much as 60% of circulating drug, as the majority of drug is unbound to protein; but unsuff data to support this.
  •   Withhold for 2 days in patients with normal renal function and high risk of bleeding or major surgery.  For otherwise avg risks, 24 hours.
• Desirudin (Iprivask):

3.  P2Y-12 RECEPTOR INHIBITORS (Antiplatelets):

• Clopidogrel (Plavix):
  • Peak platelet inhibition:  300 mg load 6 hours, 600 mg load 2 hours.
  • Approved for ACS medically or PCI
  • Discontinue 5 days before surgery.  CABG hold time 5 days.
  • 2C19 and 3A4 metabolism (PPIs can reduce the effect of antiplatelet by inhibiting 2C19)
  • Loading dose:  300-600 mg; Maintenance dose:  75 mg/day
• Ticagrelor (Brilinta): 
  • Peak platelet inhibition:  180 mg less than hour
  • LD: 180 mg, maintenance dose: 90 mg twice daily
  • Contraindications: ICH, severe hepatic disease
  • Not prodrug, reversible, noncompetitive binding, 3A4 (primary), 3A5, P-gp
  • Careful with asthma, bradycardia, enhanced bleeding with NSAIDs, VKA, strong 3A4 inhibitors increases Ticagrelor conc, strong 3A4 inducers decrease Ticagrelor conc, do not exceed 40 mg of simvastatin or lovastatin.  Limit ASA < 100 mg.
  • CABG hold time 5 days
  • Box warning: age-related bleeding CVA
• Prasugrel (Effient): 
  • Peak platelet inh 60 mg load 1-1.5 hrs.
  • LD: 60 mg MD: 10 mg daily (5 mg if <60 kg; bw >/=75 yrs)
  • CIs: TIA/stroke
  • Bleeding risk higher than clopidogrel
  • D/C 7 days before surgery (CABG included), avoid in patient with active bleeding or a history of TIA or stroke and over 75 old unless pt has DM or history of MI
  • Box warning: aspirin dosing > 100 mg

4.  HEPARIN AND LOVENOX (Anticoagulants):  

• Heparin:
  • No renal adjustment required
  • Different dosing depending on indication

  • Watch for HIT:  1-2% of patients.  Typically the platelet count will fall 5-14 days after heparin is first given; if someone has received heparin in the previous three months, the fall in platelets may occur sooner, sometimes within a day.

Enoxaparin (Lovenox):

• Renal adjust < 30 mL/hr (treatment and prophylaxis)

• HIT still an issue (it is a low molecular weight heparin)

Hopefully this review will help you identify which are anticoags, which are antiplatelets, and which could overlap or not based on profile.

Pharmacists and Provider Status

What is provider status?  Why is it important to the profession to gain?

Pharmacists and pharmacists’ patient care services are not included in key sections of the Social Security Act (SSA), which determines eligibility for health care programs such as Medicare Part B. In the case of Medicare Part B, the omission of pharmacists as listed providers limits Medicare beneficiaries’ access to pharmacists’ services in the outpatient setting. Other health care professionals who are listed as providers in Part B of the SSA include physicians, physician’s assistants, certified nurse practitioners, qualified psychologists, clinical social workers, certified nurse midwives, and certified registered nurse anesthetists. In addition to providers, Part B provides the list of medical and other health services covered.

Many state and private health plans often cite the omission from Medicare Part B as a reason for lack of coverage for beneficiaries or lack of compensation of pharmacists for providing comprehensive, patient-centered care. Omission from Medicare Part B can also result in barriers to optimizing the use of pharmacists’ patient care services in emerging integrated care delivery models promoted by the Affordable Care Act (ACA), such as medical homes and accountable care organizations (ACOs), which are located in another section of the SSA.

The American Pharmacists Association has a full page of the hows and whys.

The American Society of Health-System Pharmacists is on board as well.

California has passed legislation and just like most bills starting in CA, it will sweep the country.

Here's a summary of what was passed in California last year:

Pharmacist Provider Status Legislation SB 493 (Hernandez) Summary

Now that the pharmacist provider status bill has been signed by the Governor, many pharmacists are asking: “what does this bill do for me?” SB 493 grants all pharmacists certain authorities in all practice settings that had previously been limited to inpatient settings or integrated systems. The bill also establishes a new “Advanced Practice Pharmacist” recognition. This recognition can be granted when specified experience and/or certification requirements are met. The Advanced Practice Pharmacist recognition is not mandatory, but it does allow pharmacists to provide additional services. Below is a summary of SB 493’s changes, which take effect January 1, 2014, though some provisions require regulations by the Board of Pharmacy and will not take effect until those regulations are approved.

• Declares pharmacists as healthcare providers who have the authority to provide health care services.
• Authorizes all licensed pharmacists to:
• Administer drugs and biologics when ordered by a prescriber. Previously, this was limited to oral and topical administration. SB 493 allows pharmacists to administer drugs via other methods, including by injection. 
• Provide consultation, training, and education about drug therapy, disease management and disease prevention. 
• Participate in multidisciplinary review of patient progress, including appropriate access to medical records. 
• Furnish self-administered hormonal contraceptives (the pill, the patch, and the ring) pursuant to a statewide protocol. This authority is similar to the existing emergency contraception protocol. Once a statewide protocol is adopted by the Board of Pharmacy, it will automatically apply to all pharmacists. 
• Furnish travel medications recommended by the CDC not requiring a diagnosis. 
• Furnish prescription nicotine replacement products for smoking cessation pursuant to a statewide protocol if certain training, certification, recordkeeping, and notification requirements are met. Once a statewide protocol is adopted by the Board of Pharmacy, it will automatically apply to all pharmacists. 
• Independently initiate and administer immunizations to patients three years of age and older if certain training, certification, recordkeeping, and reporting requirements are met. A physician protocol is still required to administer immunizations on children younger than three years of age. 
• Order and interpret tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies, in coordination with the patient’s primary care provider or diagnosing prescriber. 
• Establishes an Advanced Practice Pharmacist (APP) recognition, and authorizes APPs to:  

1. Perform patient assessments
2. Order and interpret drug therapy-related tests in coordination with the patient’s primary care provider or diagnosing prescriber. 
3. Refer patients to other healthcare providers. 
4. Initiate, adjust, and discontinue drug therapy pursuant to an order by a patient’s treating prescriber and in accordance with established protocols. 
5. Participate in the evaluation and management of diseases and health conditions in collaboration with other healthcare providers. 
6. Requires pharmacists seeking recognition as APPs to complete any two of the following three criteria: Earn certification in a relevant area of practice, such as ambulatory care, critical care, oncology pharmacy or pharmacotherapy. Complete a postgraduate residency program. Have provided clinical services to patients for one year under a collaborative practice agreement or protocol with a physician, APP pharmacist, CDTM pharmacist, or health system.

I want recognition for the value brought to patients and the health care team.

Pharmacists are an integral part of the healthcare team.  I hope to see this sweep across the country in the next few years and that board certification propels us into a whole new recognized role.