MPF Golf Classic

There's still time to register for the Michigan Pharmacy Foundation Golf Classic, June 21, 2023, at Eldorado Golf Course in Mason.

Don't miss this excellent opportunity to enjoy a day on the links, while also supporting the Foundation's mission "To Foster the Future of Pharmacy." There will also be a chance to win a $25,000 grand prize during the Hole-in-One contest!

Click the buttons below to sign up for this amazing event!

Michigan Pharmacist Journal Published

The April/May/June 2023 edition of the Michigan Pharmacist Journal is now available online! Click the cover image to the right to read about the following topics:

• MPA Members Stack Up Awards: At home and nationally, MPA members bring home hardware.
• President's Platform: MPA President Hope Broxterman looks at opportunities ahead for pharmacists.
• From the Foundation: Don't take a mulligan on the annual MPF Golf Classic June 21.
• Advocacy Update: Read up on how you can promote pharmacy priorities at the state and federal levels.
• MSCP Focus: MSCP President Brooke Roe gives pharmacists some phrases to live by, while Thomas Burns looks at how pharmacists can help women have greater access to hormonal contraception.
• New program: Wayne State professors and students give a glimpse of the school's new ambulatory care concentration.

Please note: The Michigan Pharmacist will be available in digital format only. Printed copies may be requested via email at MPA@MichiganPharmacists.org.

Promote With the MPA Social Media Request Form

Have something you want MPA to share on its social media channels? The MPA social media request form might be right for you!

This valuable tool can now be found on the MPA website here. This form can be used to promote events or resources, recognize member accomplishments, or share other messages and information. Submitting this form does not guarantee your content will be shared, but you will be contacted if MPA is unable to post your content.

You must be logged in to your MPA account in order to view and complete the form.

Contact MPA Communications Manager Ryan Weiss with any questions.

Register Now for the MSHP Annual Meeting!

Registration is now open for the Michigan Society of Health-System Pharmacists (MSHP) Annual Meeting, which will be held Friday, Oct. 27, at the Crowne Plaza Lansing West, 925 S. Creyts Road in Lansing.

Held each fall, the MSHP Annual Meeting offers up to six hours of live continuing education credit. Programming is geared toward health-system pharmacists, residents, pharmacy technicians and student pharmacists. The MSHP Annual Meeting focuses on clinical, leadership management and residency topics as well as other general areas of pharmacy practice.

In addition to continuing education programs, the event offers the annual MSHP Town Hall Meeting to install new MSHP Board of Directors members into office officially, recognize volunteers and award recipients, a clinical skills competition for students and an exhibit hall to provide attendees with a chance to exchange ideas and learn about new products and services.

Building a Bridge Using Technology

By Diana Kostoff, BS Pharm, Pharm.D., BCPS, BCOP, senior application analyst, Henry Ford Health; director, MSHP

As I have been familiarizing myself with social determinants of health (SDoH) and the screening tool, I realized that questions regarding access to any type of technology are missing. Knowing if a patient has a smartphone, computer, or internet access – and if they are using them in any way regarding their health care – is essential.

The COVID-19 pandemic was a major driving force in increasing electronic and telemedicine visits, but many patients did not know how to utilize the patient portal of the electronic medical record (EMR) to set up their visits. I personally witnessed this while sharing an office with one of our medical assistants, who spent her day coaching patients and their caregivers on how to set up appointments. Many times, the visits became telephone visits only.

The link between health care and technology will only continue to grow. The primary literature is still limited, but articles are mentioning digital equity, digital health, digital health literacy and “techquity.” They are calling technology access and digital literacy “super” determinants of health since they are impacting an individual’s abilities to access education, employment, food and/or transportation. There is mention of a health tech “bridge” where technology is intended to be the “bridge” between patients and the health care system. For those who are able and willing to use health tech, “crossing the bridge” will be seamless. If not, technology can become a barrier and perpetuate inequities.

The newest advancement within health systems is integrating the SDoH screening tool into our EMRs. This is a huge step in the right direction, but it also has opened new questions for pharmacy practice. In many health systems, social work and primary care providers are the primary users of the SDoH tool. In some institutions, pharmacists may view the results, but may not contribute to completing the questions. If a patient informs a pharmacist of a need (for example, transportation), the pharmacist will more than likely refer the patient to the appropriate provider to assist the patient. Pharmacists might not even have security access to the tool and health systems may need to ask for this access during implementation.

In addition, health systems may want to request to add the SDoH tool to a visible location in the EMR. Regardless of pharmacy staff access or extent of access, education will need to be provided to understand the information contained in the tool and how to use it in practice. There are also pharmacy-specific questions that are not included in this tool. MSHP president Michelle Dehoorne has charged committees to identify additional patient information that pharmacists and pharmacy technicians may need collected in the EMR (for example, data that patient drug assistance programs need) and potential solutions on how to accomplish adding this information to the EMR.

This new era of increased technology and access will provide opportunities to improve and optimize patient care and address SDoH. All providers are taking steps in learning more about SDoH and this learning will need to expand beyond literacy and include digital literacy. Bridging the gap between technology and health care will help accomplish the goal of health and digital equity for all.

Glossary

Digital equity: Condition in which all individuals and communities have the information technology capacity needed for full participation in our society, democracy and economy.

Digital health: Use of technology and electronic communications tools, services and processes to deliver health care services or to facilitate better health.

Digital health literacy: Ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.

“Techquity”: The strategic design, development and deployment of technology to advance health equity. It encompasses the notion that technology can either support or inhibit advancements in health equity if not implemented in an intentional and inclusive manner at the organizational or systemic level.

References

1. Advancing Health Equity Through Technology. Nov 2021. CTA.tech | connecthi.com

2. Anderson A, et al. The Path to Techquity. An introduction to key issues impacting equitable design & deployment of technology in the US healthcare system. Collaborative whitepaper developed by Ipsos & the HLTH Foundation. March 2022.

- TRANSITIONS OF CARE -

Applying Our Knowledge of SDoH in the Workplace

By Heather Rickle, Pharm.D.; clinical specialty pharmacist, ambulatory care, Corewell Health; MPA past president

Julie Schmidt’s article in April’s MSHP Monitor had a unique theme of “The More You Know.” She shared information on social determinants of health (SDoH) and some history. To build on her idea, the next step logically looks at how the care we provide in our daily work applies to what we know. We all have different roles within our health systems and our systems have differing methods for documentation; however, as pharmacy professionals, how we address SDoH within our work matters. 

SDoH is “the conditions in environments where people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning and quality-of-life outcomes and risks.”

The health system where I work, Corewell Health West, uses Epic for their electronic medical record (EMR) and as clinicians, we are fortunate to view patients' SDoH in the wheel found on the snapshot for each patient. The wheel (Figure 1) shows 10 domains that should be considered when shared decisions are made for each patient. The SDoH in the wheel includes finances, transportation, use of alcohol, depression, partner violence, social connections, physical activity, tobacco use, stress and food insecurity. Colors are used to signify risk: green is low risk, yellow moderate and red is high. Intuitively, the higher the risk, the more likely that particular domain is to impact one's outcomes, care and goals.

Figure 1

The information included in the wheel is only as good as our documentation. When questions have not been addressed or updated, developing a plan by simply looking at the wheel may not result in the best outcomes. In reflecting on what I now know and providing equitable care, my practice did not incorporate using the tools to help decision-making as best as I could. As pharmacy professionals managing chronic disease, we are expected to discuss diet, consumption of alcohol, use of cigarettes, marijuana, or illicit substances, affordability of medication and the impact of new therapy on one’s ability to pay their bills, but how are we documenting this information? 

Historically, I included answers to these questions in my notes but did not call out the significance related to SDoH. This led me to change my practice by creating a dotphrase to help prompt me in the assessment of my patients to include relevant documentation, allowing me to then go back and update the wheel.   

What are you doing in your practice to document the work you are doing to increase equality? See more information in the links below:

• Michigan Social Determinants of Health
• Map the Meal Gap 2022 Technical Brief.pdf (feedingamerica.org)
• Understanding Social Determinants of Health in Michigan (mibluesperspectives.com)

- MEMBER SPOTLIGHT -

Rachel Griffioen

Pharm.D., BCPS, clinical pharmacist specialist and PGY-1 pharmacy residency program director, McLaren Greater Lansing

Member Since: 2013 (SMPA); 2017 (MPA/MSHP)

Describe Your Role/Day in the Life: I am a clinical pharmacist at McLaren Greater Lansing, specializing in internal medicine. I attend multidisciplinary rounds and work closely with our nurses, medical residents, nurse practitioners, physician assistants and attending physicians to optimize medication regimens. I participate in our medical resident didactics, presenting various topics, including antibiotic reviews, anticoagulants and pain management. As the RPD, I am responsible for the design and conduct of our residency program and I also precept the internal medicine rotation.



Why You’re an MSHP/MPA Member: I believe in giving back and promoting our profession. As an executive board member of the Capital Area Pharmacists Association (CAPA), I enjoy helping plan our continuing education activities, participating in social and community events and selecting our student scholarship recipients. Being a member of MPA and MSHP provides me with opportunities and resources to serve and advocate for my profession that I would not have otherwise.

Recent Accomplishments: Over this last year, I started a new PGY-1 pharmacy residency program at McLaren Greater Lansing. We just completed our initial accreditation survey in May and look forward to graduating our first class of residents at the end of June!

How MSHP/MPA Has Helped You Achieve Any Accomplishments: As a new RPD, MPA/MSHP have been invaluable resources. MPA has hosted both of my residents for an elective rotation. MSHP recently hosted a webinar on research in pharmacy residency programs containing fantastic tips I plan to implement for my next class of residents. 

- RESIDENT'S CORNER -

Lessons Learned From Administering CPR

in a Real-Life Scenario

By Samantha Bodan, Pharm.D., PGY-1 pharmacy resident, Sparrow Hospital

We all learned it: “Ah, ha, ha, ha, stayin’ alive, stayin’ alive.” Administer 30 chest compressions every two breaths. Hands centered on the chest, shoulders directly over hands; elbows locked out, depth 2 inches, allowing for chest recoil.

Sounds easy – until you need to put it into action.

I was in the emergency department on my fourth rotation during my residency year. It was my last week on rotation and I had just completed my Advanced Cardiac Life Support (ACLS) training the week prior and officially received my ACLS provider certificate two days before I had to put it to use. I knew that whenever I performed CPR for the first time, I wanted to be in a controlled environment – like an emergency department surrounded by nurses, doctors and interns. It was a goal of mine to give CPR during my rotation.

Everyone’s pagers went off about five minutes before the ambulance arrived at our emergency department: “male with complaints of chest pain and shortness of breath.” As soon as the stretcher's wheels reached the emergency department door, I heard, “he’s starting to code!” My eyes widened, and my heart started racing as I rushed to open the crash cart. I broke the lock on the crash cart and started pulling out the epinephrine and connecting the parts while putting a handful of saline flushes in my pocket. When the patient arrived at the trauma bay, one of the paramedics was administering compressions while the other paramedic was giving report. The emergency department team quickly transferred the patient to the hospital bed while connecting the patient to the monitor and AED.

The emergency department attending, nurse practitioner, medical residents, several nurses and a handful of other people are crammed into the trauma bay. I stood between the Pyxis and crash cart, ready to hand out meds. I looked at the monitor; there was a rhythm; I thought, “the rhythm looks like normal sinus, he’s going to be OK.” Then the attending shouted, “I can’t find a pulse, give a round of epi and continue compression!” I handed over the stick of epinephrine, repeating the order out loud and reached down to get the next dose ready.

The code continued for what felt like forever; every three minutes, another dose of epinephrine was given and caregivers switched places every two to four minutes to provide compressions. Finally, we were able to obtain a weak pulse. An epi-drip was ordered and I pulled out a bag of epinephrine from the Pyxis, primed the tubing and started to program the IV pump. The nurse connected the epinephrine to the patient, who appeared to be fairly stable. I assumed the code was complete, I started back to the crash cart to help clean up. Before I could reach the crash cart that was less than 5 feet away, the NP called out, “he’s in v-tach, prepare to deliver a shock.”

Compressions were started again, with pulse checks every two minutes and more epinephrine being given every three minutes. It was time for someone to switch out for compressions and I asked the NP if I could provide compressions with the next round. She nodded and I stood behind the nurse giving compressions. At the next pulse check, we switched places. I interlocked my fingers, locked out my elbows and pressed down on the patient’s chest. For two of the longest minutes of my life, I administered compressions to our patient.

After two minutes of compressions, I switched places with another nurse. I was exhausted and my body was buzzing with adrenaline. I resumed my position at the crash cart, ready for the next order. At this point, we were approximately 30 minutes into the code. We finally learned that the man had recently had an aortic dissection repair. His point-of-care hemoglobin had dropped to 4 mg/dL during the code and it was assumed at this time that his aortic repair had failed.

The providers looked around and asked, “Does anyone have any suggestions on how we can save this man’s life?” No one responded. The attending instructed the team to continue CPR while she talked to the family.



The attending and the patient’s wife entered the room as we were still giving CPR. At the next pulse check, the provider called the time of death. The room was silent and everyone looked at the wife. She was in shock, understandably so. One by one, we exited the room, giving our condolences.

I knew that giving compressions in a real-life scenario would better prepare me if the day came again when I needed to administer CPR. I am grateful that I gained this experience during my residency; it taught me how invaluable completing a pharmacy residency can be. Overall, I have become a more confident pharmacist through the gained experience over the last year.

Direct Oral Anticoagulant Dosing in Obesity 

By J. Patrick Mucci and Christopher Niendorf, 

2023 Pharm.D. candidates, Ferris State University 

Direct oral anticoagulants (DOACs) such as apixaban (Eliquis®) and rivaroxaban (Xarelto®) are the preferred anticoagulants in patients with atrial fibrillation. Compared to warfarin, they have a decreased risk of bleeding, require less monitoring and the ARISTOTLE and ROCKET AF trials demonstrated superiority and noninferiority, respectively, in preventing stroke or systemic embolism in atrial fibrillation.^1,2

In the ARISTOTLE trial, the median patient weight was 82 kilograms, with an interquartile range of 70 to 96 kilograms. Patients in the ROCKET AF trial had an average body mass index (BMI) of approximately 28 kilograms per meter squared (kg/m2) with an interquartile range of approximately 25 to 32 kg/m2. While neither study excluded patients based on weight, most patients weighed less than 100 kilograms, which makes it difficult to extrapolate this data to obese patients. 

This raises the question: Are DOACs safe and effective in obesity?  

Currently, apixaban dosing in atrial fibrillation is 5 milligrams twice daily unless the patient meets two of the following criteria: they are at least 80 years old, weigh less than 60 kilograms, or have serum creatinine of greater than or equal to 1.5 milligrams per deciliter.³ If two criteria are met, the recommended dose becomes 2.5 milligrams twice daily.³ For rivaroxaban, the standard atrial fibrillation dosing is 20 milligrams daily with food. This dose is adjusted to 15 milligrams daily when creatine clearance is less than 50 milliliters per minute. 

Currently, neither the International Society on Thrombosis and Hemostasis (ISTH), American College of Cardiology (ACC), nor American Heart Association (AHA) guidelines recommend dose increases for DOACs in obesity.^4,5  However, ACC guidelines recommend getting a DOAC serum level in patients weighing more than 120 kilograms, while ISTH guidelines suggest not regularly following peak or trough levels. This contradiction between guidelines questions the pharmacokinetic and pharmacodynamic profiles of DOACs in obesity. 

To assess DOAC efficacy in obese populations, a small single-center, retrospective study was conducted at Montefiore Medical Center in New York.⁶ The authors assessed anticoagulant use in patients with BMI greater than or equal to 40 kg/m2 by monitoring the incidence of stroke and venous thromboembolism (VTE). Of 429 patients prescribed an anticoagulant for atrial fibrillation, the incidence of stroke was similar between the treatment cohorts – one of 103 patients on apixaban (1.0 percent; 95 percent confidence interval (CI) 0.0–2.9), four of 174 on rivaroxaban (2.3 percent; 0.1–4.5) and two of 152 on warfarin (1.3 percent; 0.0–3.1), p=0.71.6 This study suggests that in patients with BMI greater than or equal to 40 kg/m2, a dose adjustment might not be necessary. Still, this study’s retrospective nature and small sample size raises more questions than it answers.  

Another small, two-center observational study in the United Kingdom compared peak or trough concentrations of apixaban (5 milligrams twice daily) or rivaroxaban (20 milligrams once daily) in patients weighing at least 120 kilograms (median weight 139 kilograms).⁷ Factor Xa peak and trough concentrations were measured and only two of 100 patients had trough levels below the author’s expected range. No relationship between body weight and drug concentrations was found.⁷ Because anti-Xa levels are not routinely monitored and no defined therapeutic ranges exist, anti-Xa levels should not influence treatment decisions. 

The currently available data suggest that obesity does not significantly affect the efficacy of DOACs, and weight-based dosing adjustments are not necessary. While there is meager study data regarding DOACs in patients weighing more than 200 kilograms, the available evidence suggests that obesity does not significantly alter the pharmacokinetic or pharmacodynamic profiles of DOACs. Until more information becomes available, DOACs may continue to be considered in obese populations where appropriately indicated, as DOACs have provided positive outcomes, consistent dosing schedules, and decreased therapeutic drug monitoring.  

References

1. Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus Warfarin in Patients with Atrial Fibrillation. New England Journal of Medicine. 2011;365(11):981-992. doi:10.1056/NEJMoa1107039 
2. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. New England Journal of Medicine. 2011;365(10):883-891. doi:10.1056/NEJMoa1009638 
3. Reference ID: 3237516 - Food and Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/202155s000lbl.pdf 
4. CMartin KA, Beyer-Westendorf J, Davidson BL, Huisman MV, Sandset PM, Moll S. Use of direct oral anticoagulants in patients with obesity for treatment and prevention of venous thromboembolism: Updated communication from the ISTH SSC Subcommittee on Control of Anticoagulation. J Thromb Haemost. 2021 Aug;19(8):1874-1882. doi: 10.1111/jth.15358. Epub 2021 Jul 14. PMID: 34259389. 
5. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Journal of the American College of Cardiology. 2019;74(1):104-132. doi:10.1016/j.jacc.2019.01.011
6. Kushnir M, Choi Y, Eisenberg R, et al. Efficacy and safety of direct oral factor Xa inhibitors compared with warfarin in patients with morbid obesity: a single-centre, retrospective analysis of chart data. Lancet Haematol. 2019;6(7):e359-e365. doi:10.1016/S2352-3026(19)30086-9 
7. Martin AC, Thomas W, Mahir Z, Crowley MP, Dowling T, Breen K, Collings V, Moore GW, MacDonald S, Hunt BJ, Cohen AT. Direct Oral Anticoagulant Concentrations in Obese and High Body Weight Patients: A Cohort Study. Thromb Haemost. 2021 Feb;121(2):224-233. doi: 10.1055/s-0040-1715834

- REGIONAL UPDATE -

Western Michigan Society of Health-System Pharmacists

By Shelby Kelsh, Pharm.D., BCPS; associate professor of pharmacy practice,

Ferris State University College of Pharmacy; WMSHP president

The Western Michigan Society of Health-System Pharmacists (WMSHP) has had a great start to 2023. We were back to hosting in-person continuing education (CE) events covering pulmonary hypertension, chronic heart failure and resident research projects. It was great to be physically back together to network and enjoy dinner. We were able to take advantage of our virtual CE in March by having Dr. Staso from Washington join us to discuss drug allergies.

On May 9, we ended our spring events with our annual Spring Seminar in Grand Rapids. We hosted a full day of live CE, which fulfilled many requirements, including pain, law and implicit bias. We also awarded three student scholarships to deserving area pharmacy students.

WMSHP is looking forward to its summer social event at the West Michigan Whitecaps baseball game Aug. 17. The board will meet this summer to start planning our fall events, including monthly CEs, residency showcase and mock interviews for pharmacy students.

If you are interested in learning more about WMSHP, please visit WMSHP.net. 

OFFICERS

PRESIDENT | Michelle Dehoorne | (313) 343-6381 | Ascension, Detroit

PRESIDENT-ELECT | Kyle Schmidt | (616) 685-6675 | Mercy Health St. Mary's, Grand Rapids

IMMEDIATE PAST PRESIDENT | Shawna Kraft | (734) 232-6667 | Michigan Medicine, Ann Arbor

TREASURER | Marc Guzzardo | (810) 606-6095 | Ascension, Detroit

EXECUTIVE VICE PRESIDENT | Edward Szandzik | (313) 587-6279 | Detroit

DIRECTORS

Stacy Brousseau | (269) 341-7407 | Bronson Methodist Hospital, Kalamazoo

Diana Kostoff | (313) 725-7925 | Henry Ford, Detroit

Nada Farhat | nmhammou@med.umich.edu | Michigan Medicine, Ann Arbor

Julie Schmidt | (989) 450-6695 | Bronson Methodist Hospital, Kalamazoo

REGIONAL SOCIETY REPRESENTATIVES 

CENTRAL | Tim Ekola | (734) 845-3418 | VA Ann Arbor Healthcare System

NORTHERN | Miranda Maitland | mirandapmaitland@gmail.com | My Michigan Medical Center, Sault Ste. Marie

SOUTHEASTERN | Jessica Jones | (313) 982-5737 | Beaumont Health, Detroit

WESTERN | Shelby Kelsh | shelbyKelsh@ferris.edu | Ferris State University, Big Rapids

MANAGING EDITOR | Ryan Weiss | (517) 377-0232 | Michigan Pharmacists Association, Lansing