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!

Discounted registration is available through May 31. 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.

Fill out the form and return it to MPA Communications Manager Ryan Weiss.

Save the Date for the MSHP Annual Meeting

Building Bridges – Not Boundaries – Through Transitions of Care

By Nada M. Farhat, Pharm.D., BCPS, BCACP

When I first heard Michigan Society of Health-System Pharmacists (MSHP) President Michelle Dehoorne discuss the 2023 theme of “Building Bridges,” I immediately thought about the “bridges” patients must cross in care. Similar to bridges, there are many phases across the care continuum that pose challenges, eventually leading to complications preventing a successful transition from one location to the next.

Several factors play a role in the foundation of a bridge that keeps patients moving seamlessly throughout the healthcare system. As we know, many health-related social needs (HRSN) and social determinants of health (SDoH) factor into the success of patient transitions.

From a patient perspective, there is data to support that patients specifically report several barriers related to SDoH through their transitions of care (TOC) processes and racial disparities may affect their post-discharge care as well.¹ Lack of transportation is a key barrier that could be overcome with the increase in telehealth services such as those provided during the COVID-19 pandemic.¹ However, as the pandemic comes to an end, additional strategies to continue telehealth monitoring may be especially important for patients transitioning across multiple settings. With more health care systems implementing initiatives focused on SDoH, it is imperative that pharmacists improve their knowledge regarding our role in assessing SDoH and resolving potential barriers.

Remember, transitions can be to and from any setting – home, hospital, outpatient clinic, laboratory, pharmacy, skilled nursing facility, etc.

Regardless of your practice setting, I’m sure all pharmacists have come across a situation where there was a discrepancy or error after a transition. Each transition could result in significant patient harm, especially if the error persists across the care continuum. Recent studies suggest that up to 51 percent of errors at hospital discharge may result in moderate to severe patient harm.² Although TOC is a complex process which should involve a multitiered approach, pharmacists are uniquely trained and positioned to help not only reconcile medications, but also prevent adverse events related to medication discrepancies.²

Lastly, similar to how bridges require regular maintenance, patients require continued follow up in the outpatient setting to ensure optimal outcomes. With the appropriate foundation, resolution of barriers (including addressing HRSN/SDoH), and continued follow up, patients should be able to transition across various healthcare settings with improved safety and efficacy.

Regardless of our practice setting, I challenge each one of us to do our part to ensure that patients are provided with the necessary resources so that we can continue to build strong bridges to support patient transitions across multiple settings. As Joseph Newton once said, “We build too many walls, and not enough bridges.” Let’s focus on working together to help create successful bridges to ensure optimal patient health outcomes across the care continuum.

References

1. Jones B, James P, Vijayasiri G, Li Y, Bozaan D, Okammor N, Hendee K, Jenq G. Patient Perspectives on Care Transitions From Hospital to Home. JAMA Netw Open. 2022 May 2;5(5):e2210774. doi: 10.1001/jamanetworkopen.2022.10774. PMID: 35522278; PMCID: PMC9077479.
2. Kreckman J, Wasey W, Wise S, Stevens T, Millburg L, Jaeger C. Improving medication reconciliation at hospital admission, discharge and ambulatory care through a transition of care team. BMJ Open Qual. 2018 Apr 20;7(2):e000281. doi: 10.1136/bmjoq-2017-000281. PMID: 29713690; PMCID: PMC5922563.

- ORGANIZATIONAL AFFAIRS -

Preview of the 2023 ASHP House of Delegates

By Jesse Hogue, Pharm.D.

The American Society of Health-System Pharmacists (ASHP) will convene its 75^th annual session of the House of Delegates in June. The agenda includes considering policy recommendations and statements; receiving board and committee reports; and considering a variety of other society business items. The Michigan Society of Health-System Pharmacists’ (MSHP) elected delegates this year are Rox Gatia, Jesse Hogue, Jessica Jones and Becky Maynard.

House of Delegates activities begin well before June, so we have already been busy this year. In March, we caucused to consider 17 policy recommendations for the virtual House of Delegates in order to vote as a bloc as much as possible. After voting, 10 of the policies met the 85 percent threshold needed to pass and seven were deferred for consideration in June. We all also participated in Regional Delegate Conferences (RDCs) in late April and will participate in another virtual house session this month to vote on policies that were not controversial in the RDCs. While a full discussion of all the items we will be considering is beyond the scope of this article, we wanted to highlight a few of them for you.

Equity, social determinants of health (SDoH) and access to care are very timely topics this year and are related to MSHP’s theme for 2023. We will be considering three relevant policy recommendations:

• Use of SDoH Data in Pharmacy Practice from the Council on Pharmacy Management
• Pharmacoequity from the Council on Pharmacy Practice
• Therapeutic and Psychosocial Considerations of Patients Across the Gender Identity Spectrum from the Council on Therapeutics

While there will likely be minor amendments suggested on these recommendations, delegates seem to be in agreement that disparities in social determinants of health and clinical practice adversely affect the health of our patients and should be addressed. Gender affirming care is a unique aspect of health equity that is a key area of focus that delegates generally feel warrants its own policy.

Somewhat related to access to care, there are several policy recommendations this year from the Council on Therapeutics related to pharmacist prescriptive authority. ASHP has recognized that a targeted approach to pharmacist prescribing as a way to improve access to care is a more successful strategy than pursuing blanket prescriptive authority. This allows us to demonstrate our value and the resulting positive outcomes, building evidence for broader efforts in the future.

• Pharmacist Prescribing Authority for Antiretroviral Therapy for the Prevention of HIV/AIDS
• Point-of-Care Testing and Treatment
• Retire ASHP Statement on Criteria for an Intermediate Category of Drugs
• Nonprescription Availability of Oseltamivir
• Over-the-Counter Availability of Oral Contraceptives

I would note that a resolution supporting pharmacist prescribing of HIV PEP/PrEP was recently approved at the MPA House of Delegates, so this is an item of interest to Michigan pharmacists. Regarding the intermediate category of drugs, the council noted that ASHP has moved away from this approach in recent years as we’ve shifted toward advocating for prescriptive authority. Retirement of the statement prompted revisions of the oseltamivir and oral contraceptives policies. Many delegates took exception to those two policies. Not everyone agrees that the safety profile of oseltamivir supports OTC status, or that we should have a policy focused on that specific drug, so we would prefer to retire the policy in deference to the test to treat policy. In terms of over-the-counter oral contraceptives, many delegates felt strongly that advocating for pharmacist prescriptive authority would be a safer approach that would still greatly expand access to care.

Sticking with the broad access to care theme, the Council on Pharmacy Practice has proposed a revision to their Medication Administration by the Pharmacy Workforce policy. This policy reinforces medication administration as within the scope of pharmacy practice. The MPA House of Delegates approved a resolution supporting pharmacist administration of long-acting injectable medicines in 2022, so this is another area of interest to pharmacists in Michigan.

Injectable promethazine has been a very hotly-debated topic over the years. Current ASHP policy states that injectable promethazine should only be used when necessary, but Institute for Safe Medication Practices (ISMP) recommendations have been strengthened to not allow it at all. The Council on Therapeutics therefore crafted a revised policy recommendation that advocated for removal from formularies but allowed for some exceptions. The ASHP Board pointed out that such a policy conflicted with itself, so the policy was further revised to advocate for removal from hospital formularies and for advocacy with the FDA for removal from the market.

Many delegates, however, have noted that the ISMP recommendation was opinion-based rather than evidence-based and that promethazine is safe and effective as a second-line agent if diluted and administered appropriately. For that reason, many of us intend to propose a significant amendment: to go back to the original “when necessary” language and add a clause encouraging ISMP to review the existing patient safety data and update its stance.

This might seem like quite a bit of information, but it merely scratches the surface of the policy recommendations. As you can see in the complete list below, many other policy recommendations will also be of significant interest to MSHP members, and they all will affect us as health-system pharmacists. I encourage you to review the proposed policies and contact one of the delegates with any questions or comments you may have: Becky Maynard (maynardr@bronsonhg.org); Jesse Hogue (hoguej@bronsonhg.org); Jessica Jones (Jessica.Jones2@corewellhealth.org); and Rox Gatia (rgatia1@hfhs.org).

ASHP members can view the official language of the policy recommendations at the ASHP House of Delegates website. They can also follow online discussions via the House of Delegates community within ASHP Connect. There has already been quite a bit of good discussion on ASHP Connect - feel free to join the conversation!

COUNCIL ON PHARMACY MANAGEMENT POLICY RECOMMENDATIONS

1. Payer-Directed Drug Distribution Models
2. Use of Social Determinants of Health Data in Pharmacy Practice
3. Pharmacy Accreditations, Certifications, and Licenses
4. ASHP Statement on Leadership as a Professional Obligation

COUNCIL ON PHARMACY PRACTICE POLICY RECOMMENDATIONS

1. Emergency Medical Kits
2. Raising Awareness of the Risks Associated with the Misuse of Medications
3. Standardization of Medication Concentrations
4. Reducing Healthcare Sector Carbon Emissions to Promote Public Health
5. Pharmacoequity
6. Medication Administration by the Pharmacy Workforce

COUNCIL ON THERAPEUTICS POLICY RECOMMENDATIONS

1. Availability and Use of Fentanyl Test Strips
2. Manipulation of Drug Products for Alternate Routes of Administration
3. DEA Scheduling of Controlled Substances
4. Pharmacist Prescribing Authority for Antiretroviral Therapy for the Prevention of HIV/AIDS
5. Point-of-Care Testing and Treatment
6. ASHP Statement on Criteria for an Intermediate Category of Drugs
7. Nonprescription Availability of Oseltamivir
8. Over-the-Counter Availability of Oral Contraceptives
9. Responsible Medication-Related Clinical Testing and Monitoring
10. Therapeutic and Psychosocial Considerations of Patients Across the Gender Identity Spectrum
11. Removal of Injectable Promethazine from Hospital Formularies

COUNCIL ON EDUCATION AND WORKFORCE DEVELOPMENT POLICY RECOMMENDATIONS

1. Well-Being and Resilience of the Pharmacy Workforce

SECTION OF PHARMACY EDUCATORS POLICY RECOMMENDATION

1. ASHP Statement on Precepting as a Professional Obligation 

- MEMBER SPOTLIGHT -

Katherine Bromm

Graduating P4 student, University of Michigan;

incoming PGY1 resident for Veterans Affairs Ann Arbor

Member Since: 2019

Describe Your Role/Day in the Life: As a graduating P4 pharmacy student, I am currently on my last rotation of pharmacy school in a community setting. Eight rotations are required for my Pharm.D. program to graduate and they have been in a variety of settings, from a warfarin clinic, to general pediatrics, to a multiple sclerosis-focused specialty pharmacy. I am grateful to have experienced pharmacy in many cities all over the state, including Grass Lake, Midland, Ann Arbor and Troy. In my free time I am studying for the Multistate Pharmacy Jurisprudence Examination (MPJE) and the North American Pharmacist Licensure Examination (NAPLEX). I look forward to relaxing before residency begins.

Why You’re an MSHP/MPA Member: Pharmacy advocacy at a local and state level is what attracted me to MPA as a student. MPA does a great job of inviting students as early as their P1 year to participate in Pharmacy Day at the Capitol and helps keep us up to date with current legislation impacting pharmacy.

Recent Accomplishments: I was awarded the Larry Wagenknecht Leadership Scholarship in February at MPA’s Annual Convention and Exposition (ACE) and successfully matched to a PGY1 residency program.

How MSHP/MPA Has Helped You Achieve Any Accomplishments: MPA has provided an incredible amount of support throughout pharmacy school. MPA provides financial support through student scholarships and discounted student rates to ACE. MPA’s investment in students has allowed me to be a more informed pharmacy student and given me the opportunity to participate in Pharmacy Day at the Capitol early on in pharmacy school. The mentors I have met through MPA have played a large part in being able to match at a PGY1 program. MPA has given me so much throughout pharmacy school, and I cannot wait to help support future pharmacists as I begin my career!

- RESIDENT'S CORNER -

Left Ventricular Thrombus Update

Yingcong Tan, Pharm.D.; Nicholas Panecaldo, Pharm.D.;

Kenneth Kue, Pharm.D.; Helena Knox, Pharm.D.

Pharmacists often encounter patients with myocardial infarctions and dilated cardiomyopathy (DCM) and should be aware that these disease states increase the risk of developing left ventricular (LV) thrombi. The pathophysiology is likely due to the presence of endothelial injury, increased hypercoagulability and stasis of the blood in the left ventricle, which are the three components of Virchow's Triad.¹ Although the management of LV thrombus remains challenging, recent literature has emerged exploring alternative therapeutic agents that pharmacists can consider for patient care.

Historically, warfarin has been the mainstay treatment for LV thrombus in DCM. However, in recent years, direct oral anticoagulants (DOACs) have emerged as an alternative with several advantages over warfarin. The American Heart Association and American Stroke Association (AHA/ASA) recently released a scientific statement recommending that DOACs be considered as a reasonable alternative to warfarin.¹ Alternatively, the American College of Cardiology (ACC) still recommends the use of warfarin but states DOACs should be used if warfarin cannot be tolerated.²

A meta-analysis published by the AHA in 2022 compared the efficacy and safety of DOACs and warfarin for treatment of LV thrombus. This meta-analysis looked at four different outcomes: stroke or systemic thromboembolism, all-cause mortality, thrombus resolution, and bleeding. The results showed that there was no significant difference for stroke or systemic thromboembolism between DOACs and warfarin [odds ratio (OR) 0.94; 95 percent confidence interval (CI) 0.70–1.25; p=0.65]. Additionally, there were no significant differences between DOACs and warfarin for all the other outcomes analyzed. Results concluded that DOACs are a reasonable alternative to warfarin in patients with LV thrombus.¹

Several prospective studies have produced conflicting results regarding DOAC use versus warfarin for LV thrombus. Two randomized controlled trials (RCTs) evaluated the efficacy of apixaban compared to warfarin in patients newly diagnosed with LV thrombus who were not on prior anticoagulants. Both studies showed noninferiority of apixaban compared to warfarin in reducing the size or resolution of LV thrombus with similar safety outcomes.^3,4 Another RCT by Adelnabi et al. compared rivaroxaban to warfarin in complete LV thrombus resolution. The study resulted in 87.17 percent vs. 80 percent (p=0.7) at six months and concluded noninferiority of rivaroxaban in terms of efficacy and safety.⁵ Lastly, a prospective, observational study compared warfarin to DOAC therapy (rivaroxaban 58.5 percent, apixaban 36.5 percent and edoxaban 5 percent) and resulted in overall rates of LV thrombus resolution of 79.7 percent in the DOAC group and 48.3 percent in the warfarin group (p=0.04). The study concluded that DOAC use consistently improved LV thrombus resolution compared to warfarin.⁶ However, these studies were underpowered and excluded critically ill and patients with multiple comorbidities.

Pharmacokinetic characteristics and patient-specific factors must be considered when determining optimal anticoagulation therapy. Warfarin has been the standard of care for LV thrombus and is an inexpensive medication compared to DOACs. However, warfarin does require routine monitoring, which may not be an option for patients with structural or systemic inequities that may limit their access to healthcare. Additionally, there is a concern for interactions between both food and drugs, required bridging and/or potential for subtherapeutic INR levels. DOACs have shown to have lower rates of bleeding and do not require routine monitoring or dietary considerations.⁷ Despite this, DOACs also have drug interactions and both hepatic and renal function considerations that must be evaluated. Furthermore, DOACs may also be cost-prohibitive if not covered by insurance – especially in vulnerable patient populations ­– and require patient-focused support with patient assistance programs. All the above should be considered when deciding optimal anticoagulation for a patient with LV thrombus. 

Based on the studies mentioned before, DOACs may be a reasonable consideration for the management of LV thrombus based on emerging literature, but other factors must be considered in ultimately determining the intervention that will best optimize patient care. It is recommended that patients with LV thrombus should be treated for three to six months with anticoagulation. Cessation of treatment may depend on LV ejection fraction recovery, thrombus resolution, or bleeding complications. Thus, collaboration with the medical team is crucial in determining the most appropriate anticoagulation regimen for patients.

References

1. Levine GN, McEvoy JW, Fang JC, et al. Management of Patients at Risk for and With Left Ventricular Thrombus: A Scientific Statement From the American Heart Association. Circulation. 2022;146(15):e205-e223. doi:10.1161/CIR.0000000000001092
2. Camaj A, Fuster V, Giustino G, Bienstock SW, Sternheim D, Mehran R, et al. Left ventricular thrombus following acute myocardial infarction: jacc state-of-the-art review. J Am Coll Cardiol. 2022 Mar 15;79(10):1010–22.
3. Isa WYHW, Hwong N, Yusof AKM, Yusof Z, Loong NS, Wan-Arfah N, Naing NN. Apixaban versus Warfarin in Patients with Left Ventricular Thrombus: A Pilot Prospective Randomized Outcome Blinded Study Investigating Size Reduction or Resolution of Left Ventricular Thrombus. J Clin Prev Cardiol 2020;9:150-4.
4. Alcalai R, Butnaru A, Moravsky G, et al. Apixaban vs. warfarin in patients with left ventricular thrombus: a prospective multicentre randomized clinical trial‡. Eur Heart J Cardiovasc Pharmacother. 2022;8(7):660-667. doi:10.1093/ehjcvp/pvab057
5. Abdelnabi M, Saleh Y, Fareed A, et al. Comparative Study of Oral Anticoagulation in Left Ventricular Thrombi (No-LVT Trial). J Am Coll Cardiol. 2021;77(12):1590-1592. doi:10.1016/j.jacc.2021.01.049
6. Jones DA, Wright P, Alizadeh MA, et al. The use of novel oral anticoagulants compared to vitamin K antagonists (warfarin) in patients with left ventricular thrombus after acute myocardial infarction. Eur Heart J Cardiovasc Pharmacother. 2021;7(5):398-404. doi:10.1093/ehjcvp/pvaa096
7. Zeng S, Zheng Y, Jiang J, Ma J, Zhu W, Cai X. Effectiveness and Safety of DOACs vs. Warfarin in Patients With Atrial Fibrillation and Frailty: A Systematic Review and Meta-Analysis. Front Cardiovasc Med. 2022;9:907197. Published 2022 Jun 24. doi:10.3389/fcvm.2022.907197

- REGIONAL UPDATE -

Capital Area Pharmacists Association

2023 CAPA Presidential Address

Susan Benivegna, R.Ph., CAPA president

It is truly an honor and privilege to represent the Capital Area Pharmacists Association (CAPA) as its president this year. I look forward to helping our members become engaged with organized pharmacy. For 24 years I have been a Michigan Pharmacists Association (MPA) and CAPA member, enjoying the continuing education (CE) programs. Since 2020, I have also become actively involved in our Advent House Ministry and helping organize events for Poison Prevention Week and Pharmacy Week. 

Realizing that CAPA’s core values align with my own, it was easy to say “yes” when asked to join the Executive Board. This wonderful group of mentors has provided the training and support to move into a leadership role and renewed my passion for our great profession. Now I hope to lead the challenge to grow the pipeline of new pharmacy leaders and increase membership during our “new normal.”

Our local association provides a multitude of ways that pharmacists and technicians can add quality to their professional lives. Your membership in CAPA provides many tangible benefits, such as continuing education, community outreach, advocacy and providing scholarships. With these membership offers, CAPA strives to remain relevant to its members at every stage of their career. CAPA and MPA are guided in this effort by our mission statements “to encourage and support its members as professionals” and to “unite and empower Michigan pharmacy professionals.”

As we approach the second half of 2023, I extend my gratitude to the past CAPA Executive Board and officers for their devotion to our organization and its mission. With excitement and energy, I welcome and challenge the members-at-large to try our CE and other programs, get involved, bring a friend and help make CAPA a relevant, fresh and fulfilling component for 2023 and into the future!

Prevention at Impression 5

Poison Prevention Week was March 19-25, 2023. To raise awareness, CAPA staffed a table at Impression 5 Science Center in downtown Lansing from 11 a.m. to 3 p.m. on Saturday, March 25. The event had a full house of families with children enjoying the museum. In total, our pharmacists spoke with roughly 80 to 100 people about Poison Prevention and the Michigan Poison Control Helpline. We played “Medicine vs. Candy,”; gave away Helpline stickers and magnets, coloring books, pamphlets and lollipops; demonstrated how to best draw up oral liquids for kids and more. We even shared information about pets and toxins.

Future Events

The CAPA Executive Board will meet in early September to plan more future events; however, some have already been planned for 2023, including the following events:

July 29 – Dinner to be served at the Advent House

Sept. 30 – Dinner to be served at the Advent House

Anyone interested in joining CAPA and becoming more involved can visit capapharm.org. 

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