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**Students: Check out Page 5 for Scholarship Info!! September 2004 Chapter Newsletter: Volume I, From the Dean’s Desk Robert L. McCarthy, PhD happenings in the School of Pharmacy. staff of the Office of Experiential Education Connecticut pharmacy is justly proud to are busy at work on several projects, the have one of the preeminent ASCP chapters most exciting being serving as one of the in the nation. We are grateful for the nu- pilot’s for the University’s e-portfolio initia- merous ways in which Connecticut consult- tive. We hope to develop a student portfo- ant pharmacists support our School, espe- lio of work that can move with the student cially by providing state-of-the-art practice from rotation to rotation as they complete site learning opportunities for our students. their advanced practice experiences. Dr. We are equally proud of two accomplished Hritcko is also overseeing the redesign of members of our faculty—Professors Dennis our P1-P3 introductory practice experi-Chapron and Sean Jeffery—who have ences. played and continue to play such integral roles in the chapter’s success. Clearly, pharmacy practice in Connecticut, and the patients we serve, is indebted to the high Hewitt Scholar in Residence Program. This CT-ASCP Chapter program, funded from an endowment es- Communications tablished by the 3rd dean of the School of Pharmacy Harold Hewitt, will bring one-two Committee: national-recognized scholars to campus • Amy Huie-Li, PharmD, CGP The 2004-2005 academic year each year for an intensive period of schol- will culminate with the completion of a new arly exchange with faculty members, post- • Kevin Chamberlin, PharmD docs, graduate students, residents and • Anna Egle, RPh, FASCP pect to begin moving some areas within fellows. It is expected that the scholar will the School into the new building as soon as contribute to the research efforts of the • James Conklin, PharmD early May 2005; we should be fully opera- tional in time for the start of classes in late to multiple researchers or programs. August 2005. We plan to combine the alumni banquet, and 80th anniversary cele- This is but a glimpse of some of Inside this is bration of the School into a festive week- learn more, be sure to watch for our annual Metolazone + Saturday, October 21-22, 2005. Please report and the reintroduction of our experi- Furosemide ential education newsletter later this fall. under the leadership of Dr. Gerry Gianut- sos, has made a series of preliminary rec- ommendations, a number of which will be University of Connecticut C h a p t e r N e w s l e t t e r : V o l u m e I , N u m b e r 4
Medication Appropriateness Index and Inpatients Kevin W. Chamberlin, PharmD The prevalence of inappropriate prescribing Medication Appropriateness Index Criteria in frail nursing home residents has been well de- scribed1. However, with regard to their inpatient coun- terparts, the data has lacked sufficient examination. In the early 1990s, Joseph Hanlon, PharmD, MS and 2. Is the medication effective for the condition? colleagues developed a systematic approach to as- sessing drug therapy appropriateness in the ambula- tory elderly by way of the Medication Appropriateness Index (MAI). The study of primary interest looked at 5. Are there clinically significant drug-drug interactions? how this tool might also be applied to hospitalized frail 6. Are there clinically significant drug-disease The study involved 11 VA Medical Centers 7. Are the directions practical? and the Geriatric Evaluation and Management (GEM) unit patients. The eligibility requirements of the 1388 8. Is the drug the least expensive alternative compared patients enrolled included: over 65 years, hospital- ized on a medical or surgical ward more than 48 9. Is there unnecessary duplication with other drugs? hours, and met 2 or more criteria for frailty. As ex- pected with frailty eligibility criteria, the patients had 10. Is the duration of therapy acceptable? multiple comorbidities and medications and most had As defined by the MAI ratings, there are 10 Reference of primary interest: questions per medication. For 2796 total medica- 1Hanlon JT, et al. “Inappropriate Medication Use tions, there were then 27,960 ratings of which 2207 Among Frail Elderly Inpatients.” The Annals of Pharmacother- (8%) had inappropriateness of some level. 78% of the apy. 2004;38:9-14. drugs and nearly 92% of the patients had one or more MAI problems. The common problems exposed by the MAI involved: expense, practical directions, and dos- age. Drug interactions, duplication, and effectiveness Cohen HJ et al. “A controlled trial of inpatient and were among the least common problems identified. outpatient geriatric evaluation and management.” NEJM. According to pharmacologic class, cardiovascular, 2002;346:905-912. gastric, CNS, and respiratory agents were among the Hanlon JT, et al. “A method for assessing drug ther- apy appropriateness.” J Clinical Epidemiology. 1992;45:1045-1051. Where lower is better, only 8% of patients reviewed had an MAI score of 0; 19.4% had a score > 15, with the average score being 8.95. Analyses re- vealed that the only significant factors associated with Kevin W. Chamberlin, PharmD is an Assistant Clinical Faculty in Internal having a higher MAI score was the total number of Medicine at the University of Connecticut School of Pharmacy. prescription and nonprescription drugs. Of concern was the number of drugs with no indication (n = 250, 8.9%) within the patients’ drug regimens. from the outpatient-to-inpatient-to-outpatient setting is a challenge. The MAI may be a useful tool in man- aging the medication additions occurring while the frail elderly are inpatients. While the validity of its predictability may still need to be assessed for inpa-tients, the MAI is nonetheless an excellent assess-ment for any clinical pharmacist to apply to any drug regimen. C h a p t e r N e w s l e t t e r : V o l u m e I , N u m b e r 4
Mechanism of the Synergistic Effect of Metolazone & Furosemide The diuretic effect of the combination treat- trolyte imbalances (hypomagnesemia, hypochloremic ment metolazone-furosemide is greater than either alkalosis, hyponatremia), orthostatic hypotension, and therapy alone. This phenomenon is due to the phar- dizziness. Additional monitoring is advised with regard to macokinetic and pharmacodynamic interaction within blood pressure, weight, chemistry, input and output, and the kidneys. A kidney has approximately 300,000 renal and hepatic function. In order to maximize this ad-nephrons which are the functional units. Nephrons ditive effect, metolazone should be administered 30 min-are composed of a Bowman's capsule, the proximal utes after furosemide allowing for sequential removal of tubule, the loop of Henle, distal tubule, collecting duct sodium, chloride, and water. However, there is no clear and closely associated blood vessels. In the Bow- evidence in literature indicating which one should be man’s capsule, water, sodium, chloride, salts, urea, given prior to the other. glucose, and amino acids are filtered from the blood. In the descending and ascending loops of Henle and in distal tubule, reabsorption of water, sodium, chlo- ride, amino acids, and glucose are returned to the Reference of primary interest: kidney and ultimately to the blood. In the distal tu- bule, secretion K+, H+, some drugs, and toxins are < from the blood. In the collecting ducts, renal 3.pdf> pelvis, ureter, bladder and urethra, urine is removed Trinh T. Bùi, PharmD is a 2004 graduate of the University of Connecti- cut School of Pharmacy and is currently doing a Pharmacy Practice Residency at the VA Connecticut Healthcare System. Loop diuretics are anthranilic acid derivatives with a sulfonamide substituent (e.g., furosemide, bu-metanide), or aryloxyacetic acids without a sulfona-mide substituent (e.g., athacrynic acid). These agents are believed to reversibly bind to the sodium, potas-sium, and chloride mainly in the lumen of the loop of Henle, thereby inhibiting the active reabsorption of these ions. Loop diuretics are used to treat edema from congestive heart failure (CHF), hepatic cirrhosis, renal disease and pulmonary edema, and ascites. The commonly used thiazide diuretics are most closely related to the benzothiadiazides with variable substituents. The prototypical agent is chlorothiazide. The primary action of benxothiadi-azides is to increase diuresis by blocking the reab-sorption of sodium, chloride and water in the distal tubule. These agents are used to treat chronic edema, hypertension, and heart failure. Conclusion: This treatment regimen takes advantage of the differ-ent pharmacologic classes and mechanisms of action of metolazone and furosemide. This combination therapy can be helpful in the treatment of refractory edema, chronic heart disease, or conditions that have accumulated large volumes of fluid. However, this intensive therapy is accompanied by high risks of elec- C h a p t e r N e w s l e t t e r : V o l u m e I , N u m b e r 4
Pharmacy Students & Fellow Practitioners: Why complete a Pharmacy Practice Residency? Amy Huie-Li, PharmD, CGP A general pharmacy practice residency is an grams are the right paths for you to follow. I completed organized, directed, salaried, postgraduate training my Doctor of Pharmacy degree and residency training program of one-year duration that concentrates on the many years after receiving my BS degree; it is definitely development of knowledge, attitudes, and skil s possible to attain this goal even after a long absence needed to pursue rational drug therapy for a wide from the academic field of pharmacy. Do develop a pas-range of patients in a variety of pharmacy practice sion for the pharmacy profession and never stop learn-settings. A specialized residency program provides an ing. Get involved with your local, state, and national pro-additional year of training in a more focused area of fessional pharmacy organizations. Find a mentor or men- pharmacy practice such as geriatrics, cardiology, on- tors for guidance regarding your career choices. There cology, acute care, and so on, while a pharmacy fel- are many different avenues in the practice of pharmacy. lowship program of 1-2 year duration prepares a par- Talk to other pharmacists, look around and do your re- ticipant to develop competency in the scientific re- search. You will find your niche and everything that Pharmacy residency training provides not only Further readings on residency information: a competitive advantage in the job market over appli- cants who have not completed residency program, but it also offers opportunities for networking, planning a 6&CFToken=87904149 pharmacy career and gaining an in-depth vision of the pharmacy profession during the course of the resi- I completed a Geriatric Specialty Residency Program at the University of Connecticut and VA Con- necticut Healthcare System in 2003, which was de- signed to develop skilled clinicians and instructors in geriatric pharmacotherapy and senior care pharmacy Amy Huie-Li, PharmD, CGP is a Clinical Pharmacist in the Geriatrics and practice. During the year-long program, I had the op- Extended Care Unit at VA Connecticut Healthcare System, West Haven, CT. portunity to gain valuable clinical, teaching and schol-arly skills through interactions with multidisciplinary staff, faculty and trainees associated with the Univer-sity Of Connecticut School Of Pharmacy, the VA Con-necticut Healthcare System, the American Society of Consultant Pharmacists Foundation, and the Con- necticut Area Agency on Aging. Through my residency training and my mentor, Dr. Sean Jeffery, I learned to apply the facts that I acquired in pharmacy school and I developed the competency in areas of sub-acute geriatric patient rehabilitation, home healthcare, geri-atric ambulatory/primary care, and other areas of geri-atric pharmacy that have been of immense help to me in my present position as a geriatric clinical pharma-cist. In conclusion, my advice to current pharmacy students and fellow practitioners is to consider your long-term professional and personal goals before de-termining whether post-graduate trainings such as general residency, specialty residency, fellowship, the ASHP or ASCP Pharmacotherapy Traineeship pro- C h a p t e r N e w s l e t t e r : V o l u m e I , N u m b e r 4
Arnold S. Feldman Senior Care Pharmacy Scholarship Program Applications are being accepted from fourth professional year pharmacy students for the The Arnold S. Feldman Memorial Senior Care Pharmacy Scholarship who, upon graduation will have completed at least one course in geriatrics or geriatric pharmacotherapy, and is committed to developing and implementing a specific research or educational project related to geriatric pharmacotherapy that will be completed during his/her final year of pharmacy school. Preference will be given to students who are ASCP members and have decided to dedicate their careers to serving the older adults by addressing the unique medication needs of this growing population. The Arnold S. Feldman Memorial Senior Care Pharmacy Scholarship Program recognizes one pharmacy stu- dent in his/her fourth professional year of pharmacy school. One award $500 will be given on an annual basis. The first will be awarded in November 2004. The application deadline is Monday, October 1, 2004. The Arnold S. Feldman Memorial Senior Care Pharmacy Scholarship Program is administered by ASCP Foun- dation and is supported by contributions from family members and friends of Arnold S. Feldman and his son Stephen Feldman, current Chair of the ASCP Board of Directors. This scholarship program acknowledges the contributions pharmacy students can make towards appropriate, safe and effective medication use for older adults. Application materials can be downloaded from the ASCP Foundation Website at Please share this information with other eligible class-mates. For more information about the Arnold S. Feldman Memorial Senior Care Pharmacy Scholarship Program, please contact the American Society of Consultant Pharmacists Research and Education Foundation at 800-355- 2727, extension 107. Irma Pomales-Connors is the Program Officer and Senior Grant Writer for the American Society of Consultant Pharmacists Research and Educa-tion Foundation in Alexandria, Virginia.



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